Peptidoglycan in osteoarthritis synovial tissue is associated with joint inflammation

OBJECTIVES

Peptidoglycan (PG) is an arthritogenic bacterial cell wall component whose role in human osteoarthritis is poorly understood. The purpose of this study was to determine if PG is present in synovial tissue of osteoarthritis patients at the time of primary total knee arthroplasty (TKA), and if its presence is associated with inflammation and patient reported outcomes.

METHODS

Intraoperative synovial tissue and synovial fluid samples were obtained from 56 patients undergoing primary TKA, none of whom had history of infection. PG in synovial tissue was detected by immunohistochemistry (IHC) and immunofluorescence microscopy (IFM). Synovial tissue inflammation and fibrosis were assessed by histopathology and synovial fluid cytokine quantification. Primary human fibroblasts isolated from arthritis synovial tissue were stimulated with PG to determine inflammatory cytokine response.

RESULTS

A total of 33/56 (59%) of primary TKA synovial tissue samples were positive for PG by IHC, and PG staining colocalized with markers of synovial macrophages and fibroblasts by IFM. Synovial tissue inflammation and elevated IL-6 in synovial fluid positively correlated with PG positivity. Primary human fibroblasts stimulated with PG secreted high levels of IL-6, consistent with ex vivo findings. Interestingly, we observed a significant inverse correlation between PG and age at time of TKA, indicating younger age at time of TKA was associated with higher PG levels.

CONCLUSION

Peptidoglycan is commonly found in synovial tissue from patients undergoing TKA. Our data indicate that PG may play an important role in inflammatory synovitis, particularly in patients who undergo TKA at a relatively younger age.

Human leukocyte antigen HLA-DR-expressing fibroblast-like synoviocytes are inducible antigen presenting cells that present autoantigens in Lyme arthritis

Background

HLA-DR-expressing fibroblast-like synoviocytes (FLS) are a prominent cell type in synovial tissue in chronic inflammatory forms of arthritis. We recently showed that peptides from several extracellular matrix (ECM) proteins, including fibronectin-1 (FN1), contained immunogenic CD4+ T cell epitopes in patients with postinfectious Lyme arthritis (LA). However, the role of FLS in presentation of these T cell epitopes remains uncertain.

Methods

Primary LA FLS and primary murine FLS stimulated with interferon gamma (IFNγ), Borrelia burgdorferi, and/or B. burgdorferi peptidoglycan (PG) were assessed for properties associated with antigen presentation. HLA-DR-presented peptides from stimulated LA FLS were identified by immunopeptidomics analysis. OT-II T cells were cocultured with stimulated murine FLS in the presence of cognate ovalbumin antigen to determine the potential of FLS to act as inducible antigen presenting cells (APC).

Results

FLS expressed HLA-DR molecules within inflamed synovial tissue and tendons from patients with post-infectious LA patients in situ. MHC class II and costimulatory molecules were expressed by FLS following in vitro stimulation with IFNγ and B. burgdorferi and presented both foreign and self MHC-II peptides, including T cell epitopes derived from two Lyme autoantigens fibronectin-1 (FN1) and endothelial cell growth factor (ECGF). Stimulated murine FLS induced proliferation of naïve OT-II CD4+ T cells, particularly when FLS were stimulated with both IFNγ and PG.

Conclusions

MHC-II+ FLS are inducible APCs that can induce CD4+ T cell activation and can present Lyme autoantigens derived from ECM proteins, thereby amplifying tissue-localized autoimmune CD4+ T cell responses in LA.

Peptidoglycan in osteoarthritis synovial tissue is associated with joint inflammation

Objectives

Peptidoglycan (PG) is an arthritogenic bacterial cell wall component whose role in human osteoarthritis is poorly understood. The purpose of this study was to determine if PG is present in synovial tissue of osteoarthritis patients at the time of primary total knee arthroplasty (TKA), and if its presence is associated with inflammation and patient reported outcomes.

Methods

Intraoperative synovial tissue and synovial fluid samples were obtained from 56 patients undergoing primary TKA, none of whom had history of infection. PG in synovial tissue was detected by immunohistochemistry (IHC). Synovial tissue inflammation and fibrosis were assessed by histopathology and synovial fluid cytokine quantification. Primary human fibroblasts isolated from arthritis synovial tissue were stimulated with PG to determine inflammatory cytokine response.

