Safety and efficacy of percutaneous transabdominal and transesophageal decompression gastric catheters for palliation of malignant bowel obstruction

PURPOSE

To evaluate the safety and primary technical success rate of gastric decompression via percutaneous transabdominal gastrostomy (PTAG) or percutaneous transesophageal gastric (PTEG) catheter placement for management of malignant bowel obstruction (MBO). A secondary purpose was to evaluate the safety and success rate for PTAG catheter placement in patients with both MBO and ascites.

METHODS

A single-institution retrospective review of 385 patients who underwent attempted decompression gastric catheter placement from March 2013 to August 2018 was performed. Medical records and imaging studies were reviewed. A subgroup of patients with concomitant MBO and ascites were identified. The primary outcome measures were procedural technical success and procedural complications.

RESULTS

394 decompression gastrostomy catheters were attempted from 2013 to 2018, n = 353 PTAG and n = 41 PTEG. The success rate was 95.5% (n = 337 of 353) for PTAG and 97.6% (n = 40 of 41) for PTEG. There were 63 total complications involving 47 (13.9%) patients following PTAG and 13 total complications involving 9 (22.5%) patients following PTEG, P = 0.16. For the subgroup of patients with MBO and ascites, the success rate was 94.8% (n = 182 of 192 patients), and there were 20 complications involving 17 (12.9%) of 132 patients.

CONCLUSION

Gastric decompression for patients with MBO via PTAG or PTEG catheter placement is associated with high success rates and low complications.

Physician Burnout: The Hidden Health Care Crisis

Physician burnout is an under-recognized and under-reported problem. Characterized by a state of mental exhaustion, depersonalization, and a decreased sense of personal accomplishment, burnout may affect more than 60% of family practice providers and at least one third of gastroenterologists. Some studies have shown that younger physicians, physicians performing high-risk procedures, and physicians experiencing work-life conflicts are at greatest risk. If unrecognized, the costs to the physician and to the health care system can be enormous because physician burnout is associated with increased rates of depression, alcohol and drug abuse, divorce, suicide, medical errors, difficult relationships with coworkers, and patient dissatisfaction, as well as physician attrition. If properly recognized, appropriate treatments are available. This article presents a case study of a physician suffering from burnout, reviews how burnout is defined, identifies those providers at greatest risk, discusses root causes, and outlines a treatment program.

Comparative effectiveness of i-SCAN™ and high-definition white light characterizing small colonic polyps

AIM: To evaluate accuracy of in vivo diagnosis of adenomatous vs non-adenomatous polyps using i-SCAN digital chromoendoscopy compared with high-definition white light.

METHODS: This is a single-center comparative effectiveness pilot study. Polyps (n = 103) from 75 average-risk adult outpatients undergoing screening or surveillance colonoscopy between December 1, 2010 and April 1, 2011 were evaluated by two participating endoscopists in an academic outpatient endoscopy center. Polyps were evaluated both with high-definition white light and with i-SCAN to make an in vivo prediction of adenomatous vs non-adenomatous pathology. We determined diagnostic characteristics of i-SCAN and high-definition white light, including sensitivity, specificity, and accuracy, with regards to identifying adenomatous vs non-adenomatous polyps. Histopathologic diagnosis was the gold standard comparison.

RESULTS: One hundred and three small polyps, detected from forty-three patients, were included in the analysis. The average size of the polyps evaluated in the analysis was 3.7 mm (SD 1.3 mm, range 2 mm to 8 mm). Formal histopathology revealed that 54/103 (52.4%) were adenomas, 26/103 (25.2%) were hyperplastic, and 23/103 (22.3%) were other diagnoses include “lymphoid aggregates”, “non-specific colitis,” and “no pathologic diagnosis.” Overall, the combined accuracy of endoscopists for predicting adenomas was identical between i-SCAN (71.8%, 95%CI: 62.1%-80.3%) and high-definition white light (71.8%, 95%CI: 62.1%-80.3%). However, the accuracy of each endoscopist differed substantially, where endoscopist A demonstrated 63.0% overall accuracy (95%CI: 50.9%-74.0%) as compared with endoscopist B demonstrating 93.3% overall accuracy (95%CI: 77.9%-99.2%), irrespective of imaging modality. Neither endoscopist demonstrated a significant learning effect with i-SCAN during the study. Though endoscopist A increased accuracy using i-SCAN from 59% (95%CI: 42.1%-74.4%) in the first half to 67.6% (95%CI: 49.5%-82.6%) in the second half, and endoscopist B decreased accuracy using i-SCAN from 100% (95%CI: 80.5%-100.0%) in the first half to 84.6% (95%CI: 54.6%-98.1%) in the second half, neither of these differences were statistically significant.

CONCLUSION: i-SCAN and high-definition white light had similar efficacy predicting polyp histology. Endoscopist training likely plays a critical role in diagnostic test characteristics and deserves further study.

