Identification of putative promoter elements for epsilon glutathione s-transferases genes associated with resistance to DDT in the malaria vector mosquito anopheles arabiensis

The purpose of this study was to identify the putative regulatory elements in the promoter region of An. arabiensis strains which differed in susceptibility to DDT and compare with those identified in its sibling An. gambaie. Basal expression level of Epsilon class GSTs (Glutathione S - transferases) GSTe1 gene was 0.512 - 0.658 (95% CI) and GSTe2 0.672 - 1.204 (95% CI) in adults of DDT resistant KGB compared to 0.031 - 0.04 (95% CI) and 0.148 - 0.199 (95% CI) respectively in susceptible MAT strains of An. arabiensis. Induced mean expression of GSTe2 in larvae exposed to DDT for one hour was 0.901 - 1.172 (95% CI) in KGB and 0.475 - 0.724 (95% CI) in MAT strain. In present work, strain specific primers were used to amplify and sequenced the promoter regions of GSTe1 and GSTe2 in the KGB, MAT and field specimens. Computational analysis revealed presence of classical arthropod initiator sequence TCAGT and putative core promoter elements, GC, CAAT, TATA boxes. A typical TATA box was identified at 35 bp upstream Transcription Start Site (TSS) in GSTe1 but was absent in GSTe2. Several binding sites for regulatory elements downstream and multiple polymorphic sites were identified between strains. The role of these regulatory elements in transcription of these genes has not been determined. However, on comparison the 2 bp adenosine indel (insertion/deletion) which was essential in driving the promoter activity in An. gambiae was identified only DDT resistant KGB strain.

Safety and immunogenicity of a serum-free purified Vero rabies vaccine in healthy adults: A randomised phase II pre-exposure prophylaxis study

A serum-free, highly purified Vero cell rabies vaccine (PVRV-NG) is under development. We previously demonstrated that pre-exposure prophylaxis (PrEP) with PVRV-NG had a satisfactory safety profile and was immunogenically non-inferior to the licensed purified Vero cell rabies vaccine in adults. Here, we evaluated the safety and immunogenic non-inferiority of PrEP with PVRV-NG compared to the licensed human diploid cell vaccine (HDCV) in healthy adults (NCT01784874). Participants received three vaccinations (days 0, 7, and 28) as PrEP with or without a booster injection after 12 months. Rabies virus neutralising antibodies (RVNA) were evaluated on days 0, 28 (subgroup only), and 42, and Months 6, 12, and 12 + 14 days (booster group only). Non-inferiority (first primary objective) was based on the proportion of participants with RVNA titres ≥ 0.5 IU/mL (World Health Organization criteria for seroconversion) on day 42, expected to be ≥ 99% (second primary objective). Safety was evaluated after each dose and monitored throughout the study. At day 42, PVRV-NG was non-inferior to HDCV and the first primary objective was met; seroconversion was observed for 98.3% of PVRV-NG recipients and 99.1% of HDCV recipients. As < 99% of participants in the PVRV-NG group had RVNA titres ≥ 0.5 IU/mL, the second primary objective was not met. Booster vaccination produced a strong increase in RVNA titres for all groups, primed with PVRV-NG or HDCV. RVNA geometric mean titres tended to be higher for HDCV than PVRV-NG primary vaccine recipients. In a complementary evaluation using alternative criteria for seroconversion (complete virus neutralization at 1:5 serum dilution), 99.6% and 100% of participants in the PVRV-NG and HDCV groups, respectively, achieved seroconversion across the vaccine groups. No major safety concerns were observed during the study. PVRV-NG was well tolerated, with a similar safety profile to HDCV in terms of incidence, duration, and severity of adverse events after primary and booster vaccinations. ClinicalTrials.gov number: NCT01784874.

AB1247 ELEVATED SERUM COMPLEMENT (C3/C4) LEVEL AS AN INFLAMMATORY MARKER FOR INFECTION IN PATIENTS WITH FEVER: A RETROSPECTIVE STUDY

Background:

The functions of the complement system are to protect the host against infection, clearance of immune complexes, and regulate adaptive immunity after activation by C-reactive protein (CRP) or foreign cells.1C3 and C4 may increase up to 50 percent of baseline values as part of the acute-phase response, which is an expected host response for infection and injury.2

Objectives:

We aimed to examine the correlation between elevated C3/C4 levels and the underlying causes (infectious vs. non-infectious) of fever (subjective and/or objective) in adults admitted to Community Regional Medical Center (CRMC).

Methods:

This is a retrospective study of C3/C4 level that was ordered in adult patients who were admitted to CRMC in April 1st, 2018 to September 30th, 2018 with fever. This was also analyzed in comparison to elevated lactic acid, erythrocyte sedimentation rate (ESR), and CRP level.