Results

A total of 33/56 (59%) of primary TKA synovial tissue samples were positive for PG by IHC, with mean 8 PG occurrences per 10 mm2 of tissue in PG-positive samples. Synovial tissue inflammation and elevated IL-6 in synovial fluid positively correlated with PG positivity. Primary human fibroblasts stimulated with PG secreted high levels of IL-6, consistent with ex vivo findings. Interestingly, we observed a significant inverse correlation between PG and age at time of TKA, indicating younger age at time of TKA was associated with higher PG levels.

Conclusion

Peptidoglycan is commonly found in synovial tissue from patients undergoing TKA. Our data indicate that PG may play an important role in inflammatory synovitis, particularly in patients who undergo TKA at a relatively younger age.

BBB07 contributes to, but is not essential for, Borrelia burgdorferi infection in mice

Borrelia burgdorferi, a causative agent of Lyme disease, encodes a protein BBB07 on the genomic plasmid cp26. BBB07 was identified as a candidate integrin ligand based on the presence of an RGD tripeptide motif, which is present in a number of mammalian ligands for β₁ and β₃ integrins . Previous work demonstrated that BBB07 in recombinant form binds to β₁ integrins and induces inflammatory responses in synovial cells in culture. Several transposon mutants in bbb07 were attenuated in an in vivo screen of the transposon library in mice. We therefore tested individual transposon mutant clones in single-strain infections in mice and found that they were attenuated in terms of ID₅₀ but did not have significantly reduced tissue burdens in mice. Based on data presented here we conclude that BBB07 is not essential for, but does contribute to, B. burgdorferi infectivity in mice.

Fibroblast-like synoviocytes shape inflammation and wound healing in Lyme arthritis

Lyme arthritis (LA) is caused by infection with Borrelia burgdorferi (Bb) and, in many patients, can trigger autoimmune and autoinflammatory pathways. Despite proper treatment, some individuals can develop proliferative synovitis that persists for months or years, a condition known as post-infectious LA. Fibroblast-like synoviocytes (FLS) are the most abundant cell type found in the synovial lesion and are critical in wound healing. The aim of this study is to determine the role of FLS in dysregulated pro-inflammatory and tissue repair pathways in LA. FLS were cultured from joints of C57BL/6 (B6) mice and B6 Il10−/− mice and stimulated with interferongamma (IFNγ) and/or Bb. Cell culture supernatants were used for multiplex cytokine analysis, and RNA was isolated from cells for gene expression analysis. FLS were also used in flow cytometry and color flow imaging to identify immune markers, and in cell migration and proliferation assays as a measure of wound healing. When treated with IFNγ, FLS developed an immune-like phenotype. These immune fibroblasts were hyper-responsive to Bb and produced high levels of inflammatory mediators. FLS were also capable of internalizing Bb and expressing MHC-II molecules, suggesting the ability to present Bb antigen. Moreover, B6 FLS treated with IFNγ and/or Bb displayed an impaired wound healing phenotype, whereas this phenotype was seen intrinsically in both treated and untreated Il10−/− FLS. Under pro-inflammatory conditions seen in joints of patients, FLS likely play a key role in numerous pathogenic pathways, most notably in driving inflammation and blocking appropriate repair of damaged tissue. Further studies will examine the epigenetic pathways in both murine and human synovial tissue.

Immunopeptidomics analysis of Lyme arthritis: insights into infection and autoimmunity

Background:

Lyme arthritis (LA) is caused by infection with the Lyme disease spirochete Borrelia burgdorferi (Bb) and in humans is often accompanied by autoimmune T and B cell responses. In this study, we used an immunopeptidomics approach to gain further insight into mechanisms of infection-induced autoimmunity.

Methods:

C57BL/6 (B6) mice, which develop mild, self-limiting LA, and B6 Il10−/− mice, which develop chronic, autoimmune-like LA, were inoculated with 2×104 Bb. Inguinal and popliteal lymph nodes (LN) were harvested from infected mice at 4 weeks and 16 weeks post-inoculation. MHC class II molecules were isolated by immunoaffinity capture and MHC-bound peptides were identified by LC/MS/MS.