Day/night variations of high-molecular-weight adiponectin and lipocalin-2 in healthy men studied under fed and fasted conditions

AIMS/HYPOTHESIS

Adiponectin and lipocalin-2 are adipocyte-derived plasma proteins that have been proposed to have opposite effects on insulin sensitivity. Given the epidemiological, physiological and molecular links between sleep, the circadian timing system and glucose metabolism, the aim of this study was to assess effects of the sleep/wake cycle and the fasting/feeding cycle on high-molecular-weight adiponectin (HMW-adiponectin; the biologically active form) and lipocalin-2. We also aimed to compare the 24 h rhythms in the levels of these proteins with those of cortisol, leptin, leptin-binding protein and total adiponectin.

METHODS

Lean men underwent a 3 day in-laboratory study, either in the fed state (n = 8, age: 20.9 ± 2.1 years, BMI: 22.8 ± 2.3 kg/m²) or fasting state (3 day fast, n = 4, age: 25.3 ± 3.9 years, BMI: 23.3 ± 2.2 kg/m²). The sleep episode was scheduled in darkness from 23:00 to 07:00 hours. Blood was sampled every 15 min for 24 h on the third day of each study.

RESULTS

While fed, HMW-adiponectin and lipocalin-2 had large daily rhythms with troughs at night (HMW-adiponectin: ~04:00 hours, peak-to-trough amplitude 36%, p < 0.0001; lipocalin-2: ~04:00 hours, 40%, p < 0.0001). On the third day of fasting, the timing and relative amplitudes were unchanged (HMW-adiponectin: ~04:00 hours, 38%, p = 0.0014; lipocalin-2: ~05:00 hours, 38%, p = 0.0043).

CONCLUSIONS/INTERPRETATION

These data show that HMW-adiponectin and lipocalin-2 both have significant day/night rhythms, both with troughs at night, that these are not driven by the feeding/fasting cycle, and that it is important to report and/or standardise the time of day for such assays. Further studies are required to determine whether the daily rhythm of HMW-adiponectin levels influences the daily rhythm of insulin sensitivity.

Detection of a SERK-like gene in coconut and analysis of its expression during the formation of embryogenic callus and somatic embryos

Somatic embryogenesis involves different molecular events including differential gene expression and various signal transduction pathways. One of the genes identified in early somatic embryogenesis is S OMATIC E MBRYOGENESIS R ECEPTOR-like K INASE (SERK). Cocos nucifera (L.) is one of the most recalcitrant species for in vitro regeneration, achieved so far only through somatic embryogenesis, although just a few embryos could be obtained from a single explant. In order to increase efficiency of this process we need to understand it better. Therefore, the purpose of the present work was to determine if an ortholog of the SERK gene is present in the coconut genome, isolate it and analyze its expression during somatic embryogenesis. The results showed the occurrence of a SERK ortholog referred to as CnSERK. Predicted sequence analysis showed that CnSERK encodes a SERK protein with the domains reported in the SERK proteins in other species. These domains consist of a signal peptide, a leucine zipper domain, five LRR, the Serine-Proline-Proline domain, which is a distinctive domain of the SERK proteins, a single transmembrane domain, the kinase domain with 11 subdomains and the C terminal region. Analysis of its expression showed that it could be detected in embryogenic tissues before embryo development could be observed. In contrast it was not detected or at lower levels in non-embryogenic tissues, thus suggesting that CnSERK expression is associated with induction of somatic embryogenesis and that it could be a potential marker of cells competent to form somatic embryos in coconut tissues cultured in vitro.

Effects of moisturization on epidermal homeostasis and differentiation

Moisturizers are commonly used for routine skin care. This study assessed the effects of a moisturizer on barrier function, epidermal architecture, keratinocyte proliferation, and physiological regulation of the epidermis in photoaged but otherwise normal skin. Fifteen women with moderately photoaged forearms were treated twice a day for 4 weeks with a moisturizer containing dimethicone and glycerine. Baseline and post-treatment transepidermal water loss (TEWL) and ipsilateral forearm biopsies were obtained. Epidermal thickness, melanin levels, keratinocyte proliferation, and expression of keratins were evaluated. Induction of keratins 6 and 16, commonly associated with keratinocyte proliferation and wound healing, was observed. Epidermal thickness increased by 0.019 mm (P = 0.005), barrier function improved (TEWL decreased by 13%) and melanin intensity decreased (P = 0.004). Even nonxerotic, photoaged skin may appear younger, benefiting structurally and functionally from routine use of moisturizers containing dimethicone and glycerine.

Peptide YY levels are decreased by fasting and elevated following caloric intake but are not regulated by leptin

AIMS/HYPOTHESIS

Peptide YY (PYY) is a gut-derived hormone that has been shown to reduce short-term food intake in animals and humans. It has been proposed that deficiency of PYY contributes to obesity in humans. However, the physiology of PYY regulation by factors such as caloric restriction, or by other molecules important in energy homeostasis, e.g. leptin, remains to be fully elucidated.

MATERIALS AND METHODS

We evaluated the effect on PYY levels of: (1) caloric ingestion (a mixed meal) in five healthy normal-weight subjects; (2) fasting for 2 or 3 days in eight lean men and seven lean women respectively; and (3) recombinant human leptin administration at physiological replacement and pharmacological doses.