Results:

Complement levels were ordered in 210 patients admitted to CRMC medicine or intensive care units. Among these patients, 28.09% (59/210) were diagnosed with various infectious diseases confirmed by gold standard methods (cultures, serology tests, computerized tomography, or magnetic resonance imaging), regardless of fever status during admission.

About 26.6% (56/210) had subjective or objective (temperature greater than100.4 F or above), and52of them had complement levels (C3/C4) ordered with resulted in either normal or elevated. Within these52patients, lactic acid, ESR, and CRP were ordered in33,28,25of them respectively.

Table 1.

Elevated C3/C4 level vs. normal C3/C4 level in detecting infection in fever patients when tested against gold standards.

Patients with infectious disease diagnosisPatients without infectious disease diagnosisElevated C3 or C4 or both (screen test +)137Positive predictive value (PPV)=13/20=65%Both normal C3 and C4 (screen test -)824Negative predictive value (NPV)=15/32=48.9%Sensitivity=13/21=61.9%Specificity=24/31=77.4%Table 2.

Sensitivity, specificity, PPV, NPV, likelihood ratio positive (LR+), and likelihood ratio negative (LR-) among C3/C4, lactic acid, ESR, CRPI/CRPH in detecting infection in patient with fever

C3/C4 (N=52)Lactic Acid(N=33)ESR(N=28)CRPI/CRPH(N=25)Sensitivity61.9%50%90%100%Specificity77.4%91.3%11.1%11.8%PPV65%71.4%36%34.8%NPV48.9%80.8%66.6%100%LR+2.75.71.01.1LR -0.490.550.90

Conclusion:

Complement levels can be used as a rapid screening test to guide infection consideration as it correctly identified 61.9 % of febrile patients with infection, and 77.4% who didn’t have an infection. A positive screening test in itself still requires further investigation in the causes of fever to confirm the diagnosis since the PPV is 65%. With the NPV of 48.9%, a negative screening test is still not reassuring that the febrile patient doesn’t have an infection. Our study demonstrated the potential utilization of the elevated complement level as an inflammatory marker for infectious etiology of fever, as it has better LR+ when compares to ESR and CRP with similar turnaround time.

This study helps educate providers to acknowledge the fact that complement level does not have to be limited to be used on autoimmune related disorders only. Further large pool studies will be necessary to further investigate the role of complement levels as part of the screening test in a patient with fever.

References:

[1]Walport. MJ. Complement. Second of two parts. N Engl J Med.2001 Apr 12; 344(15):1140-4. DOI: 10.1056/NEJM200104123441506

[2]Wen L, Atkinson JP, Giclas PC. Clinical and laboratory evaluation of complement deficiency. J Allergy Clin Immunol. 2004;113(4):585. DOI: 10.1016/j.jaci.2004.02.003

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Disclosure of Interests:

None declared

The Natural History and Management of Intracranial Dural Arteriovenous Fistulae

The recently proposed classification scheme of Borden, Wu, and Shucart (Borden*) should have the ability to identify those intracranial dural arteriovenous fistulae (ICDAVF) which will continue to behave in a benign fashion. We examine for the first time the natural history of benign ICDAVF, including the predictive ability of this grading scale, and the implications for lesion management.

A cohort of 55 Borden* grade I lesions was selected from a heterogeneous series of 102 consecutive ICDAVF seen at one institution between 1984 and 1995. Data were collected prospectively from 1991. Grade I lesions were those whose nidus drained directly into a dural venous sinus (DVS) or meningeal vein. The absence of retrograde leptomeningeal venous drainage (RLVD) was an important feature. Intracranial haemorrhage (ICH), non haemorrhagic neurological deficit (NHND), and death were considered aggressive features.

There were 23 cavernous sinus, 2 foramen magnum, 1 middle cranial fossa, and 29 transverse sinus lesions. One patient received obliterative surgical treatment. Thirty-two lesions were observed only, and 22 patients developed symptoms or signs requiring palliative embolisation.

Two minor complications occurred following embolisation: transient pulmonary aedema (1), and an asymptomatic pericallosal artery embolus (1). Follow-up was available on 48 (89%) patients for a total of 133 patient years (mean 33 months). This included 26 of the 32 patients observed and all 22 of the patients embolised. Aggressive interval behavior was seen in only one patient. Symptom improvement or resolution was observed in the majority of patients, whether observed only [21/26 (81%)], or whether they required embolisation for symptom palliation [19/22 (86%)]. Overall, 53 of the 54 (98%) of ICDAVF behaved in a benign fashion in the follow-up period.

The predictable benign natural history of patients identified as Borden* grade I at presentation mandates a conservative approach to these ICDAVF. In some patients, when symptom severity demands, palliative embolisation is an effective and safe therapy.

Acylation stimulating protein: a female lipogenic factor?