Results:

Nearly 10,000 MHCII-bound peptides were identified. At 4 weeks post-inoculation, representing the peak of LA, proteins involved in leukocyte trans-endothelial migration, tissue repair, and immune activation, including a known Lyme autoantigen ApoB-100, were over-represented in both B6 and Il10−/− mice. Peptides from these proteins returned to near baseline levels in LN from B6 mice at 16 weeks post-inoculation, when arthritis resolves, but were further enriched in Il10−/− mice at 16 weeks, during the chronic, autoimmune-like phase. Surprisingly, only 27 peptides derived from Bb proteins were identified, all but one of which were from proteins found in the inner membrane, periplasm, or cytosol.

Conclusions:

This study identified immune-relevant proteins presented by APCs in draining LN that are associated with LA development, which included ApoB-100, a known Lyme autoantigen in humans. Further studies are underway to assess T cell responses to identified Bb and self-peptides, including ApoB-100, during Bb infection.

Borrelia burgdorferi peptidoglycan triggers inflammatory responses in Lyme arthritis

Background:

Lyme arthritis (LA) is the predominant late-stage manifestation of Lyme disease, caused by the tick-borne spirochete Borrelia burgdorferi (Bb). Bacterial peptidoglycan (PG) is abundant in inflamed joints of LA patients, even months to years after antibiotic therapy, but the role of PG in LA pathogenesis is unclear.

Methods:

Primary murine macrophages and synovial fibroblasts, two cell types abundant in LA synovial tissue, were stimulated for 24–72 hours with IFNγ, PG, or both. Inflammatory responses were determined by flow cytometric analysis of CD80, CD86, MHC-II, CD206, ICAM1, and IL-15R.

Results:

Macrophage stimulation with PG+IFNγ for 24 hours led to up-regulation of costimulatory molecules CD80/CD86, compared with PG or IFNγ alone, consistent with classical (M1) activation. In contrast, stimulation for 72 hours resulted in marked suppression of MHC-II and upregulation of CD206, consistent with M2 macrophage polarization. When stimulated with PG+IFNγ for 24 hours, synovial fibroblasts upregulated activation markers ICAM1 and IL-15R, whereas these activation markers were only partially up-regulated when stimulated with PG or IFNγ alone. Current experiments include analyzing cytokine secretion by these cells at different time points.

Conclusion:

Both innate immune and stromal cells abundant in joint tissue are responsive to stimulation with PG, but these responses may be either pro-inflammatory or anti-inflammatory, depending on cell type and duration of stimulation. This highlights the complex relationship between PG and the cellular environment of infected joints. Future experiments will identify relevant immune response pathways, such as TLR2 and NOD2 signaling, in shaping these responses.

Novel malaria antigen Plasmodium yoelii E140 induces antibody-mediated sterile protection in mice against malaria challenge

Only a small fraction of the antigens expressed by malaria parasites have been evaluated as vaccine candidates. A successful malaria subunit vaccine will likely require multiple antigenic targets to achieve broad protection with high protective efficacy. Here we describe protective efficacy of a novel antigen, Plasmodium yoelii (Py) E140 (PyE140), evaluated against P. yoelii challenge of mice. Vaccines targeting PyE140 reproducibly induced up to 100% sterile protection in both inbred and outbred murine challenge models. Although PyE140 immunization induced high frequency and multifunctional CD8⁺ T cell responses, as well as CD4⁺ T cell responses, protection was mediated by PyE140 antibodies acting against blood stage parasites. Protection in mice was long-lasting with up to 100% sterile protection at twelve weeks post-immunization and durable high titer anti-PyE140 antibodies. The E140 antigen is expressed in all Plasmodium species, is highly conserved in both P. falciparum lab-adapted strains and endemic circulating parasites, and is thus a promising lead vaccine candidate for future evaluation against human malaria parasite species.

Immune fibroblasts are unconventional antigen presenting cells and nonprofessional phagocytes in Lyme arthritis