RESULTS

PYY levels increased 50% after a mixed meal (p=0.01), and short-term complete fasting for 2 or 3 days decreased leptin and PYY levels to 20-30% and 40-60% of baseline, respectively (both p<0.05). However, recombinant human leptin administration at physiological doses to restore the fasting-induced decrease of leptin levels and at pharmacological doses over the short term had no effect on PYY levels.

CONCLUSIONS/INTERPRETATION

PYY increases after meal ingestion and decreases after fasting in a manner consistent with a meal-related signal of energy homeostasis. Importantly, circulating levels of this gut-secreted molecule are independent of regulation by leptin over the short term. These findings contribute towards our understanding of the homeostatic systems that regulate appetite in humans, including the possible redundancy of gastrointestinally secreted and adipocyte-secreted signals. This may be of importance for the future development of medications to treat obesity.

Sleep loss reduces diurnal rhythm amplitude of leptin in healthy men

The aim of the current study was to investigate the effects of sleep loss on the diurnal rhythm of circulating leptin levels. An indwelling forearm catheter was used to sample blood at 90-min intervals for a total of 120 h, which included 88 h of sustained sleeplessness, in 10 healthy men. The diurnal amplitude of leptin was reduced during total sleep deprivation and returned toward normal during the period of recovery sleep. This finding provides evidence that sleep influences the nocturnal leptin profile, and may have implications for the understanding of the role of sleep in metabolic regulation and the aetiologies of obesity and the night eating syndrome.

The Q223R polymorphism of the leptin receptor gene is significantly associated with obesity and predicts a small percentage of body weight and body composition variability

Genetic variation at the leptin receptor gene locus may play an important role in the pathophysiology of human obesity, a leptin-resistant state. Previous studies exploring potential associations between leptin receptor gene polymorphisms and obesity have reported conflicting results. The aim of this study was to evaluate a genetically homogeneous population for associations between body composition variables and three common leptin receptor gene polymorphisms (K109R, Q223R, and K656N) that have potential functional significance as well as to assess the contributions of these polymorphisms to the variability of obesity. One hundred and eighteen consecutively enrolled subjects (62 women: mean age, 17.5 +/- 1.6 yr; body mass index range, 16.2-30.1; 56 men: mean age, 17.8 +/- 1.8 yr; body mass index range, 15.4-35.9) were genotyped for the three polymorphisms, and their body mass index, sum of 4 skinfolds, fat-free mass, percent fat mass, serum leptin levels, caloric intake, fat intake, and exercise patterns were determined. Allele frequencies were estimated by the gene-counting method, and genotype distributions between 89 normal weight (body mass index, < or =25 kg/m(2)) and 29 overweight-obese (body mass index, >25 kg/m(2)) subjects were compared using chi(2) test (using codominant, dominant, and recessive models). Analysis of covariance was also performed to evaluate associations between the polymorphisms and body composition variables after controlling for potential confounders. For the Q223R polymorphism, there was a higher prevalence of the R223 allele in the homozygous form among overweight-obese subjects vs. normal weight subjects (20.7% vs. 4.5%; P = 0.01). Furthermore, simple and multiple regression analyses revealed that the R223 allele in the homozygous form is a significant predictor of both body mass index (P = 0.015) and percent fat mass (P = 0.02) even after adjusting for age and gender and explains 4.5% of the variance in percent fat mass and 5% of the variance in body mass index. There was no significant difference in allele frequencies or genotype distributions for the K109R or K656N polymorphisms. These findings support the hypothesis that the Q223R polymorphism (but not the K109R or K656N polymorphism) of the leptin receptor gene is associated with obesity and predicts a small percentage of body weight and body composition variability in a genetically homogeneous population.

Leptin and the hypothalamic-pituitary regulation of the gonadotropin-gonadal axis

Leptin is an adipocyte-derived protein hormone which not only conveys a signal of the amount of energy stores to the central nervous system but also plays an important role in regulating neuroendocrine function. The importance of leptin in the reproductive system has been suggested by the reproductive dysfunction associated with leptin deficiency and resistance in both animal models and humans as well as the ability of leptin to accelerate the onset of reproductive function in normal mice. Transgenic mice overexpressing leptin also have accelerated puberty, and leptin administration reverses the fasting-induced suppression of sexual maturation in rodents, indicating that leptin may serve as the critical link between sufficient energy stores and proper functioning of the reproductive system. Normal women have a pulsatile release pattern of leptin that is significantly associated with the variations in luteinizing hormone (LH) and estradiol levels. In various animal models, leptin administration restores the LH pulsatility pattern which is suppressed during fasting, indicating a hypothalamic site of action since LH pulsatility is under the control of gonadotropin-releasing hormone (GnRH). In humans, leptin has been administered to a 9-year-old leptin-deficient girl, resulting in a gonadotropin secretory pattern consistent with early puberty. While in vitro experiments with hypothalamic explants and a GnRH-secreting neuronal cell line have shown that leptin can directly stimulate GnRH secretion, the lack of leptin receptors on GnRH neurons suggests that leptin may act through other hypothalamic neuropeptides. Several neuropeptides which act as downstream effectors of leptin have been investigated, and recent studies indicate that cocaine and amphetamine-regulated transcript may be such a mediator of leptin's effect on GnRH. Leptin receptors have also been identified in human pituitaries, and leptin may influence LH release from the pituitary. However, the current evidence is conflicting, and further studies are needed in order to clarify leptin's role at the level of the pituitary. Thus, accumulating evidence suggests that leptin can regulate gonadotropin levels, and its secretion may, in turn, be influenced by GnRH or gonadal steroids but appears to be independent of LH control.

