A pilot study to measure marks in children with cerebral palsy using a novel measurement template

AIM

The primary aim of this pilot study was to trial a method of assessing bruises in a population of disabled children. If the method was found to be sufficiently robust it would be our intention to undertaking a more extensive observational study.

BACKGROUND

Less is known about normal bruising patterns in children with disability than in those without. It is important that the method used to assess bruising is objective and repeatable. In an effort to define and improve repeatability, we employed a novel bruise measurement template which was printed onto transparent acetate sheets.

METHOD

Twenty primary school age children, the majority of whom were non-ambulant and severely disabled with cerebral palsy, underwent full skin examination. The template was used to assess any bruises seen. A comparison was then made between measurements made by experienced paediatricians using the template and using a standard tape measure on a series of bruise images in 25 photographs.

RESULTS

The majority of children in our pilot were found to have bruises, with one child having 6 and one 7 bruises. This comparative study showed that the two techniques had a very similar precision and that the template was easy to use. Greater precision would require a tighter measurement protocol, whether with a template or a tape measure.

CONCLUSIONS

Further evaluation of the application of such a template would be worthwhile. We would suggest that our finding of some bruising in this population of disabled children is borne in mind whenever bruising is found in a non-ambulant child.

Lymphoblastic leukaemia presenting as a carotid-cavernous fistula

A carotid-cavernous fistula is a life-threatening condition characterised by an abnormal communication between the carotid arterial vessels and the cavernous venous system. Although these fistulae can arise spontaneously, they mainly occur after trauma, especially road traffic accidents, falls and penetrating cranial or orbital injuries. The mainstay of treatment involves endovascular embolization, but in those patients where this is not possible or where embolization fails, direct surgical intervention and ligation of the artery may be necessary. Here we describe an interesting case of a suspected carotid-cavernous fistula which turned out to be cavernous sinus syndrome secondary to lymphoma.

Extra-cranial metastasis of glioblastoma multiforme presenting as acute parotitis

We present an unusual case of extracranial metastasis of glioblastoma multiforme (GBM) to the parotid gland and cervical lymph nodes. The patient had previously undergone two craniotomies to debulk a left frontal GBM, followed by radiotherapy. After the second craniotomy, while waiting for chemotherapy, the patient was re-admitted with a short history of a painful swelling of his left parotid gland. The initial diagnosis was infective parotitis; however, as there was no improvement with broad-spectrum antibiotics, CT was undertaken, which revealed a mass in the parotid gland with a necrotic centre and enlarged cervical lymph nodes. Parotid gland biopsy revealed a parotid GBM metastasis. This case illustrates how GBM behaves in an aggressive manner even outside the CNS. A brief review of the literature and of the theories, which might explain the extra-neural metastasis of this tumour is also presented.

Multimodality MR imaging depiction of hemodynamic changes and cerebral ischemia in subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) is a common and serious neurologic emergent condition. We tested the hypothesis that multimodality MR imaging depicts changes in cerebral blood flow SAH, before any surgical or endovascular intervention, and that the frequency of these changes increases with time after ictus.

METHODS

We prospectively examined 37 patients with suspected SAH and three with symptoms of acute stroke but who subsequently had SAH. Routine CT and multimodality MR imaging were performed within 18 h of presentation. Standard MR imaging, diffusion-weighted MR imaging, time-of-flight MR angiography, and dynamic first-pass gadolinium-enhanced MR perfusion imaging were performed. Images were reviewed for abnormalities in cerebral blood flow, ischemia, and infarction. Nine patients did not have SAH at CT and CSF investigations. Of 31 patients with proved SAH, 13 were examined during the acute stage (within 4 d of ictus) and 18, during the subacute stage (4-14 d after ictus).

RESULTS

MR imaging showed alteration in cerebral blood flow parameters in 16 of 31 patients before surgery or endovascular treatment. The frequency of blood flow changes and associated complications increased with worsening clinical grade and increasing time after ictus.

