The International Personality Disorder Examination. The World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration international pilot study of personality disorders

BACKGROUND

One of the aims of the World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration joint program on psychiatric diagnosis and classification is the development and standardization of diagnostic assessment instruments for use in clinical research worldwide. The International Personality Disorder Examination (IPDE) is a semistructured clinical interview compatible with the International Classification of Diseases, Tenth Revision, and the DMS-III-R classification systems. This is the first report of the results of a field trial to investigate the feasibility of using the IPDE to assess personality disorders worldwide.

METHODS

The IPDE was administered by 58 psychiatrists and clinical psychologists to 716 patients enrolled in clinical facilities at 14 participating centers in 11 countries in North America, Europe, Africa, and Asia. To determine interrater reliability, 141 of the IPDEs (20%) were independently rated by a silent observer. To determine temporal stability, 243 patients (34%) were reexamined after an average interval of 6 months.

RESULTS

The IPDE proved acceptable to clinicians and demonstrated an interrater reliability and temporal stability roughly similar to instruments used to diagnose the psychoses, mood, anxiety, and substance use disorders.

CONCLUSION

It is possible to assess personality disorders with reasonably good reliability in different nations, languages, and cultures using a semistructured clinical interview that experienced clinicians find relevant, meaningful, and user-friendly.

Effect of nitroglycerin on cerebral circulation measured by transcranial Doppler and SPECT

We used a combination of transcranial Doppler ultrasonography and single-photon emission computed tomography to noninvasively assess changes in the diameter of the middle cerebral artery induced by sublingual nitroglycerin in 10 healthy subjects. Nitroglycerin reduced mean blood flow velocities without concurrently changing regional cerebral blood flow in the perfusion territory of this vessel. Our results strongly suggest that nitroglycerin causes vasodilatation of the basal intracranial arteries.

Effect of pre- vs postoperative inguinal field block on postoperative pain after herniorrhaphy

The analgesic effects of an identical inguinal field block, performed before or immediately after inguinal herniorrhaphy, were evaluated in 32 healthy patients in a double-blind, randomized study. During surgery, all patients received a light general anaesthesia with thiopentone, alfentanil and nitrous oxide in oxygen. After induction of general anaesthesia, patients were allocated randomly to receive an inguinal field block with lignocaine, either 15 min before operation or immediately after operation, after closure of the surgical wound, but before the patients were awake. Pain score on a visual analogue scale and on a verbal scale at rest, during mobilization from supine into sitting position and during cough was assessed 1, 2, 4, 6, 8 and 24 h, and 7 days after operation. No significant differences between the groups were observed in VAS scores or verbal pain scores during rest or ambulation at any time. There was no significant difference in time to first request for morphine or total morphine consumption. These results do not show pre-emptive analgesia with a conventional inguinal field block to be of clinical importance compared with a similar block administered after operation.

A new X linked recessive deafness syndrome with blindness, dystonia, fractures, and mental deficiency is linked to Xq22

X linked recessive deafness accounts for only 1.7% of all childhood deafness. Only a few of the at least 28 different X linked syndromes associated with hearing impairment have been characterised at the molecular level. In 1960, a large Norwegian family was reported with early onset progressive sensorineural deafness, which was indexed in McKusick as DFN-1, McKusick 304700. No associated symptoms were described at that time. This family has been restudied clinically. Extensive neurological, neurophysiological, neuroradiological, and biochemical, as well as molecular techniques, have been applied to characterise the X linked recessive syndrome. The family history and extensive characterisation of 16 affected males in five generations confirmed the X linked recessive inheritance and the postlingual progressive nature of the sensorineural deafness. Some obligate carrier females showed signs of minor neuropathy and mild hearing impairment. Restudy of the original DFN-1 family showed that the deafness is part of a progressive X linked recessive syndrome, which includes visual disability leading to cortical blindness, dystonia, fractures, and mental deficiency. Linkage analysis indicated that the gene was linked to locus DXS101 in Xq22 with a lod score of 5.37 (zero recombination). Based on lod-1 support interval of the multipoint analysis, the gene is located in a region spanning from 5 cM proximal to 3 cM distal to this locus. As the proteolipid protein gene (PLP) is within this region and mutations have been shown to be associated with non-classical PMD (Pelizaeus-Merzbacher disease), such as complex X linked hereditary spastic paraplegia, PLP may represent a candidate gene for this disorder. This family represents a new syndrome (Mohr-Tranebjaerg syndrome, MTS) and provides significant new information about a new X linked recessive sydromic type of deafness which was previously thought to be isolated deafness.

