Determining the Degree of Dopaminergic Denervation Based on the Loss of Nigral Hyperintensity on SMWI in Parkinsonism

BACKGROUND AND PURPOSE

Nigrostriatal dopaminergic function in patients with Parkinson disease can be assessed using ¹²³I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl)-nortropan dopamine transporter (¹²³I-FP-CIT) SPECT, and a good correlation has been demonstrated between nigral status on SWI and dopaminergic denervation on ¹²³I-FP-CIT SPECT. Here, we aim to correlate quantified dopamine transporter attenuation on ¹²³I-FP-CIT SPECT with nigrosome-1 status using susceptibility map-weighted imaging (SMWI).

MATERIALS AND METHODS

Between May 2017 and January 2018, consecutive patients with idiopathic Parkinson disease (n = 109) and control participants (n = 29) who underwent ¹²³I-FP-CIT SPECT with concurrent 3T SWI were included. SMWI was generated from SWI. Two neuroradiologists evaluated nigral hyperintensity from nigrosome-1 on each side of the substantia nigra. Using consensus reading, we compared the ¹²³I-FP-CIT-specific binding ratio according to nigral hyperintensity status and the ¹²³I-FP-CIT specific binding ratio threshold to confirm the loss of nigral hyperintensity was determined using receiver operating characteristic curve analysis.

RESULTS

The concordance rate between SMWI and ¹²³I-FP-CIT SPECT was 65.9%. The ¹²³I-FP-CIT-specific binding ratios in the striatum, caudate nucleus, and putamen were significantly lower when nigral hyperintensity in the ipsilateral substantia nigra was absent than when present (all, P < .001). The ¹²³I-FP-CIT-specific binding ratio threshold values for the determination of nigral hyperintensity loss were 2.56 in the striatum (area under the curve, 0.890), 3.07 in the caudate nucleus (0.830), and 2.36 in the putamen (0.887).

CONCLUSIONS

Nigral hyperintensity on SMWI showed high positive predictive value and low negative predictive value with dopaminergic degeneration on ¹²³I-FP-CIT SPECT. In patients with Parkinson disease, the loss of nigral hyperintensity is prominent in patients with lower striatal specific binding ratios.

A Death Case of Bulimia Nervosa Presented with Abdominal Distention

Bulimia nervosa is one of the eating disorders. Psychological manifestations of this disease, such as guilt or denial, may interfere with patient communication. The patients with bulimia nervosa are most commonly between ages of 17 and 25 years old, and often maintain normal body weight. It is not easy to screen out and diagnose bulimia nervosa patients at the emergency department. We reported two bulimia nervosa patients who visited our emergency department with abdominal distension, and one of them died of abdominal compartment syndrome. We confirmed collapse of the abdominal aorta and key arteries in enhanced abdominal computed tomography. Promptly, we performed gastrostomy for reduction of abdominal pressure, but she finally succumbed due to multiple organ failure 12 hours after the surgery.

18F-NaF PET/CT for the evaluation of temporomandibular joint disorder

AIM

To investigate the usefulness of a quantitative parameter (maximum standardised uptake value [SUVmax]) of ¹⁸F-sodium fluoride (NaF) positron-emission tomography (PET)/computed tomography (CT) for the evaluation of temporomandibular joint (TMJ) disorder (TMD).

MATERIALS AND METHODS

Seventy-six TMD patients (male: female=14:62, age=40.3±17.1 years, bilateral: unilateral=40:36) with 152 TMJs were enrolled. The ¹⁸F-NaF PET/CT parameter (SUVmax) was compared with the presence of TMJ arthralgia (arthralgic=86, non-arthralgic=66) and clinical subtypes based on the Research Diagnostic Criteria for TMD Axis I (TMD osteoarthritis=49, non-TMD osteoarthritis=67, and asymptomatic TMJ=36). Splint therapy was applied to 48 patients for 6 months without considering ¹⁸F-NaF PET/CT findings. Post-splint therapy ¹⁸F-NaF PET/CT was performed in 32 patients and clinical responses to the therapy were classified into improvement (n=33), no change (n=10), or aggravation (n=7) for 50 TMJs excluding asymptomatic TMJs (n=14).

RESULTS

SUVmax was significantly greater in arthralgic TMJs than in non-arthralgic TMJs (6.62±3.56 versus 4.32±1.53, p<0.0001). SUVmax was also significantly greater in TMD osteoarthritis (6.75±3.85) than in non-TMD osteoarthritis (5.21±2.70) and asymptomatic TMJs (4.86±1.99; p=0.0386). After splint therapy, SUVmax was significantly increased in aggravated TMJs (from 7.80±3.72 to 11.00±5.74, p=0.0156), whereas no significant change in SUVmax was observed in improved (from 6.16±2.68 to 6.09±2.60, p=0.4915) and unchanged (from 6.46±4.19 to 6.77±4.32, p=0.3223) TMJs.

CONCLUSIONS

¹⁸F-NaF PET/CT is a useful imaging tool for TMD evaluation because SUVmax showed a fair diagnostic performance for arthralgic TMJ and TMD osteoarthritis, and a correlation with the therapeutic response.

Validation of the Vectra H1 portable three-dimensional photogrammetry system for facial imaging

Three-dimensional (3D) surface imaging using stereophotogrammetry has become increasingly popular in clinical settings, offering advantages for surgical planning and outcome evaluation. The handheld Vectra H1 is a low-cost, highly portable system that offers several advantages over larger stationary cameras, but independent technical validation is currently lacking. In this study, 3D facial images of 26 adult participants were captured with the Vectra H1 system and the previously validated 3dMDface system. Using error magnitude statistics, 136 linear distances were compared between cameras. In addition, 3D facial surfaces from each system were registered, heat maps generated, and global root mean square (RMS) error calculated. The 136 distances were highly comparable across the two cameras, with an average technical error of measurement (TEM) value of 0.84mm (range 0.19-1.54mm). The average RMS value of the 26 surface-to-surface comparisons was 0.43mm (range 0.33-0.59mm). In each case, the vast majority of the facial surface differences were within a ±1mm threshold. Areas exceeding ±1mm were generally limited to facial regions containing hair or subject to facial microexpressions. These results indicate that 3D facial surface images acquired with the Vectra H1 system are sufficiently accurate for most clinical applications.

