Intraoperative Neuromonitoring of the Visual Pathway in Asleep Neuro-Oncology Surgery

Brain tumour surgery in visual eloquent areas poses significant challenges to neurosurgeons and has reported inconsistent results. This is a single-centre prospective cohort study of patients admitted for asleep surgery of intra-axial lesions in visual eloquent areas. Demographic and clinical information, data from tractography and visual evoked potentials (VEPs) monitoring were recorded and correlated with visual outcomes. Thirty-nine patients were included (20 females, 19 males; mean age 52.51 ± 14.08 years). Diffuse intrinsic glioma was noted in 61.54% of patients. There was even distribution between the temporal, occipital and parietal lobes, while 55.26% were right hemispheric lesions. Postoperatively, 74.4% remained stable in terms of visual function, 23.1% deteriorated and 2.6% improved. The tumour infiltration of the optic radiation on tractography was significantly related to the visual field deficit after surgery (p = 0.016). Higher N75 (p = 0.036) and P100 (p = 0.023) amplitudes at closure on direct cortical VEP recordings were associated with no new postoperative visual deficit. A threshold of 40% deterioration of the N75 (p = 0.035) and P100 (p = 0.020) amplitudes correlated with a risk of visual field deterioration. To conclude, direct cortical VEP recordings demonstrated a strong correlation with visual outcomes, contrary to transcranial recordings. Invasion of the optic radiation is related to worse visual field outcomes.

Measurement of the ν_{e}-Nucleus Charged-Current Double-Differential Cross Section at ⟨E_{ν}⟩=2.4 GeV Using NOvA

The inclusive electron neutrino charged-current cross section is measured in the NOvA near detector using 8.02×10^{20} protons-on-target in the NuMI beam. The sample of GeV electron neutrino interactions is the largest analyzed to date and is limited by ≃17% systematic rather than the ≃7.4% statistical uncertainties. The double-differential cross section in final-state electron energy and angle is presented for the first time, together with the single-differential dependence on Q^{2} (squared four-momentum transfer) and energy, in the range 1  GeV≤E_{ν}<6  GeV. Detailed comparisons are made to the predictions of the GENIE, GiBUU, NEUT, and NuWro neutrino event generators. The data do not strongly favor a model over the others consistently across all three cross sections measured, though some models have especially good or poor agreement in the single differential cross section vs Q^{2}.

Search for Active-Sterile Antineutrino Mixing Using Neutral-Current Interactions with the NOvA Experiment

This Letter reports results from the first long-baseline search for sterile antineutrinos mixing in an accelerator-based antineutrino-dominated beam. The rate of neutral-current interactions in the two NOvA detectors, at distances of 1 and 810 km from the beam source, is analyzed using an exposure of 12.51×10^{20} protons-on-target from the NuMI beam at Fermilab running in antineutrino mode. A total of 121 of neutral-current candidates are observed at the far detector, compared to a prediction of 122±11(stat.)±15(syst.) assuming mixing only between three active flavors. No evidence for ν[over ¯]_{μ}→ν[over ¯]_{s} oscillation is observed. Interpreting this result within a 3+1 model, constraints are placed on the mixing angles θ_{24}<25° and θ_{34}<32° at the 90% C.L. for 0.05  eV^{2}≤Δm_{41}^{2}≤0.5  eV^{2}, the range of mass splittings that produces no significant oscillations at the near detector. These are the first 3+1 confidence limits set using long-baseline accelerator antineutrinos.

Short-lasting retroorbital pain attacks as a form of ictal epileptic headache: Case report

Background and objectives

Ictal epileptic headache is a rare form of painful seizure, habitually consisting of migrainous or tension-type headache. We describe a case of a patient with short-lasting, severe retroorbital pain attacks caused by frontal lobe epilepsy.

Case report

A 25-year-old male patient presented with recurrent attacks of paroxysmal, short-lasting, excruciating left periorbital and facial pain mainly occurring from sleep. After intracranial EEG exploration and resection of a right prefrontal focal cortical dysplasia, long-term seizure and headache remission was obtained.

Discussion

Our case extends the clinical and neuroanatomical spectrum of ictal epileptic headache and suggests that long-term remission can be obtained by resective epilepsy surgery. It also reinforces the role of the prefrontal cortex in the pain matrix and pain generation.

Conclusion

Despite its rarity, ictal epileptic headache should be suspected in selected patients, particularly those with other ictal symptoms and signs, history of epileptic seizures, or neuroimaging abnormalities.