A comparison of transcranial Doppler and cerebral blood flow studies to assess cerebral vasoreactivity

BACKGROUND AND PURPOSE

The aim of this study was to determine the ability of transcranial Doppler ultrasonography when used to assess cerebral vasoreactivity. The results of this method were compared with regional cerebral blood flow measurements.

METHODS

Forty-three patients with symptoms suggesting cerebrovascular disease took part. Transcranial Doppler findings in the middle cerebral arteries were compared with regional cerebral blood flow in the corresponding perfusion territories before and after acetazolamide administration.

RESULTS

There was a significant positive correlation between the absolute increase in cerebral blood flow in milliliters per 100 g per minute and the percent increase in velocity (r = 0.63). The right-left, side-to-side difference of the acetazolamide response obtained by the two methods also showed a positive correlation (r = 0.80). Control limits obtained from healthy subjects were used for both the blood flow increase (absolute values and asymmetry in absolute values) and the velocity increase (percent increase and asymmetry in percent increase). The two methods then agreed in their evaluation of vasoreactivity in 74 (86%) of the 86 middle cerebral artery perfusion territories; 20 (23%) were assessed by both methods as having a reduced vasodilatory reserve. Eleven hemispheres with a slightly reduced regional cerebral blood flow response to acetazolamide were not detected by transcranial Doppler, whereas all territories with a marked reduction were identified by Doppler. Only one hemisphere with a normal cerebral blood flow increase after acetazolamide administration was assessed by Doppler as having reduced vasoreactivity.

CONCLUSIONS

Transcranial Doppler and the acetazolamide test may be used in clinical situations to assess cerebral vasoreactivity.

Effect of acetazolamide on cerebral artery blood velocity and regional cerebral blood flow in normal subjects

The effect of intravenous acetazolamide 1 g on cerebral artery blood velocity and regional blood flow (rCBF) was investigated in eight normal subjects. Blood velocity was measured with 2 MHz pulsed Doppler in the proximal segments of the middle, anterior and posterior cerebral artery (MCA, ACA, and PCA) and in the distal extracranial internal carotid artery (ICA). The rCBF in the regions of interest tentatively corresponding to the perfusion territories of these vessels was estimated using 133Xe inhalation and a rapidly rotating single photon emission computer tomograph. Both blood velocity and rCBF increased after acetazolamide. There was no significant difference between the percentage ICA blood velocity increase (22 +/- 12%) and the percentage rCBF increase in the ICA region of interest (25 +/- 9%). In the MCA, ACA, and PCA, however, blood velocity increased more (mean increase 36-42%) than the rCBF in the corresponding regions of interest (mean increase 24-26%). These differences were highly significant suggesting a direct and site specific effect of acetazolamide in narrowing the lumen of the proximal MCA, ACA, and PCA, but not of the extracranial ICA. We also propose that the effect of acetazolamide induces reciprocal changes in the extent of adjacent perfusion territories in individual brain hemispheres. Data compiled from all subjects investigated at two very different perfusion levels (before and after acetazolamide) revealed a significant positive correlation between blood velocity and rCBF.

Blood velocity and regional blood flow in defined cerebral artery systems

Cerebral artery blood velocity and regional blood flow (rCBF) were investigated in 17 normal subjects. Blood velocity was measured with 2 MHz pulsed Doppler ultrasound in the proximal segments of the middle, anterior and posterior cerebral artery (MCA, ACA, and PCA) and in the distal extracranial internal carotid artery (ICA). The rCBF in the regions of interest tentatively corresponding to the perfusion territories of these vessels was estimated using 133Xe inhalation and a rapidly rotating single photon emission computer tomograph. Concomitant capnograph recordings showed that the end-expiratory pCO2 was higher during the rCBF than during the blood velocity examinations. This differences was highly significant. While there was no significant correlation between blood velocity and rCBF when these clear differences in pCO2 were disregarded, we did find significant positive correlations when the data were normalized to a standard pCO2 (5.3 kPa) using accepted formulas. The best correlation was found for the MCA (r = 0.630, p less than 0.001) and the PCA (r = 0.73, p less than 0.001), with a lower correlation in the ACA (r = 0.49, p less than 0.01) and the ICA (r = 0.41, p less than 0.05). The estimated blood velocity (V) given rCBF = 0 was not significantly different from 0. The results support the validity of expressing the relationship between blood velocity (V) and rCBF in defined cerebral artery systems as: V = 1/60 (rCBF) T (A)-1, where A represents the area of the lumen of the vessel segment where the velocity is being measured, and T denotes the size of the brain region being perfused from this artery.

