Altered nerve excitability properties after stroke are potentially associated with reduced neuromuscular activation

OBJECTIVE

To determine limb differences in motor axon excitability properties in stroke survivors and their relation to maximal electromyographic (EMG) activity.

METHODS

The median nerve was stimulated to record compound muscle action potentials (CMAP) from the abductor pollicis brevis (APB) in 28 stroke subjects (57.3 ± 7.5 y) and 24 controls (56.7 ± 9.3 y).

RESULTS

Paretic limb axons differed significantly from non-paretic limb axons including (1) smaller superexcitability and subexcitability, (2) higher threshold during subthreshold depolarizing currents, (3) greater accommodation (S3) to hyperpolarization, and (4) a larger stimulus-response slope. There were smaller differences between the paretic and control limbs. Responses in the paretic limb were reproduced in a model by a 5.6 mV hyperpolarizing shift in the activation voltage of Ih (the current activated by hyperpolarization), together with an 11.8% decrease in nodal Na⁺ conductance or a 0.9 mV depolarizing shift in the Na⁺ activation voltage. Subjects with larger deficits in APB maximal voluntary EMG had larger limb differences in excitability properties.

CONCLUSIONS

Stroke leads to altered modulation of Ih and altered Na⁺ channel properties that may be partially attributed to a reduction in neuromuscular activation.

SIGNIFICANCE

Plastic changes occur in the axon node and internode that likely influence axon excitability.

What does it mean to be alive? Philip Ball University of Chicago Press, 2019. 384 pp

A winding romp through advances in cell biology pushes readers to ponder the boundaries of life

An essential domain of an early-diverged RNA polymerase II functions to accurately decode a primitive chromatin landscape

A unique feature of RNA polymerase II (RNA pol II) is its long C-terminal extension, called the carboxy-terminal domain (CTD). The well-studied eukaryotes possess a tandemly repeated 7-amino-acid sequence, called the canonical CTD, which orchestrates various steps in mRNA synthesis. Many eukaryotes possess a CTD devoid of repeats, appropriately called a non-canonical CTD, which performs completely unknown functions. Trypanosoma brucei, the etiologic agent of African Sleeping Sickness, deploys an RNA pol II that contains a non-canonical CTD to accomplish an unusual transcriptional program; all protein-coding genes are transcribed as part of a polygenic precursor mRNA (pre-mRNA) that is initiated within a several-kilobase-long region, called the transcription start site (TSS), which is upstream of the first protein-coding gene in the polygenic array. In this report, we show that the non-canonical CTD of T. brucei RNA pol II is important for normal protein-coding gene expression, likely directing RNA pol II to the TSSs within the genome. Our work reveals the presence of a primordial CTD code within eukarya and indicates that proper recognition of the chromatin landscape is a central function of this RNA pol II-distinguishing domain.

Smokeless Tobacco and Severe Active Periodontal Disease, NHANES III

Whereas smoking is a major risk factor for periodontal disease, the role of smokeless tobacco is unclear. The purpose of this US population-based study of 12,932 adults participating in the Third National Health and Nutrition Examination Survey was to evaluate the association between smokeless tobacco use and severe active periodontal disease. Univariable and multivariable logistic regression modeling quantified the associations between tobacco use and severe active periodontal disease. All adults and never-smokers who currently used smokeless tobacco were twice as likely to have severe active periodontal disease at any site [respective odds ratios (ORAdj) and 95% confidence intervals: ORAdj = 2.1; 1.2–3.7 and ORAdj = 2.1; 1.0–4.4] or restricted to any interproximal site [respective ORAdj = 2.1; 1.0–4.2 and ORAdj = 2.3; 0.9–6.3], simultaneously adjusted for smoking, age, race, gender, diabetes, and having a dental visit in the past year. These results indicate that smokeless tobacco may also be an important risk factor for severe active periodontal disease.