Maximum standardised uptake value of quantitative bone SPECT/CT in patients with medial compartment osteoarthritis of the knee

AIM

To evaluate the correlation between the maximum standardised uptake value (SUVmax) from bone single-photon-emission computed tomography/computed tomography (SPECT/CT) and other imaging parameters for medial compartment osteoarthritis (OA) of the knee.

MATERIALS AND METHODS

Patients (n=26; male:female=2:24; age, 55.3±5.8 years) underwent quantitative knee SPECT/CT using technetium-99m (Tc-99m) hydroxymethylene diphosphonate (HDP) before surgical operation for medial OA of the knee. SUVmax was calculated using dedicated quantitative software. Visual grades of tracer uptake on bone SPECT/CT and Kellgren-Lawrence (KL) OA scores on plain radiographs were assessed using a five-point scale. Magnetic resonance imaging (MRI) scores (n=22) and patient symptom scores were also assessed.

RESULTS

The operated knees (n=34) had a greater SUVmax than the non-operated knees (n=18) in the medial compartment (14.1±6.1 versus 5.3±4.4, p<0.0001). In the medial compartment, the SUVmax was significantly correlated with SPECT/CT visual grades (rho=0.794, p<0.0001), KL scores (rho=0.703, p<0.0001), and MRI scores (rho=0.714-0.808, p≤0.0002); however, SUVmax and other imaging parameters were not correlated with patient symptom scores (p>0.05).

CONCLUSIONS

The SUVmax of quantitative bone SPECT/CT was highly correlated with traditional imaging parameters for medial compartment OA severity of the knee. Quantitative bone SPECT/CT is a promising imaging technique for the objective assessment of knee OA.

Does serum uric acid act as a modulator of cerebrospinal fluid Alzheimer's disease biomarker related cognitive decline?

BACKGROUND AND PURPOSE

The association of serum uric acid, cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease (AD) and longitudinal cognitive decline was evaluated using the AD Neuroimaging Initiative database.

METHODS

In 271 healthy subjects, 596 mild cognitive impairment patients and 197 AD patients, serum uric acid and CSF AD biomarkers were measured at baseline, and Mini-Mental State Examination and AD Assessment Scale - Cognitive Subscale (ADAS-cog) were assessed serially (mean duration, 2.9 years). The effect of uric acid on longitudinal cognitive decline was evaluated using linear mixed effect models for Mini-Mental State Examination and ADAS-cog scores in female and male subjects separately, with possible confounders controlled (model 1). To determine the effects of uric acid independent of CSF biomarker (Aβ1-42 or tau) and to test whether the detrimental effects of CSF biomarker differ according to uric acid, CSF biomarker and its interaction with uric acid were further included in model 1 (model 2).

RESULTS

Higher levels of uric acid were associated with slower cognitive decline, particularly in the mild cognitive impairment and dementia subgroups, and more prominently in female subjects. Model 2 with CSF Aβ1-42 showed that higher levels of uric acid were associated with a slower cognitive decline and alleviated the detrimental effect of Aβ1-42 on cognitive decline. Model 2 with CSF tau showed that higher levels of uric acid alleviated the detrimental effect of tau on cognitive decline in female subjects but not in male subjects.

CONCLUSION

Higher levels of uric acid had protective effects on longitudinal cognitive decline independent of and interactively with CSF AD biomarkers.

Long-term control of diabetes in immunosuppressed nonhuman primates (NHP) by the transplantation of adult porcine islets

Pig islets are an alternative source for islet transplantation to treat type 1 diabetes (T1D), but reproducible curative potential in the pig-to-nonhuman primate (NHP) model has not been demonstrated. Here, we report that pig islet grafts survived and maintained normoglycemia for >6 months in four of five consecutive immunosuppressed NHPs. Pig islets were isolated from designated pathogen-free (DPF) miniature pigs and infused intraportally into streptozotocin-induced diabetic rhesus monkeys under pretreatment with cobra venom factor (CVF), anti-thymocyte globulin (ATG) induction and maintenance with anti-CD154 monoclonal antibody and low-dose sirolimus. Ex vivo expanded autologous regulatory T cells were adoptively transferred in three recipients. Blood glucose levels were promptly normalized in all five monkeys and normoglycemia (90-110 mg/dL) was maintained for >6 months in four cases, the longest currently up to 603 days. Intravenous glucose tolerance tests during the follow-up period showed excellent glucose disposal capacity and porcine C-peptide responses. Adoptive transfer of autologous regulatory T cells was likely to be associated with more stable and durable normoglycemia. Importantly, the recipients showed no serious adverse effects. Taken together, our results confirm the clinical feasibility of pig islet transplantation to treat T1D patients without the need for excessive immunosuppressive therapy.

Experimental demonstration of energy-chirp control in relativistic electron bunches using a corrugated pipe

The first experimental study is presented of a corrugated wall device that uses wakefields to remove a linear energy correlation in a relativistic electron beam (a "dechirper"). Time-resolved measurements of both longitudinal and transverse wakefields of the device are presented and compared with simulations. This study demonstrates the feasibility to employ a dechirper for precise control of the beam phase space in the next generation of free-electron-lasers.

52 IMPLANTATION OF TRANSGENIC BOVINE CLONED EMBRYOS DERIVED FROM TRANSFECTED CELLS BY PiggyBac TRANSPOSITION

A gene-delivery system, PiggyBac (PB) transposition, has been applied to transgene expression in mammalian cells or animals. In this study, to produce transgenic cattle, we used PB in bovine fibroblasts and then the transfected cells were microinjected into enucleated bovine oocytes to produce embryos and offspring. For this study, 2 different fluorescence genes (GFP, transcribed by constitutive promoter and RFP, transcribed by tetracycline-dependent promoter), which were flanked by PB sequences, were transfected into the bovine fetal fibroblasts by the FuGENE transfection protocol. The developmental rate of blastocysts among the cleaved embryos derived from GFP cells and doxycycline-induced RFP cells was developed at 23.1% (31/134) and 40.9% (442/1082), respectively. After transferring the GFP- or RFP-expressing blastocysts into recipient cows, pregnancies were detected by ultrasonography from both recipients of GFP or RFP. To know gene expression in fetal stage, embryonic sacs were collected surgically. The primary cells were successfully isolated from both embryonic sacs. Every cell from the GFP embryonic sac expressed GFP. When the cells from the RFP embryonic sac were treated with doxycycline, RFP was homogenously expressed. In conclusion, this study demonstrated that PB transposition could be applied to deliver genes into bovine somatic cells. Furthermore, transgenic embryos from transfected cells using the PB system were developed into blastocysts, implanted, and were able to form embryonic sacs. The PB system will be a useful method to produce transgenic cattle. This study was financially supported by IPET (grant no. 109023-05-3-CG000, 111078-03-1-CG000) and the BK21 Program for Veterinary Science.