Synovial fibroblasts are the primary cell type in synovial tissue and are one of the first cell types involved in immune responses to Borrelia burgdorferi invasion of joint tissue. Recent studies of human Lyme arthritis have shown that synovial fibroblasts up-regulate numerous genes involved in T cell activation upon exposure to the Th1 cytokine IFN-gamma. However, animal model studies are required to better understand their role in host defense and pathogenesis in Lyme arthritis. Using primary synovial fibroblasts isolated from the tibiotarsal joint of C57BL/6 mice, we have found that fibroblasts stimulated with IFN-gamma and B. burgdorferi express MHC class II molecules, a number of costimulatory molecules, and effector cytokines involved in lymphocyte activation, including activation of CD4+ T cells and NK cells. MHC class II molecules isolated from stimulated fibroblasts contained MHC-II peptides, indicating that these cells are capable of presenting antigen to CD4+ T cells. Stimulation with IFN-gamma also reduced fibroblast migration, indicating these cells have impaired ability to repair damaged tissue. Synovial fibroblasts were also able to internalize B. burgdorferi in cell culture, indicating that these cells are capable of acting as nonprofessional phagocytes. Ongoing experiments will determine which lymphocyte subsets interact with inflammatory synovial fibroblasts, and whether these subsets are protective against B. burgdorferi invasion of joint tissue and/or arthritogenic. Together, these data indicate that immune fibroblasts are important in shaping tissue-specific immune responses to B. burgdorferi infection and subsequent inflammation.

Expression of HLA class II molecules in humanized NOD.Rag1KO.IL2RgcKO mice is critical for development and function of human T and B cells

BACKGROUND

Humanized mice able to reconstitute a surrogate human immune system (HIS) can be used for studies on human immunology and may provide a predictive preclinical model for human vaccines prior to clinical trials. However, current humanized mouse models show sub-optimal human T cell reconstitution and limited ability to support immunoglobulin class switching by human B cells. This limitation has been attributed to the lack of expression of Human Leukocyte Antigens (HLA) molecules in mouse lymphoid organs. Recently, humanized mice expressing HLA class I molecules have been generated but showed little improvement in human T cell reconstitution and function of T and B cells.

METHODS

We have generated NOD.Rag1KO.IL2RγcKO mice expressing HLA class II (HLA-DR4) molecules under the I-E(d) promoter that were infused as adults with HLA-DR-matched human hematopoietic stem cells (HSC). Littermates lacking expression of HLA-DR4 molecules were used as control.

RESULTS

HSC-infused HLA-DR4.NOD.Rag1KO.IL-2RγcKO mice developed a very high reconstitution rate (>90%) with long-lived and functional human T and B cells. Unlike previous humanized mouse models reported in the literature and our control mice, the HLA-DR4 expressing mice reconstituted serum levels (natural antibodies) of human IgM, IgG (all four subclasses), IgA, and IgE comparable to humans, and elicited high titers of specific human IgG antibodies upon tetanus toxoid vaccination.

CONCLUSIONS

Our study demonstrates the critical role of HLA class II molecules for development of functional human T cells able to support immunoglobulin class switching and efficiently respond to vaccination.

Ubiquilin and p97/VCP bind erasin, forming a complex involved in ERAD

Loss of ubiquilin or erasin activates ER stress, increases accumulation of polyubiquitinated proteins, and shortens lifespan in worms.

Unwanted proteins in the endoplasmic reticulum (ER) are exported into the cytoplasm and degraded by the proteasome through the ER-associated protein degradation pathway (ERAD). Disturbances in ERAD are linked to ER stress, which has been implicated in the pathogenesis of several human diseases. However, the composition and organization of ERAD complexes in human cells is still poorly understood. In this paper, we describe a trimeric complex that we propose functions in ERAD. Knockdown of erasin, a platform for p97/VCP and ubiquilin binding, or knockdown of ubiquilin in human cells slowed degradation of two classical ERAD substrates. In Caenorhabditis elegans, ubiquilin and erasin are ER stress-response genes that are regulated by the ire-1 branch of the unfolded protein response pathway. Loss of ubiquilin or erasin resulted in activation of ER stress, increased accumulation of polyubiquitinated proteins, and shortened lifespan in worms. Our results strongly support a role for this complex in ERAD and in the regulation of ER stress.

Questionnaire test-retest reliability: outcome measure of a vocational rehabilitation programme

In a clinical follow-up case series study, the test-retest reliability of an outcome measure questionnaire was tested. The study group consisted of 48 patients who had taken part in a vocational rehabilitation programme. Test-retest reliability of a questionnaire was evaluated with the reliability index two years after entering the programme. It was found that the test-retest reliability of demographic data was rather good, although the questions concerning basic and occupational training showed instability over time. The answers concerning general health symptoms, mental working capacity and perceived changes in life during the past 12 months showed particularly high variability. The respondents' opinions on their general outlook of life seemed rather stable. Opinions about the perceived benefits from the intervention were marginally stable. The respondents' opinions about the benefits perceived from the physicians' work were more stable than the opinions about the perceived help from the other members of the rehabilitative team. It was concluded that an outcome analysis questionnaire is a useful tool to document the respondents' general and present perception of life and their present health situation as well as the rehabilitation process. The further development of generally applicable outcome measures for health promotion programmes will require unified, long-term efforts.