Enhancing tolerance to short-chain alcohols by engineering the Escherichia coli AcrB efflux pump to secrete the non-native substrate n-butanol

The microbial conversion of sugars to fuels is a promising technology, but the byproducts of biomass pretreatment processes and the fuels themselves are often toxic at industrially relevant levels. One promising solution to these problems is to engineer efflux pumps to secrete fuels and inhibitory chemicals from the cell, increasing microbial tolerance and enabling higher fuel titer. Toward that end, we used a directed evolution strategy to generate variants of the Escherichia coli AcrB efflux pump that act on the non-native substrate n-butanol, enhancing growth rates of E. coli in the presence of this biofuel by up to 25%. Furthermore, these variants confer improved tolerance to isobutanol and straight-chain alcohols up to n-heptanol. Single amino acid changes in AcrB responsible for this phenotype were identified. We have also shown that both the chemical and genetic inactivation of pump activity eliminate the tolerance conferred by AcrB pump variants, supporting our assertion that the variants secrete the non-native substrates. This strategy can be applied to create an array of efflux pumps that modulate the intracellular concentrations of small molecules of interest to microbial fuel and chemical production.

The impact of ethnic population dynamics on neonatal ECMO outcomes: a single urban institutional study

INTRODUCTION

Neonatal extracorporeal membrane oxygenation ECMO has been clinically used for the last 25 y. It has been an effective tool for both cardiac and non cardiac conditions. The impact of ethno-demographic changes on ECMO outcomes however remains unknown. We evaluated a single institution's experience with non cardiac neonatal ECMO over a 28-y period.

METHODS

A retrospective review of all neonates undergoing noncardiac ECMO between the y 1984 and 2011 was conducted and stratified into year groups I, II, III (≤1990, 1991-2000, and ≥2001). Demographic, clinical, and outcome data were collected. The patient specifics, ECMO type, ECMO length, blood use, complications, and outcomes were analyzed. Univariate, bivariate, and multivariate analyses were then performed.

RESULTS

Data was available for 827 patients. The number of African-American and Hispanic patients increased over the last 27 y (27.5% versus 45.0% and 3.3% versus 21.5%, year group I versus year group III, respectively). The proportion of congenital diaphragmatic hernia (CDH) patients by ethnicity also increased for African-Americans and Hispanics between the two year groups (22.0% to 33.0% and 4.9% to 33.0%, respectively). Similar pattern was noted for non-CDH diagnoses. Low birth weight, low APGAR scores, CDH, primary pulmonary hypertension, central nervous system hemorrhage, and ECMO were independent predictors of mortality. Ethnicity, in itself however, was not associated with mortality on adjusted analysis.

CONCLUSION

More African-Americans and Hispanics have required ECMO over the years with a concurrent decrease in the number of Caucasians. While ethnicity was not an independent predictor of mortality, it appears to be a surrogate for fatal but sometime preventable diagnoses among minorities. Further investigations are needed to better delineate the reason behind this disparity.

Practice parameter: the evaluation of distal symmetric polyneuropathy: the role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation

BACKGROUND

Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of autonomic testing, nerve biopsy and skin biopsy for the assessment of polyneuropathy.

METHODS

A literature review using MEDLINE, EMBASE, Science Citation Index and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence.

RESULTS AND CONCLUSIONS

1. Autonomic testing may be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). 2. Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP). However, the literature is insufficient to provide a recommendation regarding when a nerve biopsy may be useful in the evaluation of DSP (Level U). 3. Skin biopsy is a validated technique for determining intraepidermal nerve fiber (IENF) density and may be considered for the diagnosis of DSP, particularly SFSN (Level C). There is a need for additional prospective studies to define more exact guidelines for the evaluation of polyneuropathy.

Practice parameter: the evaluation of distal symmetric polyneuropathy: the role of laboratory and genetic testing (an evidence-based review). Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation

BACKGROUND

Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of laboratory and genetic tests for the assessment of DSP.

METHODS

A literature review using MEDLINE, EMBASE, Science Citation Index and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence.

RESULTS AND CONCLUSIONS

1. Screening laboratory tests may be considered for all patients with polyneuropathy (Level C). Those tests that provide the highest yield of abnormality are blood glucose, serum B12 with metabolites (methylmalonic acid with or without homocysteine) and serum protein immunofixation electrophoresis (Level C). If there is no definite evidence of diabetes mellitus by routine testing of blood glucose, testing for impaired glucose tolerance may be considered in distal symmetric sensory polyneuropathy (Level C). 2. Genetic testing is established as useful for the accurate diagnosis and classification of hereditary neuropathies (Level A). Genetic testing may be considered in patients with cryptogenic polyneuropathy who exhibit a hereditary neuropathy phenotype (Level C). Initial genetic testing should be guided by the clinical phenotype, inheritance pattern, and electrodiagnostic (EDX) features and should focus on the most common abnormalities which are CMT1A duplication/HNPP deletion, Cx32 (GJB1), and MFN2 mutation screening. There is insufficient evidence to determine the usefulness of routine genetic testing in patients with cryptogenic polyneuropathy who do not exhibit a hereditary neuropathy phenotype (Level U).

