Case Report: Congenital Tuberculosis in a Premature Infant Requiring Extracorporeal Membrane Oxygenation

Congenital tuberculosis is a rare infectious disease with less than 500 cases documented worldwide. Mortality is significant, ranging from 34-53%, and death without treatment is inevitable. Patients exhibit nonspecific symptoms such as fever, cough, respiratory distress, feeding intolerance, and irritability which can make appropriate diagnosis challenging[1]. Tuberculosis prevalence is particularly high in developing countries where access to resources can be limited[2]. We present a 2.4-kg premature male infant with acute respiratory distress syndrome secondary to congenital tuberculosis caused by Mycobacterium bovis and tuberculosis-immune reconstitution inflammatory syndrome who was successfully supported with veno-arterial extracorporeal membrane oxygenation.

2021 Year in Review: Pediatric Mechanical Ventilation

Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics include physiology, ventilator modes, alarms, disease states, airway suctioning, ventilator liberation, prolonged ventilation, and others.

High-Frequency Jet Ventilation in Infants With Congenital Heart Disease

BACKGROUND

High-frequency jet ventilation (HFJV) is primarily used in neonates but may also have a role in the treatment of infants with congenital heart disease and severe respiratory failure. We hypothesized that HFJV would result in improved gas exchange in these infants.

METHODS

We retrospectively reviewed the records of all pediatric patients with complex congenital heart disease treated HFJV in our pediatric cardiac ICU between 2014 and 2018. Patients in whom HFJV was started while on extracorporeal membrane oxygenation (ECMO) were excluded. We extracted data on demographics, pulmonary mechanics, gas exchange, the subsequent need for ECMO, use of inhaled nitric oxide, and outcomes.

RESULTS

We included 27 subjects (median [interquartile range {IQR}] weight 4.4 [3.3-5.4] kg; median [IQR] age 2.5 [0.3-5.4] months), 22 (82%) of whom had cyanotic heart disease. Thirteen subjects (48%) survived and 6 (22%) required ECMO. HFJV was started after a median (IQR) of 8.4 (2.1-26.3) d of conventional mechanical ventilation. The subjects spent a median (IQR) of 1.2 (0.5-2.8) d on HFJV. The median (IQR) pre-HFJV blood gas results (n = 25) were pH 7.22 (7.17-7.31), [Formula: see text] 69 (51-77) mm Hg, and [Formula: see text] 51 (41-76) mm Hg. Median (IQR) initial HFJV settings were peak inspiratory pressure of 45 (36-50) cm H₂O, breathing frequency of 360 (360-380) breaths/min, and inspiratory time of 0.02 (0.02-0.03) s. Compared with conventional mechanical ventilation, at 4-6 h after HFJV initiation, there were significant improvements in the median pH (7.22 vs 7.34; P = .001) and [Formula: see text] (69 vs 50 mm Hg; P = .001), respectively, but no difference in median [Formula: see text] (51 vs 53 mm Hg; P = .97).

CONCLUSIONS

HFJV was associated with a decrease in [Formula: see text] and an increase in pH in infants with congenital heart disease who remained on HFJV 4 to 6 h after initiation.

Extracorporeal membrane oxygenation in critically ill neonatal and pediatric patients with acute respiratory failure: a guide for the clinician

Intro: Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure continues to demonstrate improving outcomes, largely due to advances in technology along with refined management strategies despite mounting patient acuity and complexity. Successful use of ECMO requires thoughtful initiation and candidacy strategies, along with reducing the risk of ventilator induced lung injury and the progression to multiorgan failure.Areas Covered: This review describes current ECMO management strategies for neonatal and pediatric patients with acute refractory respiratory failure and summarizes relevant published literature. ECMO initiation and candidacy, along with ventilator and sedation management, are highlighted. Additionally, rapidly expanding areas of interest such as anticoagulation strategies, transfusion thresholds, rehabilitation on ECMO, and drug pharmacokinetics are described.Expert Opinion: Over the last few decades, published studies supporting ECMO use for acute refractory respiratory failure, along with institutional experience, have resulted in increased utilization although more randomized-controlled trials are needed. Future research should focus on filling the knowledge gaps that remain regarding anticoagulation, transfusion thresholds, ventilator strategies, sedation, and approaches to rehabilitation to subsequently implement into clinical practice. Additionally, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations.

Anticoagulation and Transfusion Management During Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Survey of Medical Directors in the United States

OBJECTIVES

To compare current practices within the United States of anticoagulation management and blood transfusion in neonatal and pediatric extracorporeal membrane oxygenation patients with a 2013 international report.

DESIGN

Cross-sectional survey distributed between August and December 2019.

SETTING

Extracorporeal Life Support Organization-registered neonatal and pediatric extracorporeal membrane oxygenation centers in the United States.

PARTICIPANTS

Extracorporeal membrane oxygenation medical directors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eighty-three medical directors at 108 centers responded. After removing four duplicate responses, 79 surveys were analyzed. Seventy-nine percent (n = 62) report a written extracorporeal membrane oxygenation protocol for both anticoagulation and blood product management. Ninety-four percent (n = 74) report unfractionated heparin as their primary anticoagulant; the remaining use the direct thrombin inhibitor, bivalirudin. Ninety percent (n = 71) report measuring antifactor Xa levels. Most centers report using a combination of assays to monitor heparin therapy, either antifactor Xa and activated partial thromboplastin time (54%) or more commonly antifactor Xa and activated clotting time (68%). Forty-one percent use viscoelastic tests to aid management. Goal monitoring levels and interventions generated by out of range values are variable. Fifty-one percent will replace antithrombin. Platelet transfusion thresholds vary by age and center with ranges from 50,000 to 100,000 cells/µL. Eighty-two percent of respondents are willing to participate in a randomized controlled trial comparing anticoagulation strategies for patients receiving extracorporeal membrane oxygenation.