[Psycho-neurogenic factors as a cause of life-threatening arrhythmias]

Tachyarrhytmias often occur during increased emotional arousal or mental excitation. The implantable cardioverter defibrillator (ICD) allows the exact documentation of arrhythmic episodes and their time of onset. Therefore, the type of arrhythmia can be differentiated as well as the circumstances surrounding the event. These features allow the assessment of possible psychic arrhythmogenic factors in the natural environment. We analyzed the ICD-protocols of three male patients (in ages between 60 and 68), whose devices had successfully terminated a ventricular tachycardia and compared the onset of the episodes with the patients' detailed descriptions of the corresponding life situations. The analysis of the circumstances at the time of arrhythmia-onset revealed a relationship between the occurrence of life-threatening arrhythmias in natural environment and emotional stress. The stressors could be defined as situations of increased vulnerability leading to sympathetic excitation. The induction of tachyarrhythmia was promoted in case 1 by acute psychic distress (public speaking), by the increasing panic-attack-like vicious circle of the cognitive anticipation of an unfavorable outcome (case 2), and an adverse anger reaction superimposed on persistent feelings of help- and hopelessness (case 3). These findings are in line with several experimental and epidemiological studies providing evidence for a relationship between psychic arousal and the induction of tachyarrhythmias. The knowledge of emotional and mental factors that function as a trigger for arrhythmias may lead to new therapeutic approaches in the prevention of sudden cardiac death.

Long-acting psychotraumatic properties of a cardiac arrest experience

OBJECTIVE

Progress in resuscitation medicine allows an increasing proportion of patients to survive an out-of-hospital cardiac arrest. However, little is known about long-term adaptation to the vital breakdown. The present study assessed the long-term prevalence and severity of emotional disability of cardiac arrest survivors and ascertained whether survivors suffer from recurrent and intrusive recollections of the cardiac arrest.

METHOD

Follow-up analysis was performed on all cardiac arrest survivors discharged from the hospital over a 5-year interval (1990-1994) in a defined inner city and suburban area. From 118 initially hospitalized cardiac arrest survivors, 45 patients were discharged alive from the hospital. After a mean follow-up period of 39 months (range = 22-64), 25 patients exhibited sufficient cerebral performance for psychodiagnostic assessment; 21 patients were assessed.

RESULTS

Despite an impaired ability to concentrate, cardiac arrest survivors had levels of psychological adjustment at follow-up that were similar to those of 35 cardiac patients whose clinical course was not complicated by cardiac arrest. However, the diagnosis of psychotraumatic symptoms in cardiac arrest survivors led to a sharp separation between favorable and nonfavorable outcome in affective regulation and level of functioning. Of the cardiac arrest patients, those with high scores of intrusion and avoidance (N = 8) reported an enduring sense of demoralization with significantly more somatic complaints, depression, anxiety, lack of confidence in the future, and narrowing of social activities than those with low scores (N = 11). Long-acting sedation at illness onset significantly predicted a favorable outcome.

CONCLUSIONS

This study provides the first empirical evidence that the application of the posttraumatic stress disorder paradigm in the long-term evaluation of cardiac arrest survivors significantly contributes to defining a patient population at high risk for serious emotional disability.

Sustaining and improving working capacity--programme description and two years follow-up

In 1991 the Social Insurance Institution Rehabilitation Act introduced a working capacity sustaining and improving training programme (TYK). The goal of this programme is to sustain the physio-psycho-social competences of older workers and employees by creating a chain of in-house rehabilitation phases and training phases at the workplace. We describe the programme in its early state of implementation. Two years after entering the programme 17 patients were working, six were on sick leave, three were out of work, 16 were on pension, and six patients could not be retrieved.

Effects of early defibrillation by ambulance personnel on short- and long-term outcome of cardiac arrest survival: the Munich experiment

OBJECTIVES

This study evaluates the feasibility of implementing early defibrillation of out-of-hospital cardiac arrest patients for basic life-support providers (EMT-D) in a two-tier emergency system in the city of Munich, Germany.

DESIGN

Retrospective consecutive analysis of all EMT-D attempts during a 5-year initiation phase (1990 to 1994) and prospective follow-up of all cardiac arrest survivors discharged from hospital.