Overview Of Process Integration Issues For Low K Dielectrics

The era of silicon Ultra-Large-Scale-Integration (ULSI) has spurred an everincreasing level of functional integration on-chip, driving a need for greater circuit density and higher performance. While traditional transistor scaling has thus far met this challenge, interconnect scaling has become the performance-limiting factor for new designs. Both interconnect resistance and capacitance play key roles in overall performance, but modeling simulations have highlighted the importance of reducing parasitic capacitance to manage crosstalk, power dissipation and RC delay. New dielectric materials with lower permittivity (k) are needed to meet this challenge. This paper summarizes the process integration and reliability issues associated with the use of novel low k materials in multilevel interconnects.

Differences in the prevalence of colorectal polyps in patients undergoing endoscopic removal of gastric adenoma or early gastric cancer and in healthy individuals

BACKGROUND AND AIMS

We compared the prevalence of adenomatous and cancerous colon polyps in patients who underwent endoscopic removal of gastric neoplasms and in healthy controls.

MATERIALS AND METHODS

This retrospective study reviewed the medical records of 186 patients with gastric neoplasms and 186 healthy subjects from January 2002 to October 2008. The gastric neoplasm group was comprised of patients undergoing endoscopic removal of gastric adenomas or early gastric cancers and serial fiberoptic colonoscopy (FCS) for checkups. The control group was comprised of subjects undergoing fiberoptic esophagogastroduodenoscopy (FEGD) and FCS for general checkup and was matched for age and sex with the gastric neoplasm group. Advanced colonic neoplasm was defined by any of the following: (1) the presence of three or more polyps; (2) polyp size at least 1.0 cm; (3) high-grade dysplasia or adenocarcinoma confirmed by histopathologic examination.

RESULTS

Of the 372 persons, colorectal polyps were detected in 124 (33.3 %), advanced colonic neoplasms in 44 (11.8 %), and adenocarcinomas in 10 (2.7 %). The overall prevalence of adenomatous or cancerous polyps ("all polyps") and the prevalence of advanced colonic neoplasms were significantly higher in the gastric neoplasm group than in the control group (all polyps: 40.9 % in the gastric neoplasm group vs. 25.8 % in the control group, P = 0.002; advanced colonic neoplasms: 15.6 % vs. 8.1 %, P = 0.025). The risk factors for all polyps were age, male sex, diabetes mellitus, and being assigned to the gastric neoplasm group, and those for advanced colonic neoplasms were age and being assigned to the gastric neoplasm group. Confining the analysis to the gastric neoplasm group, the risk factors for all polyps were identical with those for the total group; however, those for advanced colonic neoplasm were different (age vs. diabetes and hypertriglyceridemia).

CONCLUSION

Endoscopists should consider performing routine FCS in patients undergoing endoscopic removal of gastric neoplasms.

Gyrokinetic studies on turbulence-driven and neoclassical nondiffusive toroidal-momentum transport and the effect of residual fluctuations in strong E x B shear

A significant inward flux of toroidal momentum is found in global gyrokinetic simulations of ion temperature gradient turbulence, leading to core plasma rotation spin-up. The underlying mechanism is identified to be the generation of residual stress due to the k parallel symmetry breaking induced by global quasistationary zonal flow shear. Simulations also show a significant off-diagonal element associated with the ion temperature gradient in the neoclassical momentum flux, while the overall neoclassical flux is small. In addition, the residual turbulence found in the presence of strong E x B flow shear may account for neoclassical-level ion heat and anomalous momentum transport widely observed in experiments.

FDG uptake and glucose transporter type 1 expression in lymph nodes of non-small cell lung cancer

AIMS

FDG uptake in NSCLC is related to glucose transporter type 1 (Glut-1) expression. Here, we investigated the direct causal relationship between FDG uptake and Glut-1 expression to determine the role of Glut-1 in FDG uptake by malignant and benign lymph nodes (LNs).

METHODS

Fifty-five curative lung resections in 53 NSCLC patients (male:female=36:17, age=62.0+/-11.8 years) were included. Maximum standardized uptake values (maxSUVs) of LNs in preoperative whole body FDG-PET and Glut-1 immunostaining results were compared.

RESULTS

Of 316 pathologically confirmed LNs, 12.3% (39/316) were malignant, and in malignant LNs, FDG positive LNs were no different from FDG negative LNs in terms of size (15.0+/-6.7 mm vs 10.0+/-6.1mm, p>0.05), or in terms of the proportion of LNs occupied by tumor (60.0+/-28.8% vs 39.2+/-38.4%, p>0.05), but had greater percentages of Glut-1 positive cells in tumors (74.1+/-31.8% vs 22.7+/-18.7%, p<0.01), and Glut-1 staining intensities (3.4+/-0.9 vs 1.8+/-1.3, p<0.01). FDG negative malignant LNs featured cytoplasmic Glut-1 expression and adenocarcinoma. Glut-1 staining intensities were found to be significantly correlated with the maxSUVs of malignant LNs (rho=0.516, p<0.05), but the percentages of Glut-1 positive cells in tumors were not (r=0.2072, p>0.05). Analysis of FDG positive benign LNs showed that maxSUV was not correlated with degree of follicular hyperplasia, or Glut-1 expression (p>0.05).

CONCLUSIONS

Intense Glut-1 immunoreactivity was found to be proportionally related to the degree of FDG uptake by malignant LNs in NSCLC. However, the finding that Glut-1 expression in lymphoid hyperplasia showed no correlation with FDG uptake in benign LNs requires further investigation.