Acylation stimulating protein (ASP) is a potent lipogenic factor produced from adipocytes. Plasma ASP levels were shown to increase in obesity, diabetes mellitus type II and dyslipidemia, and decrease after weight loss and fasting. Growing evidence suggests that ASP may significantly contribute to subcutaneous fat storage in females. In vitro, ASP stimulated triglyceride synthesis to a larger extent in subcutaneous compared with omental adipocytes. The ASP receptor binding affinity to plasma membranes prepared from adipose tissue showed higher binding affinity to plasma membranes from female adipose tissue compared with male adipose tissue, and was more pronounced to subcutaneous compared with omental plasma membranes. Human studies demonstrated that postprandial triglyceride clearance predicted by ASP levels was more efficient in women than in men. In mice, postprandial triglyceride clearance, with intraperitoneal ASP administration, was faster in females compared with males. The ASP deficient mice were resistant to weight gain and had reduced fat mass that was more pronounced in females. Recent findings in humans and mice point to a significant association between progesterone and ASP variations in females. In this review, we highlight findings, to date, linking ASP to physiological and hormonal alterations that may contribute to subcutaneous fat distribution typical to females.

Middle East and North Africa consensus on osteoporosis

With the increasing life expectancy, osteoporosis is becoming a major worldwide health problem. The magnitude of the disease may become larger in developing countries, more particularly in the Middle East region where the prevalence of low bone mass is higher than in western countries. Although several local organizations and countries have developed guidelines for osteoporosis, no previous regional guidelines have been developed encompassing all Middle-Eastern and North African countries. The present document reviews all the regional published data on bone mineral density, risk factors, fracture prevalence and vitamin D status. It also gives simple recommendations applicable to all these countries. This document was endorsed by leading members of all the different regional countries including, Iran, Egypt, Tunisia, Jordan, Palestine, Syria, Iraq, Libya, Oman, Kuwait, Saudi Arabia and Bahrain.

Acylation stimulating protein (ASP) acute effects on postprandial lipemia and food intake in rodents

BACKGROUND

In vitro studies have shown that acylation stimulating protein (ASP) stimulates triglyceride (TG) synthesis and storage in adipocytes. We have previously demonstrated that intraperitoneal (i.p.) injection of ASP in C57BL/6J mice accelerated TG clearance following an orally-administered fat load as well as reducing postprandial glucose levels.

RESULTS

In the present study, we first examined the effect of i.p. and intracerebroventricular (i.c.v.) injection of ASP on food intake in Sprague-Dawley rats. Intraperitoneal injection resulted in a short-term increase in food intake (maximum increase 29.3% within the first hour, P<0.025) decreasing thereafter as compared to vehicle alone. i.c.v. Administration of a comparable dose of ASP resulted in a similar but delayed increase in food intake with a maximum at 2-4 h, suggesting that the actions of ASP are peripherally mediated. However, there was no significant difference in 24 h food intake with either i.p. or i.c.v. injection. We also examined the effects of ASP on TG clearance in two obese mouse strains with different metabolic profiles: ob/ob (C57BL/6J-Lep(ob)) and db/db (C57BLKS/J-Lepr(db)). In a crossover design, the response to an oral fat load was determined with and without i.p. injection of exogenous ASP. In ob/ob mice, there was a 44% greater clearance of postprandial TG (area under the curve (AUC)=245+/-49 control vs 138+/-43 mg/dl h with ASP; P<0.05 by RM ANOVA). The db/db mice showed a greater response, with a 62% decrease in postprandial TG (AUC=4080+/-1489 control vs 1540+/-719 mg/dl h with ASP; P=0.004 by RM ANOVA). In addition there were decreases in postprandial glucose and non-esterified fatty acid (NEFA) levels in response to ASP.

CONCLUSION

These results are the first to report that ASP can increase food intake in rats and also enhance postprandial TG clearance in obese animals. These data therefore support previous in vitro evidence pointing to ASP as a regulator of lipid metabolism.

New developments in the biology of the glucagon-like peptides GLP-1 and GLP-2

Glucagon-like peptides 1 and 2 (GLP-1 and GLP-2) are coencoded within a single mammalian proglucagon precursor, and are liberated in the intestine and brain. GLP-1 exerts well known actions on islet hormone secretion, gastric emptying, and food intake. Recent studies suggest GLP-1 plays a central role in the development and organization of islet cells. GLP-1 receptor signaling appears essential for beta cell signal transduction as exemplified by studies of GLP-1R-/- mice. GLP-2 promotes energy assimilation via trophic effects on the intestinal mucosa of the small and large bowel epithelium via a recently cloned GLP-2 receptor. The actions of GLP-2 are preserved in the setting of small and large bowel injury and inflammation. The biological actions of the glucagon-like peptides suggest they may have therapeutic efficacy in diabetes (GLP-1) or intestinal disorders (GLP-2).