CONCLUSION

Multimodality MR imaging provides information not available from CT in patients with SAH. MR imaging shows oligemic and ischemic areas in SAH before surgery or endovascular treatment. MR imaging is a simple noninvasive method of assessing cerebral blood flow and its complications in SAH. It can be performed in a clinical environment.

Meningiomas, dicentric chromosomes, gliomas, and telomerase activity

Lack of telomere maintenance during cell replication leads to telomere erosion and loss of function. This can result in telomere associations which probably cause the dicentric chromosomes seen in some tumour cells. One mechanism of telomere maintenance in dividing cells is the action of telomerase, a ribonucleoprotein enzyme that adds TTAGGG repeats onto telomeres and compensates for their shortening during cell division. Over 90 per cent of extracranial malignant neoplasms have been found to have telomerase activity. This study sought to determine if there was a relationship between absence of telomerase activity and presence of dicentric chromosomes in meningiomas and to what extent the other main group of central nervous system tumours, the gliomas, expressed telomerase activity. Telomerase activity was measured on 25 meningiomas and 29 gliomas. Four of the meningiomas were atypical variants and 11 were positive for dicentric chromosomes. Twenty-five of 29 gliomas were glioblastoma multiforme tumours. Measures were taken to ensure absence of false positives due to primer-dimer interaction and false negatives due to protein degradation or the presence of Taq polymerase inhibitors. All 25 meningiomas and the four low-grade gliomas (WHO grade II) were telomerase activity-negative. Seven (28 per cent) of the 25 glioblastoma multiforme tumours showed telomerase activity. The absence of telomerase activity in meningiomas and the high frequency of telomere associations support the hypothesis that these tumours are benign, transformed but pre-crisis. The relatively low frequency of telomerase activity in the malignant glioblastoma multiforme suggests that most of these tumours may have other mechanisms of telomere maintenance and that the potentially therapeutic telomerase inhibitors will not be of great value in the future management of the majority of patients suffering from these tumours.

Expression and localisation of stanniocalcin 1 in rat bladder, kidney and ovary

Bony fish use the glycoprotein hormone stanniocalcin (STC) to counteract hypercalcaemia. This is achieved through dual mechanisms involving gill calcium uptake inhibition and stimulation of renal inorganic phosphate reabsorption. Human STC (hSTC-1) shows considerable homology with both rat and mouse STC (mSTC) and their mRNA is expressed in a wide range of tissues. In fish, STC is produced by endocrine glands known as the corpuscles of Stannius but in mammals the widespread expression is suggestive of a paracrine rather than an endocrine role. In order to determine the distribution and strucutral characteristics of hSTC-1, the recombinant protein was expressed in bacteria, purified by metal-ion affinity chromatography, and a study was made of the likely epitopes for raising an antibody. This novel hSTC-1 antibody was used to test the purification protocol. Since the role of mammalian STC is largely unknown, the specific distribution of STC needed to be addressed. To test the specificity of the antibody, sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE)/Western blotting was undertaken in homogenised rat bladder, ovary and kidney.

Potent 2'-amino-, and 2'-fluoro-2'-deoxyribonucleotide RNA inhibitors of keratinocyte growth factor

Reiterative in vitro selection-amplification from random oligonucleotide libraries allows the identification of molecules with specific functions such as binding to specific proteins. The therapeutic usefulness of such molecules depends on their high affinity and nuclease resistance. Libraries of RNA molecules containing 2'amino-(2'NH2)- or 2'fluoro-(2'F)-2'-deoxypyrimidines could yield ligands with similar nuclease resistance but not necessarily with similar affinities. This is because the intramolecular helices containing 2'NH2 have lower melting temperatures (Tm) compared with helices containing 2'F, giving them thermodynamically less stable structures and possibly weaker affinities. We tested these ideas by isolating high-affinity ligands to human keratinocyte growth factor from libraries containing modified RNA molecules with either 2'NH2 or 2'F pyrimidines. We demonstrated that 2'F RNA ligands have affinities (Kd approximately 0.3-3 pM) and bioactivities (Ki approximately 34 pM) superior to 2'NH2 ligands (Kd approximately 400 pM and Ki approximately 10 nM). In addition, 2'F ligands have extreme thermo-stabilities (Tm approximately 78 degrees C in low salt, and specificities).