SETTING

A strictly defined inner-city and suburban area of 978 km2 and a residential population of 1,530,000 inhabitants with 22 ICUs in urban hospitals. One dispatching center to alert a two-tier emergency system with 56 EMT-D-staffed ambulances and physician-staffed mobile ICUs stationed at the nearest of nine hospitals.

METHODS

AH EMT-D cases were identified and data on patients were documented in a standardized manner from patients' records, including the resuscitation protocol in the hospitals to which the patients were referred. For those patients discharged from the hospital, a standardized telephone interview was undertaken with the physician in charge of the patient and with the patient/relative leading to an assessment of the patient's status according to the Glasgow-Pittsburgh cerebral performance categories.

INTERVENTION

None.

RESULTS

During the 5-year initiation phase of the EMT-D program in the two-tier emergency system in Munich, there were 243 resuscitation attempts by EMTs, using the semiautomated defibrillator; 125 patients died immediately on the scene. In 118 patients, spontaneous circulation was reestablished and these patients were admitted to an ICU in 1 of the 22 urban hospitals. Median call-response interval for the EMT-D was 5 min (interquartile range, 3 to 6) and was 10 min (interquartile range, 7 to 13) for the second tier (p < or = 0.0001). In 34 cases (28.8%), EMT-D staff had reestablished spontaneous circulation (ROSC) before the second tier arrived on the scene. Patients with ROSC on the arrival of the second tier were more frequently discharged alive from hospital than were patients without ROSC at that time (p < or = 0.0001). The hospital discharge rate of initially successful resuscitated patients presenting with out-of-hospital ventricular fibrillation was 38.1% (45/118). Overall success rate of all EMT-D attempts was 18.5% (45/243). After a mean follow-up time of 39 (range, 22 to 64) months, 29 (66%) patients were still living. Twenty-five (56.8%) were neurologically not disabled or mildly disabled (CPC 1/2); disability was moderate in 3 (6.8%) patients and was severe in 1 (2.3%) patient. One case was lost to follow-up.

CONCLUSION

The present study demonstrates that the upgrading of basic life support providers with semiautomated defibrillators has a significant benefit for cardiac arrest victims outside the hospital in an urban environment.

Effect of computerized instructions on measurement of lift capacity: Safety, reliability, and validity

The evaluation of lift capacity is an important part of most functional capacity evaluations. Several different methods have been developed to evaluate lift capacity in a safe, reliable, and valid manner. Isometric strength testing is one approach which has been demonstrated to be highly reliable. However, questions have been raised about the safety and validity of isometric strength testing as a predictor of "real world" lift capacity. One method to improve safety is to provide real time performance feedback so that the evaluee is able to increase psychophysical input to appropriately gauge his or her effort level. One method to improve reliability is to provide standardized instructions that are well understood by the evaluee. Both of these approaches have been utilized in the ERGOS Work Simulator, a computer-controlled multiple-task evaluation instrument that presents visual and auditory instructions to the evaluee along with "real-time" performance feedback. The safety, reliability, and validity of this computer-automated approach in comparison to an experienced human evaluator was evaluated in this research project. The results of this study demonstrate the efficacy of computerized instructions in an isometric strength testing system to achieve safe, reliable, and valid results. Intra-task variability may be improved by providing pre-test practice trials.

[The sonography of rotator cuff ruptures. The correlation of the sonographic, arthrographic and intraoperative findings in rotator cuff ruptures]

We have compared the findings of sonography, arthrography and at surgery in 66 cases of rotator cuff rupture in order to clarify the sonographic and radiological signs. Preoperative sonography was better than arthrography at demonstrating a partial rupture and at showing the extent of the lesion.

Referral diagnosis versus electroneurophysiological finding. Two years electroneuromyographic consultation in a rehabilitation clinic

This study describes the referral practice to an electrodiagnostic unit in a rehabilitation clinic and compares the provisional diagnoses of different referring sources with the outcome of the neurophysiological tests. The study comprises data of 495 patients which were examined over a two years period. General practitioners, the author, physiatrists and surgeons, followed by occupational health physicians and neurologists used the electrodiagnostic service. Two thirds of the cases were referred to rule out upper limb mononeuropathies or cervical root and plexus neuropathies. Carpal tunnel syndrome (20%), and other upper limb mononeuropathies (10%) were the most common EMG findings. Other frequent neurophysiologic diagnoses were: lumbar root and plexus neuropathy (6%), polyneuropathy (5.5%), lower limb mononeuropathy (3.4%), and cervical root and plexus neuropathy (3.4%). In 49% the electrodiagnostic was normal or inconcensive.