A comparison of regional cerebral blood flow and middle cerebral artery blood flow velocities: simultaneous measurements in healthy subjects

Blood flow velocities were measured in both middle cerebral arteries (MCAs) of 36 healthy subjects using transcranial Doppler ultrasound. Measurements were first made using a hand-held probe. Velocities were then studied bilaterally with fixed probes under resting conditions and during simultaneous regional CBF (rCBF) measurements. A significant (p < 0.05) positive correlation was found between MCA flow velocities and rCBF in the estimated perfusion territory of this artery. The correlation coefficient was highest when the measurements were performed simultaneously (p < 0.001) or when velocities recorded with a hand-held probe were adjusted to take into account the significant velocity increase induced by the CBF study situation. The increased velocities during CBF measurements cannot be fully explained by the moderate but significant PCO2 increase. Other possible mechanisms are increased blood flow due to mental activation or MCA vasoconstriction secondary to stimulation of the sympathetic nervous system. The effect of mental activation and PCO2 differences should therefore be considered when comparing the results of repeated velocity and CBF measurements.

Cerebral vasoreactivity assessed with transcranial Doppler and regional cerebral blood flow measurements. Dose, serum concentration, and time course of the response to acetazolamide

BACKGROUND AND PURPOSE

To improve the assessment of cerebral vasoreactivity using acetazolamide (ACZ), we studied the time course of the response and the relationship between dose, response, and serum concentration.

METHODS

Blood flow velocities were measured with the use of transcranial Doppler ultrasonography in one of the middle cerebral arteries of 48 healthy subjects after the intravenous administration of 1 to 1.6 g ACZ. In 34 subjects (group 1), velocities were measured every second minute to detect the maximum middle cerebral artery velocity increase. We also measured regional cerebral blood flow using single-photon emission computed tomography in 27 of the subjects in group 1 before and approximately 15 to 20 minutes after the ACZ injection. The serum concentration of ACZ was measured in 15 subjects. In the remaining 14 subjects (group 2), middle cerebral artery velocity measurements were made 10, 25, 30, and 45 minutes after ACZ administration to obtain information regarding the late time course of the response.

RESULTS

In group 1 the plateau phase of the velocity response was reached 8 to 15 minutes after ACZ administration. A large range of velocity increase was observed, and a significant correlation was found between the maximum velocity increase and the dose and serum concentration of ACZ. In group 2 subjects, maximum velocities were maintained 30 minutes after the injection, but after 45 minutes velocities had decreased to 68% of their highest level. No significant relationship was found between dose or serum concentration of ACZ and the regional cerebral blood flow increase. The velocity increase after ACZ was similar in both older and younger subjects.

CONCLUSIONS

This study shows that cerebral vasoreactivity is best assessed 10 to 30 minutes after ACZ administration and that the dose should probably exceed 15 mg/kg if a maximum vasodilatory response in the cerebral circulation is to be obtained.

Dual redundant sequencing strategy: Full-length gene characterisation of 1056 novel and confirmatory HLA alleles