Inhibitory DNA ligands to platelet-derived growth factor B-chain

We have identified a group of DNA molecules that bind to platelet-derived growth factor (PDGF)-AB with subnanomolar affinity from a randomized DNA library using in vitro selection. Individual ligands cloned from the affinity-enriched pool bind to PDGF-AB and PDGF-BB with comparably high affinity (Kd approximately 10(-10) M) and to PDGF-AA with lower affinity (> 10(-8) M), indicating specific recognition of the PDGF B-chain in the context of the hetero- or homodimer. The consensus secondary structure motif for most of the high-affinity ligands is a three-way helix junction with a three-nucleotide loop at the branch point. Photo-cross-linking experiments with 5-iodo-2'-deoxyuridine-substituted ligands establish a point contact between a thymidine nucleotide in the helix junction loop region and phenylalanine 84 of the PDGF-B chain. Representative minimal DNA ligands inhibit the binding of 125I-PDGF-BB but not of 125I-PDGF-AA to PDGF alpha- or beta-receptors expressed in porcine aortic endothelial (PAE) cells in a concentration-dependent manner with half-maximal effects of approximately 1 nM. The same ligands also exhibit a similar inhibitory effect on PDGF-BB-dependent [3H]thymidine incorporation in PAE cells expressing the PDGF beta-receptors. These DNA ligands represent a novel class of specific and potent antagonists of PDGF-BB and, by inference, PDGF-AB.

Inhibitory DNA ligands to platelet-derived growth factor B-chain

We have identified a group of DNA molecules that bind to platelet-derived growth factor (PDGF)-AB with subnanomolar affinity from a randomized DNA library using in vitro selection. Individual ligands cloned from the affinity-enriched pool bind to PDGF-AB and PDGF-BB with comparably high affinity (Kd approximately 10(-10) M) and to PDGF-AA with lower affinity (> 10(-8) M), indicating specific recognition of the PDGF B-chain in the context of the hetero- or homodimer. The consensus secondary structure motif for most of the high-affinity ligands is a three-way helix junction with a three-nucleotide loop at the branch point. Photo-cross-linking experiments with 5-iodo-2'-deoxyuridine-substituted ligands establish a point contact between a thymidine nucleotide in the helix junction loop region and phenylalanine 84 of the PDGF-B chain. Representative minimal DNA ligands inhibit the binding of 125I-PDGF-BB but not of 125I-PDGF-AA to PDGF alpha- or beta-receptors expressed in porcine aortic endothelial (PAE) cells in a concentration-dependent manner with half-maximal effects of approximately 1 nM. The same ligands also exhibit a similar inhibitory effect on PDGF-BB-dependent [3H]thymidine incorporation in PAE cells expressing the PDGF beta-receptors. These DNA ligands represent a novel class of specific and potent antagonists of PDGF-BB and, by inference, PDGF-AB.

Needs of disabled children and their families

In the new NHS those who provide services for disabled children need to measure and demonstrate their effectiveness, but there are no easily available outcome measures for use by child development centres and teams. The development of an alternative approach, using a series of statements of good practice, is described. Parents of children with cerebral palsy were asked to participate in semistructured interviews, to ascertain the value and relevance of these quality statements. Parents were most concerned about the standard of news breaking and early follow up, the sharing of information, and the supply and repair of equipment. The findings were used to modify the quality checklist and it is proposed that this should form the basis of a "charter for disabled children and their families'.

Nuclease-resistant nucleic acid ligands to vascular permeability factor/vascular endothelial growth factor

BACKGROUND

Vascular permeability factor/vascular endothelial growth factor (VPF/VEGF) is a potent inducer of new blood vessel growth (angiogenesis) that contributes to the pathology of many angiogenesis-associated disease states such as psoriasis, rheumatoid arthritis and cancer. Few molecular entities capable of binding to VPF/VEGF with high affinity and specificity have been described to date.