CONCLUSIONS

Compared with the 2013 pediatric population, extracorporeal membrane oxygenation center anticoagulation and blood transfusion approaches continue to vary widely. Most report continued use of heparin as their primary anticoagulant and follow a combination of monitoring assays with the majority using the antifactor Xa assay in their practices, a significant shift from prior results. Antithrombin activity levels and viscoelastic tests are followed by a growing number of centers. Platelet transfusion thresholds continue to vary widely. Future research is needed to establish optimal anticoagulation and blood transfusion management.

Pharmacokinetic, efficacy, and safety considerations for the use of antifungal drugs in the neonatal population

INTRODUCTION

Invasive fungal infections are an important cause of morbidity and mortality in infants, particularly in extreme prematurity. Successful systemic treatment requires consideration of antifungal efficacy, safety, and pharmacokinetics, including optimization of dosing in this population.

AREAS COVERED

This review summarizes published pharmacokinetic data on four classes of antifungal agents used in the neonatal population. Alterations in absorption, distribution, drug metabolism and clearance in infants compared to adult populations are highlighted. Additionally, pharmacodynamics, safety, and therapeutic drug monitoring are discussed. Recent advancements in neonatal antifungal pharmacotherapies are examined, with emphasis on clinical application.

EXPERT OPINION

Over the last two decades, published studies have provided increased knowledge on pharmacokinetic considerations in the neonatal population. Future research should focus on filling in the knowledge gaps that remain regarding the benefits and risks of combination antifungal therapy, the rising use of micafungin for invasive candidiasis given its fungicidal activity against polyene and azole-resistant Candida species and its minimal adverse effect profile, and the need for pharmacokinetic and safety data of broad spectrum triazoles, like voriconazole and posaconazole, in infants. Furthermore, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations with subsequent implementation into clinical practice.

Histoplasmosis Myocarditis in an Immunocompetent Host After a Recreational Mud Run

Mud runs are an increasingly popular recreational fitness activity across the United States, combining a running race through an obstacle course with submersion in mud. Recent reports estimate 4 million people have participated in these types of events over the last 5 years. We describe an atypical case of myocarditis and multiorgan failure from disseminated histoplasmosis in a previously healthy pediatric patient, likely acquired during participation in a mud run. Although cases of histoplasmosis-associated endocarditis and pericarditis have been reported in the literature, cases of histoplasmosis myocarditis are rare.

Revisiting the bis(dimethylamido) metallocene complexes of thorium and uranium: improved syntheses, structure, spectroscopy, and redox energetics of (C5Me5)2An(NMe2)2 (An = Th, U)

The reaction of (C₅Me₅)₂AnCl₂ (An = Th, U) with 2.8 or 4 equivalents of LiNMe₂, respectively, affords (C₅Me₅)₂An(NMe₂)₂ in high yields. In addition to improved syntheses, the solid-state structures, voltammetric data, and UV-visible-NIR spectra for these classic actinide bis(dimethylamido) complexes are presented for the first time.

Mitoxantrone, etoposide and cytarabine following epigenetic priming with decitabine in adults with relapsed/refractory acute myeloid leukemia or other high-grade myeloid neoplasms: a phase 1/2 study

DNA methyltransferase inhibitors sensitize leukemia cells to chemotherapeutics. We therefore conducted a phase 1/2 study of mitoxantrone, etoposide, and cytarabine following “priming” with 5-10 days of decitabine (dec/MEC) in 52 adults (median age 55 [range: 19-72] years) with relapsed/refractory acute myeloid leukemia (AML) or other high-grade myeloid neoplasms. During dose escalation in cohorts of 6-12 patients, all dose levels were well-tolerated. As response rates appeared similar with 7 and 10-days of decitabine, a 7-day course was defined as the recommended phase 2 dose (RP2D). Among 46 patients treated at/above the RP2D, 10 (22%) achieved a complete remission (CR), 8 without measurable residual disease; five additional patients achieved CR with incomplete platelet recovery, for an overall response rate of 33%. Seven patients (15%) died within 28 days of treatment initiation. Infection/neutropenic fever, nausea, and mucositis were the most common adverse events. While the CR rate compared favorably to a matched historic control population (observed/expected CR ratio=1.77), CR rate and survival were similar to two contemporary salvage regimens used at our institution (G-CLAC and G-CLAM). Thus, while meeting the pre-specified efficacy goal, we found no evidence that dec/MEC is substantially better than other cytarabine-based regimens currently used for relapsed/refractory AML.

Investigation of the physical properties of the tetragonal CeMAl4Si2 (M = Rh, Ir, Pt) compounds

The synthesis, crystal structure and physical properties studied by means of x-ray diffraction, magnetic, thermal and transport measurements of CeMAl4Si2 (M = Rh, Ir, Pt) are reported, along with the electronic structure calculations for LaMAl4Si2 (M = Rh, Ir, Pt). These materials adopt a tetragonal crystal structure (space group P4/mmm) comprised of BaAl4 blocks, separated by MAl2 units, stacked along the c-axis. Both CeRhAl4Si2 and CeIrAl4Si2 order antiferromagnetically below TN1 = 14 and 16 K, respectively, and undergo a second antiferromagnetic transitition at lower temperature (TN2 = 9 and 14 K, respectively). CePtAl4Si2 orders ferromagnetically below TC = 3 K with an ordered moment of μsat = 0.8 μB for a magnetic field applied perpendicular to the c-axis. Electronic structure calculations reveal quasi-2D character of the Fermi surface.