Evaluation of distal symmetric polyneuropathy: the role of laboratory and genetic testing (an evidence-based review)

Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of laboratory and genetic tests for the assessment of DSP. A literature review using MEDLINE, EMBASE, Science Citation Index, and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence. (1) Screening laboratory tests may be considered for all patients with polyneuropathy (Level C). Those tests that provide the highest yield of abnormality are blood glucose, serum B(12) with metabolites (methylmalonic acid with or without homocysteine), and serum protein immunofixation electrophoresis (Level C). If there is no definite evidence of diabetes mellitus by routine testing of blood glucose, testing for impaired glucose tolerance may be considered in distal symmetric sensory polyneuropathy (Level C). (2) Genetic testing is established as useful for the accurate diagnosis and classification of hereditary neuropathies (Level A). Genetic testing may be considered in patients with cryptogenic polyneuropathy who exhibit a hereditary neuropathy phenotype (Level C). Initial genetic testing should be guided by the clinical phenotype, inheritance pattern, and electrodiagnostic (EDX) features and should focus on the most common abnormalities, which are CMT1A duplication/HNPP deletion, Cx32 (GJB1), and MFN2 mutation screening. There is insufficient evidence to determine the usefulness of routine genetic testing in patients with cryptogenic polyneuropathy who do not exhibit a hereditary neuropathy phenotype (Level U).

Evaluation of distal symmetric polyneuropathy: the role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review)

Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of autonomic testing, nerve biopsy, and skin biopsy for the assessment of polyneuropathy. A literature review using MEDLINE, EMBASE, Science Citation Index, and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence. (1) Autonomic testing may be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). (2) Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP). However, the literature is insufficient to provide a recommendation regarding when a nerve biopsy may be useful in the evaluation of DSP (Level U). (3) Skin biopsy is a validated technique for determining intraepidermal nerve fiber (IENF) density and may be considered for the diagnosis of DSP, particularly SFSN (Level C). There is a need for additional prospective studies to define more exact guidelines for the evaluation of polyneuropathy.

Practice Parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation

BACKGROUND

Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of autonomic testing, nerve biopsy, and skin biopsy for the assessment of polyneuropathy.

METHODS

A literature review using MEDLINE, EMBASE, and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence.

RESULTS AND RECOMMENDATIONS

1) Autonomic testing should be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). 2) Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP). However, the literature is insufficient to provide a recommendation regarding when a nerve biopsy may be useful in the evaluation of DSP (Level U). 3) Skin biopsy is a validated technique for determining intraepidermal nerve fiber density and may be considered for the diagnosis of DSP, particularly SFSN (Level C). There is a need for additional prospective studies to define more exact guidelines for the evaluation of polyneuropathy.

Routine electrodiagnosis and a multiparameter technique in lumbosacral radiculopathies

OBJECTIVE

This study compares Routine nerve conductions studies (NCS)/needle electromyography (nEMG) with a multiparameter recording method (NC-stat; NeuroMetrix Inc., Waltham, MA, USA) in patients with lumbosacral radiculopathies (LSR).

METHODS

Charts from 34 consecutive patients with a clinical history and/or examination consistent with an LSR were retrospectively reviewed. All underwent both Routine NCS/nEMG studies and NC-stat EDX. NC-stat testing included peroneal and posterior tibial nerve distal motor latencies and amplitudes and F-wave analysis. Twenty-eight patients had magnetic resonance imaging of the lumbosacral spine, and two had post-myelogram computerized tomography scan.

RESULTS

In the 24 patients with abnormal routine NCS/nEMG, NC-stat EDX was abnormal in 22. Raw agreement values between specific abnormal Routine and NC-stat EDX parameters ranged from 065 to 0.76. NC-stat amplitude and F-wave data provide reasonable electrodiagnostic 'rule in, rule out' information for LSR. Routine and NC-stat EDX had comparable positive and negative likelihood ratios with radiographic findings based on blinded neuroradiological evaluation. This included good 'stand alone' values for NC-stat F-wave and compound muscle action potential (CMAP) amplitude abnormalities in patients with spinal stenosis.