Stroke service: how can we improve and measure outcomes? Consensus summary from a global stroke forum

The success of acute stroke treatment is first and foremost time-dependent, and the need for improvement in acute stroke management is demonstrated by the fact that only a minority of patients gain access to treatment - in particular, intravenous recombinant tissue plasminogen activator (IV tPA) - within the necessary time window. Standards of acute stroke care vary widely both regionally and nationally; consequently, various healthcare organizations have undertaken initiatives to measure and improve quality of care. To date, most quality measures have been process-based, focusing primarily on metrics of patient care in the acute hospital-based setting (e.g., time to recombinant tPA administration). Therefore, there remains a need for metrics designed to assess how improvements in process translate into patient outcomes. A global forum was convened to share best practice and provide consensus recommendations on core metrics for measuring improvements in access to care and patient outcomes. Recommendations for core metrics of patient outcomes include hospital-based outcomes (e.g., neurological status at 24 h, ambulatory status at discharge) and post-discharge outcomes (e.g., modified Rankin Scale score at 30 and/or 90 days). Recommendations for best practice relating to aspects of people, process, and technology involved in the stroke treatment pathway that may help provide improvements in these core outcome measures are also outlined.

Dynamic MR imaging patterns of cerebral fat embolism: a systematic review with illustrative cases

Different MR imaging patterns of cerebral fat embolism have been reported in the literature without a systematic review. Our goal was to describe the patterns, explore the relationship between disease course and the imaging patterns, and discuss the underlying mechanism. We reveal 5 distinctive MR imaging patterns: 1) scattered embolic ischemia occurring dominantly at the acute stage; 2) confluent symmetric cytotoxic edema located at the cerebral white matter, which mainly occurs at the subacute stage; 3) vasogenic edematous lesions also occurring at the subacute stage; 4) petechial hemorrhage, which persists from the acute to the chronic stage; and 5) chronic sequelae, occurring at late stage, including cerebral atrophy, demyelinating change, and sequelae of infarction or necrosis. Underlying mechanisms of these imaging patterns are further discussed. Recognition of the 5 evolving MR imaging patterns of cerebral fat embolism may result in adjustment of the appropriate management and improve the outcome.

The ventriculocholecystic shunt: two case reports and a review of the literature

We describe the re-siting of ventriculoperitoneal shunts to the gallbladder in two children. The first child had a rare case of hydrocephalus associated with plasminogen deficiency. She had had multiple VP shunt revisions due to non-absorption of CSF from the peritoneum. The second had craniopharyngioma-related hydrocephalus with once again a non-absorbing peritoneum. We report no surgical complications in the revisions for both the cases, and there has been a subsequent follow-up of 46 and 28 months, respectively, without incident. A review of the relevant literature describing the use and the performance of ventriculocholecystic shunts in comparison with other ventricular shunts is considered.

Abstract 94: Patient Selection using CT Perfusion (CTP) Imaging Improves Effectiveness of Stroke Thrombolysis in the 0-4.5 Hour Time Window

Background: The role of CT perfusion (CTP) in thrombolysis decisions remains controversial and there are no studies that compare outcomes of thrombolysis in patients with or without mismatch on CT perfusion imaging.

Methods: We analysed registry data between Jan 2009 and December 2010 for patients thrombolysed within 0-4.5 hours of stroke onset in whom CTP studies were performed prior to thrombolysis. The centre followed thrombolysis guidelines but patients >80 years were included. CTP was not obligatory in the treatment protocol and failure to demonstrate a mismatch was not a contraindication to thrombolysis. We retrospectively analysed data for estimated CTP mismatch of ≥ 100% according to pre-defined criteria and compared outcomes of thrombolysed patients showing perfusion mismatch with those showing no mismatch.

Findings: The sample included 160 patients aged between 32-95 years of whom 63 had no mismatch and 97 had a significant mismatch. The two groups were comparable for mean age (73 v 70 years, p=0.18), sex (49% v 54% male, p=0.75), premorbid Rankin Score (mRS) 0-2 (81% v 92%, p=0.77), vascular risk factors profile, mean baseline BP (148/87 v 148/79 mm Hg, p=0.92), mean blood glucose (6.6 v 6.6 mmols/L, p=0.98) and mean National Institute of Health Stroke Scale (NIHSS) score (14.0 v 12.6,p=0.12). Patients who had mismatch prior to thrombolysis showed lower mean 24 hour NIHSS score (7.6 v 11.8, p=0.002) and greater mean 24 hour improvement in NIHSS score (5.1 v 2.0, p=0.010). A higher proportion of patients with mismatch achieved mRS 0-1 and mRS 0-2 at 3 months (36% v 18%, p= 0.012 and 51% v 32%, p=0.015 respectively) but there were no differences in symptomatic sICH rates (1.1% v 0%). Mortality (29% v 18%) and any intracranial haemorrhages (19% v 13%) were lower in mismatch patients but did not achieve significance. Regression analyses showed that PCT mismatch prior to thrombolysis was an independent predictor of both early improvement and functional outcomes at 3 months.