RESULTS

Nuclease-resistant 2'-amino-2'-deoxypyrimidine nucleotide RNA (2'-aminopyrimidine RNA) ligands that bind to VPF/VEGF with high affinity have been identified by iterative rounds of affinity-selection/amplification from two independent random libraries. The sequence information that confers high affinity binding to VPF/VEGF is contained in a contiguous stretch of 24 nucleotides, 5'-CCCUGAUGGUAGACGCCGGGGUG-3' (2'-aminopyrimidine nucleotides are designated with italic letters). Of the 14 ribopurines in this minimal ligand, 10 can be substituted with the corresponding 2'-O-methylpurine nucleotides without a reduction in binding affinity to VPF/VEGF. In fact, the 2'-O-methyl substitution at permissive positions leads to a approximately 17-fold improvement in the binding affinity to VPF/VEGF. The higher affinity results from the reduction in the dissociation rate constant of the 2'-O-methyl-substituted RNA ligand from the protein compared to the unsubstituted ligand. The 2'-O-methyl-substituted minimal ligand, which folds into a bulged hairpin motif, is also more thermally stable than the unsubstituted ligand. Nuclease resistance of the ligand is further improved by the 2'-O-methyl substitutions and the addition of short phosphorothioate caps to the 3'- and 5'-ends.

CONCLUSIONS

We have used the SELEX (systematic evolution of ligands by exponential enrichment) process in conjunction with post-SELEX modifications to define a highly nuclease-resistant oligonucleotide that binds to VPF/VEGF with high affinity and specificity.

Potent 2'-amino-2'-deoxypyrimidine RNA inhibitors of basic fibroblast growth factor

Screening of random oligonucleotide libraries with SELEX [systematic evolution of ligands by exponential enrichment; Tuerk, C., & Gold, L. (1990) Science 249, 505-510] has emerged as a powerful method for identifying high-affinity nucleic acid ligands for a wide range of molecular targets. Nuclease sensitivity of unmodified RNA and DNA, however, imposes considerable restrictions on their use as therapeutics or diagnostics. Modified RNA in which pyrimidine 2'-hydroxy groups have been substituted with 2'-amino groups (2'-aminopyrimidine RNA) is known to be substantially more resistant to serum nucleases. We report here on the use of SELEX to identify high-affinity 2'-aminopyrimidine RNA ligands to a potent angiogenic factor, basic fibroblast growth factor (bFGF). High-affinity ligands with the same consensus primary structure have been isolated from two independent libraries of approximately 6 x 10(14) molecules containing 30 or 50 randomized positions. Compared to unmodified RNA with the same sequence, 2'-aminopyrimidine ligands are at least 1000-fold more stable in 90% human serum. The sequence information required for high-affinity binding to bFGF is contained within 24-26 nucleotides. The minimal ligand m21A (5'-GGUGUGUGGAAGACAGCGGGUGGUUC-3'; G = guanosine, A = adenosine, C = 2'-amino-2'-deoxycytidine, U = 2'-amino-2'-deoxyuridine, and C = 2'-amino-2'-deoxycytidine or deoxycytidine) binds to bFGF with an apparent dissociation constant (Kd) of 3.5 +/- 0.3) x 10(-10) M at 37 degrees C in phosphate-buffered saline (pH 7.4). Disassociation of m21A from bFGF is adequately described with a first-order rate constant of (1.96 +/- 0.08) x 10(-3) s-1 (t1/2 = 5.9 min). The calculated value for the association rate constant (kon = k(off)/Kd) was 5.6 x 10(6) M-1 s-1. Highly specific binding of m21A to bFGF was observed: binding to denatured bFGF, five proteins from the FGF family (acidic FGF, FGF-4, FGF-5, FGF-6, and FGF-7), and four other heparin binding proteins is substantially weaker under the same conditions with KdbFGF/Kdprotein values ranging from (4.1 +/- 1.4) x 10(-2) to > 10(-6). Heparin but not chondroitin sulfate competed for binding of m21A to bFGF. In cell culture, m21A inhibited [125I]bFGF binding to both low-affinity sites (ED50 approximately 1 nM) and high-affinity sites (ED50 approximately 3 nM) on CHO cells expressing transfected FGF receptor-1.(ABSTRACT TRUNCATED AT 400 WORDS)

How are children's growth problems diagnosed?