Molecular analysis of CYP-21 mutations for congenital adrenal hyperplasia in Singapore

BACKGROUND

Congenital adrenal hyperplasia arising from 21-hydroxylase deficiency is associated with mutations in the CYP21 gene on chromosome 6p. This is the first report on the mutational spectrum of the CYP21 gene in Singapore.

METHODS

To catalogue the mutations, ten exons of the CYP21 gene from 28 Singaporean patients were analyzed by PCR amplification and direct sequencing.

RESULTS

Common mutations in descending order were the intron 2 splice site mutation (32.7% of the alleles), the I172N mutation (23.1% of the alleles), and the R356W mutation (19.2% of the alleles). Two potentially novel mutations were discovered: (1) duplication of 111 bp from codon 21 to codon 57 (exon 1) and (2) missense mutation (L261P, exon 7). There was generally a good genotype-phenotype correlation, allowing accurate prediction of the disease severity.

Hispanic and non-Hispanic white patient pain management expectations

This study compares emergency department (ED) pain management expectations in Hispanic versus non-Hispanic white patients with painful conditions. A prospective convenience sample of patients was enrolled at a university ED. Patient expectations of pain relief were recorded on a 100-mm visual analogue scale (VAS). Surveys from 58 Hispanics and 408 non-Hispanic whites were completed and used for data analysis. Sample size was adequate to detect a minimum difference in pain relief of 13 mm. Both groups had similar chief complaints and degree of pain at presentation. Their demographics differed in age and language spoken. Mean expectations for pain relief were not significantly different (76mm [95% confidence interval (CI) 70-82] and 72mm [95% CI 70-74]) between Hispanics and non-Hispanic whites, respectively. Mean expectations of a reasonable time to wait for pain medications were also not significantly different (31 minutes [95% CI 28-33] and 33 minutes [95% CI 26-48]) between Hispanics and non-Hispanic whites, respectively.

Epidemiologic and clinical survey of Behcet's disease in Korea: the first multicenter study

The prevalence of Behcet's disease is the highest in the East Asian and the Mediterranean countries. Behcet's disease is also distributed in the Asian countries, but the nationwide survey has not been performed in Korea yet. The Korean Study Group for Behcet's Disease, founded in 1999, conducted a multicenter, retrospective survey on epidemiologic and clinical features of the patients with Behcet's disease from 20 hospitals around the nation from 1997 to 1999. Of 3,497 patients, 1,527 were classified into complete or incomplete type of Behcet's disease according to the revised Shimizu's classification. The sex ratio was 1:1.75 with the female predominance. Geographical distribution showed the highest frequency in Seoul (38.5%). Clinically, 98.8% had oral ulcers, 83.2% had genital ulcers, 84.3% had skin lesions and 50.9% had ocular lesions. As for the minor clinical manifestations, articular symptoms were the most frequent. The pathergy test showed positive in 15.4% of patients and revealed a higher positive rate in males (20.2%) than in females (12.7%). In conclusion, we performed the first multicenter study on Behcet's disease in Korea and revealed the female predominance, higher frequency of ocular lesions, and lower positivity of pathergy test in the patients.

Suboptimality in human categorization and identification

Categorization and identification decision processes were examined and compared in 4 separate experiments. In all tasks, the critical stimulus component was a line that varied across trials in length and orientation, and the optimal decision rules were always complex piecewise quadratic functions. Evidence was found that identification is mediated by separate explicit and implicit systems. In addition, a common type of suboptimality was found in both categorization and identification. In particular, observers apparently approximated the piecewise quadratic functions of the optimal decision rules with simpler piecewise linear functions. A computational model, which was motivated by a recent neuropsychological theory of category learning, successfully accounted for this suboptimal performance in both categorization and identification. The model assigns a key role to the striatum and assumes the observed suboptimality was largely due to massive convergence of visual cortical cells onto single striatal units.

Modulation of collagen-induced arthritis by IL-4 and dexamethasone: the synergistic effect of IL-4 and dexamethasone on the resolution of CIA

We investigated effects of IL-4, dexamethasone (DXM), and the combination of IL-4 and DXM, low- or high-dose, on collagen-induced arthritis (CIA) in DBA/1 mice and correlated severity of arthritis with changes in IL-10 and IFN-gamma. Compared with control mice, mice treated with IL-4 had increased IL-10 with the same degree of arthritis, whereas mice treated with high-dose DXM had decreased IL-10 and increased IFN-gamma production with less severe arthritis. Mice treated with low-dose DXM showed the absence of IL-10 and increased IFN-gamma production with a trend toward the resolution of arthritis. Mice treated with IL-4 and low-dose DXM had neither IL-10 nor IFN-gamma production but revealed less severe arthritis, compared with mice treated with low-dose DXM alone. These results suggest that the beneficial effects of high-dose DXM and the combination of IL-4 and DXM on CIA are independent of IL-10 and IFN-gamma.

The accuracy of pulse oximetry in the emergency department

The objective of this retrospective study was to identify factors affecting the accuracy of pulse oximetry in the ED. Over a 3-year period, 664 consecutive emergency department (ED) patients had simultaneous arterial blood gas (ABG) and pulse oximeter readings taken. Pulse oximeter saturations (SpO2) were compared with ABG CO-oximeter saturations (SaO2) for accuracy. Multiple variables including age, sex, hemoglobin, bicarbonate, pH, and carboxyhemoglobin (COHb) were analyzed to see if they affected SpO2 accuracy. ROC curves were used to determine the best pulse oximeter threshold for detecting hypoxia. Using multivariate analysis, COHb was the only statistically significant factor affecting the accuracy of pulse oximetry. In patients with COHb <2%, SpO2 overestimated SaO2 by more than 4% in 8.4% of cases. In patients with COHb > or = 2%, SpO2 overestimated SaO2 by more than 4% in 35% of cases. The best pulse oximetry threshold for detecting hypoxia is 92%. At this threshold, if COHb is <2%, pulse oximetry has a sensitivity of 0.92 and specificity of 0.90. If COHb is > or =2%, sensitivity is 0.74 and specificity is 0.84. For patients likely to have a COHb < 2, pulse oximetry is an effective screening tool for detecting hypoxia. However, more caution must be exercised when using pulse oximetry in patients likely to have a COHb > or = 2%.