Conclusion: Stroke patients who have perfusion mismatch on CTP imaging prior to thrombolysis within the 4.5 hour time window show better early and 3 month outcomes compared with those in whom mismatch cannot be demonstrated. Patient selection using multimodal CT may improve the effectiveness of thrombolysis.

A new MRI rating scale for progressive supranuclear palsy and multiple system atrophy: validity and reliability

AIM

To evaluate a standardised MRI acquisition protocol and a new image rating scale for disease severity in patients with progressive supranuclear palsy (PSP) and multiple systems atrophy (MSA) in a large multicentre study.

METHODS

The MRI protocol consisted of two-dimensional sagittal and axial T1, axial PD, and axial and coronal T2 weighted acquisitions. The 32 item ordinal scale evaluated abnormalities within the basal ganglia and posterior fossa, blind to diagnosis. Among 760 patients in the study population (PSP = 362, MSA = 398), 627 had per protocol images (PSP = 297, MSA = 330). Intra-rater (n = 60) and inter-rater (n = 555) reliability were assessed through Cohen's statistic, and scale structure through principal component analysis (PCA) (n = 441). Internal consistency and reliability were checked. Discriminant and predictive validity of extracted factors and total scores were tested for disease severity as per clinical diagnosis.

RESULTS

Intra-rater and inter-rater reliability were acceptable for 25 (78%) of the items scored (≥ 0.41). PCA revealed four meaningful clusters of covarying parameters (factor (F) F1: brainstem and cerebellum; F2: midbrain; F3: putamen; F4: other basal ganglia) with good to excellent internal consistency (Cronbach α 0.75-0.93) and moderate to excellent reliability (intraclass coefficient: F1: 0.92; F2: 0.79; F3: 0.71; F4: 0.49). The total score significantly discriminated for disease severity or diagnosis; factorial scores differentially discriminated for disease severity according to diagnosis (PSP: F1-F2; MSA: F2-F3). The total score was significantly related to survival in PSP (p<0.0007) or MSA (p<0.0005), indicating good predictive validity.

CONCLUSIONS

The scale is suitable for use in the context of multicentre studies and can reliably and consistently measure MRI abnormalities in PSP and MSA. Clinical Trial Registration Number The study protocol was filed in the open clinical trial registry (http://www.clinicaltrials.gov) with ID No NCT00211224.

Hypertension-related cognitive decline: is the time right for intervention studies?

The importance of lowering blood pressure in hypertensive subjects is well known but the relationship between hypertension and cognitive function has been a subject of considerable controversy. Cross-sectional studies investigating the relationship between blood pressure and cognition have shown conflicting relationships whilst the majority of longitudinal studies have demonstrated elevated blood pressure to be associated with cognitive decline. Randomised studies have demonstrated heterogeneous and sometimes conflicting effects of blood pressure lowering on cognitive function and suggested reasons include multiple mechanisms by which hypertension affects the brain, the variety of cognitive instruments used for assessment and differences in antihypertensive treatments. Chronic hypertension accelerates arteriosclerotic changes in the brain with a disproportionate effect on subcortical circuits associated with cerebral small vessel disease. Randomised clinical trials assessing the cognitive consequences of blood pressure reduction in people with small vessel disease are lacking and many of the existing controversies on the cognitive consequences of blood pressure lowering, especially in older people, arise from the design limitations of studies. This article describes the methodological issues in designing such a trial and the results of a pilot evaluation to see if careful selection of subjects and measurements would make undertaking intervention studies feasible. Given the predicted upswing in people with cognitive impairments, the time is right for randomised clinical trials with specific cognitive end-points to examine the relationship between cognitive function and hypertension and guide practice.

Cerebrovascular reactivity and dynamic autoregulation in ischaemic subcortical white matter disease

BACKGROUND

It has been suggested that impaired cerebral autoregulation and vasodilatory capacity may play in role in the pathogenesis of the leukoaraiosis seen in small vessel disease. Adequate perfusion of the deep white matter of the brain depends on the relationships between blood pressure (BP), cerebral vasoreactivity and autoregulation.

METHODS

24 h ambulatory BP measurement, quantitative volumetric MRI analysis of white matter lesion (WML) volume and transcranial Doppler ultrasound assessments of CO(2) reactivity in response to hypercapnia and dynamic cerebral autoregulatory index (ARI) were undertaken in 64 patients with cerebral small vessel disease.