Single crystal study of antiferromagnetic CePd3Al9

Single crystal x-ray diffraction, magnetic susceptibility (M), heat capacity (C), and electrical resistivity (ρ) measurements are reported for specimens of the new tetragonal compound CePd3Al9, which forms in a new structure type. X-ray diffraction measurements reveal that the nearest neighbor Ce-Ce distances are large (d(Ce-Ce) = 5.272 Å), suggesting that this compound may be described as a stoichiometric dilute Kondo lattice. Thermodynamic and transport measurements reveal antiferromagnetic order near T(N) = 0.9 K. The ordered ground state emerges from a lattice of localized Ce ions that are weakly hybridized with the conduction electrons, as revealed by the moderate electronic coefficient of the specific heat γ ≈ 45 mJ mol(-1) K(-2) (extrapolated from above T(N)) and the lack of evidence for Kondo coherence in the magnetic susceptibility and electrical resistivity. The application of a magnetic field initially suppresses the magnetic order at a rate of -0.04 K kOe(-1), but Zeeman splitting of the doublet ground state produces a nonmagnetic singlet before TN reaches zero. The data additionally reveal that chemical/structural disorder plays an important role, as evidenced by results from single crystal x-ray diffraction, the broadness of the peak at TN in the heat capacity, and the small residual resistivity ratio RRR = ρ(300 K)/ρ0 = 1.3.

Localized 5f electrons in superconducting PuCoIn₅: consequences for superconductivity in PuCoGa₅

The physical properties of the first In analog of the PuMGa(5) (M = Co, Rh) family of superconductors, PuCoIn(5), are reported. With its unit cell volume being 28% larger than that of PuCoGa(5), the characteristic spin-fluctuation energy scale of PuCoIn(5) is three to four times smaller than that of PuCoGa(5), which suggests that the Pu 5f electrons are in a more localized state relative to PuCoGa(5). This raises the possibility that the high superconducting transition temperature T(c) = 18.5 K of PuCoGa(5) stems from the proximity to a valence instability, while the superconductivity at T(c) = 2.5 K of PuCoIn(5) is mediated by antiferromagnetic spin fluctuations associated with a quantum critical point.

Single crystal study of the heavy-fermion antiferromagnet CePt₂In₇

We report the synthesis, structure, and physical properties of single crystals of CePt(2)In(7). Single crystal x-ray diffraction analysis confirms the tetragonal I4/mmm structure of CePt(2)In(7) with unit cell parameters a = 4.5886(6) Å, c = 21.530(6) Å and V = 453.32(14) Å(3). The magnetic susceptibility, heat capacity, Hall effect and electrical resistivity measurements are all consistent with CePt(2)In(7) undergoing an antiferromagnetic order transition at T(N) = 5.5 K, which is field independent up to 9 T. Above T(N), the Sommerfeld coefficient of specific heat is γ ≈ 300 mJ mol(-1) K(-2), which is characteristic of an enhanced effective mass of itinerant charge carriers. The electrical resistivity is typical of heavy-fermion behavior and gives a residual resistivity ρ(0) ∼ 0.2 µΩ cm, indicating good crystal quality. CePt(2)In(7) also shows moderate anisotropy of the physical properties that is comparable to structurally related CeMIn(5) (M = Co, Rh, Ir) heavy-fermion superconductors.

Magnetic order in Pu₂M₃Si₅ (M = Co, Ni)

The physical properties including magnetic susceptibility, specific heat, and electrical resistivity of two new plutonium compounds Pu2M3Si5 (M = Co, Ni) are reported. Pu2Ni3Si5 crystallizes in the orthorhombic U2Co3Si5 structure type, which can be considered a variant of the BaAl4 tetragonal structure, while Pu2Co3Si5 adopts the closely related monoclinic Lu2Co3Si5 type. Magnetic order is observed in both compounds, with Pu2Ni3Si5 ordering ferromagnetically at T(C) = 65 K then undergoing a transition into an antiferromagnetic state below T(N) = 35 K. Two successive magnetic transitions are also observed at T(mag1) = 38 K and T(mag2) = 5 K in Pu2Co3Si5. Specific heat measurements reveal that these two materials have a moderately enhanced Sommerfeld coefficient γ ∼ 100 mJ/mol Pu K(2) in the magnetic state with comparable RKKY and Kondo energy scales.

Synthesis, structure and physical properties of YbNi3Al9.23

The physical properties of YbNi(3)Al(9.23(1)), including the crystal structure, magnetization, specific heat, valence, and electrical resistivity, are reported. Single crystal x-ray diffraction reveals that the compound crystallizes with the rhombohedral space group R32 and has unit cell parameters a = 7.2443(3) Å and c = 27.251(3) Å with some crystallographic disorder at Al sites. The compound orders antiferromagnetically at T(N) = 3 K despite the presence of strong ferromagnetic correlations, accompanied by a spin-flop-like transition to a moment-aligned state above 0.1 T. X-ray absorption spectroscopy and magnetic susceptibility measurements indicate a localized Yb(3+) electronic configuration, while the Sommerfeld coefficient for the magnetically ordered state was determined as approximately 135 mJ mol(-1) K(-2), suggesting moderately heavy fermion behavior. Therefore, these data indicate a balance between competing Ruderman-Kittel-Kasuya-Yosida (RKKY) and Kondo interactions in YbNi(3)Al(9.23(1)) with a somewhat dominant RKKY interaction that leads to a relatively high ordering temperature.

Results of donor lymphocyte infusions for relapsed myelodysplastic syndrome after hematopoietic cell transplantation

Allogeneic hematopoietic cell transplantation (HCT) represents a potentially curative approach for patients with myelodysplastic syndromes (MDSs). While a large proportion of HCT recipients become long-term disease-free survivors, recurrence of MDS remains the leading cause of mortality after HCT. The role of donor lymphocyte infusion (DLI) in patients with relapsed MDS after HCT is unclear. We report results among 16 patients treated with DLI for relapsed MDS after HCT at a single institution between March 1993 and February 2004. The cohort contained 10 men and 6 women with a median age of 49 (range, 22-67) years. CR with resolution of cytopenias and prior disease markers occurred in 3 of 14 patients who could be evaluated. Two patients survived without MDS for 68 and 65 months after DLI, respectively, but died with pneumonia. Grades II-IV acute GVHD and chronic GVHD occurred after DLI in 6 (43%) and 5 (36%) patients, respectively. All three responders developed grades III-IV acute GVHD and extensive chronic GVHD after DLI. Our results confirm prior reports that DLI can result in CR in some patients with recurrent MDS after transplant, but long-term survival is infrequent.