Iatrogenic compartment syndrome, A follow-up of four cases caused by elastic bandage

We describe four patients suffering from lower limb compartment syndromes which were caused by constrictive bandages applied after stripping of varices. The dressing was erroneously only partially removed, when the patients started complaining of severe pain and tension in the operated legs. The damages varied from extended irreversible neuromuscular defects to lesser functional handicaps. Three patients had corrective surgery. The clinical follow up over several years showed little improvement, secondary complaints were frequent.

Comparison of the effects of carbamazepine and oxcarbazepine on peripheral nerve conduction

Twenty-five epileptic outpatients were studied to assess possible effects of the first 6 months of treatment with carbamazepine or oxcarbazepine using serial peripheral nerve conduction measurements. Carbamazepine caused a small slowing effect on the motor conduction of the median nerve after 4 weeks of treatment, and the effect was correlated with the fasting serum concentration of the drug. Slowed motor conduction value of the median nerve was also observed after 6 months of treatment with carbamazepine. Oxcarbazepine did not cause any statistically significant slowing of nerve conduction.

Seizures in an atelencephalic infant. Is the cortex essential for neonatal seizures?

Clinical and electrographic seizures were recorded in an infant with atelencephaly. Because the infant had no cerebral hemispheres, the ictal discharges were presumed to arise from the disorganized diencephalic derivatives that occupied the entire supratentorial space. The case provided strong support for the concept that, unlike epileptic seizures in older patients, some types of neonatal seizures may originate and propagate exclusively in subcortical structures. This may explain the striking dissociation between the electrographic and behavioral aspects of seizures occasionally observed in newborns, as well as the frequent intractability of such seizures to standard anticonvulsants.

Cortical spike wave discharges during audiogenic convulsions in rats

Audiogenic seizure-susceptible rats show high-amplitude spikes and waves in the electrocorticogram during the tonic phase of a maximal audiogenic convulsion. This observation establishes the validity of this seizure type as an animal model for human generalized epilepsy.

Prospective neurometric studies during the beginning of carbamazepine and phenytoin therapy

We studied 23 epileptic outpatients to assess carbamazepine and phenytoin therapy effects on the peripheral nerve conduction velocity, the electromyogram, and the EEG background activity. Immediately before and 3, 5, 11, 22 months after beginning treatment with 300-800 mg carbamazepine or 200-400 mg phenytoin, the patients were examined with electroneuromyographic and quantified EEG tests. Carbamazepine, phenytoin, folate, and vitamin B12 serum concentration were simultaneously monitored. Clinical signs of intoxication or polyneuropathy were not observed. The mean serum concentrations were 29 mumol/l for carbamazepine and 43 mumol/l for phenytoin. There was little evidence that anticonvulsants' serum concentration at these levels are related to changes in the electroneuromyographic tests or the alpha rhythm.

[Electrophysiologic monitoring at the start of anticonvulsive therapy with phenytoin]

The effect of phenytoin on the peripheral nerve function and the EEG frequency spectrum is described by means of prospective neurometric tests. Three patients showed changes in peripheral nerve function, four patients in the EEG frequency spectrum.

Unilateral thenar hypoplasia

This report documents a patient with unilateral hypoplasia of the thenar eminence. The clinical, electrodiagnostic, and radiological findings indicated a developmental abnormality which must be considered in the differential diagnosis of carpal tunnel syndrome.

Electroneuromyographical and morphological findings in progressive myoclonus epilepsy (PME)

The purpose of this study was to assess the function of peripheral nerves and muscles and to describe morphological changes in muscle biopsies of patients with progressive myoclonus epilepsy. Electroneuromyographic studies were performed on 24 adult patients whose mental and motor skills were either little, moderately or severely impaired by the disease. In 5 patients a specimen of tibial anterior muscle was morphologically and histochemically investigated. The electrophysiological functions of the peripheral nerves and muscles showed gradual increasing abnormalities parallel to the severity of clinical deterioration. The muscle biopsies of 2 patients showed signs compatible with peripheral neuropathy. These findings suggested that progressive myoclonus epilepsy may be related to a systemic membrane disorder.