RESULTS

Subjects had mean 24 h BP 133/76 mm Hg (SD 13/9), median WML volume 7169 (IQR 20497) mm(3), mean CO(2) reactivity 83.6 (SD 37.4)% and mean ARI 5.6 (SD 1.4) (range 0-9). In multivariate models, after adjusting for age, gender, vascular risk profile and WML volume, ARI correlated with 24 h mean BP levels (R(2) = 0.127, t = 2.440, p = 0.019) and CO(2) reactivity correlated with duration of hypertension (R(2) = 0.085, t = -2.244, p = 0.029). In individuals with hypertension for more than 10 years, ARI also correlated with nocturnal BP dipping (r = 0.806, p = 0.002). ARI and CO(2) reactivity were unaffected by WML volumes, and ARI and CO(2) reactivity were unrelated.

CONCLUSION

Cerebral autoregulation and CO(2) reactivity are two distinct processes which are not related to WML volume but are related to BP levels and duration of hypertension, respectively. Greater nocturnal dipping was associated with higher ARI values, suggesting preservation of autoregulation in patients with increased vulnerability to reduced cerebral perfusion.

Closed cranial meningocele with no communication to the CNS

We present a case of two separate closed parietal meningoceles without communication to the CNS and not in the midline. This is the first such case reported in the literature.

Islet isolation under cGMP conditions: replacing the coil

INTRODUCTION

Clinical islet transplantation is increasingly regulated, with isolation standards defined under current good manufacturing practices (cGMPs). cGMP requires validation of equipment cleaning and sterilization. The automated process for islet isolation requires rapid thermal exchange during processing, manipulating a metal coil containing cellular product into and out of chilled/heated waterbaths. We recognize challenges of validating cleaning and sterilization of this coil and propose replacement with a disposable blood warming system. Our specific aims were to assess the system's ability to accommodate flow rates utilized during various phases of pancreatic digestion and to assess its efficiency of heat exchange and temperature control.

METHODS

In a pancreas digestion circuit, heat exchange occurred via the coil in a digital water bath, or Warmflo blood warming bag in a digital warming unit. Temperature within the digestion chamber was assessed using an inserted thermocouple. Time to achieve 37 degrees C was measured for set heating element temperatures 38.5 degrees C to 41 degrees C. Circuit temperature maintenance characteristics were also recorded.

RESULTS

The Warmflo bloodbag easily accommodated flows of 150 and 300 mL/min. At all set temperatures, the bag resulted in shorter or equivalent time to 37 degrees C than the coil. Maintenance of 37 degrees C was also equivalent. We have utilized this system for four human islet isolations with mean time to 37 degrees C of 5.5 minutes, without difference in digestion quality.

CONCLUSIONS

Use of a disposable blood warming system in place of the coil during islet isolation provides adequate flow characteristics, heat exchange, and temperature control and may facilitate evolution of islet isolation toward cGMP compliance.

The clinical spectrum of epilepsy in children and adults with hypothalamic hamartoma

PURPOSE

Hamartomas of the hypothalamus (HH) cause an uncommon and unusual epilepsy syndrome. The condition is recognized to affect children, but the presentation in adults is not well understood. We present 19 children and adult patients with HH, including three patients whose epilepsy began in adult life. The patterns of clinical presentation, evolution of the epilepsy from childhood to adult life, and electroclinical diagnostic features are presented.

METHODS

Nineteen patients, both children and adults with HH and epilepsy, were evaluated clinically, with EEG, video-EEG, and magnetic resonance imaging (MRI) scanning. Seven patients underwent surgical resection of the hamartoma. Stereotactic thermocoagulation of the hamartoma was performed in two patients.

RESULTS

Gelastic seizures occurred at onset of epilepsy in 15 of 16 early-onset cases. Subsequently, multiple seizures types occurred, which then evolved to mainly partial epilepsy with tonic or complex partial seizures (five of eight adults), or became entrenched symptomatic generalized epilepsy with atypical absences, drop attacks, and secondarily generalized seizures, and cognitive impairment (three of eight adults). In the adult-onset patients, gelastic seizures were not prominent, the epilepsy was milder, and they functioned normally. Stereotactic thermocoagulation of the hamartoma resulted in improvement in seizure control in two patients.

CONCLUSIONS

Gelastic seizures are not a prominent feature of epilepsy in adult patients with HH. The epilepsy associated with HH, although severe at onset, can evolve into a milder syndrome in later life. For less severely affected patients, minimally invasive alternatives to the traditionally difficult open surgical treatment should be considered.

Effectiveness evaluation of available without prescription medicines for postoperative pain treatment after "one day surgery"

The quality of pain relief during the first 24 hours following day case surgery has been poorly documented. This study was conducted to evaluate the quality of postoperative pain relief when using dexibuprofen or paracetamol. 127 patients in the age group 17-78 who underwent day case surgery were asked to complete questionnaire 24 hours after the end of the operation. The majority of patients (74,02%) had pain after operation. 66,14% had only mild pain (VAS 1-5), 7,87% had difficulty in sleeping at night due to severe pain (VAS 6-8). In 88,89% of outpatients the use of dexibuprofen or paracetamol was effective with pain relief.