Myeloablative vs nonmyeloablative allogeneic transplantation for patients with myelodysplastic syndrome or acute myelogenous leukemia with multilineage dysplasia: a retrospective analysis

Transplant outcome was analyzed in 150 patients with myelodysplastic syndrome (MDS) or acute myelogenous leukemia transformed from MDS (tAML) conditioned with nonmyeloablative or myeloablative regimens. A total of 38 patients received nonmyeloablative regimens of 2 Gy total body irradiation alone (n=2) or with fludarabine (n=36), 90mg/m2. A total of 112 patients received a myeloablative regimen of busulfan, 16mg/ kg (targeted to 800-900 ng/ml), and cyclophosphamide 120 mg/ kg. Nonmyeloablative patients were older (median age 62 vs 52 years, P<0.001), more frequently had progressed to tAML (53 vs 31%, P=0.06), had higher risk disease by the International Prognostic Scoring System (53 vs 30%, P=0.004), had higher transplant specific comorbidity indices (68 vs 42%, P=0.01) and more frequently had durable complete responses to induction chemotherapy (58 vs 14%). Three-year overall survival (27%/48% (P=0.56)), progression-free survival (28%/4 44%, (P=0.60)), and nonrelapse mortality (41%/34%, (P=0.94)) did not differ significantly between nonmyeloblative/myeloablative conditioning. Overall (HR=0.9, P=0.84) and progression-free survivals (HR=1, P=0.93) were similar for patients with chemotherapy-induced remissions irrespective of conditioning intensity. Graft vs leukemia effects may be more important than conditioning intensity in preventing progression in patients in chemotherapy-induced remissions at the time of transplantation. Randomized prospective studies are needed to further address the optimal choice of transplant conditioning intensity in myeloid neoplasms.

Optimization of allogeneic transplant conditioning: not the time for dogma

Numerous reduced-intensity conditioning regimens for allogeneic hematopoietic cell transplantation are currently being explored, primarily in older patients and in individuals with comorbid conditions who are not eligible for conventional myeloablative conditioning regimens. There is agreement that these approaches have reduced early transplant-related (non-relapse) toxicity and mortality. It is unclear, however, whether these strategies improve long-term survival. Furthermore, as most trials with reduced-intensity regimens have enrolled older patients and patients with comorbid conditions, it is not appropriate to compare the results of these trials to those obtained with more conventional approaches. It remains to be determined whether younger patients, and patients without comorbid conditions, will derive significant long-term benefits from reduced-intensity regimens when compared to conventional strategies. It may be that the different approaches are complementary and in the end will preferentially serve specific patient populations based on age, comorbid conditions and malignancy type. To determine the role of reduced-intensity approaches, controlled prospective trials are needed, with enrolled patients being stratified according to comorbid conditions, disease characteristics, pre-transplant therapy and source of stem cells, at a minimum.

Family-based case-control study of cigarette smoking and Parkinson disease

OBJECTIVE

To determine whether people with Parkinson disease (PD) are less likely to report a history of cigarette smoking than their unaffected siblings.

BACKGROUND

Previous studies reported that individuals with PD are half as likely to have smoked as those unaffected by PD. Other studies reported that smoking modified the risk of PD due to polymorphisms in the MAO-B and nNOS genes. Thus, genetic studies of PD should consider confounding or interaction with smoking history as well. The authors have collected detailed smoking histories on a family-based case-control sample ascertained for genetic studies of PD.

METHODS

In a matched case-control study of 140 sibships, individuals with PD (n = 143) were compared to sibling controls (n = 168). Cigarette smoking history was collected by a structured telephone interview. Conditional logistic regression was used to examine the relationship between smoking and PD while controlling for confounding by age and sex.

RESULTS

Ever smoking, current smoking, and increasing duration (in years), dose (in packs/day), and intensity (in pack-years) of smoking were significantly inversely associated with PD (p < 0.05). The association was not modified by sex, age at onset, or recency of exposure.

CONCLUSIONS

Consistent with previous studies, individuals with Parkinson disease are significantly less likely to have smoked regularly than their unaffected siblings. This association was detected even though discordant sibling pairs are more likely to be overmatched for environmental exposures than unmatched case and control groups.

Genetic polymorphisms of the N-acetyltransferase genes and risk of Parkinson's disease

Recently, the authors demonstrated linkage in idiopathic PD to a region on chromosome 8p that contains the N-acetyltransferase genes, NAT1 and NAT2. The authors examined NAT1 and NAT2 for association with PD using family-based association methods and single nucleotide polymorphisms (SNPs). The authors did not find evidence for association with increased risk for PD between any individual NAT1 or NAT2 SNP or acetylation haplotype (N = 397 families, 1,580 individuals).

Plutonium-based superconductivity with a transition temperature above 18 K

Plutonium is a metal of both technological relevance and fundamental scientific interest. Nevertheless, the electronic structure of plutonium, which directly influences its metallurgical properties, is poorly understood. For example, plutonium's 5f electrons are poised on the border between localized and itinerant, and their theoretical treatment pushes the limits of current electronic structure calculations. Here we extend the range of complexity exhibited by plutonium with the discovery of superconductivity in PuCoGa5. We argue that the observed superconductivity results directly from plutonium's anomalous electronic properties and as such serves as a bridge between two classes of spin-fluctuation-mediated superconductors: the known heavy-fermion superconductors and the high-T(c) copper oxides. We suggest that the mechanism of superconductivity is unconventional; seen in that context, the fact that the transition temperature, T(c) approximately 18.5 K, is an order of magnitude greater than the maximum seen in the U- and Ce-based heavy-fermion systems may be natural. The large critical current displayed by PuCoGa5, which comes from radiation-induced self damage that creates pinning centres, would be of technological importance for applied superconductivity if the hazardous material plutonium were not a constituent.

