Monogenic conditions and central nervous system anomalies: A prospective study, systematic review and meta-analysis

OBJECTIVES

Determine the incremental diagnostic yield of prenatal exome sequencing (pES) over chromosome microarray (CMA) or G-banding karyotype in fetuses with central nervous system (CNS) abnormalities.

METHODS

Data were collected via electronic searches from January 2010 to April 2022 in MEDLINE, Cochrane, Web of Science and EMBASE. The NHS England prenatal exome cohort was also included. Incremental yield was calculated as a pooled value using a random-effects model.

RESULTS

Thirty studies were included (n = 1583 cases). The incremental yield with pES for any CNS anomaly was 32% [95%CI 27%-36%; I2 = 72%]. Subgroup analysis revealed apparent incremental yields in; (a) isolated CNS anomalies; 27% [95%CI 19%-34%; I2 = 74%]; (b) single CNS anomaly; 16% [95% CI 10%-23%; I2 = 41%]; (c) more than one CNS anomaly; 31% [95% Cl 21%-40%; I2 = 56%]; and (d) the anatomical subtype with the most optimal yield was Type 1 malformation of cortical development, related to abnormal cell proliferation or apoptosis, incorporating microcephalies, megalencephalies and dysplasia; 40% (22%-57%; I2 = 68%). The commonest syndromes in isolated cases were Lissencephaly 3 and X-linked hydrocephalus.

CONCLUSIONS

Prenatal exome sequencing provides a high incremental diagnostic yield in fetuses with CNS abnormalities with optimal yields in cases with multiple CNS anomalies, particularly those affecting the midline, posterior fossa and cortex.

Muscle spasms as presenting feature of Nivelon-Nivelon-Mabile syndrome

Hedgehog acyltransferase gene (HHAT)-associated Nivelon-Nivelon-Mabile syndrome (NNMS) is a rare genetic disorder of multiple system involvement with microcephaly, central nervous system malformations, skeletal dysplasia, and 46,XY sex reversal. Other variable and inconsistent features reported in this disorder are muscle spasms, facial dysmorphism, prenatal onset growth restriction, microphthalmia, and holoprosencephaly. This is the sixth postnatal reported patient with biallelic variants in HHAT gene, who presented with microcephaly, short stature, muscle hypertrophy, muscle spasms, and facial dysmorphism. The most prominent and presenting finding in this patient were muscle hypertrophy and muscle spasms which had a clinical response to phenytoin and acetazolamide treatment. Our report emphasizes the phenotypic variability of NNMS and further reiterates muscle spasms as an important clinical manifestation of this extremely rare condition.

Recurrent Vein of Galen Aneurysmal Malformation as a Presentation of Hereditary Hemorrhagic Telangiectasia

Introduction

Vein of Galen malformation (VGM) results from an aneurysmal aberration with an arteriovenous shunting of blood and is the most frequent arteriovenous malformation in infants and fetuses. The congenital malformation develops during weeks 6-11 of fetal development. Infants often die from high-output congestive heart failure. VGM is mostly considered as a sporadic condition with minimal recurrence risk in subsequent pregnancies. Mendelian forms of VGM have rarely been described as infrequent phenotypic presentations of 2 disorders: capillary malformation-arteriovenous malformation syndrome (RASA1, EPHB4) and hereditary hemorrhagic telangiectasia (ENG, ACVRL1, and SMAD4), both showing autosomal dominant inheritance.

Case Presentation

Here, we report on a consanguineous couple with recurrent VGM in 2 pregnancies. Both partners were found to be affected by hereditary hemorrhagic telangiectasia due to a known pathogenic heterozygous c.790G>A (p.Asp264Asn) variant in ENG. Fetal DNA was unavailable, however in view of the mild phenotype in the couple, along with the severe prenatal presentation in 2 pregnancies, the fetus was presumed to be homozygous for the ENG variant. A subsequent pregnancy revealed a fetus heterozygous for the variant, which had an uneventful perinatal course.

Conclusion

This report highlights a severe perinatal lethal phenotype due to biallelic variants in a gene hitherto known to cause an autosomal dominant disorder.

Prenatal phenotype of FBXL4-associated encephalomyopathic mitochondrial DNA depletion syndrome-13

FBXL4 -associated encephalomyopathic mitochondrial DNA depletion syndrome-13 (MTDPS13) is a rare genetic disorder characterized by early neonatal onset of encephalopathy, seizures, lactic acidosis, hypotonia, dysmorphism, and severe global developmental delay. Prenatal phenotype of molecularly confirmed MTDPS13 has not been well studied. This is the case report of a non-consanguineously conceived fetus ascertained first at 20 weeks of gestation with multiple soft markers. Follow-up fetal ultrasonogram at 26 weeks revealed periventricular cysts, periventricular echogenicity, ventriculomegaly, thin corpus callosum, mega cisterna magna, and large cavum. Fetal MRI confirmed these findings. Postnatally, the baby had clinical and biochemical findings indicative of a mitochondriopathy and died on neonatal day 3. Whole exome sequencing on stored amniotic fluid DNA confirmed the diagnosis of encephalomyopathic mitochondrial DNA depletion syndrome-13 (MTDPS13). This report presents the prenatal phenotype of this rare mitochondriopathy, which has been recognized primarily in postnatal patients. The brain imaging findings in the reported fetus indicate that MTDPS13 is associated with progressive neurological involvement and brain tissue destructive changes starting as early as the second trimester of pregnancy. The case also raises concerns regarding the association of so-called soft markers, which were the only initial finding in this case, with severe monogenic diseases.

Fetal phenotypes of Mendelian disorders: A descriptive study from India

OBJECTIVE

Exome sequencing(ES) based diagnosis of Mendelian diseases in the fetus is limited by paucity of phenotypic information. This study reports the comprehensive phenotypes of some fetuses with Mendelian disorders.

METHODS

Next generation technology based sequencing of all coding regions of the genome(Exome sequencing) or targeted gene sequencing using Sanger or next generation platforms was performed in a cohort of deeply phenotyped, cytogenetically normal fetuses with morphological defects. Prenatal ultrasonographic phenotypes and Postmortem details including dysmorphology, histopathology, radiography were ascertained. Novel candidate genes, novel/ unusual findings and unusual genotypes in cases with confirmed Mendelian disorders are described.