Ultrastructural examination is essential for diagnosis of papillary meningioma

AIMS

Papillary meningioma is a rare meningeal tumour. To date only a few cases have been reported and their immunohistochemical features have not been fully documented.

METHODS AND RESULTS

A 49-year-old woman presented with a 2-month history of headaches and memory disturbance. CT and MRI imaging showed an enhancing pineal mass with extension into the occipital lobes and invasion of the splenium. At surgery, the tumour was found to be tough and vascular with a well-defined capsule. No recurrence was noted 19 months after the operation. In another case a 44-year-old woman was admitted with 1-month history of headaches, poor memory, imbalance and diplopia. CT scan showed a large hyperdense, uniformly, enhancing mass within the middle cranial fossa at the petrous ridge. The tumour recurred 19 and 25 months after first resection. The histology of both tumours was similar. The neoplasms contained polygonal cells with a moderate amount of cytoplasm, rounded regular nuclei and distinct cell borders. The cells were arranged radially around the blood vessels (perivascular pattern) and a papillary pattern was seen only focally. Mitotic figures were moderately frequent. Immunohistochemistry showed that both tumours were immunoreactive to vimentin and NSE, whereas GFAP, CAM5.2, EMA, S100 protein and synaptophysin were negative. Electron microscopy revealed interdigitating cell processes, desmosomes and intermediate filaments.

CONCLUSIONS

The histological and immunohistochemical features of these two tumours are complex and difficult to interpret. Although papillary meningiomas were considered in our initial differential diagnosis, the final conclusion was possible only when the ultrastructural features were revealed.

Chronic encephalitis and temporal lobe epilepsy: a variant of Rasmussen's syndrome?

The authors report two adult patients with chronic temporal lobe epilepsy and pathologic features consistent with Rasmussen's encephalitis. Although seizures persisted after temporal lobe surgery no progressive cognitive or neurologic deficit has emerged. Prominent auditory auras in each suggested a persisting epileptogenic focus in the superior temporal gyrus. The current findings expand the clinical spectrum of Rasmussen's encephalitis and suggest that chronic nonprogressive encephalitis may serve as the pathologic substrate of medically intractable temporal lobe epilepsy.

Immune phenomena in echinoderms

Advances in biochemistry and molecular biology have made it possible to identify a number of mechanisms active in the immune phenomena of echinoderms. It is obvious that echinoderms have the ability to distinguish between different foreign objects (pathologically changed tissues, microorganisms, parasites, grafts) and to express variable effector mechanisms which are elicited specifically and repeatably after a variety of non-self challenges. The molecular and biochemical basis for the expression of these variable defense mechanisms and the specific signals which elicit one type of effector mechanism are not, however, yet well known. The high capacity of coelomocytes to phagocytose, entrap and encapsulate invading microorganisms is a valid immune cell-mediated mechanism of echinoderms. The entrapped bacteria, discharged cellular materials and disintegrating granular cells are compacted and provoke the cellular encapsulation reaction. Moreover, humoral-based reactions form an integral part of the echinoderm defense system against microbial invaders. Factors such as lysozyme, perforins (hemolysins) vitellogenin and lectins are normal constituents of hemolymph, while cytokines are synthesized by echinoderms in response to infection.

Cluster analysis of diffusion tensor magnetic resonance images in human head injury

OBJECTIVE

Issues surrounding the nature of the edema associated with traumatic brain injury in humans, and its evolution in the acute phase, remain unresolved. This study aimed to characterize the topographical nature of the pathophysiological changes in human traumatic brain injury with diffusion tensor magnetic resonance imaging.

METHODS

Multislice diffusion-weighted magnetic resonance imaging data were acquired from five patients undergoing elective ventilation for management of traumatic focal contusion or hematomas. The diffusion tensor and the T2-weighted intensity were then computed for every voxel in the image data set for each patient. The topographical distribution of abnormalities in the trace of the diffusion tensor and T2-weighted images were characterized by cluster analysis.

RESULTS

In four patients with technically satisfactory data, a narrow band of tissue was observed in the periphery of focal lesions, which was characterized by selective reduction in the trace of the diffusion tensor, without any associated increase in the T2-weighted signal intensity.

CONCLUSION

This change is interpreted as indicating either a partial redistribution of water from the extra- to intracellular compartment, or a reduction in the diffusivity of water in the intracellular or cytosolic environment. These diffusion and T2-weighted characteristics are also found in early ischemic change, hence, such regions may represent potentially salvageable tissue at risk of permanent damage. The study illustrates the advantage of using information contained within the diffusion tensor in addition to more conventional imaging sequences.