Bilateral internal carotid artery dissection due to trivial trauma

Internal carotid artery dissection (ICAD) is a known cause of unilateral headache and focal cerebral ischemic symptoms. Other symptoms include oculosympathetic paresis, facial pain, neck pain, subjective carotid bruits, and cranial nerve deficits. Traumatic dissection has an obvious precipitating incident preceding the neurologic or visual symptoms. An ICAD that occurs spontaneously or from trivial trauma usually lacks an obvious incident and thus requires awareness of its possibility for accurate detection and treatment. Dissections arise from a defect in the internal elastic lamina allowing penetration of blood into the arterial wall. Despite its low incidence, ICAD must be considered in young to middle-aged patients who present with headache and transient cerebral or retinal ischemic symptoms. This report describes a patient who had bilateral internal carotid artery dissections following trivial trauma. The etiologies, clinical manifestations, diagnostic modalities, treatment options, and outcomes of ICAD are discussed.

Epstein-Barr virus-associated lymphoproliferative skin lesion with recurrent necrotic papulovesicles of the face

A 24-year-old man showed recurrent necrotic papulovesicles of the face. The cutaneous lesions started with erythema, followed by vesicles, necrosis, and crusting, and leaving depressed scars. Light avoidance did not prevent the development of the lesions. Histologic examination revealed lymphoproliferative lesions confined to the skin. Latent Epstein-Barr virus (EBV) infection was detected in the lymphoid cells from the skin lesions by in situ hybridization. A moderate to high dosage of corticosteroids suppressed the development of new skin lesions, but relapses occurred when these systemic corticosteroids were tapered.

Relation of salivary cotinine to blood pressure in middle-aged cigarette smokers

BACKGROUND

In laboratory research, nicotine administration is associated with increases in blood pressure. In epidemiologic research, however, the amount of reported cigarette smoking has no consistent relation with blood pressure. The objective of this study was to examine the relation of a nicotine metabolite (salivary cotinine) to systolic and diastolic blood pressure in current smokers being screened for entry to a clinical trial.

METHODS AND RESULTS

Data were obtained from 5164 middle-aged cigarette smokers during screening for the Lung Health Study. Multiple linear regression was used to examine the association of salivary cotinine and number of cigarettes smoked per day to systolic and diastolic blood pressure with age, body mass, years of education, alcohol intake, and recent caffeinated beverage use controlled in all analyses. Although smoking frequency was unrelated to blood pressure, salivary cotinine was related to greater systolic blood pressure in both men and women and greater diastolic blood pressure in men.

CONCLUSIONS

The association between salivary cotinine and blood pressure in these analyses suggests that long-term nicotine exposure may be related to modest elevations in blood pressure in cigarette smokers.

Neuroanatomical correlates to central deafness

Our research experience with five centrally deaf patients showed that damage to various anatomical sites could result in central deafness. This finding was contrary to the commonly held notion that both Heschl's gyri must be severely damaged to yield central deafness. To discover whether lesions in various brain areas could cause central deafness, we reviewed 33 cases of central deafness reported in the literature which had sufficient radiological data to determine the anatomical regions involved. Both Heschl's gyri were involved in the majority of these cases, but there were definite exceptions. In these exceptional cases of central deafness, subcortical areas were involved (usually the internal capsule), as was the insula. Overall findings are discussed and recommendations are offered for the future study of centrally deaf patients.

Early and late weight gain following smoking cessation in the Lung Health Study

The authors examine weight gains associated with smoking cessation in the Lung Health Study (1986-1994) over a 5-year follow-up period. A cohort of 5,887 male and female smokers in the United States and Canada, aged 35-60 years, were randomized to either smoking intervention or usual care. Among participants who achieved sustained quitting for 5 years, women gained a mean of 5.2 (standard error, 5.0) kg in year 1 and a mean of 3.4 (standard error, 5.5) kg in years 1-5. Men gained a mean of 4.9 (standard error, 4.9) kg in year 1 and a mean of 2.6 (standard error, 5.8) kg in years 1-5. In regression analyses, smoking-change variables were the most potent predictors of weight change. Participants going from smoking to quit-smoking in a given year had mean weight gains of 2.95 kg/year (3.61%) in men and 3.09 kg/year (4.69%) in women. Over 5 years, 33% of sustained quitters gained > or = 10 kg compared with 6% of continuing smokers. Also among sustained quitters, 7.6% of men and 19.1% of women gained > or = 20% of baseline weight; 60% of the gain occurred in year 1, although significant weight gains continued through year 5. The average gains and the high proportions of sustained and intermittent quitters who gained excessive weight suggest the need for more effective early interventions that address both smoking cessation and weight control.

Turbulent transport reduction by zonal flows: massively parallel simulations

Three-dimensional gyrokinetic simulations of microturbulence in magnetically confined toroidal plasmas with massively parallel computers showed that, with linear flow damping, an asymptotic residual flow develops in agreement with analytic calculations. Nonlinear global simulations of instabilities driven by temperature gradients in the ion component of the plasma support the view that turbulence-driven fluctuating zonal flows can substantially reduce turbulent transport. Finally, the outstanding differences in the flow dynamics observed in global and local simulations are found to be due to profile variations.

The incidence of IDDM in Singapore children

OBJECTIVE

To determine the incidence of insulin dependent diabetes mellitus (IDDM) in children 0-12 years of age in Singapore, which has a population of 2.9 million.

METHODS

The primary source was a 2-year phone and mail survey of doctors in the government and government restructured hospitals and the private sector. The secondary source was the membership records of the Diabetes Society of Singapore.

RESULTS

Using the capture-recapture method, ascertainment was assessed to be 92.2% complete. The age standardised incidence rate was 2.46 per 100,000 children 0-12 years old, for the period 1992-1994 (95% confidence interval: 2.16-2.75). The data seemed to indicate a rising incidence of IDDM in this population, being 1.4/100,000 in 1992, 2.4/100,000 in 1993 and 3.8/100,000 in 1994. The male: female ratio is 1:1.85. There was seasonal variation with fewer cases from July to October and more from November to May. Five percent of patients had a first degree relative with IDDM. Malays appeared to have a lower incidence (1.23/100,000) compared to the Chinese (2.25/100,000) and the Indians (5.78/100,000).