RESULTS

Of the 102 fetuses sequenced, 45 (44%) achieved definitive diagnosis of a Mendelian disorder with 50 pathogenic/likely pathogenic variants. The majority (87%) were autosomal recessive, 69% families were consanguineous and 54% variants were novel. Dysmorphic syndromes, skeletal dysplasias and metabolic disorders were the commonest disease categories, ciliopathies and dystroglycanopathies commonest molecular categories. We describe the first fetal description of six monogenic diseases, and nine cases with novel histological findings. Nineteen cases had novel/ unusual findings.

CONCLUSION

This cohort demonstrates how deep fetal phenotypes of some Mendelian disorders can show novel/unusual findings which have important implications for prenatal diagnosis of these conditions. This article is protected by copyright. All rights reserved.

Clinical and Surgical Insights on Bilateral Total Knee Arthroplasty in Ochronotic Arthropathy: A Case-based Review

Introduction

Ochronotic arthropathy (OcA) is a consequence of alkaptonuria, a rare systemic-inherited metabolic disorder leading to accumulation of homogentisic acid in articular cartilage and subsequent early degeneration of the joints. Only few cases of OcA managed with bilateral total knee arthroplasty (TKA) has been described in the literature so far. We aim to discuss surgical pearls, pitfalls, and clinical outcome of OcA of knees managed with simultaneous bilateral TKA.

Case Presentation

The patient was a 52-year-old female presented to outpatient facility with severe bilateral knee pain and difficult ambulation. After clinical and radiological diagnosis of osteoarthritis, she was posted for bilateral TKA. During arthrotomy, blackening of articular cartilage, quadriceps and patellar tendon, and synovium was noted. Subchondral bone was free of pigmentation though, seemed osteopenic while taking bone cuts. Right knee was implanted with cruciate retaining components with ultracongruent insert; while on the left side, posterior stabilized components were used. Diagnosis of ochronosis was made retrospectively with characteristic subtle pigmentation of nails, palms, pinnae, and urine homogentisic levels. Two years follow-up of the patient remained satisfactory without any major complications.

Conclusion

OcA may present with intra-operative surprise to the surgeon if not anticipated preoperatively. Simultaneous bilateral TKA is safe and effective treatment for end-stage arthritis. However, it is difficult to diagnose it preoperatively; a high clinical suspicion leads to meticulous assessment and counseling regarding potential anesthetic concerns, choice of implant, and possible intra-operative and post-operative complications reported sporadically though.

Altered expressions of circulating microRNAs 122 and 192 during antitubercular drug induced liver injury indicating their role as potential biomarkers

Drug induced liver toxicity is a serious health complication leading to high mortality rates and post marketing withdrawal of drugs. Although considered to be the gold standard biomarkers; aspartate aminotransferase, alanine aminotransferase, total bilirubin and alkaline phosphatase have been found to have specificities beyond liver, therefore more specific and predictive markers for the detection of antitubercular drug mediated liver damage are required. Unfortunately, the effectiveness of currently used first line antitubercular drugs namely isoniazid, rifampicin, pyrazinamide is often accompanied with liver injury, impeding the cure of patients. Keeping in view, the prognostic and diagnostic applications of microRNAs in various diseases, we tried to assess the importance of microRNAs 122 and 192 in antitubercular drug associated liver injuries. The study included subjects having tuberculosis of any type with antitubercular drug induced liver injury; naïve or newly diagnosed tuberculosis patients, tuberculosis patients on drugs not having toxicity and healthy controls. Observations from this study revealed that expression levels of miR-122 and miR-192 were significantly decreased in the serum of antitubercular drug induced liver injury patients only. Therefore, these microRNAs or the pathways associated with them can be used as a tool to predict or cure antitubercular drug associated liver injury in future.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Cross-country transport and isolation and identification of Streptococcus pneumoniae by use of alternate sources of blood supplemented media among laboratories in India

Background

The isolation of S. pneumoniae (Sp) depends on specimen integrity / transport, media and expertise. The non-availability of sheep blood agar poses a challenge in identification of colonial morphology and identification in India.

Methods

Laboratories processed swabs containing either pure Sp or Sp in mixed cultures with a second (confounding) bacterium shipped across the country in cold conditions. Duplicate set of swabs was shipped back to the central laboratory to assess the impact of shipping on culture viability. The identical swab was cultured on sheep, human blood and one additional agar plate used in the laboratory.

Results

46/60(77%) of cultures containing only Sp were correctly identified. In specimens where Sp was present in mixed culture, the proportion of isolates in which Sp was correctly identified varied, with most variability attributed to the particular confounding organism rather than the media. There was no discernible impact of temperature-controlled (4-6°C) transport on the isolation of Sp from culture swabs.

Conclusions

The study clearly elucidates the ability of laboratories for isolation of S. pneumoniae on human blood agar in resource limited settings. The results highlight the difficulties inherent in correctly identifying pathogens in mixed cultures in needs improvement using standardized tests across the study centers. The study also reaffirms the ability to transport biological specimens over long geographical distances without loss.

34 PRODUCTION OF TRANSGENIC CLONED BUFFALO EMBRYOS CONTAINING OVEREXPRESSED STEAROYL Co-A DESATURASE GENE FOLLOWING EFFICIENT TRANSFECTION