Significance of interictal bilateral temporal hypometabolism in temporal lobe epilepsy

OBJECTIVE

To assess the clinical implications and the pathophysiologic determinants of interictal bitemporal hypometabolism (BTH) in temporal lobe epilepsy (TLE) not associated with bilateral MRI abnormalities or intracranial space-occupying lesions.

METHODS

The authors compared the clinical, interictal, and ictal EEG, Wada test, and neuropsychology data of 15 patients with intractable complex partial seizures of temporal lobe origin and BTH with those of 13 consecutive patients with unilateral TLE associated with unilateral temporal hypometabolism (UTH) who remained seizure free for more than 3 years after anterior temporal lobectomy. 18F-fluorodeoxyglucose PET scans were analyzed visually and semiquantitatively, and ratios of counts in individual temporal areas to the rest of the cerebrum were compared with the corresponding values from 11 normal control subjects and with the nonepileptogenic hemisphere of the 13 patients with UTH. BTH was defined as more than 2.5 SDs below control values for two or more temporal areas on each side irrespective of any asymmetry.

RESULTS

BTH reflected bilateral independent seizure onset in eight patients (53%). The topography of the metabolic depression was not a reliable predictor of epileptogenicity, but involvement of the inferior temporal gyrus was related specifically to ipsilateral seizure onset (70% sensitivity, 100% specificity). In patients with unilateral TLE, contralateral hypometabolism was associated with longer disease duration and worst memory performance during the Wada test, which amounted to global amnesia after ipsilateral injection in three patients, precluding surgical treatment. Contralateral seizure spread in the ictal EEG was significantly faster in patients with BTH.

CONCLUSIONS

In TLE, symmetric or asymmetric BTH may signal bilateral independent seizure onset in approximately half the patients, especially when involving the inferior temporal gyrus. Alternatively, it may reflect an advanced stage of the disease process, characterized by a breakdown of the inhibitory mechanisms in the contralateral hemisphere, and secondary memory deficit associated with higher risk of postoperative memory decline. Patients with TLE and BTH but without bilateral MRI changes may still be operated on successfully, but surgical suitability should be proved by comprehensive intracranial EEG studies and Wada test.

Active resistance of entomophagous rhabditid Heterorhabditis bacteriophora to insect immunity

A specific extracellular proteinase, degrading selectively the cecropin-based defence system of insects, is secreted into the larval body during parasitism of the greater wax moth by the Heterorhabditis bacteriophora/Photorhabdus luminescens complex and by phase 1 of P. luminescens. The proteolytic digestion of insect inducible cecropin-like immune molecules was demonstrated by the disappearance of the Galleria mellonella cecropins and purified Hyalophora cecropin B peptide PAGE bands upon exposure to infected extracts, and a similar abrogation of antibacterial activity using an agar diffusion assay. Proteolytic activity of infected extracts produced by nematode/bacterial complex and phase 1 variant of P. luminescens was shown to be correlated with cecropin-inhibitory activity, suggesting that this anti-cecropin agent may be responsible for the ability of bacteria to establish infection and the insecticidal nature of H. bacteriophora. Antibacterial activity of Galleria lysozyme and that of chicken egg-white lysozyme to which P. luminescens is insensitive, was unaffected by H. bacteriophora proteinase.

Molluscan immune defenses

The interest of marine invertebrates as food resources provides a major interest to study molluscan immunity for better understanding of the host response to pathogens. Molluscs possess a natural immunity formed by anatomical and chemical protective barriers that prevent damage of the underlying tissues, body fluid losses and the infections of pathogenic microorganisms and parasites. The main physical barrier is shell and mucus which cover the soft body of molluscs. The integrity of body coverings is supported by blood clotting and wound healing. The internal defense mechanisms of molluscs involve such cellular reactions as: phagocytosis, nodule formation, encapsulation, pearl formation, atrophy, necrosis and tissue liquefaction. Granular hemocytes are the most numerous cell type of molluscan blood active in cellular defenses. Invaders small in size are eliminated by phagocytosis in which participate lectins and products of prophenyloxidase system activation. Numerous and large intruders are eliminated by nodule formation or encapsulation, either cellular or humoral. Humoral components of molluscan immunity are formed by lysozyme activity, lectins and the phenyloxidase system. Up to now the role of mercenenes, paolins, acute phase reactants, alpha 2-macroglobulins and multifunctional binding proteins with anti-protease activity is not well clarified yet. Research prospects on the field of molluscan immunology should essentially be devoted to study cellular defense functions and humoral effectors to select pathogen-resistant molluscs. This aim could also be achieved by the identification and characterization of immune genes which are candidates for molluscs genetic transformation.