Members of the Child Growth Foundation were surveyed to ascertain how children's growth problems were diagnosed. For many (46%) it was the parents who first expressed a concern about the child's growth. Routine height monitoring detected only 8%. Parents consulted a doctor promptly when worried, but there were often delays between the first medical consultation and referral to a hospital consultant. Many parents reported that their concerns were not taken seriously.

Inhibition of receptor binding by high-affinity RNA ligands to vascular endothelial growth factor

The proliferation of new blood vessels (angiogenesis) is a process that accompanies many pathological conditions including rheumatoid arthritis and solid tumor growth. Among angiogenic cytokines that have been identified to date, vascular endothelial growth factor (VEGF) is one of the most potent. We used SELEX [systematic evolution of ligands by exponential enrichment; Tuerk, C., & Gold, L. (1990) Science 249, 505-510] to identify RNA ligands that bind to VEGF in a specific manner with affinities in the low nanomolar range. Ligands were selected from a starting pool of about 10(14) RNA molecules containing 30 randomized positions. Isolates from the affinity-enriched pool were grouped into six distinct families on the basis of primary and secondary structure similarities. Minimal sequence information required for high-affinity binding to VEGF is contained in 29-36-nucleotide motifs. Binding of truncated (minimal) high-affinity ligands to VEGF is competitive with that of other truncated ligands and heparin. Furthermore, truncated ligands from the six ligand families inhibit binding of [125I]VEGF to its cell-surface receptors. Oligonucleotide ligands described here represent an initial set of lead compounds in our ongoing effort toward the development of potent and specific VEGF antagonists.

Effect of three different surgical prone positions on lung volumes in healthy volunteers

Ten healthy volunteers were placed in three different surgical prone positions (knee-chest, Eschmann frame and two supports, one each for the thorax and pelvis); the normal prone position without any supports was used as a control. Lung volumes using helium dilution and spirometry were calculated for each volunteer in each position. Compared with the control position, functional residual capacity, expiratory reserve volume, residual volume and total lung capacity were significantly higher in the knee-chest position. Functional residual capacity and expiratory reserve volume were significantly higher in the frame position. No advantage was gained with the use of the two supports position. We conclude that, of these three prone positions in awake volunteers, the knee-chest position causes least respiratory restriction.

High-affinity RNA ligands to basic fibroblast growth factor inhibit receptor binding

We have isolated RNA ligands with low-nanomolar affinity and high specificity to basic fibroblast growth factor from a pool of 10(14) molecules containing 30 randomized positions by the systematic evolution of ligands by exponential enrichment (SELEX) procedure. High-affinity ligands could be classified into two families based on sequence and secondary structure similarities. Representative RNA ligands from the two families compete with one another as well as with heparin for binding to the protein. Furthermore, we show that these ligands inhibit the first step in the signaling pathway of basic fibroblast growth factor: binding of the growth factor to its cell-surface receptors. These findings emphasize the general usefulness of SELEX as a tool for discovering potent, specific oligonucleotide antagonists of target proteins.