[The sensory-integrative process and its influence on child development (author's transl)]

A child develops and learns skills by interacting with his environment. Play provides him with the sensory stimulation his brain needs in order to be able to allow him to respond in a meaningful way to these stimuli. Until the age of seven the brain is thus prepared for the challenges of the classroom. The neurologic problem in the child with a sensory integrative dysfunction prevents him from processing the sensations of his own play, so he cannot develop the adaptive responses that organize the brain and his actions. This child needs a specially designed environment in order to experience joy and satisfaction during his play, that allow him to learn higher skills and organize the brain functions. The purpose of this article is to clarify what sensory integration is and how it influences the child's development.

Chronic anticonvulsive therapy, peripheral nerve conduction velocity, and EMG

Chronic, mentally subnormal epileptic patients were clinically and neurophysiologically studied in order to determine the occurrence and type of peripheral nerve dysfunction. We observed significant impairment of motor and sensory nerve conduction velocities and H-reflex latencies. Amplitudes of sensory and motor responses were diminished. Motor distal latencies were not prolonged. Conclusive EMG signs of active denervation were not observed. The possible role of anticonvulsive treatment as an underlying noxa is discussed.

Electrophysiological signs of peripheral nerve dysfunction in progressive myoclonus epilepsy

Electrophysiological findings were analysed in a group of 24 patients with progressive myoclonus epilepsy (PME) without Lafora bodies. Denervation activity in needle EMG and diminution of motor and sensory responses pointed out a mild axonal degeneration. We observed a significant slowing of motor and sensory conduction velocities in all the limb nerves examined, but distal motor latencies were not significantly increased. H-reflex latency of the posterior tibial nerve was prolonged. These results yielded the suggestion that there is a systemic peripheral nerve membrane dysfunction in PME.

[Measurements of nerve conduction velocity during decreasing toxic diphenylhydantoin levels and the beginning of carbamazepine medication. A clinical neurophysiological documentation (author's transl)]

Sensory and motor nerve conduction velocity was determined daily in an epileptic patient during recovery of acute diphenylhydantoin toxicity and at the beginning of carbamazepine medication. A statistical correction, which accounts for the influence of variable skin temperatures on the sensory nerve conduction velocity (SNCV), proved to be useful for SNCV measurements of the sural nerves. We found significant correlation between the increasing sensory nerve conduction of the sural nerves and the decreasing diphenylhydantoin levels. During rising carbamazepine concentrations, we observed decreasing conduction velocities in peripheral nerves.

Schistosoma mansoni and S. haematobium infections in Egypt. IV. Hepatic lesions

We performed 400 consecutive autopsies in Cairo, Egypt. The intensity of schistosome infection in these cases was measured by counting adult worms recovered by perfusion and dissection and by counting eggs in the tissues of infected cases. Symmers' clay pipestem fibrosis of the liver was clearly related to the presence and intensity of Schistosoma mansoni, but not S. haematobium, infection. Morphologic findings in cases with Symmers' fibrosis were comparable to those in Brazilian cases, and the intensity of S. mansoni infection associated with Symmers' fibrosis was similar in Brazil and Egypt. The fine bilharzial periportal fibrosis described by Hashem was not identified in our material, and Symmers' fibrosis was present in all cases of portal hypertension caused by schistosomiasis. Schistosome eggs were found concentrated in areas of portal fibrosis of cases with Symmers' fibrosis. In the absence of Symmers' fibrosis, eggs did not concentrate in large portal areas regardless of the intensity of infection or the presence of lesser degrees of portal fibrosis. We thus feel it unlikely that Symmers' fibrosis is formed by the fusion of fibrotic granulomas around the schistosome eggs.

Schistosoma mansoni and S. haematobium infections in Egypt. I. Evaluation of techniques for recovery of worms and eggs at necropsy

Four hundred consecutive autopsy cases were examined in Cairo, Egypt. Sixty percent of cases had Schistosoma haematobium eggs in the tissues and 25% also were infected with S. mansoni. Only a quarter of S. haematobium infections were active, while nearly two-thirds of S. mansoni cases remained active. Adult S. haematobium and S. mansoni were effectively recovered from the mesenteric circulation by a combination of perfusion and dissection. Quantitative recovery from the genitourinary system was reasonably complete, although small numbers of worms were missed in the dissection of these organs.