Complete genomic screen in Parkinson disease: evidence for multiple genes

CONTEXT

The relative contribution of genes vs environment in idiopathic Parkinson disease (PD) is controversial. Although genetic studies have identified 2 genes in which mutations cause rare single-gene variants of PD and observational studies have suggested a genetic component, twin studies have suggested that little genetic contribution exists in the common forms of PD.

OBJECTIVE

To identify genetic risk factors for idiopathic PD.

DESIGN, SETTING, AND PARTICIPANTS

Genetic linkage study conducted 1995-2000 in which a complete genomic screen (n = 344 markers) was performed in 174 families with multiple individuals diagnosed as having idiopathic PD, identified through probands in 13 clinic populations in the continental United States and Australia. A total of 870 family members were studied: 378 diagnosed as having PD, 379 unaffected by PD, and 113 with unclear status.

MAIN OUTCOME MEASURES

Logarithm of odds (lod) scores generated from parametric and nonparametric genetic linkage analysis.

RESULTS

Two-point parametric maximum parametric lod score (MLOD) and multipoint nonparametric lod score (LOD) linkage analysis detected significant evidence for linkage to 5 distinct chromosomal regions: chromosome 6 in the parkin gene (MLOD = 5.07; LOD = 5.47) in families with at least 1 individual with PD onset at younger than 40 years, chromosomes 17q (MLOD = 2.28; LOD = 2.62), 8p (MLOD = 2.01; LOD = 2.22), and 5q (MLOD = 2.39; LOD = 1.50) overall and in families with late-onset PD, and chromosome 9q (MLOD = 1.52; LOD = 2.59) in families with both levodopa-responsive and levodopa-nonresponsive patients.

CONCLUSIONS

Our data suggest that the parkin gene is important in early-onset PD and that multiple genetic factors may be important in the development of idiopathic late-onset PD.

Association of single-nucleotide polymorphisms of the tau gene with late-onset Parkinson disease

CONTEXT

The human tau gene, which promotes assembly of neuronal microtubules, has been associated with several rare neurologic diseases that clinically include parkinsonian features. We recently observed linkage in idiopathic Parkinson disease (PD) to a region on chromosome 17q21 that contains the tau gene. These factors make tau a good candidate for investigation as a susceptibility gene for idiopathic PD, the most common form of the disease.

OBJECTIVE

To investigate whether the tau gene is involved in idiopathic PD.

DESIGN, SETTING, AND PARTICIPANTS

Among a sample of 1056 individuals from 235 families selected from 13 clinical centers in the United States and Australia and from a family ascertainment core center, we tested 5 single-nucleotide polymorphisms (SNPs) within the tau gene for association with PD, using family-based tests of association. Both affected (n = 426) and unaffected (n = 579) family members were included; 51 individuals had unclear PD status. Analyses were conducted to test individual SNPs and SNP haplotypes within the tau gene.

MAIN OUTCOME MEASURE

Family-based tests of association, calculated using asymptotic distributions.

RESULTS

Analysis of association between the SNPs and PD yielded significant evidence of association for 3 of the 5 SNPs tested: SNP 3, P =.03; SNP 9i, P =.04; and SNP 11, P =.04. The 2 other SNPs did not show evidence of significant association (SNP 9ii, P =.11, and SNP 9iii, P =.87). Strong evidence of association was found with haplotype analysis, with a positive association with one haplotype (P =.009) and a negative association with another haplotype (P =.007). Substantial linkage disequilibrium (P<.001) was detected between 4 of the 5 SNPs (SNPs 3, 9i, 9ii, and 11).

CONCLUSIONS

This integrated approach of genetic linkage and positional association analyses implicates tau as a susceptibility gene for idiopathic PD.

Reaction of the uranyl(VI) ion (UO(2)(2+)) with a triamidoamine ligand: preparation and structural characterization of a mixed-valent uranium(V/VI) oxo-imido dimer

The synthesis and structural characterization of a mixed-valent uranium(V/VI) oxo-imido complex are reported. Reaction of the uranyl chloride complex [K(18-crown-6)](2)[UO(2)Cl(4)] (1) with the triamidoamine ligand Li(3)[N(CH(2)CH(2)NSiBu(t)Me(2))(3)] yields oxo-imido [K(18-crown-6)(Et(2)O)][UO(mu(2)-NuCH(2)CH(2)N(CH(2)CH(2)NSiBu(t)Me(2))(2))](2) (2) as the major isolated uranium product in moderate yield. The reaction that forms 2 involves activation of both the triamidoamine ligand and the uranyl dioxo unit of 1. An X-ray crystal structure determination of 2 reveals a dimeric complex in which the coordination geometry at each uranium center is that of a capped trigonal bipyramid. The multidentate triamidoamine ligand coordinates to uranium through the capping amine and two of the three pendant amido ligands, while the third pendant amido donor has been activated to generate a bridging imido ligand by loss of the silyl substituent. One of the uranyl oxo groups is retained as a terminal ligand to complete the coordination sphere for each uranium center. The oxo and imido nitrogen may be regarded as the axial ligands of the trigonal bipyramid, while the two amido ligands and the other imido donor occupy equatorial coordination sites. The central amine of the tripodal set serves as the capping ligand. Distortion of the axial O-U-N angle from 180 degrees emanates from the proximity of the capping amine and the bridging interaction to the other uranium center. The structure and bonding in 2 are assessed in the context of metal-ligand multiple bonding in high-valent actinide complexes. The possibility of valence averaging [5.5/5.5 vs 5.0/6.0] via delocalization or rapid intramolecular electron-transfer dynamics of the unpaired electron is also discussed in the context of crystallographic, spectroscopic (NMR, IR, Raman, and EPR), and electrochemical data. Crystal data for 2: triclinic space group P1 macro, a = 12.1144(6) A, b = 12.6084(6) A, c = 14.5072(7) A, alpha = 101.374(1) degrees, beta = 103.757(1) degrees, gamma = 109.340(1) degrees, z = 1, R1 = 0.0523, wR2 = 0.1359.