The high‐throughput department of DKMS Life Science Lab encounters novel human leukocyte antigen (HLA) alleles on a daily basis. To characterise these alleles, we have developed a system to sequence the whole gene from 5′‐ to 3′‐UTR for the HLA loci A, B, C, DQB1 and DPB1 for submission to the European Molecular Biology Laboratory – European Nucleotide Archive (EMBL‐ENA) and the IPD‐IMGT/HLA Database. Our workflow is based on a dual redundant sequencing strategy. Using shotgun sequencing on an Illumina MiSeq instrument and single molecule real‐time (SMRT) sequencing on a PacBio RS II instrument, we are able to achieve highly accurate HLA full‐length consensus sequences. Remaining conflicts are resolved using the R package DR2S (Dual Redundant Reference Sequencing). Given the relatively high throughput of this strategy, we have developed the semi‐automated web service TypeLoader, to aid in the submission of sequences to the EMBL‐ENA and the IPD‐IMGT/HLA Database. In the IPD‐IMGT/HLA Database release 3.24.0 (April 2016; prior to the submission of the sequences described here), only 5.2% of all known HLA alleles have been fully characterised together with intronic and UTR sequences. So far, we have applied our strategy to characterise and submit 1056 HLA alleles, thereby more than doubling the number of fully characterised alleles. Given the increasing application of next generation sequencing (NGS) for full gene characterisation in clinical practice, extending the HLA database concomitantly is highly desirable. Therefore, we propose this dual redundant sequencing strategy as a workflow for submission of novel full‐length alleles and characterisation of sequences that are as yet incomplete. This would help to mitigate the predominance of partially known alleles in the database.

Cluster headache: transcranial Doppler ultrasound and rCBF studies

Transcranial Doppler and rCBF examinations were carried out in 25 cluster headache patients. Spontaneous and glyceryl trinitrate (nitroglycerin) provoked attacks were accompanied by a bilateral decrease in middle cerebral artery blood flow velocities. This decrease was more pronounced on the symptomatic side but the difference did not reach statistical significance. Mean hemispheric blood flow and rCBF were within normal limits during provoked attacks and similar to those found when patients were attack-free. During cluster periods middle cerebral artery velocities were significantly higher on the symptomatic side. Glyceryl trinitrate caused a bilateral middle cerebral artery velocity decrease which was significantly greater on the symptomatic side. Attacks provoked by glyceryl trinitrate appeared to begin when the vasodilatory effect of this substance was receding.

Simultaneous assessment of vasoreactivity using transcranial Doppler ultrasound and cerebral blood flow in healthy subjects

Blood flow velocities in both middle cerebral arteries and regional cerebral blood flow in their perfusion territories were measured simultaneously in 36 healthy subjects. In 20 subjects, the measurements were first performed under basal conditions and then repeated 15-20 min after an intravenous injection of 1 g of acetazolamide. Reproducibility of simultaneous blood flow and velocity measurements was tested by examining 16 subjects on two occasions under basal conditions with an interval of 20 min. Relatively good reproducibility was found for repeated measurements of velocity and blood flow, being best when side-to-side asymmetry was assessed. The increase in blood flow velocities after acetazolamide was symmetrical (right side, 34.2%; and left side, 35.5%), and the velocity increase was significantly correlated with basal values. The increase in cerebral blood flow was also symmetrical (right side, 29.8%; left side, 30.1%) but not correlated with basal flow values. No significant relationship was found between velocity increase and increase in regional cerebral blood flow. This finding is probably not only due to methodological inaccuracies but may suggest that acetazolamide has an effect on the diameter of the middle cerebral artery or on the magnitude of this artery's perfusion territory. This study supports the use of acetazolamide for assessing cerebral vasoreactivity following the definition of lower limits for velocity and flow increase and for asymmetry of the response.

Intrinsic balancing in reconstruction of the tetraplegic hand

This article reviews 183 hand reconstructions in 135 consecutive tetraplegic patients. Comparisons were made between 103 extrinsic reconstructions with intrinsic balancing procedures and 80 extrinsic reconstructions without intrinsic balancing procedures. Extrinsic reconstructions (tendon transfers and tenodesis in the forearm muscles) were augmented by intrinsic reconstructive procedures (tendon transfers or tenodesis to improve the intrinsic balance of the fingers) in patients exhibiting digital imbalance. Intrinsic procedures included primarily the flexor digitorum superficialis (FDS) lasso procedure or the intrinsic tenodesis procedure. The patients were stratified by level of spinal cord injury and by type of extrinsic and intrinsic reconstruction. Hands reconstructed with intrinsic balancing versus without intrinsic balancing, as well as intrinsic balancing using a FDS lasso procedure versus an intrinsic tenodesis procedure, were compared with patients with the same level of spinal cord function. Patients who underwent reconstructions with intrinsic balancing had more grip strength, by an average of 13-26 N, than those who did not undergo intrinsic balancing. When different intrinsic procedures were compared, there was improvement in grip strength and function in activities of daily living for all hands, but there was no significant difference between FDS lasso or intrinsic tenodesis procedures. The indications for intrinsic balancing during extrinsic reconstruction are developed into treatment algorithms based on the senior author's surgical experience. The authors recommended that digital intrinsic procedures be included in hand reconstruction for tetraplegic patients exhibiting intrinsic imbalance to help improve digital function and provide increased grip strength.