CONCLUSIONS

The incidence of IDDM in Singapore children is similar to that reported for Hong Kong and Japan, but higher than that for Shanghai. The female preponderance is similar to that seen in other Asian population. The data suggests a rising incidence of IDDM in Singapore and differences in incidence between the Malays, Chinese and Indians, but further observations are needed.

Olfactory dysfunction in patients with head trauma

BACKGROUND

The ability to smell is commonly altered by head trauma (HT). However, the nature, prevalence, prognosis, and etiology of such alterations are poorly understood.

OBJECTIVES

To quantitatively determine the degree of olfactory function in patients with HT-related chemosensory complaints and to examine the influences of age, sex, HT severity, time since HT, and other variables on such function. Also, to use quantitative magnetic resonance imaging (MRI) to establish whether and to what degree damage to the olfactory bulbs and tracts, frontal lobes, and temporal lobes occurs.

PATIENTS AND METHODS

Two hundred sixty-eight patients with HT from the University of Pennsylvania Smell and Taste Center, Philadelphia, were administered a quantitative odor identification test, a depression inventory, and a medical history questionnaire; 66 were retested after individual test-retest periods ranging from 1 month to 13 years. The volume of olfactory-related brain structures was determined in 15 patients and 15 controls using MRI.

RESULTS

One hundred seventy-nine patients (66.8%) had anosmia, 55 (20.5%) had microsmia, and 34 (12.7%) had normosmia. Frontal impacts produced less dysfunction than back or side impacts. Of the 66 retested patients, 24 (36%) improved slightly, 30 (45%) had no change, and 12 (18%) worsened; only 3 patients, none of whom initially had anosmia, regained normal olfactory function. Trauma severity was related to olfactory test scores in patients with microsmia. Parosmia prevalence decreased from 41.1% to 15.4% over an 8-year posttrauma period. Olfactory bulb and tract volumes of male, but not female, patients with HT were greatly reduced relative to volumes of controls.

CONCLUSIONS

Patients complaining of HT-related olfactory dysfunction typically have anosmia and rarely regain normal olfactory ability, parosmia prevalence decreases over time in such patients, and damage to olfaction-related brain structures can be observed in most such patients using an appropriate MRI protocol.

Conventional and maximum length sequences middle latency response in patients with central nervous system lesions

Conventional and maximum length sequence (MLS) middle latency response (MLR) procedures were compared across several parameters for control patients and patients with central nervous system lesions. There were similar findings for both populations and both types of MLR for the absolute latencies of Na and Pa waves. Middle latency waves were absent more often in the neurologic than control subjects for both the conventional and MLS-MLR procedures. Overall, more MLR waves were present for the MLS technique than for the conventional MLR technique. Differences in wave amplitude were significant for several recording sites when comparing neurologic with control groups, but findings were similar for wave amplitude when comparing the two types of MLR procedures for the neurologic population. Based on these findings, no clear diagnostic advantage was shown for using the MLS-MLR technique. These findings are further discussed.

A recent case of congenital malaria in Singapore

We report a case of congenital malaria in a 2-month-old baby girl, born in Singapore of a Singaporean mother, who presented with fever for one week, gross hepatosplenomegaly and anaemia (haemoglobin 5.6 g/dL) and thrombocytopenia. Peripheral blood films showed Plasmodium vivax. There was no local transmission at that time, but the mother had spent the first 6 months of her pregnancy in Pakistan, where she had been treated for prolonged fever at 4 months amenorrhoea with ibuprofen alone. The mother and 2 siblings were asymptomatic and repeatedly tested negative on blood films for malaria parasites, but the mother tested positive for antibodies to Plasmodium on the Fluorescent Antibody Test. The child was treated with oral chloroquine and made an uneventful recovery. We postulate that this is believed to be the first recent case of congenital malaria in Singapore since it was declared malaria free in 1982. The diagnosis should be considered in babies of mothers who have travelled to places where malaria is endemic, as maternal infection may be unrecognised, and the child may be asymptomatic at birth.

Methacholine reactivity predicts changes in lung function over time in smokers with early chronic obstructive pulmonary disease. The Lung Health Study Research Group

As part of a clinical trial of early intervention in chronic obstructive pulmonary disease (COPD) (the Lung Health Study), 5,733 smokers with mild to moderate airflow obstruction underwent methacholine challenge tests at baseline. All participants were randomized to receive either usual care (no intervention) or special intervention, consisting of intensive smoking cessation counseling and the prescription of a metered-dose inhaler containing either ipratropium bromide or placebo (two inhalations three times daily). For this report, we analyzed the relationship between baseline methacholine reactivity and subsequent change in lung function. Methacholine reactivity was expressed as a logarithmic function of the two-point slope of percent decline in FEV1 over the concentration of methacholine (LMCR). Using a random effects linear model, LMCR was found to be a strong predictor of change in FEV1% predicted, after controlling for baseline lung function, age, sex, baseline smoking history, and changes in smoking status. Significant interactions were found between reactivity and smoking behavior. In the first year, participants who quit smoking showed improvement in FEV1, whereas continuing smokers showed worsening, and between Years 1 and 5, lung function declined to a greater extent in continuing smokers than in sustained quitters. For both time periods, these quitter/smoker differences increased as a function of airway reactivity. These findings indicate that methacholine reactivity is an important predictor of progression of airway obstruction in continuing smokers with early COPD, independent of the baseline level of obstruct.

Development of the 12-item Cross-Cultural Smell Identification Test (CC-SIT)

The development of the 12-item Cross-Cultural Smell Identification Test (CC-SIT), based upon items from the University of Pennsylvania Smell Identification Test (UPSIT), is described. In developing this test, the authors initially selected UPSIT items that are familiar to most persons from North American, European, South American, and Asian cultures. The CC-SIT was then administered to 198 people ranging in age from 5 to 96 years, and the the test scores were compared to analogous items from UPSITs administered to 198 age-, sex-, race-, and smoking-habit-matched control subjects. Since the pattern of test scores did not differ for the two groups, the authors developed normative data for the 12-item test using equivalent UPSIT items sampled from a database containing UPSIT scores for 3760 subjects. Norms are provided for determining the percentile ranks of a given patient's score as a function of age and gender. The CC-SIT provides, for the first time, a self-administered means for reliably assessing olfactory function in less than 5 minutes.