Coordination trends in alkali metal crown ether uranyl halide complexes: the series [A(crown)]2[UO(2)X(4)] where A=Li, Na, K and X=Cl, Br

UO(2)(C(2)H(3)O(2))(2).2H(2)O reacts with AX or A(C(2)H(3)O(2) or ClO(4)) (where A = Li, Na, K; X = Cl, Br) and crown ethers in HCl or HBr aqueous solutions to give the sandwich-type compounds [K(18-crown-6)](2)[UO(2)Cl(4)] (1), [K(18-crown-6)](2)[UO(2)Br(4)] (2), [Na(15-crown-5)](2)[UO(2)Cl(4)] (3), [Na(15-crown-5)](2)[UO(2)Br(4)] (4), [Li(12-crown-4)](2)[UO(2)Cl(4)] (5), and [Li(12-crown-4)](2)[UO(2)Br(4)] (6). The compounds have been characterized by single-crystal X-ray diffraction, powder diffraction, elemental analysis, IR, and Raman spectroscopy. The [UO(2)X(4)](2-) ions coordinate to two [A(crown)](+) cations through the four halides only (2), through two halides only (3), through the two uranyl oxygens and two halides (3, 4), or through the two uranyl oxygen atoms only (5, 6). Raman spectra reveal nu(U-O) values that correlate with expected trends. The structural trends are discussed within the context of classical principles of hard-soft acid-base theory.

203,205Tl NMR studies of crystallographically characterized thallium alkoxides. X-ray Structures of [TI(OCH2CMe3)]4 and [TI(OAr)]infinity, where OAr = OC6H3(Me)2-2,6 and OC6H3(CHMe2)2-2,6

[Tl(OCH2Me)]4 (1) was reacted with excess HOR to prepare a series of [Tl(OR)]n, where OR = OCHMe2 (2, n = 4), OCMe3 (3, n = 4), OCH2CMe3 (4, n = 4), OC6H3(Me)2-2,6 (5, n = infinity), and OC6H3(CHMe2)2-2,6 (6, n = infinity). Single-crystal X-ray diffraction experiments revealed that in the solid state the alkoxide-ligated compound 4 adopts a cubane structure, whereas the aryloxide derivatives, 5 and 6, formed polymeric chains. Compounds 1-6 were also characterized by 203,205Tl solution and 205Tl solid-state NMR spectroscopy. In solution it was determined that 1-4 retained the [Tl-O]4 cube structure, whereas the polymeric species 5 and 6 appeared to be fluxional. Variations in the solution and solid-state structures for the [Tl(OR)]4 cubes and polymeric [Tl(OAr)]infinity are influenced by the steric hindrance of the ligand. The acidity of the parent alcohol influences the degree of covalency at the Tl metal center, which is reflected in the 203,205Tl chemical shifts for 1-6.

Actinide interactions with microbial chelators: the dioxobis[pyridine-2,6-bis(monothiocarboxylato)]uranium(VI) ion

The title complex, bis(tetraphenylphosphonium) dioxobis(pyridine-2,6-dicarbothioato-O,N,O')uranium(VI), (C(24)H(20)P)(2)[UO(2)(C(7)H(3)NO(2)S(2))(2)], was prepared by reacting two equivalents of pyridine-2,6-bis(monothiocarboxylate) (pdtc) with uranyl nitrate. The geometry of the eight-coordinate U atom is hexagonal bipyramidal, with the uranyl O atoms in apical positions. This is the first reported complex in which this ligand binds a metal through the O and not the S atoms. Principal bond lengths include uranyl lengths of 1.774 (2) A, U--O distances of 2.434 (2) and 2.447 (3) A, and two U--N distances of 2.647 (3) A. The anion lies on an inversion centre.

A trigonal bipyramidal uranyl amido complex: synthesis and structural characterization of [Na(THF)2][UO2(N(SiMe3)2)3]

The synthesis and structural characterization of a rare example of a uranyl complex possessing three equatorial ligands, [M(THF)2][UO2(N(SiMe3)2)3] (3a, M = Na; 3b, M = K), are described. The sodium salt 3a is prepared by protonolysis of [Na(THF)2]2[UO2(N(SiMe3)2)4], whereas the potassium salt 3b is obtained via a metathesis reaction of uranyl chloride UO2Cl2(THF)2 (4) with 3 equiv of K[N(SiMe3)2]. A single-crystal X-ray diffraction study of 3a revealed a trigonal-bipyramidal geometry about uranium, formed by two axial oxo and three equatorial amido ligands, with average U=O and U-N bond distances of 1.796(5) and 2.310(4) A, respectively. One of the oxo ligands is also coordinated to the sodium counterion. 1H NMR spectroscopic studies indicate that THF adds reversibly as a ligand to 3 to expand the trigonal bipyramidal geometry. The degree to which the coordination sphere in 3 is electronically satisfied with only three amido donors is suggested by (1) the reversible THF coordination, (2) a modest elongation in the bond distances for a five-coordinate U(VI) complex, and (3) the basicity of the oxo ligands as evidenced in the contact to Na. The vibrational spectra of the series of uranyl amido complexes [UO2(N(SiMe3)2)n]2-n (n = 2-4) are compared, to evaluate the effects on the axial U=O bonding as a function of increased electron density donated from the equatorial region. Raman spectroscopic measurements of the nu 1 symmetric O=U=O stretch show progressive axial bond weakening as the number of amido donors is increased. Crystal data for [Na(THF)2][UO2(N(SiMe3)2)3]: orthorhombic space group Pna2(1), a = 22.945(1) A, b = 15.2830(7) A, c = 12.6787(6) A, z = 4, R1 = 0.0309, wR2 = 0.0524.