Cerebral vasoreactivity in unilateral carotid artery disease. A comparison of blood flow velocity and regional cerebral blood flow measurements

BACKGROUND AND PURPOSE

Hemodynamic information obtained by assessing cerebral vasoreactivity is of clinical interest and may have prognostic significance in patients with occlusive carotid disease. The aim of this study was to compare the results of transcranial Doppler and regional cerebral blood flow studies when used to assess cerebral vasoreactivity.

METHODS

Blood flow velocities in both middle cerebral arteries and regional cerebral blood flow in their respective perfusion territories were compared in 52 patients with severe unilateral carotid stenosis or occlusion. The studies were first performed under basal conditions and repeated after the intravenous administration of 1 g acetazolamide.

RESULTS

Asymmetry (normal compared with pathological side) in middle cerebral artery blood velocity increase was significantly greater than the asymmetry in cerebral blood flow increase in the perfusion territories of the arteries. A significant correlation (r = .63, P < .0001) was found between asymmetry in percent velocity increase and asymmetry in absolute cerebral blood flow increase. The two methods agreed in their assessment of either a normal or a reduced vasoreactivity in 38 subjects and disagreed in 14. In six of the latter patients, who had no evidence of cerebral infarction, the asymmetry in velocity increase was abnormal, whereas asymmetry in flow increase was assessed as normal.

CONCLUSIONS

We found a good correlation between the asymmetry in regional cerebral blood flow increase in the middle cerebral artery perfusion territories and asymmetry in the velocity increase in the middle cerebral arteries after administration of acetazolamide. These results suggest that transcranial Doppler examination combined with the acetazolamide test may be used in clinical situations to assess cerebral vasoreactivity.

Inhibition of lipases by phosphonates

Ethyl hexylchlorophosphonate and analogues thereof were investigated as inhibitors of lipases. Both microbial and mammalian lipases were irreversibly inhibited. The inhibition could be monitored by p-nitrophenol release from the corresponding ethyl p-nitrophenyl hexylphosphonate inhibitor. Quantitative analysis of the data indicated that a 1:1 lipase-inhibitor complex was formed during inhibition. Enantioselective inhibition was found for the lipases derived from Candida antarctica and Rhizomucor miehei using pure enantiomers of ethyl p-nitrophenyl hexylphosphonate as inhibitors. Using the same inhibitor, reversed enantioselectivity was found for the protease alpha-chymotrypsin as compared to the two lipases.

Abundant cytomegalovirus (CMV) reactive clonotypes in the CD8(+) T cell receptor alpha repertoire following allogeneic transplantation

Allogeneic stem cell transplantation is potentially curative, but associated with post-transplantation complications, including cytomegalovirus (CMV) infections. An effective immune response requires T cells recognizing CMV epitopes via their T cell receptors (TCRs). Little is known about the TCR repertoire, in particular the TCR-α repertoire and its clinical relevance in patients following stem cell transplantation. Using next-generation sequencing we examined the TCR-α repertoire of CD8(+) T cells and CMV-specific CD8(+) T cells in four patients. Additionally, we performed single-cell TCR-αβ sequencing of CMV-specific CD8(+) T cells. The TCR-α composition of human leucocyte antigen (HLA)-A*0201 CMVpp65- and CMVIE -specific T cells was oligoclonal and defined by few dominant clonotypes. Frequencies of single clonotypes reached up to 11% of all CD8(+) T cells and half of the total CD8(+) T cell repertoire was dominated by few CMV-reactive clonotypes. Some TCR-α clonotypes were shared between patients. Gene expression of the circulating CMV-specific CD8(+) T cells was consistent with chronically activated effector memory T cells. The CD8(+) T cell response to CMV reactivation resulted in an expansion of a few TCR-α clonotypes to dominate the CD8(+) repertoires. These results warrant further larger studies to define the ability of oligoclonally expanded T cell clones to achieve an effective anti-viral T cell response in this setting.