The auditory brain stem response in patients with brain stem or cochlear pathology

OBJECTIVE

The purpose of this study was to determine the value, based on true-positive and false-positive rates, of various auditory brain stem response (ABR) indices in discriminating patients with brain stem lesions from patients with cochlear lesions.

DESIGN

A factorial design was used in this retrospective study. Receiver operating characteristics (ROC) curves were constructed to analyze the performance of 32 patients with brain stem lesions and 33 patients with cochlear involvement for the absolute latency of wave V; the I-III, III-V, and I-V interwave intervals; the interaural latency difference and the V/I amplitude ratio. Analyzed in the same manner were four combinations of ABR indices.

RESULTS

Based on the ROC curves, the clinically most valuable index was the I-V interval, but overall the individual indices showed only moderate sensitivity to brain stem pathology. By combining several indices, the sensitivity to brain stem involvement was improved. However, as expected, the overall false-positive rate also increased.

CONCLUSIONS

There is a diagnostic advantage to using more than one ABR index in evaluating patients suspected of having brain stem involvement.

A study of the test-retest reliability of ten olfactory tests

Ten tests of olfactory function (including tests of odor identification, detection, discrimination, memory, and suprathreshold odor intensity and pleasantness perception) were administered on two test occasions to 57 subjects ranging in age from 18 to 83 years. The stability of the average test scores was determined across the two test sessions for 14 measures derived from these 10 tests and for subcomponents of the Japanese T&T olfactometer threshold test. In addition, the test-retest reliability (Pearson r) of each test measure was established. With the exception of a response bias measure, the average test scores did not differ significantly across the two test sessions. Statistically, the reliability coefficients of the primary test measures fell into three general classes bound by the following r values: 0.43-0.53; 0.67-0.71; 0.76-0.90. Detection threshold values were more reliable than recognition threshold values; those based upon a single ascending presentation series were much less reliable than those based upon a staircase procedure. The relationship between test length and reliability was examined for several of the tests and mathematically modeled. For example, within the staircase series incorporating the odorant phenyl ethyl alcohol, reliability was related (R2 = 0.984) to the number of reversals included in the threshold estimate by a function derived from the Spearman-Brown formula; namely, reliability = 0.455* # reversals/[1 + 0.455 (# reversals - 1)]. Reversal location, per se, had little influence on reliability. Overall, this study suggests that (i) considerable variation is present in the reliability of olfactory tests, (ii) reliability is a function of test length, and (iii) caution is warranted in comparing results from nominally different olfactory tests in applied settings since the findings may, in some instances, simply reflect the differential reliability of the tests.

Social support for smoking cessation and abstinence: the Lung Health Study. Lung Health Study Research Group

This article evaluates the relationship of social support to smoking cessation and continued abstinence of 3923 men and women with mild to moderate airway obstruction in the Lung Health Study. At both the end of a 12-week group program and after 1 year, men but not women who were supported in quitting were more likely to be successful. Married status facilitated quitting but was less strongly related to long-term abstinence. Participants supported by an ex-smoker who had attended the group program with them were very likely not smoking after 1 year (men, 74.7%; women, 72.4%). Participants supported by a smoker were less than half as likely to have achieved abstinence after 1 year but still had cessation rates greater than 30%. The nature of these relationships has implications for the distinction between women and men in studies of social support and for intervention strategies. Support people should be included in cessation intervention programs. Spouse involvement, however, is more evidently useful for men than for women.

Spirometry in the Lung Health Study: II. Determinants of short-term intraindividual variability

The Lung Health Study (LHS) is a randomized clinical trial designed to determine whether a smoking intervention program and use of an inhaled bronchodilator (BD) can reduce the rate of decline of FEV1 in cigarette smokers with airflow limitation. During recruitment, spirometry was performed at second and third screening visits, a mean of 21 d apart. A total of 5,887 smokers, 35 to 60 yr of age and of whom 63% were men, met the study eligibility requirements. Smokers taking physician-prescribed BDs or with an FEV1 < 50% or > 90% predicted were excluded, as were those whose FEV1/FVC ratio was greater than 70%. Two inhalations of isoproterenol were given to determine BD response during the second visit. A serial dilution methacholine challenge test was done during the third visit to determine nonspecific airway reactivity. Ninety-five percent of the differences between FEV1 measured at the two visits were within 240 ml for women and within 320 ml for men (coefficients of repeatability). The best independent predictors of the mean short-term (between visit) intraindividual FEV1 variability were factors indicating intrinsic airway reactivity of the participants: bronchodilator response, methacholine reactivity, and the presence of wheezing; as well as factors influenced by the quality of spirometry testing: the difference between the highest and second highest FEV1s and peak flows during baseline spirometry, and the time to reach peak flow (PEFT).

Gender difference in airway hyperresponsiveness in smokers with mild COPD. The Lung Health Study

Methacholine bronchoprovocation challenge testing was successfully completed in 5,662 participants (3,556 men and 2,106 women) at the time they were randomized into the Lung Health Study, a multicenter trial designed to evaluate early intervention in chronic obstructive pulmonary disease (COPD). All participants were smokers between the ages of 35 and 60 yr who had mild COPD. The male:female prevalence of a positive challenge (PC20FEV1) was 25%:48% and 63%:87% at a PC20FEV1 of < or = 5 mg/ml (AHR5) and < or = 25 mg/ml (AHR25), respectively. This analysis explores these marked gender differences in airway hyperresponsiveness (AHR). Relative risks (RR) for predictors of AHR and the 95% confidence intervals (95% CI) were estimated using semiparametric Cox proportional-hazards models. The initial model controlled for age, gender, smoking history, height, and weight. The RR (95% CI) for female gender was 1.75 (1.60, 1.92). When the measured baseline FEV1 was added to the model as a surrogate for airway caliber, the RR for female gender decreased to 1.06 (0.96, 1.18). Thus, in this population of middle-aged smokers with mild COPD, the high prevalence of AHR appears to be associated with a decrease in airway caliber. The higher prevalence of AHR noted in women is due to their having a smaller airway caliber than their male counterparts.