Stearoyl-CoA desaturase (SCD) is a rate-limiting enzyme that catalyses the synthesis of monounsaturated fatty acids and polyunsaturated fatty acids from saturated fatty acids, which are components of triglycerides, wax esters, cholesteryl esters, and membrane phospholipids. Alterations in phospholipid composition have been implicated in a variety of diseases including obesity and the associated metabolic syndrome. SCD also magnifies the conjugated linoleic acid (CLA) content in milk; CLA is a natural fat element, having reputed therapeutic health values including anti-carcinogenic properties. In light of this fact, this study was designed to amplify the levels of SCD at the gene level. In order to achieve the enhanced expression of SCD gene, combination of techniques were used. The somatic cells (fetal fibroblast) culture were established from ear pinnae obtained from bovine fetus procured from the abattoir and were cultured in basal medium, comprising DMEM with 10% fetal bovine serum, 1X NEAA and 1X PS antibiotics. These isolated cultured cells were transfected with a gene construct carrying buSCD gene (pAcGFPN1-buSCD) as BLGP-buSCD-BLG3′UTR-CMVP-EGFP-SV40. The buffalo fetal fibroblast cells were transfected using 3 methods: Nucleofection, Fugene and Lipofection. The successful transfection, as confirmed by PCR and Southern hybridisation, proved Nucleofection to be more efficient in transfecting cells among the techniques used, which were further maintained and selected by Geneticin (G418). These selected transfected cells were then used for nuclear transfer. Somatic cell nuclear transfer (SCNT) has provided an efficient pathway for the production of transgenic animals. Buffalo cumulus–oocyte complexes (COCs) were collected from ovaries collected from abattoir and matured in TCM-199 supplemented with 10% FBS, 5 µg mL−1 FSH, and 1 µg mL−1 β-oestradiol for 21 h in CO2 incubator at 5% CO2 in air and 38.5°C temperature with >95% relative humidity. After 21 h, these COCs were denuded and subjected to zona removal. These zona-free oocytes were manually enucleated using microsurgical blades and 2 enucleated oocytes were fused with a transgenic cell using electro cell manipulator. Further, these reconstructed embryos were activated using calcium ionophore and cultured in IVC media thereafter for 8 days. The developmental competence rate as recorded on Day 8 was 53.26 ± 1.73%, 69.87 ± 6.24%, 62.99 ± 7.15%, 42.71 ± 5.05% and 28.00 ± 3.33% for 2-cell, 4-cell, 8–16 cell, morula, and blastocyst, respectively. When observed under fluorescence microscope, the embryos showed successful expression of GFP, which can be further used for animal production or further research analysis. In conclusion, amplified SCD at gene level will result in a boost to the dairy sector as well ameliorating human health due to its crucial role in anti-cancer, anti-diabetic, reduced cardio-vascular disease, and improved immune responses.

151 EFFECT OF ASCORBIC ACID ON OXIDATIVE STRESS AND ITS THERMOPROTECTANT ROLE ON IN VITRO EMBRYONIC DEVELOPMENT OF BUFFALO (BUBALUS BUBALIS) EMBRYOS

The most important factors that lead to stress in farm animals are oxidative and thermal stress, leading to reduced reproductive efficiency. Oxidative stress leads to an increase in proportion of reactive oxygen species, whereas heat stress affects the physiology of animals, which lowers the conception rates of dairy cattle. In vitro culture systems have been enhanced by manipulating media with various supplements such as vitamins, growth factors, and antioxidants that have overcome these problems. Ascorbic acid has been shown to play an antioxidant role in many species such as sheep, goat, and pigs. Keeping this in mind, this study was conducted to investigate the effect of supplementation of in vitro-matured (IVM) and/or in vitro-cultured (IVC) media with ascorbic acid and evaluate its antioxidant role in in vitro development of buffalo embryos. Immature oocytes were collected from visible surface follicles (2 to 8 mm in diameter) in slaughterhouse buffalo ovaries and subjected to IVM, IVF, and IVC in a humidified CO2 incubator at 38.5°C. Ascorbic acid was supplemented to IVM [TCM-199 + 10% featl bovine serum (FBS) + 1 µg mL−1 oestradiol-17β + 5 µg mL−1 pFSH + 0.81 mM sodium pyruvate + 0.68 mM l-glutamine + 50 µg mL−1 gentamicin sulfate] at 50 or 100 µM or IVC (mCR2aa + 0.6% BSA + 10% FBS+ 50 µg mL−1 gentamicin sulfate) at 50 µM or both IVM and IVC media at 50 µM. Oocytes without ascorbic acid were treated as the control group. Cleavage and blastocyst rate was improved when 50 µM (66.67 ± 2.27; 16.67 ± 1.26%) ascorbic acid was supplemented to IVM medium but no significant difference (P < 0.05) was observed at 100 µM (54.04 ± 2.20; 6.16 ± 0.37%) as compared with the control (62.77 ± 2.71; 10.67 ± 0.24%), respectively. When 50 µM ascorbic acid was supplemented in IVM, IVC, or both media, though cleavage rate (66.67 ± 2.27; 69.09 ± 3.22; 66.67 ± 2.23%) was similar in 3 groups, a significant increase was observed in blastocyst rate (16.67 ± 1.26; 20.18 ± 0.86; 28.57 ± 0.37%) when both media were supplemented, respectively. To evaluate the thermoprotectant effect, 4 groups were taken: group 1 without and group 2 with ascorbic acid supplementation, oocytes were given heat treatment at 39.5°C initially for 12 h during IVM; group 3 without and group 4 with ascorbic acid supplementation, oocytes were given heat treatment at 40.5°C initially for 12 h during IVM. No significant difference in developmental rate was observed at elevated temperature of 39.5°C or 40.5°C as compared with the control. Relative mRNA abundance of heat stress-related genes, HSP 70.1 and HSP 70.2, was nonsignificantly higher in oocytes matured at 39.5°C or 40.5°C after supplementation with ascorbic acid as compared to control. Relative mRNA abundance of BAX decreased at 50 µM and increased at 100 µM ascorbic acid compared with control, whereas BID showed similar results between control and treatment. Regarding anti-apoptotic gene expression, significantly higher expression was observed in MCL1 for 50 µM and lower for 100 µM ascorbic acid, and a similar nonsignificant trend was observed for BCL-XL. Developmental genes GDF9 and BMP15 showed a nonsignificant increase in 50 µM, and a nonsignificant decrease in the 100 µM supplemented group as compared with the control. Oxidative stress-related genes SOD and GPX showed a nonsignificant decrease in treated groups as compared to control. From above results, it was concluded that ascorbic acid had an anti-oxidant as well as thermoprotectant role in developmental competence that increased the potential for generation of large domestic animal in vitro embryos for research and applied technologies such as cloning and transgenesis.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