CONCLUSIONS

This report supports the value of multiparameter clinical neurophysiological evaluations in patients with LSR including CMAPs and F-waves.

Electrophysiological patterns of diabetic polyneuropathy

OBJECTIVE

This study evaluates the pattern of electrodiagnostic (EDX) abnormalities in diabetic sensorimotor polyneuropathies.

METHODS

EDX data from 112 consecutive patients with type 2 diabetes mellitus with distal, predominantly sensory, polyneuropathies were reviewed. Motor conduction velocities (CV), distal motor latencies (DML), compound muscle action potential (CMAP) amplitudes, distal to proximal amplitude ratios (PID), and F-wave latencies (FWL) were analyzed. Data were normalized based on normative reference values, and the proportion of nerves with abnormal values in the lower and upper limbs were evaluated. These data were also analyzed in relation to whether there was possible demyelinating versus axonal injury. Statistical analyses included comparison of the proportions of abnormal nerves in upper versus lower limbs as well as using Generalized Estimating Equations (GEE) to account for correlated observations for each patient between lower and upper limbs and adjusting for patient age effect.

RESULTS

CVs were significantly more abnormal in the legs than the arms (p < 0.0006) and decreased CMAP amplitudes meeting criteria for axonal injury were also more frequent in the legs (p < 0.0001). Using the GEE model, axonal injury was more common in the legs while demyelinating injury was more common in the arms based on FWLs, especially in younger persons (e.g., 40 years old vs. 50 years old). These differences are not readily explained by the duration of the diabetes.

CONCLUSION

Since in diabetics "axonal" type injury may be more common in the legs while "demyelinating" injury more frequent in the arms, this study emphasizes the limitation of this type of classification, and supports the idea that the pattern of EDX abnormalities in different types of neuropathies may be more helpful.

Physiological improvement with moderate exercise in type II diabetic neuropathy

OBJECTIVE

The objective of this study was to demonstrate improvement in nerve function with moderate exercise in patients with type II diabetic neuropathies.

RESEARCH DESIGN AND METHODS

Fives subjects with type II diabetes mellitus and distal, predominantly sensory polyneuropathies were studied. The subjects completed an 8-week program of a supervised moderate exercise program (40-75% of maximal 02 uptake reserve) with a subsequent 16-week program of monitored similar exercise. The same experienced electrophysiologist performed the electrodiagnostic studies both before and after the 24-week exercise period. These studies monitored physiological changes (conduction velocities, response amplitudes) in motor and sensory fibers as well as F-wave latencies.

RESULTS

The exercise program produced a documented increase in aerobic exercise capacity. Despite the small number of subjects studied and the relatively short exercise period, there was a statistically significant improvement in nearly all electrophysiological parameters evaluated post exercise including motor conduction velocities and amplitudes, sensory conduction velocities, and F-wave latencies. This improvement included a statistically significant improvement in absolute median motor evoked response amplitudes as well as the recording of sensory nerve action potentials not present prior to exercise. There were no adverse effects from the exercise.

CONCLUSIONS

This study supports the hypothesis that exercise can be performed safely in patients with type II diabetic neuropathies and can produce improvement in their nerve function. This study also supports the hypothesis that ischemia may have a meaningful role in the pathogenesis of neuropathies in patients with type II diabetes mellitus.

Deterministic recurrences of sequential F-wave latencies

PURPOSE

Historically, F-waves have been classified by various linear descriptors like persistence, latency, duration, amplitude, chrono-dispersion and number of repeater waves. But because physiological signals are notoriously nonlinear in nature, the objective of this study was to apply modern nonlinear methodology to F-waves sequences to assess the presence of underlying deterministic structures. Subtle changes in these sensitive markers could give early warnings for neurological problems.

METHODS

F-waves were elicited in the left abductor pollicis breivs muscle by supra-maximally stimulating the median nerve percutaneously at the wrist. Approximately 200 stimuli were applied (0.5 Hz) to three subjects for at least four trials each. F-wave latencies were measured and assembled into sequences in proper order. Recurrence quantification analysis (RQA) was applied to these F-wave sequences from different dimensional perspectives. Controls were constructed by randomly shuffling the ordered sequences. RQA has a theoretical mathematical foundation and practical performance record on numerous other physiological systems.