Plugging the intramedullary canal of the femur in total knee arthroplasty: reduction in postoperative blood loss

A prospective, randomized trial comparing postoperative drainage was carried out in 120 consecutive knees undergoing total knee arthroplasties divided into 2 groups. In one (55 knees), the entry point for the femoral intramedullary rod was left open. In the other (65 knees), the entry point was closed by an autologous bone plug. The mean drainage after 24 hours and the total drainage were lower when the femoral canal was plugged (800 vs 960 mL and 925 vs 1,165 mL). The bone plug always united, and no loose bodies were seen 6 months after operation. We conclude that the femoral intramedullary guide hole should be plugged with autologous bone because this technique results in a small but significant reduction in early blood loss without countervailing disadvantages.

Elimination of glucagon-like peptide 1R signaling does not modify weight gain and islet adaptation in mice with combined disruption of leptin and GLP-1 action

Leptin and glucagon-like peptide 1 (GLP-1) exhibit opposing actions in the endocrine pancreas. GLP-1 stimulates insulin biosynthesis, secretion, and islet growth, whereas leptin inhibits glucose-dependent insulin secretion and insulin gene transcription. In contrast, GLP-1 and leptin actions overlap in the central nervous system, where leptin has been shown to activate GLP-1 circuits that inhibit food intake. To determine the physiological importance of GLP-1 receptor (GLP-1R)-leptin interactions, we studied islet function and feeding behavior in ob/ob:GLP-1R(-/-) mice. Although GLP-1R actions are thought to be essential for glucose-dependent insulin secretion, the levels of fasting glucose, glycemic excursion after glucose loading, glucose-stimulated insulin, and pancreatic insulin RNA content were similar in ob/ob:GLP-1R(+/+) versus ob/ob:GLP-1R(-/-) mice. Despite evidence linking GLP-1R signaling to the regulation of islet neogenesis and proliferation, ob/ob:GLP-1R(-/-) mice exhibited significantly increased islet numbers and area and an increase in the number of large islets compared with GLP-1R(+/+) or (-/-) mice (P < -0.01 to 0.05). Similarly, growth rates and both shortand long-term control of food intake were comparable in ob/ob:GLP-1R(+/+) versus ob/ob:GLP-1R4(-/-) mice. Furthermore, leptin produced a similar inhibition of food intake in GLP-1R(-/-), ob/ob:GLP-1R(+/+), and ob/ob:GLP1R4(-/-) mice. These findings illustrate that although leptin and GLP-1 actions overlap in the brain and endocrine pancreas, disruption of GLP-1 signaling does not modify the response to leptin or the phenotype of leptin deficiency in the ob/ob mouse, as assessed by long-term control of body weight or the adaptive beta-cell response to insulin resistance in vivo.

Regulation of Plasma fatty acid metabolism

Although adipose tissue serves a crucial function in energy storage, excess adipose tissue--that is, obesity--is often associated with diabetes and cardiovascular disease. A common thread in the weave of complications is increased plasma concentrations of fatty acids. In the present review, we have focused on two specific points that relate to obesity: (i) What are the metabolic consequences of increased free fatty acid concentrations? and (ii) What are the physiological factors that are involved in the regulation of fatty acid uptake or release from adipose tissue? We have tried to emphasize new factors that act as hormones on adipose tissue and in so doing regulate the net concentration of circulating free fatty acids.

Regional specificity of ASP binding in human adipose tissue

Obesity, in particular omental (OM) adiposity, is associated with diabetes and cardiovascular disease. Thus site-specific regulation of fat storage is important to understand. Acylation-stimulating protein (ASP) is a potent stimulator of glucose transport and triglyceride synthesis in adipocytes. In the present study, we characterized receptor binding of 125I-labeled ASP to human adipocyte plasma membranes from paired OM and subcutaneous (SC) sites in normal (N) and obese (O) male (M) and female (F) subjects (n = 24). Overall, specific binding of 125I-ASP was in the order of SC > OM and O > N (in SC tissue, particularly in F). Receptor affinity of 125I-ASP was higher [lower dissociation constant (Kd)] in SC than in OM (63.6 +/- 16.2 vs. 160.7 +/- 38.6 nM, P < 0.02), especially in F (37.0 +/- 11.1 F-N and 26.3 +/- 6.7 nM F-O) and lower (higher Kd) in male OM (291.8 +/- 116.8 M-N and 149.4 +/- 56.4 M-O). The greater binding and higher affinity of 125I-ASP binding to SC suggests that ASP may be an important factor in maintaining regional adipose tissue mass. Conversely, lower binding and receptor affinity in male OM adipose tissue may contribute to the fatty acid imbalance and metabolic complications associated with this syndrome, by reducing the efficiency of adipose fatty acid trapping by the ASP pathway.