230 EFFECT OF DIFFERENT CONCENTRATIONS OF GLIAL CELL LINE-DERIVED NEUROTROPHIC FACTOR ON EXPRESSION OF SELF-RENEWAL RELATED GENES IN GOAT (CAPRA HIRCUS) SPERMATOGONIAL STEM CELLS

Glial cell line-derived neurotrophic factor (GDNF), a member of the transforming growth factor-β superfamily produced by Sertoli cells, is essential for the self-renewal of spermatogonial stem cells in vivo. The present study evaluated the effects of different concentrations of GDNF (human recombinant expressed in Escherichia coli) on expression of some self-renewal related genes in spermatogonial stem cells (SSC). The SSC were isolated from prepubertal goat testes (3–6 months of age) by using double enzymatic digestion method and filtration through 80- and 60-µm nylon mesh filters. Further enrichment was achieved by differential plating on Datura stramonium agglutinin (DSA) lectin-coated dishes and Percoll density gradient centrifugation. The enriched cells were cultured on goat Sertoli cell feeder layer in DMEM + 10% fetal bovine serum at 37°C in a 5% CO2 incubator. Primary SSC colonies were formed within 7 to 10 days. These colonies were characterised through alkaline phosphatase and immunofluorescence staining on Day 10 for different SSC-specific protein markers. Colonies were found to be positive for DBA, THY1, PLZF, UCHL1, OCT-4, SOX2, and NANOG, and negative for c-Kit expression. These colonies were cultured for 15 days without or with supplementation of GDNF forming following groups: (1) without GDNF (control), (2) 10 ng mL–1 GDNF, (3) 20 ng mL–1 GDNF, and (4) 40 ng mL–1 GDNF. RNA was isolated from 100 colonies from 3 different trials on Day 15 of culture, and relative expression of different self-renewal related genes was determined by qRT-PCR. Relative mRNA abundance of PLZF was higher (P < 0.05) following supplementation with 40 ng mL–1 GDNF than in other groups (i.e. control, 10 and 20 ng mL–1 GDNF). Expression of BCL6B and ID4 was found to be significantly higher (P < 0.05) after supplementation of GDNF at all concentrations compared with the control group. Expression of UCHL1 was higher with addition of 20 and 40 ng mL–1 GDNF (P < 0.05), whereas expression of THY1 was higher with supplementation of 10 ng mL–1 GDNF (P < 0.05). In conclusion, GDNF was found to benefit expression of goat SSC candidate genes at a concentration of 40 ng mL–1.

Effect of physiologically relevant heat shock on development, apoptosis and expression of some genes in buffalo (Bubalus bubalis) embryos produced in vitro

For investigating the effects of physiologically relevant heat shock, buffalo oocytes/embryos were cultured at 38.5°C (control) or were exposed to 39.5°C (Group II) or 40.5°C (Group III) for 2 h once every day throughout in vitro maturation (IVM), fertilization (IVF) and culture (IVC). Percentage of oocytes that developed to 8-cell, 16-cell or blastocyst stage was lower (p < 0.05) and the number of apoptotic nuclei was higher (p < 0.05) for Group III > Group II > controls. At both 8-16-cell and blastocyst stages, relative mRNA abundance of stress-related genes HSP 70.1 and HSP 70.2 and pro-apoptotic genes CASPASE-3, BID and BAX was higher (p < 0.05) in Groups III and II than that in controls with the exception of stress-related gene HSF1. Expression level of anti-apoptotic genes BCL-XL and MCL-1 was also higher (p < 0.05) in Groups III and II than that in controls at both 8-16-cell and blastocyst stages. Among the genes related to embryonic development, at 8-16-cell stage, the expression level of GDF9 was higher (p < 0.05) in Group III than that in controls, whereas that of GLUT1, ZAR1 and BMP15 was not significantly different among the three groups. At the blastocyst stage, relative mRNA abundance of GLUT1 and GDF9 was higher (p < 0.05) in Group II than that in controls, whereas that of ZAR-1 and BMP15 was not affected. The results of this study demonstrate that exposure of buffalo oocytes and embryos to elevated temperatures for duration of time that is physiologically relevant severely compromises their developmental competence, increases apoptosis and affects stress-, apoptosis- and development-related genes.

Impact of a multidimensional infection control strategy on central line-associated bloodstream infection rates in pediatric intensive care units of five developing countries: findings of the International Nosocomial Infection Control Consortium (INICC)

PURPOSE

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control strategy including a practice bundle to reduce the rates of central line-associated bloodstream infection (CLAB) in patients hospitalized in pediatric intensive care units (PICUs) of hospitals, which are members of the INICC, from nine cities of five developing countries: Colombia, India, Mexico, Philippines, and Turkey.

METHODS

CLAB rates were determined by means of a prospective surveillance study conducted on 1,986 patients hospitalized in nine PICUs, over a period of 12,774 bed-days. The study was divided into two phases. During Phase 1 (baseline period), active surveillance was performed without the implementation of the multi-faceted approach. CLAB rates obtained in Phase 1 were compared with CLAB rates obtained in Phase 2 (intervention period), after implementation of the INICC multidimensional infection control program.

RESULTS

During Phase 1, 1,029 central line (CL) days were recorded, and during Phase 2, after implementing the CL care bundle and interventions, we recorded 3,861 CL days. The CLAB rate was 10.7 per 1,000 CL days in Phase 1, and in Phase 2, the CLAB rate decreased to 5.2 per 1,000 CL days (relative risk [RR] 0.48, 95% confidence interval [CI] 0.29-0.94, P = 0.02), showing a reduction of 52% in the CLAB rate.

CONCLUSIONS

This study shows that the implementation of a multidimensional infection control strategy was associated with a significant reduction in the CLAB rates in the PICUs of developing countries.

A simple assay to study social behavior in Drosophila: measurement of social space within a group

We have established a new simple behavioral paradigm in Drosophila melanogaster to determine how genes and the environment influence the behavior of flies within a social group. Specifically, we measure social space as the distance between two flies. The majority of Canton-s flies, regardless of their gender, are within two body lengths from each other. Their social experience affects this behavior, with social isolation reducing and mating enhancing social space respectively, in both males and females. Unlike several other social behaviors in the fly, including the formation of social groups themselves (a well-described behavior), social space does not require the perception of the previously identified aggregation pheromone cis-vaccenyl acetate. Conversely, performance of the assay in darkness or mutations in the eye pigmentation gene white increased social space. Our results establish a new assay for the genetic dissection of a fundamental mode of social interaction.