Basicity of uranyl oxo ligands upon coordination of alkoxides

Uranium(VI) alkoxide complexes are prepared via metathesis reactions of [UO2Cl2(THF)2]2 with potassium alkoxides in nonaqueous media. The dark red compound U[OCH2C(CH3)3]6, 1, results from redistributive exchange of oxo and neopentoxide ligands between more than one uranium species. Single-crystal X-ray diffraction analysis of 1 reveals a monomer in which the uranium is coordinated in a pseudooctahedral fashion by six neopentoxide ligands. Imposition of steric congestion at the metal center prevents oxo-alkoxide ligand exchange in the reactions using more sterically demanding alkoxides. Simple metathesis between uranyl chloride and alkoxide ligands occurs in the synthesis of golden yellow-orange UO2(OCHPh2)2(THF)2, 2, and yellow UO2[OCH(tBu)Ph]2(THF)2, 3. Single-crystal X-ray diffraction analysis of 2 reveals a monomer in which the uranium is coordinated in a pseudooctahedral fashion by two apical oxo ligands, two diphenylmethoxide ligands occupying trans positions, and two tetrahydrofuran ligands. Coordination of diisopropylmethoxide allows for synthesis of a more complex binary alkoxide system. Single-crystal X-ray diffraction analysis of watermelon red [UO2(OCH(iPr)2)2]4, 4, reveals a tetramer in which each uranium is coordinated in a pseudooctahedral fashion by two apical oxo ligands, one terminal alkoxide, two bridging alkoxide ligands, and one bridging oxo ligand from a neighboring uranyl group. These compounds are characterized by elemental analysis, 1H NMR, infrared spectroscopy, and, for 1, 2, and 4, single-crystal X-ray diffraction analysis. Luminescence spectroscopy is employed to evaluate the extent of aggregation of compounds 2-4 in various solvents. Vibrational spectroscopic measurements of 2-4 imply that, in contrast to the case of uranyl complexes prepared in aqueous environments, coordination of relatively strongly donating alkoxide ligands allows for enhancement of electron density on the uranyl groups such that the uranyl U=O bonds are weakened. Crystal data are as follows. 1: monoclinic space group C2/m, a = 10.6192(8) A, b = 18.36(1) A, c = 10.6151(8) A, beta = 109.637(1) degrees, V = 1949.1(3) A3, Z = 2, dcalc = 1.297 g cm-3. Refinement of 2065 reflections gave R1 = 0.045. 2: monoclinic space group P2(1)/c, a = 6.1796(4) A, b = 15.669(1) A, c = 16.169(1) A, beta = 95.380(1) degrees, V = 1558.7(2) A3, Z = 2, dcalc = 1.664 g cm-3. Refinement of 3048 reflections gave R1 = 0.036. 4: tetragonal space group I4, a = 17.8570(6) A, b = 17.8570(6) A, c = 11.4489(6) A, V = 3650.7(3) A3, Z = 2, dcalc = 1.821 g cm-3. Refinement of 1981 reflections gave R1 = 0.020.

Synthesis and molecular structure of a plutonium(IV) coordination complex: [Pu(NO3)2(2,6-[(C6H5)2P(O)CH2]2C5H3NO)2](NO3)2x1.5H2Ox0.5MeOH

The trifunctional ligand 2,6-[(C6H5)2P(O)CH2]2 C5H3NO (1), in a mixed EtOH/MeOH solvent system, when combined with an aqueous nitric acid solution of Pu(IV), produces a 2:1 coordination complex, [Pu(1)2(NO3)2](NO3)2. A single crystal of [Pu(NO3)2(2,6-[(C6H5)2P(O)CH2]2C5H3NO)2](NO3)2x1.5H2Ox0.5MeOH was characterized by X-ray diffraction analysis. The crystal is monoclinic, space group P2(1)/n, with a = 19.1011(9) A, b = 18.2873(9) A, c = 21.507(1) A, alpha = gamma = 90 degrees, beta = 108.64(1) degrees, and Z = 4. Two neutral ligands (1) are bonded to the Pu(IV) ion in a tridentate fashion. Two nitrate ions also occupy inner sphere coordination positions, while two additional NO3- ions reside in the outer sphere. Comparison of the solution optical absorbance and solid diffuse reflectance spectra shows the same Pu(IV) chromophore exists in both solid and solution states.

Evaluation and treatment of dystonia

BACKGROUND

Dystonia is a neurologic disorder that interferes with normal motor control, causing development of bizarre postures and writhing, twisting movements.

METHODS

The patient database of the Duke Movement Disorders Clinic was searched to identify and characterize all cases of dystonia evaluated during the 3 1/2 year period between July 1995 and December 1998.

RESULTS

Of the 68 patients identified, 44% had focal dystonia, 10% segmental dystonia, 9% hemidystonia, 7% generalized dystonia, 4% multifocal dystonia, 12% psychogenic dystonia, and 9% tardive dystonia. The remainder had either paroxysmal or pseudodystonia. Twenty-five patients had improvement with botulinum toxin injections, 16 with anticholinergics, benzodiazepines and/or baclofen, and 2 with tetrabenazine.

CONCLUSION

A variety of treatments can give symptomatic benefit in dystonia, but appropriate treatment requires proper diagnosis of the condition.

Human apolipoprotein E accelerates microtubule polymerization in vitro

Apolipoprotein E (apoE) is a 34-kDa protein implicated in Alzheimer's disease (AD) that has recently been identified in neuronal cytoplasm. In cultured neurons, the two major isoforms of apoE (E3 and E4) differentially affect neurite extension, microtubule formation, and the ratio of polymerized to depolymerized tubulin. We therefore examined the effects of apoE3 and apoE4 on microtubule assembly in vitro. ApoE3 and apoE4 equally accelerated microtubule polymerization under conditions of slow microtubule assembly. Controls comprising apolipoprotein A1, bovine serum albumin, trypsin inhibitor, and boiled apoE had no effect, demonstrating specificity of the apoE effect. The ability of both apoE isoforms to accelerate microtubule assembly in vitro suggests that isoform-specific differences in neurite extension may result from differences in the uptake, intracytoplasmic transport, or metabolism of these isoforms.