Categorization response time with multidimensional stimuli

Categorization response time (RT) was examined in three separate experiments, in each of which exemplars varied on two physical dimensions. Three different types of stimuli were used: (1) horizontal and vertical line segments of varying length that were joined at an upper left corner, (2) rectangles of varying width and height, and (3) circles or semicircles of varying size with a radial arm of varying orientation. No evidence was found that stimulus familiarity or the category prototypes played any special role in determining categorization RT. Instead, RT decreased with distance from the stimulus to the categorization decision bound.

An experimental technique for estimating regional myocardial segment work in vivo

We determined the capabilities and limitations of an experimental approach to measure segment work (force x distance) of myocardial regions in the in vivo beating heart. In 18 open-chest anesthetized dogs, segment length was measured using ultrasonic dimension transducers, and developed force was measured with miniature force transducers. Work was defined as the integrated multiples of instantaneous force and shortening during a single (averaged) beat, corresponding to the area under the length-force loop. Changes in work over a range of 9.78 x 10(-4) to 2.93 x 10(-2) J/g/min were produced by vena caval constriction, aortic constriction, atrial pacing, and isoproterenol (0.5 and 1.0 micrograms/kg/min). Work was measured in both major and minor axes. In 60% of the animals, work in the minor axis was 9.2-fold greater than in the major axis. In the others, all interventions changed regional work to the same extent in both axes (r = 0.802; p < 0.05). Work changes were also compared between the base, anterior, and posterior walls. The response was directionally similar in all regions, ranging from -79 +/- 1% during caval occlusion to 278 +/- 98% during isoproterenol. The effective size of the measured muscle mass was limited to the transducer area because the amplitude and pattern of both force development and segment shortening were not changed until deep myocardial cuts were as close as 2 mm from the measuring area. We conclude that work measurement in the minor axis is quantitatively representative of fiber work in that region.

Enterogenous cyst of the fourth ventricle: case report

The authors present an intracranial enterogenous cyst of the fourth ventricle in a Chinese woman having symptoms of headache, dizziness and vertigo for approximately six months. A computerized tomography study of the brain disclosed a low density lesion within the fourth ventricle. A cystic tumor was completely removed and a histopathological examination diagnosed it is an enterogenous cyst; a rare lesion. During the post-operative follow-up, her symptoms gradually resolved and she was free of complaints within two years.

The lung health study: airway responsiveness to inhaled methacholine in smokers with mild to moderate airflow limitation. The Lung Health Study Research Group

As part of a multicenter clinical trial (Lung Health Study), methacholine inhalation challenge testing was performed in 5,877 current cigarette smokers, ages 35 to 59 yr (mean 48.5 +/- 6.8 yr), with borderline to moderate airflow limitation (FEV1/FVC ratio 63.0 +/- 5.5). The test was successfully completed in 96.4% of subjects, of whom 63% were male and 95.9% were white. Symptomatic reactions to methacholine were rarely severe enough to require evaluation by a trial physician. Nonspecific airways hyperresponsiveness (AHR) was defined as a greater than or equal to 20% decline in FEV1 from the post-diluent control value after inhalation of less than or equal to 25 mg/ml methacholine. AHR was noted in a significantly higher percentage of women (85.1%) than men (58.9%). Moreover, nearly twice as many women as men (46.6 and 23.9%, respectively) responded to less than or equal to 5 mg/ml of methacholine. In both men and women, baseline degree of airways obstruction and clinical center were strongly associated with AHR (p less than 0.001), whereas age was not. Additional associations with AHR were analyzed in men and women separately using logistic regression after adjustment for baseline lung function, age, and center-to-center differences. In men, AHR was significantly related to symptoms of wheeze, chronic cough and/or sputum, and a history of asthma or hay fever (p less than 0.004), but not to current or lifetime tobacco use. By contrast, among women, AHR was not significantly associated with chronic cough and/or phlegm (p greater than 0.05) or a past history of asthma or hay fever (p greater than 0.1) and was only weakly related to wheeze and current asthma (p = 0.04), as well as to cigarette pack-years (p = 0.044). These results indicate that most continuing smokers with functional evidence of early chronic obstructive pulmonary disease have nonspecific AHR that is strongly related to gender and baseline lung function and, to a lesser extent, to respiratory symptoms. The reason for the striking effect of gender on AHR in early chronic obstructive pulmonary disease is unclear but cannot be attributed to male-female differences in age, cigarette use, presence of asthma, or baseline degree of airflow obstruction.

Structure-activity relationships for tumour radiosensitization by analogues of nicotinamide and benzamide

Nicotinamide has been shown in our laboratory and those of other investigators to be an effective radiosensitizer of a variety of mouse tumours, while producing little or no radiosensitization of normal tissues. Its mechanism of action is different from classical electron-affinic compounds and appears to be the result of improved tumour oxygenation. In this study we have synthesized 29 analogues of nicotinamide and benzamide and characterized them for their tumour radiosensitization and acute toxicity in mice. The data show that a wide range of additions to the nicotinamide and benzamide ring produce tumour radiosensitization similar to that produced by equimolar doses of misonidazole, but that substitutions of the amide tend to reduce radiosensitization. Other structure-activity relationships are evident. Although some compounds produce similar tumour radiosensitization to nicotinamide at equimolar doses, and are comparably low in acute toxicity, none appears sufficiently superior to supplant nicotinamide itself as a candidate for clinical trials. Thus these data provide evidence that nicotinamide, because of the extensive experience with its use in man, is likely to be the best drug in the benzamide-nicotinamide series for development as a radiosensitizer of human tumours.

Predicting similarity and categorization from identification

In this article, the relation between the identification, similarity judgment, and categorization of multidimensional perceptual stimuli is studied. The theoretical analysis focused on general recognition theory (GRT), which is a multidimensional generalization of signal detection theory. In one application, 2 Ss first identified a set of confusable stimuli and then made judgments of their pairwise similarity. The second application was to Nosofsky's (1985b, 1986) identification-categorization experiment. In both applications, a GRT model accounted for the identification data better than Luce's (1963) biased-choice model. The identification results were then used to predict performance in the similarity judgment and categorization conditions. The GRT identification model accurately predicted the similarity judgments under the assumption that Ss allocated attention to the 2 stimulus dimensions differently in the 2 tasks. The categorization data were predicted successfully without appealing to the notion of selective attention. Instead, a simpler GRT model that emphasized the different decision rules used in identification and categorization was adequate.