Comparison of dietary fat and fatty acid intake estimated by the duplicate diet collection technique and estimated dietary records

INTRODUCTION

A high saturated fatty acid intake is a well recognized risk factor for coronary heart disease development. More recently a high intake of n-6 polyunsaturated fatty acids (PUFA) in combination with a low intake of the long chain n-3 PUFA, eicosapentaenoic acid and docosahexaenoic acid has also been implicated as an important risk factor.

AIM

To compare total dietary fat and fatty acid intake measured by chemical analysis of duplicate diets with nutritional database analysis of estimated dietary records, collected over the same 3-day study period.

METHODS

Total fat was analysed using soxhlet extraction and subsequently the individual fatty acid content of the diet was determined by gas chromatography. Estimated dietary records were analysed using a nutrient database which was supplemented with a selection of dishes commonly consumed by study participants.

RESULTS

Bland & Altman statistical analysis demonstrated a lack of agreement between the two dietary assessment techniques for determining dietary fat and fatty acid intake.

CONCLUSION

The lack of agreement observed between dietary evaluation techniques may be attributed to inadequacies in either or both assessment techniques. This study highlights the difficulties that may be encountered when attempting to accurately evaluate dietary fat intake among the population.

Dietary profile of sportswomen participating in team games at state/national level

A cross sectional study was conducted toassess dietary profile of 100 Delhi based national / state level sportswomen, aged 18-25 years, participating in team games--volleyball, hockey, football and kabaddi. Mean energy intake was found to be 1471 +/- 479 Kcal. Only 24 percent of the sports women met the recommendations of 60-65 energy percent from carbohydrates and 87 percent were consuming more than 25 energy percent from fat. The mean macronutrients and micronutrient intakes of all the subjects were much lower than the recommendations. Improper food choices were also observed in majority. It becomes necessary to generate awareness among sports personnel regarding proper nutrition practices.

Plasticity of myenteric neurons

The nervous system exerts a profound influence on all digestive processes. The wall of digestive system is endowed with its own, local nervous system referred to as the enteric or intrinsic nervous system which is responsible for the modulation of the rhythmic gastrointestinal peristaltic activities along with other functions. The principal components of the enteric nervous system are two neuronal networks: myenteric and submucosal, embedded in the wall of the digestive tract and extend from esophagus to anus. The musculature of different parts of gastrointestinal tract is differently disposed to perform different functions. Thus the aim of present study was to demonstrate the presence of neurons and to quantify the number of collections of neurons, number of neurons in each collection and area of the neurons of the plexus. One cm piece from all the parts of GIT containing entire wall was taken from the same region of 5 adult cadavers of postmortem cases which were embalmed in the Department ofAnatomy, Postgraduate Institute of Medical Sciences and Research, Chandigarh and were processed for paraffin sectioning. 5 and 10 micro thick serial sections were obtained and 6th and 7th slides were stained with: Hematoxylin and Eosin and Marsland, Glees and Erikson's silver stain. The slides were photomicrographed using digital camera. The morphometrical analysis was done using Image Pro Express software. Aggregations of 1-31 neurons present in myenteric network located between longitudinal and circular muscle layers of the GIT whose size varied from 10.263-259.660 microm2. They were oval or round; multipolar, arranged in two rows and dispersed in groups in connective tissue of muscularis propria. The collections of neurons were appeared to be more numerous in appendix and ileoceacal valve.

Evaluation of liver function impairment and lipid peroxidation induced by lantana camara leaf powder administration in adult rat serum and liver

Lantana camara is a common weed and certain medicinal properties have been attributed to this plant, but most varieties of this plant are reported to be highly toxic to animals. The plant is a native of America but a few varieties are indigenous to tropical Asia and Africa. The present investigation was done to study the hepatotoxic and lipid peroxidative effects of this noxious weed on female Wistar rats. Eighty four percent (84%) increase was observed in the activity of AST in group B and 120% increase was noted in group C in serum. In, liver tissue this increase was 66% and 258%. In the case of ALT, 165% increase was observed in group B and 219% increase was observed in group C in serum. In, liver there was 46% increase in group B and 216% increase in group C in the ALT activity. Similarly, 30% and 50% increase in group B and 120% and 300% increase in group C in the activity of ALP was observed with respect to control group. The overall protein concentration was increased in serum and decreased in liver tissue. Lipid peroxidation in liver tissue was inhibited by 22% in group B and 55% in group C. Thus Lantana camara is a toxic plant which produces severe hepatotoxicity in rats, but it also prevented lipid peroxidation that may suggest that Lantana camara may be acting as antioxidant but, exactly which of its component is responsible for this activity is not known and needs future investigations.

Successful treatment of human immunodeficiency virus-related Castleman's disease with interferon-alpha

Multicentric Castleman's disease is an atypical lymphoproliferative disorder for which multiple chemotherapeutic regimens have been used without much success. Role of biological response modifiers like interferon used as a single agent is discussed in this case report.

Ileal perforation caused by cytomegalovirus infection in a critically ill adult

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract is common and is most often seen in patients with acquired immunodeficiency syndrome (AIDS), inflammatory bowel disease, or those receiving immunosuppressive therapy. CMV infection of the small bowel accounts for only 4.3% of all CMV infections of the GI tract. Isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient has died. This article reports the first case of an ileal perforation due to transfusion-associated CMV infection in a critically-injured non-AIDS patient. Immediate surgical resection and antiviral therapy led to complete recovery. The development of abdominal pain, fever, watery diarrhea, and GI bleeding in a critically ill patient should prompt the clinician to consider the diagnosis of CMV enteritis. If standard stool pathogens and Clostridium difficile toxin studies are nondiagnostic, endoscopic evaluation and CMV serology should be obtained. If CMV infection is confirmed, ganciclovir therapy should be initiated without delay. If bowel perforation occurs. prompt surgical resection is indicated. A heightened level of suspicion for CMV infection in multiply injured trauma victims and other critically ill patients, with earlier recognition of potential small bowel involvement, can hopefully decrease the incidence of bowel perforation, which is usually a fatal event.