Vav3 mediates receptor protein tyrosine kinase signaling, regulates GTPase activity, modulates cell morphology, and induces cell transformation

A recently reported new member of the Vav family proteins, Vav3 has been identified as a Ros receptor protein tyrosine kinase (RPTK) interacting protein by yeast two-hybrid screening. Northern analysis shows that Vav3 has a broad tissue expression profile that is distinct from those of Vav and Vav2. Two species of Vav3 transcripts, 3.4 and 5.4 kb, were detected with a differential expression pattern in various tissues. Transient expression of Vav in 293T and NIH 3T3 cells demonstrated that ligand stimulation of several RPTKs (epidermal growth factor receptor [EGFR], Ros, insulin receptor [IR], and insulin-like growth factor I receptor [IGFR]) led to tyrosine phosphorylation of Vav3 and its association with the receptors as well as their downstream signaling molecules, including Shc, Grb2, phospholipase C (PLC-gamma), and phosphatidylinositol 3 kinase. In vitro binding assays using glutathione S-transferase-fusion polypeptides containing the GTPase-binding domains of Rok-alpha, Pak, or Ack revealed that overexpression of Vav3 in NIH 3T3 cells resulted in the activation of Rac-1 and Cdc42 whereas a deletion mutant lacking the N-terminal calponin homology and acidic region domains activated RhoA and Rac-1 but lost the ability to activate Cdc42. Vav3 induced marked membrane ruffles and microspikes in NIH 3T3 cells, while the N-terminal truncation mutants of Vav3 significantly enhanced membrane ruffle formation but had a reduced ability to induce microspikes. Activation of IR further enhanced the ability of Vav3 to induce membrane ruffles, but IGFR activation specifically promoted Vav3-mediated microspike formation. N-terminal truncation of Vav3 activated its transforming potential, as measured by focus-formation assays. We conclude that Vav3 mediates RPTK signaling and regulates GTPase activity, its native and mutant forms are able to modulate cell morphology, and it has the potential to induce cell transformation.

Differential requirements of the MAP kinase and PI3 kinase signaling pathways in Src- versus insulin and IGF-1 receptors-induced growth and transformation of rat intestinal epithelial cells

There have been few studies on the specific signaling pathways involved in the transformation of epithelial cells by oncogenic protein tyrosine kinases. Here we investigate the requirement of MAP (MAPK) and phosphatidylinositol 3- (PI3K) kinases in the transformation of rat intestinal epithelial (RIE) cells by oncogenic forms of insulin receptor (gag-IR), insulin-like growth factor-1 receptor (gag-IGFR), and v-Src. MAPK is not significantly activated in cells transformed by gag-IR and gag-IGFR but is activated in v-Src transformed cells. Treatment with PD98059, a MEK inhibitor, at concentrations where MAPK activity was reduced below the basal level showed that MAPK is partially required for the monolayer growth of parental and transformed RIE cells. However, MAPK is not essential for the focus forming ability of the three oncogene-transformed cells. It is also not necessary for the colony forming ability of gag-IR- and gag-IGFR-, but is partially required for v-Src-transformed cells. PI3K is significantly activated in all three oncogene transformed RIE cells. LY294002, a PI3K inhibitor, potently inhibited monolayer growth of all three oncogene-transformed cells. However, at concentrations of LY294002 where activated forms of Akt, a downstream component of the PI3K pathway, were undetectable, colony and focus forming abilities of the v-Src-RIE cells were only slightly affected whereas those of gag-IR/IGFR-RIE cells were greatly inhibited. These results were confirmed using a different pharmacological inhibitor, wortmannin, and a dominant negative form of PI3K, Ap85. Similarly, rapamycin, known to inhibit p70S6 kinase, a downstream component of the PI3K-Akt pathway, also inhibited gag-IR/IGFR-induced, but not v-Src-induced, focus and colony formation. We conclude that the MAPK and PI3K signaling pathways are differentially required for transformation of RIE cells by oncogenic IR and IGFR versus Src and the pattern of requirements is different from that of fibroblast transformation.

Anatomical correlates of alien hand syndromes

OBJECTIVE

The objective of this study was to correlate various alien hand syndromes (AHS) with sites of lesion in 16 patients with anterior cerebral artery (ACA) territory infarction.