Effect of long-term oxygen therapy on cognitive and neurological dysfunction in chronic obstructive pulmonary disease

The aim of this study was to assess effect of long-term oxygen therapy (LTOT) on the function of central and autonomic nervous system in patients with hypoxaemic chronic obstructive pulmonary disease (COPD). A battery of neuropsychological tests was used together with the Short Test of Mental Status in addition to transcranial Doppler ultrasonography, and five cardiovascular tests as well as a questionnaire on autonomic function. Ten COPD patients, 4 males and 6 females, with a mean age of 65.9 +/- 7.3 (SD) years, were studied at the beginning and after 3 months of LTOT. At start PaO2 was 6.7 +/- 1.1 kPa without oxygen and 9.9 +/- 1.5 kPa after 3 months with oxygen. Our results demonstrate that neuropsychological function, cerebral blood flow velocity and autonomic function were positively influenced after 3 months of LTOT although the changes did not reach statistical significance. The COPD patients were cognitively impaired as compared to age-matched healthy controls. Our findings were consistent with the previous notion of improvement of hypoxic cognitive dysfunction by LTOT.

Transcallosal approach to the third ventricle: normative morphometric data based on magnetic resonance imaging scans, with special reference to the fornix and forniceal insertion

OBJECTIVE

The ability to visualize median-sagittal brain structures by magnetic resonance imaging (MRI) improves the planning for surgical removal of lesions located in and around the third ventricle. The transcallosal approach is the most appropriate path to the anterior part of the third ventricle. The present study was undertaken to obtain normative morphometric data, derived from sagittal MRI scans, which are necessary for operation planning that takes into account the surgical microanatomy and landmarks encountered during this approach.

METHODS

The morphometric evaluation was performed on 72 median-sagittal MRI scans. The surface landmarks for the corridor were the two points, P5 and P7, located 5 and 7 cm anterior to the central sulcus, respectively. With these two points on the cortical surface as references, a variety of measurements were made to provide quantitative information about distances between brain structures encountered during the surgical approach. In addition, various parameters were determined to characterize the different shapes of the fornix and the different types of forniceal insertion.

RESULTS

The following measurements (means) were obtained: 1) the distance between P5/P7 and the cingulate sulcus was 25.76 mm (range, 17.113-42.73 mm) with reference to P5, and 25.41 mm (range, 12.91-36.29 mm) with reference to P7; 2) the distance between the cingulate sulcus and the corpus callosum was 12.91 mm (range, 7.19-22.60 mm) with reference to P5, and 12.92 mm (range, 6.75-23.37 mm) with reference to P7; 3) the height of the corpus callosum was 6.22 mm (range, 3.07-9.00 mm) with reference to P5, and 6.92 mm (range, 3.50-13.57 mm) with reference to P7; 4) the distance between the anterior commissure and the foramen of Monro was 6.78 mm (range, 1.86-14.57 mm), independent of P5 and P7; 5) the distance between the lower margin of the corpus callosum and the upper insertion point of the fornix was 12.44 mm (range, 2.71-26.13 mm) with reference to P5, and 13.34 mm (range, 3.74-27.58 mm) with reference to P7; 6) the distance between the lower margin of the corpus callosum and the lower insertion point of the fornix was 18.08 mm (range, 9.47-29.71 mm) with reference to P5, and 18.58 mm (range, 10.48-30.40 mm) with reference to P7; and 7) the distance between the lower margin of the corpus callosum and the anterior commissure was 23.46 mm (range, 11.98-32.70 mm) with reference to P5, and 22.89 mm (range, 11.05-33.04 mm) with reference to P7. Four different insertion types between the fornix and the corpus callosum were noted and classified.

CONCLUSION

Morphometric data concerning the surrounding structures of the third ventricle have received very little attention in the literature. This morphometric study permitted definition of the surgical corridor to the third ventricle by preserving important anatomic structures such as the motor strip, genu of the corpus callosum, forniceal commissure (hippocampal commissure), anterior commissure, and forniceal columns. The detailed morphometric data obtained on median-sagittal MRI scans of the brain structures involved in the transcallosal interforniceal and/or transcallosal transforaminal approach allow for exact planning of the surgical approach.