Earthworm immune responses

The knowledge of the immunity in annelids started with the use of earthworms as biomarkers indicating changes caused by environmental pollution. Defence strategies effectively protect earthworms against bacterial infections and parasitic invasion. A natural immunity formed by anatomical and chemical protective barriers prevents damage of the underlying tissues, body fluid losses, and microbial infections of the body cavity. The internal defence mechanisms of annelids involve phagocytosis, nodule formation and encapsulation, blood coagulation and wound repair, and antibacterial immune proteins. The antibacterial activity of coelomic fluid associated with lysozyme-like substances and inducible humoral molecules support haemocytic reactions in the annelid defence system.

Transcatheter uterine artery embolisation to treat large uterine fibroids

Bilateral uterine artery embolisation was performed to treat eight women with symptomatic large fibroids requiring treatment. Uterine volume was quantitatively assessed by magnetic resonance imaging. Both uterine arteries were occluded effectively in all women, and the procedure was well tolerated, with a 24-36 hour admission for pain relief. The level of pain experienced was variable, but well controlled. Some women experienced intermittent vaginal discharge and pain following the procedure. Improvement of symptoms occurred in six of the seven women and the eighth woman conceived. There were no significant complications. At three months four women had a uterine volume of < 350 cm3. Embolisation appears to be a good alternative to surgery, but longer follow up is required to evaluate the long term effects and to determine those patients for whom the procedure is suitable.

Identification of immune inhibitor from Pseudomonas aeruginosa of inducible cell-free antibacterial activity in insects

Insect-pathogenic strains of Pseudomonas aeruginosa produce specific proteinase which selectively degrades the cecropin-based defence system of insects. This was demonstrated by the disappearance of the Galleria cecropin and purified Hyalophora cecropin B peptide PAGE bands, but not the lysozyme band, upon exposure to infected extracts and a similar abrogation of antibacterial activity using an agar diffusion assay. In addition, the proteolytic activity of infected extracts produced by high and low virulence Pseudomonas strains was shown to be correlated with cecropin-inhibitory activity. This indicated that the bacterial proteinase was responsible for the ability of bacteria to establish infections and strain virulence.

Polydnaviruses of hymenopteran endoparasitoids knock out the host insect immune response

The insect immune system reacts against invading microorganisms and parasites with the recruitment of haemocytes and with humoral response. Cellular immune reactions involve phagocytosis, nodule formation and encapsulation by different types of haemocytes whereas insect cell-free antibacterial immunity depends on the production of a number of peptides and proteins, among which lysozyme, cecropins and attacins represent the major group of immune proteins. Polydnaviruses from certain hymenopterous parasitoids interfere with both host immunity and host development. These immunosuppressive viruses exhibit an intimate genetic relationship with the parasitoid since viral sequences are integrated within the parasitoid chromosomal DNA. The viral genes expression in parasitized host induces immunosuppression and alters development of the host insect. The parasitoids developing in the host body cavity knock out the insect immune system, inducing a decline in cellular and humoral components of the immune system so that parasitoid eggs are not recognized as foreign and thereby are not encapsulated. Polydnaviruses carrying parasitoids escape the host immune response and may develop within the insect host whereas other invaders are normally destroyed by defense factors of insect haemolymph.

Ecology of anti-microbials produced by bacterial associates of Steinernema carpocapsae and Heterorhabditis bacteriophora

Based on the ability of bacterial associates of entomopathogenic nematodes to produce antibiotic compounds on artificial media, it has been commonly accepted that Xenorhabdus sp. and Photorhabdus sp. inhibit a wide range of invading microorganisms in insects infected with Steinernema spp. or Heterorhabditis spp. Therefore, the question of whether antibiotic compounds produced by the primary form of bacterial symbionts associated mutualistically with S. carpocapsae and H. bacteriophora explain why insect carcasses do not putrefy but provide nutritional requirements for insect parasitic rhabditoid nematodes to complete their life-cycle was examined. Laboratory bioassays of anti-bacterial activity on nutrient agar and during parasitism in larvae of Galleria mellonella have confirmed earlier observations that in virto colonies of the primary form of X. nematophilus and P. luminescens produced agar-diffusible antibiotic compounds of a broad spectrum of anti-bacterial activity; their role in parasitism seems doubtful, however. This hypothesis is supported by a low antibiotic potency of a limited spectrum of anti-bacterial activity throughout the life-cycle of the parasites, principally in Galleria infected with S. carpocapsae. Since the lack of putrefaction cannot be explained simply by antibiotic inhibition of contaminating bacterial microflora, other competition mechanisms must be operating in parasitized insects. I postulated that a rapid and massive colonization of the insect body by nematophilic bacteria creates unfavorable conditions for the growth and multiplication of bacterial (proteolytic) contaminators making the insect carcass decay-resistant. In the case of H. bacteriophora, low antibiotic activity at an early stage of parasitism could support the colonization by P. luminescens of the host.