Detection of loss of heterozygosity on chromosome 9q22.3 in microdissected sporadic basal cell carcinoma

Identification of loss of heterozygosity (LOH) at specific genetic loci in cancer cells suggests the presence of a tumor suppressor gene within the deleted region. A basal cell carcinoma (BCC) susceptibility gene, human homolog of drosophila patched (PTC), has been recently cloned and localized on chromosome 9q22.3. Mutation and deletion of this region has been reported in BCCs using frozen tumor tissue. The objective of this study was to test whether LOH of human PTC on chromosome 9q22 could be detected in archival sporadic BCCs. We studied 20 randomly selected sporadic BCCs by microdissection and polymerase chain reaction using paraffin-embedded, formalin-fixed material on glass slides. In all cases, analysis was performed with the polymorphic markers D9S53, D9S15, D9S287, and D9S303. The LOH frequencies were 30%, 42%, 56%, and 75% with D9S15, D9S287, D9S53, and D9S303, respectively. LOH at 9q22 was identified in 12 of 20 cases (60%) with at least one marker. Seven cases showed LOH with two markers, two cases with three markers, and one case showed LOH with all four markers. The results indicate that BCC LOH can be frequently identified in paraffin-embedded BCC after routine processing.

Role of insulin-like growth factor-I in esophageal mucosal healing processes

The current study examines the stimulation of healing processes and signal transduction that is mediated by insulin-like growth factor-I (IGF-I) in an ex vivo esophageal explant model when using tyrphostin inhibition of receptor tyrosine kinase. The explant model provides a 3-dimensional cellular environment of multiple interacting cells isolated from the neural and vascular supply. Tyrphostins previously characterized for their interactions with epithelial growth factor (EGF) receptor-associated protein tyrosine kinases were tested for their potential effects on IGF-I growth-promoting activity. Explants of rabbit esophagus were incubated in media with or without IGF-I. Tyrphostins 1, 23, 25, 46, 47, 51, and 63 were added. We assessed DNA synthesis by tritiated thymidine incorporation. Outgrowth from the edge of the primary mucosa of the explant was evaluated on histologic sections, and cell proliferation was confirmed with immunohistology. IGF-I increased the incorporation of tritiated thymidine by 50% to 100%. Tyrphostins 23 and 47 eliminated IGF-I-induced proliferation in a dose-dependent manner. Tyrphostins 25, 46, and 51--along with negative controls tyrphostin 1 and tyrphostin 63--were ineffective, inasmuch as IGF-I-stimulated growth remained unchanged in their presence. Proliferative activity demonstrated by PCNA staining was confined to new mucosa. Two of 5 tyrphostins originally developed as EGF receptor protein tyrosine kinase inhibitors were effective in inhibiting the actions of exogenous IGF-I. We conclude that IGF-I stimulation may play an important role in repair processes in the esophagus and that this stimulation can be inhibited by using specific tyrphostins.

Does B.C.G. vaccination prevent or postpone the occurrence of tuberculous meningitis?

The reported efficiency of B.C.G. vaccine in prevention of primary childhood or sputum positive adult tuberculosis vary widely but it is believed to offer significant protection against hematogenous forms of tuberculosis. The present hospital-based, case control study was aimed at evaluation of impact of B.C.G. vaccination on one of the hematogenous forms of tuberculosis i.e. Tuberculous meningitis (TBM). Records of cases of TBM admitted in the pediatric wards of Lok Nayak Hospital, Delhi, over one year were analyzed retrospectively for B.C.G. positivity status and age distribution. The results were compared with similar data obtained from a control group comprising of non-TBM cases in pediatric wards of same hospital, recruited on 2 days, separated by an interval of three weeks. No statistically significant difference was found in B.C.G. positivity status of cases and control groups. However, there was an obvious trend in age distribution among cases of TBM with respect to the B.C.G. status, with a significantly higher proportion of B.C.G. vaccinated children in over 5-year age group, as compared to those in under 5 year age group. The results, therefore, indicate probable effectiveness of B.C.G. against TBM only for a limited duration i.e. single B.C.G. immunization only postpones rather than prevent the occurrence of TBM.

Intestinal spirochetosis and acquired immunodeficiency syndrome: ultrastructural studies of two cases

Two cases of intestinal spirochetosis (IS) with acquired immunodeficiency syndrome are reported. In case 1, a 48-year-old homosexual black man presented with a 1-month history of alternating watery diarrhea and constipation, which dissipated following the removal of two colonic hyperplastic polyps containing IS. In case 2, a 26-year-old homosexual black man presented with a 3-month history of persistent bloody diarrhea and was found to have chronic shigellosis and IS. Pathologic findings of IS were similar in both cases. Basophilic fringes typical of IS covered the surfacing colonic epithelium and consisted of dense growths of spirochetes adherent to and oriented perpendicular to the plasma membranes of the surfacing epithelium. The spirochetes measured 3 to 5 microns in length and 0.2 micron in width, contained four to eight axial fibrils, and closely resembled Brachyspira aalborgi ultrastructurally. These cases are notable because the histopathologic changes of IS were more extensive than generally described. There was involvement of both the right colon and rectum by IS in case 2, and in both cases there was extension of the IS down into the crypts of Lieberkühn, spirochetal invasion of the colonic mucosa, and a conspicuous inflammatory response by macrophages in the underlying lamina propria.