Effects of nitrous oxide on motor evoked potentials recorded from skeletal muscle in patients under total anesthesia with intravenously administered propofol

The effect of nitrous oxide (N2O) on motor evoked potentials (MEPs) recorded from human subjects under total intravenous anesthesia with propofol (2,6-diisopropylphenol) was studied. MEPs were recorded from the 1st dorsal interosseous muscle of the foot in nine subjects; in two of these, simultaneous recordings were made from the 2nd dorsal interosseous muscle of the hand and from the deltoid muscle. Single transcranial electrical stimuli were used in recording the MEPs. The effects of N2O were studied at concentrations from 20 to 70%. Increasing concentrations of N2O caused a progressive increase in onset latency and a fall in the peak-to-peak amplitude of the MEPs recorded from the foot. Latency values showed a significant increase above the baseline at concentrations of N2O greater than 20% (P values, 0.05-0.005). The response amplitude showed a significant decrease from the baseline at concentrations of N2O greater than 50% (P values, 0.05-0.005). The 2nd dorsal interosseous muscle of the hand demonstrated a pattern of sensitivity to N2O similar to that of the 1st dorsal interosseous muscle of the foot. The onset latency and initial peak-to-peak amplitude of the deltoid muscle were insensitive to N2O at the concentrations used. We conclude that N2O can be used as an anesthetic adjunct without a significant deleterious effect on MEPs during intraoperative monitoring in patients under propofol anesthesia, providing concentrations are maintained below 50%.

Noninvasive intraoperative monitoring of motor evoked potentials under propofol anesthesia: effects of spinal surgery on the amplitude and latency of motor evoked potentials

We present the results of intraoperative monitoring of motor evoked potentials from 34 patients undergoing spinal surgery under total anesthesia with intravenously administered propofol. Intraoperative recording was performed with transcranial electrical stimulation. Two groups of patients were studied: 1) a control population of 26 patients undergoing lumbar discectomy for prolapsed intervertebral disc, all of whom had normal preoperative motor conduction; and 2) a population of 8 patients undergoing neurosurgical procedures for spinal tumor (5 patients) and spinal arteriovenous malformation (3 patients), all of whom had abnormal preoperative neurological signs and abnormal preoperative motor conduction. In the first group, electromyographic responses were recorded intraoperatively either from the 2nd dorsal interosseous muscle of the hand (5 patients) or from the 1st dorsal interosseous muscle of the foot (21 patients). In the second group, responses were recorded intraoperatively either from the 1st dorsal interosseous muscle of the foot (7 patients) or from the anterior tibial muscle (1 patient). Intraoperative monitoring of motor function was successful in 88.5% of the patients in the control group. Propofol anesthesia caused a reduction in response amplitude to 7% of baseline values obtained from conscious relaxed subjects. Intraoperative monitoring was successful in 87% of the patients in the pathological group. We observed significant changes in both amplitude (greater than 50%) and/or onset latency (greater than 3 ms) from the intraoperative baseline that indicated either improvement (3 patients) or deterioration (2 patients) in motor conduction within minutes of surgical maneuvers anticipated to alter spinal cord function. Only permanent complete loss of intraoperative motor conduction (1 patient) correlated with a significant change in the postoperative neurological state.(ABSTRACT TRUNCATED AT 250 WORDS)

Separation of growth-promoting activity for human muscle cells from fetuin

Whether the growth-promoting activity of Pedersen fetuin is due to fetuin itself or to a contaminant(s) has been a long-standing puzzle. The possibility that the growth-promoting activity of Pedersen fetuin for human muscle satellite cells (HMSC) could be caused by some other component of fetal bovine serum (FBS) that remained in the fetuin as a contaminant has been investigated. One liter of FBS was first precipitated with 50% saturated ammonium sulfate, which leaves the serum albumin in solution, and then with 25% polyethylene glycol, which leaves the fetuin in solution, to generate a fraction 50 PEG 2x that was enriched 11-fold in growth-promoting activity for HMSC, with 68% recovery of total activity. Further purification with FPLC anion exchange chromatography achieved 99-fold enrichment of the activity with 30% overall recovery. The activity is heat labile and pH sensitive, suggesting that it is of protein nature, and the size of the activity is above 70 kDa. SDS-PAGE of the most active fractions shows that they are virtually free of fetuin. Thus, although the active fractions are not homogeneous, these studies demonstrate that the growth-promoting activity for HMSC can be fully separated from fetuin.