BACKGROUND

All previous reports of AHS were case studies. Their clinico-anatomic correlations were still controversial. While the callosal lesion appears necessary for various types of AHS, which portion of the corpus callosum is associated with which syndrome is still not yet completely resolved.

METHOD

Sixteen patients with ACA territory infarction were selected from a stroke registry containing 7355 individuals. They were divided into three lesion groups according to location identified by computed tomography or magnetic resonance imaging: mesial frontal, callosal and combined mesial frontal and callosal. Neurobehavioral examination focused on the presence or absence of grasp reflex, various alien hand signs, intermanual conflict, and callosal disconnection syndrome. By gross visual analysis of the obtained data, a trend for clinicoanatomic correlation emerged.

RESULTS

Patients with restricted mesial frontal lesions (three subjects), restricted anterior callosal lesions (four subjects) or "restricted" mesial frontal and anterior callosal lesions (two subjects) did not have symptoms of AHS. The remaining seven patients with extensive callosal injury involving the midbody and isthmus all had symptoms of AHS. Four of the patients with relatively isolated callosal involvement showed intermanual conflict (IMC) associated with a callosal AHS, while the remaining three patients with additional lesions involving the mesial frontal cortex showed impulsive reaching and grasping behaviors of the contralesional hand (a component of frontal AHS) and IMC (a component of callosal AHS).

CONCLUSIONS

A comparison of the lesions and symptoms of seven patients in two different groups shows that mesial frontal and anterior callosal (genu and rostral body) lesions are associated with a contralateral frontal AHS. Isolated involvement of the callosal midbody and isthmus is associated with a callosal AHS. When the mesial frontal cortex and corpus callosum (genu and whole body) are extensively involved, a mixed frontal and callosal AHS may occur in the same patient.

Cancer risk in collagenous colitis

Collagenous colitis is a recently described form of chronic inflammatory bowel disease. Other inflammatory bowel disorders are associated with increased risk of colorectal and extracolonic malignancies, but this has not been evaluated in collagenous colitis. Colorectal and extracolonic malignancies were identified in 117 patients with collagenous colitis from the Johns Hopkins Registry. The incidence rates of identified tumors, overall incidence rate of tumors, and overall mortality were then compared with general population through person year analysis with adjustment for population. No cases of colorectal cancer were found in collagenous colitis patients during a mean follow-up period of 7.0 years (range 2-12 years) after the diagnosis of colitis. Two patients developed colorectal cancer prior to the diagnosis of colitis, but no increase in life-time relative risk of colorectal cancer was found (relative risk 0.52; 95% confidence limits 0.05-1.5). An increased relative risk of lung cancer in women (relative risk 3.7; 95% confidence limits 1.0-9.6; p = 0.048) was noted. The relative risk of overall malignancy and overall mortality was not different than the general population. In collagenous colitis patients the life-time relative risk of colorectal cancer and the relative risk after the diagnosis of colitis with a mean observation period of 7 years was not increased. An increase in relative risk of lung cancer in women with collagenous colitis argues for further investigation of the role of smoking and other factors in this disorder.

Regeneration of coconut (Cocos nucifera L.) from plumule explants through somatic embryogenesis

A protocol was developed for coconut regeneration using plumules from mature zygotic embryos as explants, and media with the synthetic growth regulators 2,4-dichlorophenoxyacetic acid and 6-benzylaminopurine. Evidence for the regeneration process from these tissues occurring through somatic embryogenesis is presented. The somatic embryos were capable of germination, subsequent development into plantlets and successful transfer to the nursery. The yields were larger, nearly twofold for calli and over tenfold for calli bearing somatic embryos, than those previously reported with inflorescence explants. The present protocol thus represents an improvement in time and yield over previous protocols. Even though plumule explants are not the ideal tissue source due to possible genetic heterogeneity, the improvements made here may be applicable to tissues from mature plants. In addition, micropropagation of coconut using plumules is potentially useful when they are obtained from fruit produced from selected parents of outstanding performance, such as those resistant to diseases.

Relationship between isokinetic concentric and eccentric contraction modes in the knee flexor and extensor muscle groups

We investigated whether in normal subjects isokinetic concentric and eccentric strength variables were related in order to have a better picture in relation to rehabilitation and possible injury prevention. We studied the relationship between isokinetic concentric and eccentric peak torque, total work, and average power of knee extension and knee flexion at 60 degrees/sec and 120 degrees/sec in 42 young Chinese adults (22 males, age = 27 +/- 6.9 years; 20 females, age = 24.9 +/- 5.05 years) using the Cybex 6000 isokinetic dynamometer. Repeated analysis of covariance was used to compare the means between concentric and eccentric variables adjusted by limb dominance, speed of testing, and the muscle groups tested. A highly significant correlation was found between all concentric and eccentric variables, with correlation coefficients (r) ranging from 0.67 to 0.93. All but two of the eccentric variables were significantly greater than the concentric variables. Concentric and eccentric knee flexion to knee extension (H:Q) ratios were poorly correlated, with r ranging from 0.359 to 0.645. Although there is an acceptably high correlation between isokinetic concentric and eccentric strength variables of knee flexion and extension in young healthy individuals, we recommend measuring concentric and eccentric strength to plan a proper rehabilitation program and to assess muscle groups in a given contraction mode.