T cell receptor repertoires after adoptive transfer of expanded allogeneic regulatory T cells

Regulatory T cell (T_reg ) therapy has been exploited in autoimmune disease, solid organ transplantation and in efforts to prevent or treat graft-versus-host disease (GVHD). However, our knowledge on the in-vivo persistence of transfused T_reg is limited. Whether T_reg transfusion leads to notable changes in the overall T_reg repertoire or whether longevity of T_reg in the periphery is restricted to certain clones is unknown. Here we use T cell receptor alpha chain sequencing (TCR-α-NGS) to monitor changes in the repertoire of T_reg upon polyclonal expansion and after subsequent adoptive transfer. We applied TCR-α-NGS to samples from two patients with chronic GVHD who received comparable doses of stem cell donor derived expanded T_reg . We found that in-vitro polyclonal expansion led to notable repertoire changes in vitro and that T_reg cell therapy altered the peripheral T_reg repertoire considerably towards that of the infused cell product, to different degrees, in each patient. Clonal changes in the peripheral blood were transient and correlated well with the clinical parameters. We suggest that T cell clonotype analyses using TCR sequencing should be considered as a means to monitor longevity and fate of adoptively transferred T cells.

Detection of cerebral embolic signals in patients with systemic lupus erythematosus

BACKGROUND

Involvement of the CNS in systemic lupus erythematosus (SLE) is caused by several pathogenic mechanisms including cerebral embolism.

AIM

To measure the frequency of microembolic signals (MES) by using transcranial Doppler (TCD) ultrasound and to assess their association with cerebral infarction, neuropsychological dysfunction, and biochemical, sonographic and clinical variables in an unselected group of patients with SLE.

METHODS

A 1-h TCD recording from the middle cerebral artery was carried out in 55 patients with SLE having a mean age of 46 (SD 13) years. MRI of the brain, carotid artery ultrasonography with intima-media thickness and atherosclerotic plaque assessments were carried out in addition to a broad biochemical and clinical assessment. All patients underwent a neuropsychological assessment.

RESULTS

Of the 55 patients, MES were detected in 5 (9%) and cerebral infarcts were found in 9 (18%). A significant association was found between MES and cerebral infarcts and considerably more neuropsychological deficits were found in MES-positive patients compared with the negative group. MES were not associated with other clinical, sonographic and biochemical factors believed to be associated with cerebral embolism.

CONCLUSIONS

Cerebral embolism may be one of the important mechanisms responsible for the high prevalence of cerebrovascular events and the neuropsychological deficits observed in patients with SLE. Although the number of MES-positive patients was small, the lack of a significant association between MES and other known risk factors for MES suggests a complex pathogenesis for the embolisation in these patients.

Cerebral blood flow findings in moyamoya disease in adults

Three adult patients with moyamoya disease are described. They presented with intracerebral hematoma, cerebral infarction and subarachnoid hemorrhage, respectively. Subarachnoid hemorrhage is rare in moyamoya and is usually the result of aneurysm rupture. No aneurysm was found in our patient. Regional cerebral blood flow (rCBF) and the cerebral perfusion reserve assessed by the acetazolamide test, were significantly reduced in all three patients. The areas with most reduced baseline rCBF and most impaired vasoreactivity did not always correspond to the site of the vascular accident, indicating that these CBF changes were at least in part due to the moyamoya disease and/or its underlying causes, and not solely to the vascular accidents.

Autosomal recessive non-progressive ataxia with an early childhood debut

The case histories and clinical studies are given of 7 consanguineous patients, 4 adults and 3 children, with a rather uniform clinical picture of nonprogressive cerebellar ataxia manifesting in early childhood. Most patients have in addition slight spastic signs, short stature and normal intelligence. There are no signs of other organ pathology, biochemical aberrations, endocrine- or immunopathology. CT-scan and PEG show cerebellar atrophy. The pedigree analysis indicates an autosomal recessive mode of inheritance. The condition falls between the ataxic syndromes in the cerebral palsy range and the heredo-ataxias. Until now, no similar disorders seems to have been described.