RESULTS

Recurrence analysis showed that sequential F-waves form recurrent patterns with parallel trajectories with deterministic and laminated structures. These features could be destroyed by randomizing the sequential orders of F-waves, upholding the hypothesis that sequences of F-waves are deterministically formed from underlying physiological rules.

CONCLUSIONS

F-wave time series are fully amenable to recurrence analysis which provides a higher-dimensional perspective on the physiological dynamic. The recurrent patterns are complex, but not random, meaning that physiological rules dominate the sequence of F-waves. Disease processes within the central or peripheral nervous system may alter F-wave patterns. If so, RQA potentially may be a diagnostic tool to help discern subtleties between altered deterministic rules operating in disease.

Induction of CYP1A mRNA in Carp (Cyprinus carpio) from the Kalamazoo River polychlorinated biphenyl-contaminated superfund site and in a laboratory study

The Kalamazoo River Superfund site in Michigan is contaminated with polychlorinated biphenyls (PCBs), which were heavily discharged into the river from several paper companies as part of the deinking process in the 1950s through 1970s. We characterized biomarkers of chronic PCB exposure in a resident fish population using real-time reverse transcriptase-polymerase chain reaction to examine mRNA expression levels of multiple genes in carp (Cyprinus carpio) liver from PCB contaminated and reference sites in the Kalamazoo River. We also measured these same genes in juvenile carp exposed to dietary PCBs for 4 months. Kalamazoo River carp had significantly increased levels of cytochrome P450 1A (CYP1A) mRNA as did carp fed PCBs in the laboratory. No significant mRNA upregulation occurred in the specific oxidative stress genes (gamma-glutamylcysteine synthetase and magnesium superoxide dismutase) and metabolic genes (phosphoenolpyruvate carboxykinase and nucleolin) examined. These data are consistent with the idea that carp from the Kalamazoo River Superfund Site are responding to PCB exposure via upregulation of CYP1A independent of activation of the oxidative stress response genes normally thought to be co-regulated with CYP1A.

Distal symmetric polyneuropathy: a definition for clinical research: report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation

The objective of this report was to develop a case definition of distal symmetric polyneuropathy to standardize and facilitate clinical research and epidemiologic studies. A formalized consensus process was employed to reach agreement after a systematic review and classification of evidence from the literature. The literature indicates that symptoms alone have relatively poor diagnostic accuracy in predicting the presence of polyneuropathy; signs are better predictors of polyneuropathy than symptoms; and single abnormalities on examination are less sensitive than multiple abnormalities in predicting the presence of polyneuropathy. The combination of neuropathic symptoms, signs, and electrodiagnostic findings provides the most accurate diagnosis of distal symmetric polyneuropathy. A set of case definitions was rank ordered by likelihood of disease. The highest likelihood of polyneuropathy (useful for clinical trials) occurs with a combination of multiple symptoms, multiple signs, and abnormal electrodiagnostic studies. A modest likelihood of polyneuropathy (useful for field or epidemiologic studies) occurs with a combination of multiple symptoms and multiple signs when the results of electrodiagnostic studies are not available. A lower likelihood of polyneuropathy occurs when electrodiagnostic studies and signs are discordant. For research purposes, the best approach to defining distal symmetric polyneuropathy is a set of case definitions rank ordered by estimated likelihood of disease. The inclusion of this formalized case definition in clinical and epidemiologic research studies will ensure greater consistency of case selection.

Distal symmetrical polyneuropathy: Definition for clinical research

The objective of this report was to develop a case definition of "distal symmetrical polyneuropathy" to standardize and facilitate clinical research and epidemiological studies. A formalized consensus process was employed to reach agreement after a systematic review and classification of evidence from the literature. The literature indicates that symptoms alone have relatively poor diagnostic accuracy in predicting the presence of polyneuropathy; signs are better predictors of polyneuropathy than symptoms; and single abnormalities on examination are less sensitive than multiple abnormalities in predicting the presence of polyneuropathy. The combination of neuropathic symptoms, signs, and electrodiagnostic findings provides the most accurate diagnosis of distal symmetrical polyneuropathy. A set of case definitions was rank ordered by likelihood of disease. The highest likelihood of polyneuropathy (useful for clinical trials) occurs with a combination of multiple symptoms, multiple signs, and abnormal electrodiagnostic studies. A modest likelihood of polyneuropathy (useful for field or epidemiological studies) occurs with a combination of multiple symptoms and multiple signs when the results of electrodiagnostic studies are not available. A lower likelihood of polyneuropathy occurs when electrodiagnostic studies and signs are discordant. For research purposes, the best approach for defining distal symmetrical polyneuropathy is a set of case definitions rank ordered by estimated likelihood of disease. The inclusion of this formalized case definition in clinical and epidemiological research studies will ensure greater consistency of case selection.