Alien hand syndrome: influence of neglect on the clinical presentation of frontal and callosal variants

Three patients with mesial frontal and extensive callosal lesions due to anterior cerebral artery infarction manifested an alien hand syndrome (AHS) with varied features. Patient 1 with left hemispheric lesion showed right hand's impulsive reaching and grasping and left hand's antagonistic movements to the right (intermanual conflict; IMC). Patients 2 and 3 with right hemispheric lesion manifested a left hemihypokinesia which was thought to have suppressed the frequency and amplitude or even the occurrence of left hand's reaching and grasping. IMC and other left hand's non-antagonistic, irrelevant movements to the right remained. Because the term "IMC" is often misused and not strictly defined, its association with right hand's reaching and grasping is quite uncommon, its significance as a sign of callosal disconnection is not well validated, and because left hand's reaching and grasping tend to be suppressed by motor neglect, a trend may then develop for the right hand to be the sole focus of pathological behaviour in patients with the so-called frontal AHS (Feinberg, Schindler, Flanagan et al., 1992).

Mutations of Ros differentially effecting signal transduction pathways leading to cell growth versus transformation

The signaling functions of the oncogenic protein-tyrosine kinase v-Ros were studied by systematically mutating the tyrosine residues in its cytoplasmic domain. The carboxyl mutation of Tyr-564 produces the most pronounced inhibitory effect on v-Ros autophosphorylation and interaction with phospholipase Cgamma. A cluster of 3 tyrosine residues, Tyr-414, Tyr-418, and Tyr-419, within the PTK domain of v-Ros plays an important role in modulating its kinase activity. The mutant F419 and the mutant DI, deleting 6-amino acids near the catalytic loop, retain wild type protein tyrosine kinase and mitogenic activities, but have dramatically reduced oncogenicity. Both mutant proteins are able to phosphorylate or activate components in the Ras/microtubule-associated protein kinase signaling pathway. However, F419 mutant protein is unable to phosphorylate insulin receptor substrate 1 (IRS-1) or promote association of IRS-1 with phosphatidylinositol 3-kinase. This tyrosine residue in the context of the NDYY motif may define a novel recognition site for IRS-1. Both F419 and DI mutants display impaired ability to induce tyrosine phosphorylation of a series of cytoskeletal and cell-cell interacting proteins. Thus the F419 and DI mutations define v-Ros sequences important for cytoskeleton signaling, the impairment of which correlates with the reduced cell transforming ability.

Effect of dimerization on signal transduction and biological function of oncogenic Ros, insulin, and insulin-like growth factor I receptors

The avian sarcoma virus UR2 codes for an oncogenic Gag-Ros fusion protein-tyrosine kinase (PTK). We have previously derived two retroviruses, T6 and NM1, coding for oncogenic Gag-insulin receptor and Gag-insulin-like growth factor I receptor (IGFR) fusion proteins, respectively. The Gag-IGFR fusion protein dimerizes, whereas Gag-Ros does not. To identify sequences affecting dimerization and the effect of dimerization on signaling and biological functions, we generated recombinants exchanging the extracellular and transmembrane sequences among the three fusion receptors. The presence of multiple cysteines in the Gag sequence appears to preclude dimerization, since deletion of the 3' cysteine residue allows for dimerization. Most of the chimeric receptors retain high PTK activity and induce transformation regardless of their configuration on the cell surface. UT, a UR2/T6 chimera, retained mitogenic activity but has a markedly reduced transforming ability, while UN7, a UR2/NM1 recombinant, which also harbors Y950F and F951S mutations in IGFR, exhibits dramatic reductions in both activities. All of the fusion receptors can phosphorylate insulin receptor substrate 1 and activate PI 3-kinase. UT protein induces Shc phosphorylation, whereas UN7 protein does not, but both are unable to activate mitogen-activated protein kinase. Our results show that overexpressed oncogenic Gag-fusion receptors do not require dimerization for their signaling and transforming functions and that the extracellular and transmembrane sequences of a receptor PTK can affect its specific substrate interactions.

Eccentric and concentric isokinetic knee flexion and extension: a reliability study using the Cybex 6000 dynamometer

OBJECTIVE

To determine the reliability of the Cybex 6000 isokinetic dynamometer in measuring the knee muscle performance concentrically and eccentrically.

METHODS

18 male and 12 female subjects with no previous knee injuries, who had not previously undergone any isokinetic testing, were studied. The flexor and extensor muscles groups of both knees were tested at 60 degrees s-1 and 120 degrees s-1 with the continuous concentric-eccentric cycle testing protocol. Variables studied included peak torque, total work, and average power. The interclass correlation coefficient (ICC 2,1) was used to determine the reliability with P < 0.05.