[Repetitive transcranial magnetic stimulation: EEG, serum prolactin and cortisol studies in humans]

Ten adult volunteers had EEG recordings and serial serum prolactine/cortisol estimations performed during repetitive transcranial magnetic stimulation. No significant changes in either the hormone values or in the EEG traces were detected.

Induction kinetics of immune antibacterial proteins in pupae of Galleria mellonella and Pieris brassicae

1. Pupae of Galleria mellonella and Pieris brassicae given an injection with live, non-pathogenic Enterobacter cloacae or abiotic foreign molecules induce an acquired immunity that corresponds with the synthesis of haemolymph proteins of antibacterial activity. 2. This humoral defensive response which persists for several days, differs quantitatively between insect species and between the inducers used, although very different foreign bodies induced the same immune proteins in both lepidopteran insects. 3. A stronger and longer lasting response was consistently noticed in pupae immunized with non-pathogenic bacterium than after sterile nutrient broth injections. 4. A demonstrably elevated activity of haemolymph lysozyme and trace activity of cecropins found in pupae of Galleria treated with saline W, a salt solution physiological to moths, disappear soon after 36 hr from injection. 5. In P. brassicae, however, sterile insect Ringer can give a varying, if present at all, immune response. 6. A mechanical injury (sterile wounding of insect body) can occasionally induce a similar but much weaker response. 7. The antibacterial activity was drastically reduced in Pieris or completely depressed in most pupae of Galleria when actinomycin D or cycloheximide was given at an early time post-immunization with E. cloacae. 8. It is concluded that the de novo synthesis of ribonucleic acid and immune proteins is required for expression of antibacterial activity in pupal haemolymphs. 9. The synthesis of an immune mRNA was completed about 7 hr after the injection of the immunizing bacteria.

The effects of tumor necrosis factor (TNF) derivatives on TNF receptors

The pleiotropic cytokine TNF has been implicated in the regulation of many immune and inflammatory responses in vivo, and in addition exerts a wide range of effects on target cells in vitro. However, although two cell surface receptors for TNF have been identified, and their cDNAs cloned, the amino acid residues necessary for the biological activity of TNF have not been characterized. We have therefore constructed derivatives of TNF termed 'muteins', in which the first 3 to 7 amino acids of native TNF-alpha have been replaced, using synthetic cDNA expressed in E. coli. In the present study we compare the effects of native TNF-alpha and muteins III, IV, V and VI in several different in vitro systems and in one in vivo model. We observed binding to the p75 TNF receptor on Jijoye Burkitt lymphoma cells with native TNF-alpha and mutein III alone, whereas the p55 TNF receptor on the human epithelioid carcinoma cell line HeLa bound TNF-alpha, mutein III and mutein V. Muteins IV and VI failed to recognize either TNF receptor. WEHI 164 fibrosarcoma cells were killed by muteins III, V and VI. Human umbilical vein endothelial cells responded to native TNF-alpha and to muteins III, IV and V, but not to mutein VI, by increasing the surface expression of ICAM-1 antigen and secretion of the cytokines GM-CSF and IL-6. All four compounds were pro-inflammatory in a mouse in vivo model. The results presented in this report confirm that N-terminal amino acids are critical for both receptor binding and biological activity of TNF-alpha.(ABSTRACT TRUNCATED AT 250 WORDS)

The application of continuous thoracic epidural anaesthesia in outpatient oncological and reconstructive surgery of the breast

The use of continuous thoracic epidural anaesthesia allows several oncological and reconstructive operations of the breast to be performed on an outpatient basis. The method is easy and safe in the hands of an experienced anaesthetist, and the recovery is immediate. The potential side effects (transient haemodynamic changes) may result from the sympathetic blockade and can be easily controlled during the operation. The method is not advocated in cases in which substantial blood loss is anticipated.

Selective inhibition of cecropin-like activity of insect immune blood by protease from American foulbrood scales

Bioassays of American foulbrood larval scale filtrates have shown the presence of an immune inhibitor with a specific activity of proteases that selectively destroy cecropin-like activity in insect immune hemolymphs. It was an unexpected phenomenon to find that Bacillus larvae protease(s), even at trace concentrations, totally inhibits bactericidal activity of immune blood against Escherichia coli D 31. Thermal inactivation of a proteolytic enzyme coincides strictly with a disappearance of the ability to inhibit a cecropin-type activity in an assay system used, although the immune inhibitor was unaffected by trypsin digestion. Since neither bee larval hemolymph nor larval body homogenates possess demonstrable inhibitory action against cecropins present in hemolymph of Celerio euphorbiae and other insects, one can suggest that B. larvae proteases selectively destroy some molecules of the insect humoral immune system. The absence of cecropins in blood of immunized honeybee, Apis mellifera, larvae and a simultaneous high inhibitory activity of B. larvae protease(s) need further study on their role in pathogenesis of American foulbrood of the honeybee.