Coordinated release of acylation stimulating protein (ASP) and triacylglycerol clearance by human adipose tissue in vivo in the postprandial period

The objective of this study was to determine whether Acylation Stimulating Protein (ASP) is generated in vivo by human adipose tissue during the postprandial period. After a fat meal, samples from 12 subjects were obtained (up to 6 h) from an arterialized hand vein and an anterior abdominal wall vein that drains adipose tissue. Veno-arterial (V-A) gradients across the subcutaneous adipose tissue bed were calculated. The data demonstrate that ASP is produced in vivo (positive V-A gradient) With maximal production at 3-5 h postprandially. The plasma triacylglycerol (TAG) clearance was evidenced by a negative V-A gradient. It increased substantially after 3 h and remained prominent until the final time point. There was, therefore, a close temporal coordination between ASP generation and TAG clearance. In contrast, plasma insulin and non-esterified fatty acid (NEFA) had an early (1-2 h) postprandial change. Fatty acid incorporation into adipose tissue (FIAT) was calculated from V-A glycerol and non-esterified fatty acid (NEFA) differences postprandially. FIAT was negative during the first hour, implying net fat mobilization. FIAT then became increasingly positive, implying net fat deposition, and overall followed the same time course as ASP and TAG clearance. There was a direct positive correlation between total ASP production and total FIAT (r = 0.566, P < 0.05). These data demonstrate that ASP is generated in vivo by human adipocytes and that this process is accentuated postprandially, supporting the concept that ASP plays an important role in clearance of TAG from plasma and fatty acid storage in adipose tissue.

The validity of classification for the clinical presentation of intracranial dural arteriovenous fistulas

A number of classification schemes for intracranial dural arteriovenous fistulas (AVFs) have been published that claim to predict which lesions will present in a benign or aggressive fashion based on radiological anatomy. We have tested the validity of two proposed classification schemes for the first time in a large single-institution study. A series of 102 intracranial dural AVFs in 98 patients assessed at a single institution was analyzed. All patients were classified according to two grading scales: the more descriptive schema of Cognard, et al. (Cognard) and that recently proposed by Borden, et al. (Borden). According to the Borden classification, 55 patients were Type I, 18 Type II, and 29 Type III. Using the Cognard classification, 40 patients were Type I, 15 Type IIA, eight Type IIB, 10 Type IIA+B, 13 Type III, 12 Type IV, and four Type V. Intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit was considered an aggressive presenting clinical feature. A total of 16 (16%) of 102 intracranial dural AVFs presented with hemorrhage. Eleven of these hemorrhages (69%) occurred in either anterior cranial fossa or tentorial lesions. When analyzed according to the Borden classification, none (0%) of 55 Type I intracranial dural AVFs, two (11%) of 18 Type II, and 14 (48%) of 29 Type III intracranial dural AVFs presented with hemorrhage (p < 0.0001). After exclusion of visual or cranial nerve deficits that were clearly related to cavernous sinus intracranial dural AVFs, nonhemorrhagic neurological deficits were a feature of presentation in one (2%) of 55 Type I, five (28%) of 18 Type II, and nine (31%) of 29 Type III patients (p < 0.0001). When combined, an aggressive clinical presentation (ICH or nonhemorrhagic neurological deficit) was seen most commonly in intracranial dural AVFs located in the tentorium (11 (79%) of 14) and the anterior cranial fossa (three (75%) of four), but this simply reflected the number of higher grade lesions in these locations. Aggressive clinical presentation strongly correlated with Borden types: one (2%) of 55 Type I, seven (39%) of 18 Type II, and 23 (79%) of 29 Type III patients (p < 0.0001). A similar correlation with aggressive presentation was seen with the Cognard classification: none (0%) of 40 Type I, one (7%) of 15 Type IIA, three (38%) of eight Type IIB, four (40%) of 10 Type IIA+B, nine (69%) of 13 Type III, 10 (83%) of 12 Type IV, and four (100%) of four Type V (p < 0.0001). No location is immune from harboring lesions capable of an aggressive presentation. Location itself only raises the index of suspicion for dangerous venous anatomy in some intracranial dural AVFs. The configuration of venous anatomy as reflected by both the Cognard and Borden classifications strongly predicts intracranial dural AVFs that will present with ICH or nonhemorrhagic neurological deficit.

Calcaneal dome osteotomy: a new procedure for revising triple arthrodesis

A preliminary report of a new calcaneal osteotomy is presented. Five patients ranging in age from 18 to 35 years underwent a calcaneal dome osteotomy. They all had painful and significant foot deformity, recurrent tenosynovitis, callosities, and shoe wear problems. The osteotomy was developed to correct the deformity present in patients that had a previous triple arthrodesis. The crescentic shape of the osteotomy allowed for the correction of various degrees and patterns of deformity with accuracy and provided a broad area of contact resulting in osteotomy union. The results achieved by this new technique showed that deformity was corrected, callosities had disappeared, and all the osteotomies were healed. All patients were satisfied by the procedure.