Wedge resection for bronchogenic carcinoma in high-risk patients

At the Veterans Administration Medical Center in Washington, DC, 73 patients with bronchogenic carcinoma had pulmonary wedge resection from February 1967 to March 1988, with a 1.4% perioperative mortality and a 4.1% morbidity. Mean age of the patients was 63 years. Patients were considered poor risk with a mean Goldman index of 9 +/- 4 (class II), mean ASA physical status classification II, mean 1-second forced expiratory volume (FEV1) of 1.25 liters (42% predicted), ratio of FEV1 to forced vital capacity 30% predicted, and maximum voluntary ventilation 24% predicted. Staging of the bronchogenic carcinomas indicated 68% stage I, 15% stage II, and 17% stage III, and histology showed 41% epidermoid, 40% adenocarcinoma, 12% bronchoalveolar, 3% large cell, and 4% small cell type. For the 72 patients eligible for follow-up, data were available on 62 for a period ranging from 4 months to 15 years. Survival was 94% at 1 year, 55% at 3 years, 29% at 5 years, 5% at 10 years, and 2% at 15 years. Within 5 years, 21% of the patients had died of causes other than bronchogenic carcinoma. The rate of recurrence was 16%. Analysis by each stage of lung cancer showed local recurrence in 4% of patients with stage I disease, in 9% of those with stage II disease, and in 59% of those with stage III disease. We conclude that wedge resection provided acceptable surgical treatment in a group of high-risk surgical patients.

Advantages of handsewn over stapled bowel anastomosis

Bowel anastomoses are conventionally performed using a handsewn technique or a stapling device. Each has potential benefits and disadvantages. The most clinically significant complications of the bowel anastomosis are anastomotic leakage and stricture formation. The indices of healing and tissue cohesion were compared dynamically over time in 24 dogs randomized to undergo either a standard two-layer handsewn anastomosis or a stapled anastomosis with the Premium CEEA (United States Surgical Corporation, Norwalk, CT). Animals were sacrificed at 1, 4, 7, and 28 days postoperatively. Each anastomosis was evaluated for anastomotic index, burst pressure, collagen content, and histologic appearance. The anastomotic index was similar on postoperative day (POD) 1, 4, and 7; but on day 28 all handsewn anastomoses had larger diameters than the widest CEEA anastomosis. Burst pressure was higher in handsewn anastomoses at all intervals. Collagen content tended to be higher on POD 7 in the CEEA anastomoses. Histological evaluation showed more complete epithelialization and less inflammation in handsewn anastomoses on POD 28. The higher level of collagen in the CEEA anastomoses on POD 7 may be implicated in the tendency toward stricture formation found with this type of anastomosis. This study demonstrates that the greater speed and ease of the stapled anastomosis is offset by the greater strength, reduced tendency to stricture, and more complete healing of the handsewn anastomosis.

Ependymoma: ultrastructural studies of two cases

Several unusual ultrastructural findings in two ependymomas are reported. In case 1, a grade I ependymoma of the fourth ventricle, there were rosettes, perivascular pseudorosettes, and tumor cells having unusual intracytoplasmic vacuoles by light microscopy. Ultrastructurally, these vacuoles were frequently microrosettes as well as scattered, degenerated cytoplasmic processes of tumor cells. The lumina of some of the microrosettes were bordered by abnormally long and malformed zonulae adherentiae. In case 2, a recurrent grade III ependymoma of the third ventricle, there were rosettes and perivascular pseudorosettes as well as more cellular and anaplastic areas by light microscopy. Ultrastructurally, the cytoplasmic processes of tumor cells in perivascular pseudorosettes contained frequent dense-core vesicles and occasional parallel arrays of microtubules. These structures do not occur in normal mammalian ependymal cells but do occur in the ependymal tanycyte, a related cell that is plentiful in the walls of the third ventricle. Thus some of the tumor cells of this third ventricle ependymoma appear to have differentiated as tanycytes.

Anastomotic compression button: a new mechanical device for sutureless bowel anastomosis

The anastomotic compression button is a new mechanical device that uses three interlocking polypropylene buttons to produce a sutureless bowel anastomosis. The device is unique in that it allows application of the buttons via a device similar to the popular intraluminal stapler, but it leaves no staples or foreign body of any kind in the bowel wall. The authors compared the 25-mm anastomotic compression button with the 25-mm intraluminal stapler in the colon of dogs. After 28 days, the mucosal blood flow, burst pressure, and anastomotic indices were found to be identical between the anastomotic compression button and the stapler. The anastomotic compression button was easier to use, and microscopic examination showed less ulceration, fibrosis, and inflammation, and better re-epithelialization at the anastomotic compression button site. The anastomotic compression button appears to have the potential to be a superior method compared with stapled anastomoses in the colon.

Bismuth subsalicylate reduces peptic injury of the oesophagus in rabbits

Bismuth subsalicylate was tested in an in vivo perfused rabbit model of oesophagitis for its ability to prevent the mucosal injury caused by pepsin. Treatment efficacy was assessed under both a treatment-before-injury protocol and a treatment-after-injury protocol. Oesophageal mucosal barrier function was evaluated by measuring flux rates of H+, K+, and glucose. The degree of oesophagitis was determined by gross and microscopic examination of the mucosa by several independent observers. Results showed that under both treatment protocols, bismuth subsalicylate significantly reduced the pepsin induced disruption of the mucosal barrier, as well as the morphologic changes. Bismuth subsalicylate when given after exposure to pepsin was also found to protect against the morphologic injury in a dose dependent manner. Experiments in vitro suggested that bismuth subsalicylate inhibits the proteolytic action of pepsin by interacting with pepsin, rather than with the pepsin substrate. We conclude that bismuth subsalicylate can protect the oesophageal mucosa against peptic injury, probably through inactivation of pepsin.

Brain and liver monoamine oxidase type A and type B activity in alcoholics and controls

Monoamine oxidase activity in human postmortem brain and liver samples was measured in a group of patients with a prior history of alcoholism and compared to a control group with no prior history of alcoholism. Liver samples from patients with a prior history of alcoholism showed significantly lower monoamine oxidase activity with both phenylethylamine and serotonin as substrates. Postmortem brain samples, however, were not different in the two groups.

Human brain: aldehyde dehydrogenase activity and isozyme distribution in different areas

Three human post-mortem brains were dissected into seventeen areas and assayed for aldehyde dehydrogenase (EC 1.2.1.3) activity employing two assay systems: one at 68 microM and another at 13.6 mM propionaldehyde. The levels of activity with 68 microM propionaldehyde were significantly higher in cerebellum and putamen. The same brain areas were also examined by isoelectric focusing. By this procedure two distinct bands of aldehyde dehydrogenase activity (the cytoplasmic E1 and mitochondrial E2) could be readily visualized in cerebellum and putamen while other brain areas contained mainly the mitochondrial E2 isozyme.