Botulinum toxin injection into vocal cord in the treatment of malignant coprolalia associated with Tourette's syndrome

We describe a 13-year-old boy with Tourette's syndrome (TS) manifested chiefly by severe coprolalia, obsessive compulsive disorder, and attention deficit hyperactivity disorder. He was treated with unilateral injections of botulinum toxin to the vocal cord and experienced marked improvement in coprolalia as well as marked reduction in the premonitory urges associated with the vocal tics and coprolalia. As a result of the improvement, the patient was able to attend school and church and was able to socialize. Botulinum toxin may interfere with a sensory reflex arc required to perpetuate tics and coprolalia in TS, possibly by reducing local build-up of tension or muscle contraction in affected areas.

Delayed-onset progressive movement disorders after static brain lesions

We studied 53 patients (64% females) with static brain lesions who developed progressive movement disorders. Of these, 50 (94%) had dystonia, 17 (32%) tremor, eight (15%) parkinsonism, seven (13%) myoclonus, and three (6%) chorea. The precipitating insults included perinatal hypoxia/ischemia in 22 (42%), stroke in 12 (23%), head injury in eight (15%), encephalitis in eight (15%), and carbon monoxide poisoning, kernicterus, and radiation necrosis in one patient (2%) each. Among the 30 patients with initial insult occurring at age 2 years or younger (Infant group), distribution of dystonia at follow-up was focal in three (10%), segmental in eight (27%), unilateral in 10 (33%), and generalized in nine (30%). The mean latency between the original injury and onset of movement disorder was 25.5 +/- 16.7 years. Among the nine patients who developed dystonia after an insult occurring between ages 6 and 17 (Childhood group), the distribution of dystonia at follow-up was segmental in two (33%) and unilateral in seven (78%); the mean latency of dystonia onset was 4.9 +/- 7.8 years. Of the 14 patients in the Adult group (injury at age 25 or older), 11 developed dystonia, two developed parkinsonism, and one had carbon monoxide encephalopathy and parkinsonism. The distribution of dystonia in the 11 patients at follow-up was segmental in three (27%) and unilateral in eight (73%). The mean latency of movement disorder onset in the 14 patients of the Adult group was 2.5 +/- 4.9 years. No individuals in the Childhood or Adult groups became left-hand dominant; by comparison, nine of the 30 individuals in the Infant group became left-handed. In conclusion, brain injury at a young age is associated with a longer latency to onset of subsequent movement disorder, a greater tendency to development of generalized dystonia, and a greater probability of altered handedness. These tendencies may result from differences in age-related neuroplasticity.

Membrane docosahexaenoate is supplied to the developing brain and retina by the liver

Docosahexaenoic acid [22:6 omega 3; 22:6(4, 7, 10, 13, 16, 19)] is concentrated in phospholipids of cellular membranes from brain and retina. Although linolenic acid [18:3 omega 3; 18:3(9, 12, 15)] is the major omega 3 fatty acid of mouse dams' milk, 22:6 is the prevalent omega 3 fatty acid in serum and tissues. Intraperitoneal injection of [1-14C]18:3 into 3-day-old mouse pups resulted in liver and serum lipid labeling that was initially high, followed by a rapid decline. In contrast, labeling of brain and retinal lipids were initially low and increased with time. Labeled 22:6 first appeared in liver 2 hr after injection and later in brain and retina. We suggest that 22:6 synthesized from 18:3 by the liver is secreted into the bloodstream in lipoproteins, taken up by brain and retina, and incorporated into cell membranes. We hypothesize that the 22:6 requirements of membranes (e.g., during synaptogenesis, photoreceptor membrane biogenesis, or repair after ischemic injury or neurodegenerative disorders) are met by a signal that is sent by the appropriate tissues to the liver to evoke the secretion of 22:6-containing lipoproteins.

Developing rod photoreceptors from normal and mutant Rd mouse retinas: altered fatty acid composition early in development of the mutant

The phospholipid and fatty acid contents of developing rod photoreceptor cells were determined in dissociated photoreceptor cells obtained from normal mice and from rd mice exhibiting an inherited retinal degeneration. Photoreceptors were dissociated from retinas by mechanical agitation after mild protease treatment and characterized by light and electron microscopy. Phospholipid classes were isolated by thin-layer chromatography, and fatty acyl groups separated and quantitated by capillary gas-liquid chromatography. Developing photoreceptor cells of normal retinas accumulated all phospholipid classes, but in proportions which shifted with age. The mole % contents of phosphatidylcholine (PC) and phosphatidylinositol (PI) decreased with age, whereas phosphatidylethanolamine (PE) and phosphatidylserine (PS) increased. The content of the polyunsaturated fatty acid docosahexaenoate (22:6), expressed as nmol/microgram lipid phosphorus, increased rapidly during development, whereas arachidonate (20:4) content tended to decline. Mono-unsaturated fatty acid levels (palmitoleate, 16:1; oleate, 18:1) declined with age. Among saturated fatty acids, palmitate (16:0) decreased during normal development, whereas stearate (18:0) increased. The total mass of phospholipid/photoreceptor cell in the normal, adult mouse retina was estimated to be approximately 14 pg. The total phospholipid content and mole % distribution of individual phospholipid classes in immature rd photoreceptors were similar to values for normal cells. In contrast, significant changes in fatty acid composition were detected between immature rd cells and normal cells. Rd cells generally had higher levels of saturated (myristate, 14:0; palmitate, 16:0) and monounsaturated fatty acids (oleate, 18:1) and lower levels of polyunsaturated fatty acids (arachidonate, 20:4; docosahexaenoate, 22:6), suggesting that fatty acid metabolism is altered by expression of the rd gene and/or by the associated impairment of photoreceptor cell differentiation.