Dolichoectatic aneurysm of common carotid artery: an animal model with histological correlation

There is a limited understanding of the pathogenesis of dolichoectatic (dolicho = long; ectatic = dilated) aneurysms of elastic arteries. Therefore, we developed a model of dolichoectatic changes in elastic arteries by injecting porcine elastase into the media of the carotid artery of male New Zealand white rabbits. After 3 months, gross examination of the carotid arteries in vivo revealed dilated and tortuous vessels. The carotid arteries were then harvested, and cross-sections of the vessels were stained by the Verhoff-van Giesson stain. Histologically, the internal elastic lamina was dissolved in the most dilated areas. The elastic lamellae of the media were also digested and there was reorientation of the innermost medial smooth muscle layer. These gross and histologic changes were present in 80% of the treated carotid arteries and in none of the contralateral control vessels. Our study suggests the importance of the elastic lamellae for the maintenance of tubular shape and length of the carotid artery and describes a new chronic animal model of dolichoectatic aneurysm of the common carotid artery.

Hyperflexion injury of cervical spine and central cord syndrome in a child

A case of CCS in a 9-year-old boy who sustained a transient subluxation of C5 over C6 following a diving accident is reported. The clinical diagnosis of CCS is supported by a MRI finding of a traumatic lesion in the center of the cord at the level of subluxation. We postulate that hyperflexion injury was responsible for the subluxation, which in turn caused compression injury of the cervical spinal cord. Such compression injury, as shown by McVeigh, results in damage to the center of the cord. Central cord syndrome should be regarded as an entity caused by compression of the spinal cord, irrespective of the mode of injury, be it hyperflexion or hyperextension, from which no age group is exempt.

Kinetic and inhibitor studies of acetaminophen and zidovudine glucuronidation in rat liver microsomes

The antiviral drug zidovudine (ZDV) and the analgesic and antipyretic agent acetaminophen (AP) are both biotransformed in the liver of humans to ether glucuronides. A previous clinical trial of ZDV suggested the potential for a clinically significant interaction between AP and ZDV, probably based upon competing hepatic metabolism. To study the mechanism of this potential competition between AP and ZDV as substrates for uridine diphosphoglucuronyltransferase (UDPGT), enzyme kinetic studies were performed using rat liver microsome preparations. Cross inhibition studies demonstrated that AP glucuronidation was competitively inhibited by ZDV, while ZDV glucuronidation was slightly inhibited by AP in a noncompetitive interaction.

Protection after transient focal cerebral ischemia by the N-methyl-D-aspartate antagonist dextrorphan is dependent upon plasma and brain levels

Dextrorphan is a dextrorotatory morphinan and a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist. We studied the dose response characteristics of dextrorphan's neuroprotective efficacy and side effects, correlating these beneficial and adverse responses with plasma and brain levels in a rabbit model of transient focal cerebral ischemia. Thirty-three rabbits, anesthetized with halothane, underwent occlusion of the left internal carotid and anterior cerebral arteries for 1 h, followed by 4.5 h of reperfusion. One hour after the onset of ischemia, they were treated with an i.v. infusion of varying dextrorphan doses or normal saline. After killing, the brains were analyzed for ischemic high signal intensity using magnetic resonance imaging (MRI) and for ischemic neuronal damage with histopathology. A separate group of 12 anesthetized ischemic rabbits received similar doses of dextrorphan, correlating plasma with brain dextrorphan levels. Twenty-six additional dextrorphan unanesthetized, nonischemic rabbits received infusions of dextrorphan to correlate behavioral side effects with dextrorphan dose and levels. Compared with controls, dextrorphan 15 mg/kg group had significantly less cortical ischemic neuronal damage (5.3 versus 33.2%, p = 0.01) and a reduction in cortical MRI high signal area (9.1 versus 41.2%, p = 0.02). The dextrorphan 10 mg/kg rabbits showed less cortical ischemic neuronal damage (27.2%) and less MRI high signal (34.8%) but this was not statistically significant (p = 0.6). Dextrorphan 5 mg/kg had no benefit on either neocortical ischemic neuronal damage (35.8%) or MRI high signal (42.9%). The protective effect of dextrorphan was correlated with plasma free dextrorphan levels (r = -0.50, p less than 0.02 for ischemic neuronal damage; r = -0.66, p less than 0.001 for ischemic MRI high signal). All the rabbits with plasma levels greater than 2,000 ng/ml had less than 12% cortical ischemic neuronal damage and less than 34% MRI high signal. All rabbits with plasma levels greater than 3,000 ng/ml showed less than 7% ischemic neuronal damage and less than 11% MRI high signal. Plasma levels of approximately 2,500 ng/ml correlated with brain dextrorphan levels of approximately 6,000 ng/g. Unanesthetized rabbits with plasma levels of approximately 2,500 ng/ml demonstrated loss of the righting reflex. These results demonstrate that systemic treatment with dextrorphan after 1 h focal ischemia can significantly protect against cerebral damage if adequate plasma and brain levels of dextrorphan are achieved. The brain levels necessary to obtain in vivo protection are similar to concentrations that prevent glutamate or NMDA-induced injury in neuronal culture.