RESULTS

Peak torque showed significantly greater ICC than the total work and average power, with test-retest reliability ranging from 0.82 to 0.91 for peak torque, from 0.76 to 0.89 for total work, and 0.71 to 0.88 for average power. Average variability for the three variables studied ranged from 9% to 14%. The ICCs for the three variables studied were significantly greater at 120 degrees s-1. The knee extensor muscle group showed greater test-retest reliability, and the results of isokinetic testing in the concentric contraction mode were more reproducible.

CONCLUSIONS

The Cybex 6000 isokinetic dynamometer shows high reliability in measuring isokinetic concentric and eccentric variables. Some fluctuation should be allowed when evaluating variations of muscle performance between tests.

Two chimeric receptors of epidermal growth factor receptor and c-Ros that differ in their transmembrane domains have opposite effects on cell growth

Two chimeric receptors, ER1 and ER2, were constructed. ER1 contains the extracellular and transmembrane (TM) domains derived from epidermal growth factor receptor and the cytoplasmic domain from c-Ros; ER2 is identical to ER1 except that its TM domain is derived from c-Ros. Both chimeras can be activated by epidermal growth factor and are capable of activating or phosphorylating an array of cellular signaling proteins. Both chimeras promote colony formation in soft agar with about equal efficiency. Surprisingly, ER1 inhibits while ER2 stimulates cell growth on monolayer culture. Cell cycle analysis revealed that all phases, in particular the S and G2/M phases, of the cell cycle in ER1 cells were elongated whereas G1 phase of ER2 cells was shortened threefold. Comparison of signaling pathways mediated by the two chimeras revealed several differences. Several early signaling proteins are activated or phosphorylated to a higher extent in ER1 than in ER2 cells in response to epidermal growth factor. ER1 is less efficiently internalized and remains tyrosine phosphorylated for a longer time than ER2. However, phosphorylation of the 66-kDa She protein, activation of mitogen activated protein kinase, and induction of c-fos and c-jun occur either to a lesser extent or for a shorter time in ER1 cells. Cellular protein phosphorylation patterns are also different in ER1 and ER2 cells. In particular, a 190-kDa Shc-associated protein is tyrosine phosphorylated in ER2 but not in ER1 cells. Our results indicate that the TM domains have a profound effect on the signal transduction and biological activity of those chimeric receptors. The results also imply that sustained stimulation of ER1 due to its retarded internalization apparently triggers an inhibitory response that dominantly counteracts the receptor-mediated mitogenic signals. These two chimeras, expressed at similar levels in the same cell type but having opposite effects on cell growth, provide an ideal system to study the mechanism by which a protein tyrosine kinase inhibits cell growth.

Leg manifestation in alien hand syndrome

A patient with left alien hand syndrome (AHS) accompanied by leg symptoms due to right anterior cerebral artery territory infarction is reported. Magnetic resonance imaging demonstrated that the responsible lesion involved the right anterior cingulate gyrus, supplementary motor area, medical prefrontal cortex and corpus callosum extending from the genu to the isthmus. The leg symptoms included: 1) motor perseveration manifesting as compulsive straight walking with difficulty stopping on command; 2) dissociation between mind and action resulting in going to unintended places with subsequent complaints of poor memory not due to spatial disorientation; 3) discrepancy between verbal and actual leg motor responses to auditory verbal suggestions; and 4) movement dissociation between the legs resulting in transient standing still or brief sticking to the ground, a situation simulating akinesia. As the legs usually perform together to coordinate movements of standing and walking, unlike the hands performing well-learned, skilled unimanual or bimanual coordinating movements, the counterpart in the leg of the alien hand sign in AHS was not manifested. Nevertheless, in the presence of AHS, the associated leg symptoms bear similar neurobehavioral features and should be dealt with on equal terms.

Effect of tyrosine mutations on the kinase activity and transforming potential of an oncogenic human insulin-like growth factor I receptor

The tyrosines in the cytoplasmic domain of an oncogenic human insulin-like growth factor I receptor (gag-IGFR) were systematically mutated to phenylalanines to investigate the role of those tyrosines in the enzymatic and biological function of the gag-IGFR. Our results indicate that tyrosines 1131, 1135, 1136, and 1221 are important for the receptor protein-tyrosine kinase (PTK) activity. However, mutation of Tyr-1136 only slightly affects the kinase activity but dramatically reduces the transforming ability and overall substrate phosphorylation, in particular, annexin II, which is strongly phosphorylated by the gag-IGFR but not by the Phe-1136 mutant. Single mutation of either Tyr-943 or Tyr-950 resulted in significantly reduced phosphorylation of the receptor but not on its PTK activity or transforming ability. Tyr-950 together with its surrounding sequence is involved in mediating the interaction between the gag-IGFR and insulin receptor substrate 1. Our data also suggest that Tyr-1316 is involved in phosphorylation of phospholipase C-gamma, which is, however, not important for cell transforming activity. Overall, our study has identified several tyrosine residues of IGFR important for its PTK activity and substrate interaction. The transforming potential of the gag-IGFR correlates well with its ability to phosphorylate overall cellular substrates and to activate phosphatidylinositol 3-kinase via insulin receptor substrate 1.