Vrms/T quantitation in patients with lumbar spinal stenosis

Thirty consecutive patients with clinical and radiographic findings consistent with lumbosacral root injury were evaluated. Electrodiagnostic examinations included determination of root mean square (Vrms)/turns (T) values. Vrms/T values > or =1 are consistent with chronic neurogenic injury and have been correlated with increase in fiber density. Radiographic studies were independently classified as having severe (group I; n= 8), mild (group II; n=11), or no lumbar spinal stenosis (group III; n=11). Abnormal Vrms/T values were present in all 8 patients in group I in comparison to 0/11 in group II and 2/11 in group III (p<0.0001 and 0.0007 respectively in comparison to group I). In 5/8 patients in group I, Vrms/T values provided unique information. Large amplitude motor units were also present more frequently in group I in comparison to the other groups (p<0.02). This study indicates Vrms/T values can be helpful in the electrodiagnostic evaluation of patients with lumbosacral radiculopathies, particularly where chronic multilevel radicular injury might be expected such as in lumbar spinal stenosis.

Genetic diversity and transcriptional analysis of the bys1 gene from Blastomyces dermatitidis

Blastomyces dermatitidis, a pathogenic fungal organism, is able to exist in two different morphologies, a multicellular mycelium or a unicellular yeast, according to temperature, 25 degrees C and 37 degrees C respectively. The switching between morphologies must be accompanied by a cascade of signaling events in which expression of genes responsible for the change of morphology is increased or decreased. bys1, a gene from B. dermatitidis isolate #58, is expressed at high levels in the unicellular yeast, but gradually diminishes as the temperature is lowered and the organism converts to the mycelial phase where there is no transcription of bys1. We explored if bys1 homologs are found in other B. dermatitidis isolates and if the transcription of the homologs were regulated by temperature. bys1 was identified in all B. dermatitidis isolates tested and could be grouped into two classes by Southern blot, PCR, and DNA sequence. Although the bys1 transcripts of both classes were regulated by temperature, transcription rates varied between the three isolates tested.

Epidemiology of Toxascaris leonina infection post-weaning within a colony of dogs

This communication reports incidental observations on Toxascaris leonina infections in a beagle breeding colony. Regular faecal monitoring demonstrated that T. leonina was endemic in the adult dam population within this colony. Small numbers of T. leonina eggs were also detected in the faeces of weaned pups from eight weeks of age possibly produced by a patent infection. This would mean a pre-patent period for T. leonina of 56 days or less. Worm counts on 10 pups showed that 60% of pups had acquired a T. leonina infection by 12 weeks of age. Since prenatal and lactogenic transmission do not occur and as the pups were kept in an environment which reduced chances of infection with T. leonina and there was no apparent source of paratenic hosts, the source of infection must have been embryonated T. leonina eggs from the whelping environment. These observations on T. leonina demonstrate that, if pups are exposed to an infected environment, patent infections may be seen in a younger age group than is normally associated with T. leonina infections.

Electrodiagnostic patterns in MGUS neuropathy

Monoclonal gammopathies of undetermined significance (MGUS) are frequently associated with neuropathies, particularly in the elderly. To better characterize the electrodiagnostic findings in MGUS-associated neuropathies, we analyzed electrodiagnostic data from 35 patients with MGUS-associated neuropathies (mean age 70.6; 12 IgM, 19 IgG, 4 IgA) who had no other cause for their neuropathies. Data was also analyzed for 29 age-matched patients (mean age 69.8) with diabetic neuropathies. Using electrodiagnostic criteria, studies were classified as being consistent with demyelination; 9 patients had findings consistent with axonal injury; and, in 3 patients, criteria for both demyelination and axonal injury were present. However, 24 of the 35 patients with MGUS-associated neuropathies had dyssummetric findings. In contrast, only 4 of the 29 patients with only diabetes had a dyssymmetric process (p < 0.0001). In MGUS-associated neuropathies, dyssymmetry is the most common, definable abnormal electrodiagnostic pattern.