Meningioma: the role of a foreign body and irradiation in tumor formation

A case of meningioma is reported. At the age of 18 years, the patient had undergone insertion of a Torkildsen shunt through a posteroparietal burr hole for obstructive hydrocephalus secondary to a tumor of the pineal region, of which no biopsy had been made. After the hydrocephalus was relieved, he underwent irradiation of the tumor. Thirty years later, he was treated for an intracranial meningioma wrapped around the shunt. The tumor followed the shunt in all of its intracranial course. Microscopy disclosed pieces of the shunt tube within the meningioma. The role of a foreign body and irradiation in the induction of meningiomas is discussed, and a comprehensive review of the literature is presented.

Gigantic mammary hyperplasia in pregnancy associated with pseudohyperparathyroidism

This is the first report of hypercalcemia due to benign gigantic mammary hyperplasia in a pregnant women. Endocrinologic examinations did not disclose any known cause for the symptomatic hypercalcemia. Bilateral total mastectomy decreased the serum calcium level to normal. The case is presented with discussion and a literature review.

Pretreatment with the NMDA antagonist dextrorphan reduces cerebral injury following transient focal ischemia in rabbits

We studied the efficacy of systemic pre-treatment with dextrorphan (DX), a clinically tested N-methyl-D-aspartate (NMDA) antagonist, in a rabbit model of transient focal cerebral ischemia. Rabbits were treated with either a 24 mg/kg i.v. loading dose followed by 12 mg/kg/h i.v. infusion of 0.48% DX in normal saline (NS), or with an equivalent volume of NS alone. One and 1/2 h after starting the drug or NS, the rabbits underwent a 1 h occlusion of the left internal carotid and anterior cerebral arteries, followed by 4 h of reperfusion. The DX-treated rabbits had significantly less neocortical ischemic neuronal damage (7.4%) than the normal saline group (31.6%) and demonstrated a significant decrease in ischemic cortical edema. DX may prove useful in the treatment of clinical cerebrovascular disease.

Protective effect of N-methyl-D-aspartate antagonists after focal cerebral ischemia in rabbits

We studied the efficacy of postischemic, systemic treatment with the N-methyl-D-aspartate (NMDA) receptor antagonists dextromethorphan and dextrorphan in a rabbit model of transient focal cerebral ischemia. Twenty-two rabbits underwent 1-hour occlusion of the left internal carotid and anterior cerebral arteries followed by 4.5 hours of reperfusion before sacrifice. One hour after the onset of ischemia, immediately after removing the arterial clips, the rabbits were blindly assigned to treatment with dextromethorphan (20 mg/kg i.v. loading dose followed by 10 mg/kg/hr maintenance infusion, n = 7), dextrorphan (15 mg/kg i.v. loading dose followed by 15 mg/kg/hr maintenance infusion, n = 7), or an equivalent volume of normal saline alone (n = 8). The maintenance infusion of drugs or saline was continued for the duration of the experiment. The formalin-fixed brains were analyzed with magnetic resonance imaging using coronal T2-weighted images, and ischemic neuronal damage was assessed on standard coronal hematoxylin-and- eosin-stained sections. The area of neocortical ischemic neuronal damage was significantly reduced in the groups treated with dextromethorphan (4.2%, p less than 0.01) and dextrorphan (6.1%, p less than 0.01) compared with the controls (36.2%). Magnetic resonance imaging demonstrated significantly smaller areas of cortical edema in the groups treated with dextromethorphan (14.6%, p less than 0.01) and dextrorphan (8.0%, p less than 0.01) compared with the controls (32.9%). These clinically tested antitussives with NMDA-antagonist properties may have therapeutic value in the treatment of human cerebrovascular disease.

A significant feature of Nager's syndrome: palatal agenesis

Nager's syndrome, which has the facial features of Treacher Collins syndrome, preaxial upper limb defects, short stature, and frequently subnormal intelligence, is very rare. Five new cases have been collected. In four, there was virtually total absence of the soft palate. This has been described in two patients in the past. Differing methods of correcting this are presented.