Carotid ultrasonographic findings in intracranial internal carotid artery occlusion

Five cases of unilateral intracranial internal carotid artery (ICA) occlusion received both carotid angiographic and ultrasonographic studies. The Doppler examination showed that the resistive index (RI) of the common carotid artery (CCA) and ICA was higher but the peak systolic velocity was lower on the diseased side as compared with the normal side. Absence of the diastolic phase was found in the CCA flow in 2 cases and in the ICA flow in 3 cases on the diseased side. The mean CCA flow volume on the diseased side (271 +/- 82 mL/min) was half or less than that on the normal side (680 +/- 86 mL/min) (P < 0.01). The flow volume of the diseased ICA (49 +/- 20 mL/min) was markedly lower than that of the normal side (344 +/- 49 mL/min) (P < 0.01) and was also less than that of the ipsilateral external carotid artery (ECA) (129 +/- 43 mL/min). The Doppler ophthalmic artery flow all showed a forward direction. The authors propose that the following extracranial carotid ultrasonographic findings may be helpful in the prediction of intracranial carotid artery occlusion: (1) diminished frequencies, increased RI, and a more than 50% reduction of flow volume in the CCA as compared with the opposite side; (2) diminished frequencies to loss of the diastolic phase, a more than 50% reduction of the flow volume, and reversed ICA/ECA flow volume in the ICA as compared with the opposite side; and (3) a forward Doppler ophthalmic artery flow.

Multiple brain abscesses as a complication of pulmonary arteriovenous fistula. A case report

A case of pulmonary arteriovenous fistula (PAVF) complicated by brain abscess is presented. The incidence of this complication has been quoted to be 1-5%. After reviewing all inpatients in Chang Gung Memorial Hospital from 1977 to 1988, we found a total of 9 cases of PAVF; only one case of PAVF complicated by brain abscess was noted. PAVF is often asymptomatic in the early stage, and its diagnosis may sometimes be quite difficult. However, untreated PAVF tends to enlarge and become symptomatic. There is also a continuing risk of severe neurologic complications. For these reasons, early diagnosis and treatment are essential. In a case of brain abscess associated with unexplained hypoxemia and extra-cardiac murmur on auscultation, PAVF should be considered.

Antemortem diagnosis of central pontine myelinolysis--report of a case

A 64-year-old hypertensive woman with hyponatremia due to acute gastroenteritis and the use of diuretics developed dysarthria, dysphagia, and quadriparesis 4 days after rapid correction of hyponatremia. The clinical course, electrodiagnosis (blink reflex) and cranial computed tomographic findings are compatible with an antemortem diagnosis of central pontine myelinolysis (CPM). CPM can be prevented by cautious correction of hyponatremia. Spontaneous recovery in this case contrasts sharply to the poor outcome in previously reported cases of CPM.

Left-handed mirror writing following right anterior cerebral artery infarction: evidence for nonmirror transformation of motor programs by right supplementary motor area

A patient with acquired, pathologic left-handed mirror writing and mirror movements during bimanual coordination is reported. CT demonstrated an ischemic infarction involving the right supplementary motor area, medial prefrontal cortex, and anterior cingulate gyrus with nearly total sparing of the corpus callosum. This case, together with recent experimental findings in monkeys, supports the hypothesis that the supplementary motor area may be responsible for nonmirror transformation of motor programs originating in the left hemisphere prior to execution by the primary motor area in the right hemisphere.

Aprosodia in Chinese patients with right cerebral hemisphere lesions

Recent publications, all involving native speakers of English, have established that lesions in the right cerebral hemisphere produce a deficit in the comprehension and execution of tonal change in language related to the affective component of prosody. We tested 12 Chinese patients with right-hemisphere lesions and seven controls for comprehension, discrimination, repetition, and expression of prosody and gesture. In 11 of the 12 patients, aprosodia was identified. The subjects were also tested for their ability to detect semantic tonal difference in Chinese. Only five of the 12 showed a mild deficit in this task, suggesting that the left cerebral hemisphere is more dominant for comprehension of tone essential to word meaning.

Equidensitometry by coherent optical filtering

A new and simple method has been developed for fabrication of multilevel halftone screens that have proved useful for generation of equidensity contours by means of coherent optical filtering. Up to ten contours of constant brightness have been generated on a picture by coherent optical filtering of a single halftone copy of that picture. The possible application of this method to optical analog-to-digital conversion using a single halftone photograph is discussed.

Selective material x-ray imaging using spatial frequency multiplexing

A method is presented of encoding the transmission at specific regions of the x-ray energy spectrum onto a radiograph. A grating structure is placed in the x-ray beam that consists of alternate strips of material having different x-ray transmission spectra. The average spectral transmission of the two strips produces an image comparable to a conventional radiograph. The difference between the two transmission spectra produces an amplitude modulation of the grating pattern on the radiograph. When this grating pattern is decoded, through optical or scanning methods, it represents the transmission at the specific x-ray difference spectrum.