Sensory nerve conduction deficit in experimental monoclonal gammopathy of undetermined significance (MGUS) neuropathy

An emerging body of evidence from in vitro studies and in vivo animal models supports a pathogenic role of antibodies in the development of peripheral neuropathy associated with monoclonal gammopathy of undetermined significance (MGUS). Although the assessment of motor and sensory nerve fiber function is of clinical importance, it is seldom applied experimentally. We describe the application of an electrophysiologic method for the evaluation of motor and sensory nerve fiber function using an experimental model of MGUS neuropathy. Supramaximal stimulation of the tibial nerve elicited an early motor response (M-wave, 1.7 +/- 0.1 ms, n = 10) and a late sensory (H-reflex, 7.8 +/- 0.1 ms, n = 10) response that was recorded from the hind foot of anesthetized rats. Intraneural injection of serum antibodies from a MGUS patient with sensorimotor polyneuropathy, but not from an age-matched control subject, produced a marked attenuation of the H-reflex (P < 0.01, n = 10) without affecting the M-wave. Light and electron microscopy of affected nerve showed myelinoaxonal degeneration with sparing of the smaller unmyelinated nerve fibers. The combined electrophysiologic and morphologic findings presented in this study are consistent with a selective sensory conduction deficit in MGUS neuropathy. Selective injury of afferent nerve fibers by this patient's serum antibodies may result from reactivity to neural antigens uniquely expressed by sensory neurons.

Adverse events associated with hepatitis B vaccine in U.S. children less than six years of age, 1993 and 1994

PURPOSE

This study evaluated infrequent adverse reactions to hepatitis B vaccine by investigating the association of this vaccine with adverse health outcomes for U.S. children less than six years of age. The evaluation of the association between hepatitis B vaccine and chronic arthritis provides needed data, relevant to the Institute of Medicine's Report that there are inadequate data available to assess the causal relationship of hepatitis B vaccine to arthritis risk.

METHODS

The 1993 (n = 5505 children) and 1994 (n = 6515 children) National Health Interview Survey (NHIS) datasets were analyzed to provide post-marketing surveillance data from probability samples of the U.S. population. Incident cases of adverse events were determined from the temporal association between the hepatitis B vaccination and the adverse events. Logistic regression modeling was used to adjust for potential confounding.

RESULTS

Controlling for age, race, and gender simultaneously in the 1994 NHIS, hepatitis B vaccine was found to be associated with prevalent arthritis [odds ratio (OR) = 5.91, 95% confidence interval (CI) = 1.05-33.14], incident acute ear infections (OR = 1.60, 95% CI = 1.00-2.58), and incident pharyngitis/nasopharyngitis (OR = 1.41, 95% CI = 0.95-2.09).

CONCLUSIONS

Evidence from this study suggests that hepatitis B vaccine is positively associated with adverse health outcomes in the general population of US children.

Cadmium-regulated gene fusions in Pseudomonas fluorescens

To study the mechanisms soil bacteria use to cope with elevated concentrations of heavy metals in the environment, a mutagenesis with the lacZ-based reporter gene transposon Tn5B20 was performed. Random gene fusions in the genome of the common soil bacterium Pseudomonas fluorescens strain ATCC 13525 were used to create a bank of 5,000 P. fluorescens mutants. This mutant bank was screened for differential gene expression in the presence of the toxic metal cadmium. Fourteen mutants were identified that responded with increased or reduced gene expression to the presence of cadmium. The mutants were characterized with respect to their metal-dependent gene expression and their metal tolerance. Half the identified mutants reacted with differential gene expression specifically to the metal cadmium, whereas some of the other mutants also responded to elevated concentrations of copper and zinc ions. One of the mutants, strain C8, also showed increased gene expression in the presence of the solvent ethanol, but otherwise no overlap between cadmium-induced gene expression and general stress response was detected. Molecular analysis of the corresponding genetic loci was performed using arbitrary polymerase chain reaction (PCR), DNA sequencing and comparison of the deduced protein products with sequences deposited in genetic databases. Some of the genetic loci targeted by the transposon did not show any similarities to any known genes; thus, they may represent 'novel' loci. The hypothesis that genes that are differentially expressed in the presence of heavy metals play a role in metal tolerance was verified for one of the mutants. This mutant, strain C11, was hypersensitive to cadmium and zinc ions. In mutant C11, the transposon had inserted into a genetic region displaying similarity to genes encoding the sensor/regulator protein pairs of two-component systems that regulate gene expression in metal-resistant bacteria, including czcRS of Ralstonia eutropha, czrRS of Pseudomonas aeruginosa and copRS of Pseudomonas syringae. Although the P. fluorescens strain used in this study had not been isolated from a metal-rich environment, it nevertheless contained at least one genetic region enabling it to cope with elevated concentrations of heavy metals.