Desmoid tumors of the head and neck

Desmoid tumors of the head and neck are uncommon and associated with a posttreatment recurrence rate as high as 70 percent. This study was undertaken to determine cure rates achievable by surgery and radiotherapy and the factors influencing failure. A chart review of all patients at our institution with desmoid tumors of the head and neck from 1919 to 1982 was undertaken, and pertinent data were tabulated. Forty-eight patients were found with this problem. Average duration of symptoms was 1.6 years, and tumor size ranged from 1 to 12 cm (mean 5.1 cm). Average follow-up was 5.8 years. The most common site of occurrence was the neck (34 patients). Thirty-two patients underwent complete excision with 8 recurrences; 4 were reexcised with no further recurrence at last follow-up. Fourteen patients had incomplete excision with 12 recurrences. Radiotherapy was employed as the primary therapy in two patients; both experienced recurrence. Complete excision is the only effective treatment for desmoid tumors of the head and neck, resulting in a disease-free state in 75 percent of the patients (87 percent after reexcision). Involvement of the brachial plexus was the chief factor precluding complete excision. Radiotherapy was of very little value.

Delayed treatment with dextromethorphan and dextrorphan reduces cerebral damage after transient focal ischemia

The N-methyl-D-aspartate (NMDA) antagonists dextromethorphan (DM) and dextrorphan (DX) were found to reduce significantly neocortical severe ischemic neuronal damage (SIND) when administered in a delayed fashion after the ischemic insult. Rabbits underwent occlusion of the left internal carotid artery and anterior cerebral artery for 1 h, followed by 4 h of reperfusion. Immediately after the completion of the 1 h arterial occlusion, animals were blindly treated intravenously with 20 mg/kg loading dose followed by 10 mg/kg/h of DM, 15 mg/kg loading dose followed by 15 mg/kg/h of DX, or an equivalent volume of normal saline (NS) alone. The area of neocortical SIND was 3.7% in the DM group, 4.4% in the DX group, and 41.3% in the normal saline controls. These drugs may have considerable therapeutic potential in clinical stroke.

Comparative study of brain abscess by computed tomography and magnetic resonance imaging: report of two cases

Two cases of cerebral abscess with different presentations are reported. The source of the abscess remained obscure in one case while in the other arose from infection of the right frontal sinus. While in one case a magnetic resonance image was obtained preoperatively, both cases underwent parallel monitoring in the postsurgery period by computed tomography and magnetic resonance imaging. The relative merits of these two imaging techniques in the diagnosis and monitoring of such lesions are discussed, and the literature is reviewed.

Diagnosis of chronic subdural haematoma: the advantages of MR imaging compared with the CT-scan

Two cases of chronic subdural haematoma are reported. Both highlight the difficulties associated with the diagnosis of such collections in the isodense phase on Computed Tomography. Magnetic Resonance Imaging proved its higher discriminating power by delineating the haematomas in both cases. The respective values of these two imaging techniques are discussed with a review of the current literature.

Metastatic carcinoid tumour of the CNS from two different primary sites

Two cases of carcinoid tumour affecting the central nervous system through their metastases were treated surgically. The first case was carcinoid tumour of the lung with a single metastases in the right frontal lobe of the brain, while the second developed metastases of the sixth thoracic vertebra from a terminal ileum bowel primary causing spinal cord compression. Neither case developed carcinoid syndrome. The rarity of such metastases affecting the central nervous system is discussed together with a review of the literature.

Spinal cord astrocytoma with intracranial spread: detection by magnetic resonance imaging

An astrocytoma of the thoracic spinal cord in a 9-year-old boy was treated by partial tumour removal and postoperative radiotherapy. The development of intracranial spread causing cranial nerve signs and diabetes insipidus was detectable only by Magnetic Resonance Imaging. The spread of these tumours and difficulties in diagnosis are discussed together with a review of the current literature.

Metoclopramide in the treatment of gastric bezoars

The effect of metoclopramide as an adjunct to the conventional treatment of gastric bezoars was studied. All patients received conventional endoscopic treatment which consisted of mechanical fragmentation and the instillation of papain solution. Fifteen patients received only endoscopic treatment while nine patients were given, in addition, metoclopramide 10 mg orally before meals and at bedtime. The conventionally treated group required a mean of 1.9 courses of endoscopic treatments, while the metoclopramide treated group required a mean of 1.2 courses to resolve the bezoar. This difference was statistically significant. It was also found that long-term metoclopramide treatment reduced the frequency of bezoar formation in four patients with recurrent gastric bezoars.

GODDESS: A Goal-Directed Decision Structuring System

This paper describes an operational version of a computerized, domain-independent, decision support system which is based on a novel, goal-directed structure for representing decision problems. The structure allows the user to state relations among aspects, effects, conditions, and goals, in addition to actions and states which are the basic components of the traditional decision tree approach. The program interacts with the user in a stylized English-like dialogue, starting with the stated objectives and proceeding to unravel the more detailed means by which these objectives can be realized. At any point in time, the program focuses the user's attention on the issues which are most crucial to the problem at hand. The structure used is more compatible with the way people encode knowledge about problems and actions, and therefore promises to offer the following advantages: 1) judgments and beliefs issued by the user constitute a more valid representation of the user's experience; and 2) the user may be guided toward the discovery of action alternatives he otherwise would not have identified.