Trace element levels in human alcoholic brain

Copper, magnesium, zinc and manganese levels in the temporal cortex of human alcoholic and control brains were measured by atomic absorption spectrophotometry using both the flame and graphite furnace. All of the 21 alcoholics were male with a mean age of 54.1 years; the 19 male controls had a mean age of 60.2 years. The only statistically significant change in ion levels was an increase in manganese concentration (expressed both as microgram/g wet weight and ng/mg protein) in the alcoholic group when compared to the control group. Five of the alcoholics had malignancies, while 16 of the controls had systemic malignancies. Covariance analysis showed there was no effect of age on the level of manganese in the temporal cortex.

A comparison of computed tomography and radionuclide scanning for detection of brain metastases in small cell lung cancer

Neurologic history and examination, radionuclide brain scans (RN), and computed tomographic brain scans (CT) were performed at diagnosis and sequentially in 153 consecutive patients with small cell lung cancer (SCLC) to assess the sensitivity and accuracy of these screening methods and to determine whether the early detection of brain metastases influences survival. CT scans (sensitivity, 98%; positive predictive accuracy, 98%) were superior to RN scans (sensitivity, 71%; positive predictive accuracy, 86%) in patients with or without neurologic signs or symptoms. However, CT scans were positive in only 6% of asymptomatic patients at diagnosis and 13% of asymptomatic patients after systemic therapy. Brain metastases detected by CT scan were the sole site of extensive-stage disease in 6% of patients at diagnosis. Despite the enhanced ability of CT scans to detect asymptomatic lesions, survival after therapeutic cranial irradiation was similar for asymptomatic and symptomatic patients. The results suggest that CT brain scans should be used routinely in SCLC patients with neurologic signs or symptoms, at diagnosis (when treatment decisions are based on stage), and at six-month intervals in patients with prior brain metastases and in whom erratic follow-up is likely.

Pulmonary hyalinizing granuloma. Electron microscopic and immunologic studies

We present a case of pulmonary hyalinizing granuloma (PHG). On light microscopy, the pulmonary nodular lesions consisted of extracellular, eosinophilic hyaline lamellae. Histochemical stains of the hyaline lamellae for amyloid were focally positive and the diagnosis of amyloidosis was seriously considered; however, on electron microscopic examination, the hyaline lamellae consisted of electrondense, compact, amorphous material quite unlike fibrillar amyloid. Although circulating immune complexes containing IgA were detected in our patient, immunoperoxidase stains did not reveal immunoglobulins in the hyaline lamellae. This case illustrates the value of electron microscopy in differentiating PHG from amyloidosis and supports the hypothesis that PHG represents an exaggerated immune response.

Myorhythmia: a widespread movement disorder. Clinicopathological correlations

The clinical manifestations of 24 cases and the autopsy findings of 6 cases of extremity myorhythmia are presented. Extremity myorhythmia is that form of myorhythmia in which rhythmic alternating movements predominantly involve the limbs. The main difference between the tremor of extremity myorhythmia and the tremor of parkinsonism is the slower tremor rate, 2 to 3 cycles/s in myorhythmia and 4 to 6 cycles/s in parkinsonism. The mechanograms, except for the slower frequencies in myorhythmia, can be very similar, including sinusoidal oscillation patterns in both conditions. Myorhythmia may be defined as a coarse, alternating tremor, present at rest and usually during movement, which occurs at rates varying from 50 to 240 oscillations/min but mostly at either 120 to 140 or 160 to 180 cycles/min. The alternating movements may be intermittent or continuous or both types may be present in different body parts. When multiple parts are involved, synchronous or asynchronous movements are about equally common. Movements are usually relatively rhythmic and regular but may vary over periods of time in rate, rhythm or amplitude and rarely so, even over the course of a few hours and are absent during sleep. Movements may involve single limbs, several limbs or a combination of limbs plus face, palate, head, jaw, neck, tongue, eyes or trunk. The frequency of the movements in the 24 cases varied from 120 to 180 oscillations/min with two exceptions the slowest being 60 and the fastest 240, with most tending to cluster near either 120 or 180 cycles/min. The most common aetiologies were brainstem vascular disease and cerebellar degeneration secondary to chronic alcoholism-nutritional deficiency. The best prognosis occurred in the latter group. Clinicopathological correlations in our autopsy series indicate that myorhythmia of the limbs may occur ipsilateral to the dentate nucleus or superior cerebellar peduncle lesions or contralateral to inferior olive involvement. Unilateral lesions of the dentate nucleus may result in bilateral limb movements and bilateral dentate lesions may be associated with unilateral limb movements. The frequent involvement of the cerebellum and the substantia nigra suggests possible roles for the cerebellum and substantia nigra in the myorhythmia process.

The course of alcoholic-nutritional peripheral neuropathy

63 patients with alcoholic-nutritional peripheral neuropathy were given neurologic, electrophysiologic and nutritional examinations. 24 of these patients were reexamined later in the course of their disease, after from 2 to 72 months (mean 33). Alcoholic-nutritional neuropathy appeared and worsened after bouts of heavy alcohol intake and malnutrition. Initially it was sensory and symmetric in character, with prominent involvement of the posterior tibial nerves. With repeated attacks it became more proximal, more motor, and associated with more severe slowing of nerve conduction velocity. 11 of the patients were able to stop drinking alcohol. Initial subjective improvement was seen within the first week or two, but substantial improvement was not seen for 5 to 6 months. Most leg motor nerve velocity improved at a mean rate of increase of 0.12 M/sec per abstinent month. Large motor units and slowed nerve conduction persisted in "cured" patients. The largest motor units detected in the legs grew, despite alcohol intake.

Cerebral mucormycosis (Phycomycosis) in a heroin addict

Cerebral mucormycosis was found at autopsy in a 27-year-old male narcotic addict with rapidly progressive focal neurologic signs. There was no evidence of rhinocerebral involvement of systemic illness, and a nuclide brain scan suggested brain abscess.