Electrodiagnostic criteria in CIDP: comparison with diabetic neuropathy

This study examines current criteria for CIDP by comparing the electrodiagnostic data from 17 patients who have biopsy proven CIDP with 29 patients with diabetic neuropathy. The groups were comparable in age. Data were examined using four sets of published criteria for primary demyelination. Two sets (A & B) defined demyelination based on distal motor latencies, F-wave latencies, motor conduction velocities, and temporal dispersion or conduction block. The other two sets defined demyelination based on slowing of motor conduction velocity < 70% of the lower limit of normal (LLN) in either 2 nerves (set C), or in a single nerve (set D). Using set A, 3/17 patients with CIDP met the criteria for a demyelinating neuropathy, while this was true in 2/29 of the patients with diabetic neuropathy. For sets B and C, data consistent with a demyelinating neuropathy were identified in 2/17 and 1/29 patients, respectively. Using set D criteria for demyelination was met in 6/17 of the patients with CIDP and in 5/29 of the diabetic patients. None of the criteria sets showed a significant difference between CIDP and diabetic neuropathy (p = 0.3 to 0.5). Though electrodiagnosis is an important element in the diagnosis of CIDP, current electrodiagnostic criteria alone are insufficient for defining many cases of CIDP.

Rhabdomyolysis as the presenting manifestation of calciphylaxis

A 43-year-old woman was admitted with progressive leg pains and weakness and was found to have rhabdomyolysis. Prior to this admission the patient had hypercalcemia, but this returned to normal following treatment with calcitonin. During the hospitalization, she developed the syndrome of calciphylaxis consisting of necrotic skin and muscle associated with vascular calcification. This is the first case report of rhabdomyolysis caused by calciphylaxis in a patient without chronic renal failure.

Use of a polymerase chain reaction method to detect the leukotoxin gene lktA in biogroup and biovariant isolates of Pasteurella haemolytica and P trehalosi

OBJECTIVE

To determine whether Pasteurella haemolytica and P trehalosi isolates possess the structural gene for Pasteurella leukotoxin lktA and whether beta-hemolytic activity of these isolates correlated with detection of the lktA gene.

SAMPLE POPULATION

147 P haemolytica isolates from 21 biovariant groups and 101 P trehalosi isolates from 7 biovariant groups. In addition, P multocida and organisms from 7 other genera were tested to establish specificity of the procedure.

PROCEDURE

Isolates were observed for beta-hemolysis. A polymerase chain reaction (PCR) procedure was used to amplify the RTX domain of the Pasteurella lktA gene.

RESULTS

The lktA gene was detected in 108 (44%) isolates, including 15 associated with respiratory tract disease. All but 2 (98%) of the isolates that had the lktA gene were beta-hemolytic when grown on sheep blood agar. The remaining 140 isolates were negative for the lktA gene and hemolytic activity.

CONCLUSIONS AND CLINICAL RELEVANCE

Hemolytic activity of P haemolytica and P trehalosi isolates correlated with detection of the lktA gene for all but 2 isolates. However, 56% of isolates tested were negative for the lktA gene and beta-hemolytic activity. Leukotoxin production and secretion is a major virulence factor when other conditions are favorable for disease development. Therefore, identification of strains that possess the lktA gene may aid in the evaluation of the pathogenic potential of Pasteurella strains carried by wild and domestic animals.

Drug treatment of common STDs: Part II. Vaginal infections, pelvic inflammatory disease and genital warts

The Centers for Disease Control and Prevention (CDC) released new guidelines for the treatment of sexually transmitted diseases (STDs) in 1998. Several treatment advances have been made since the previous guidelines were published. Part II of this two-part series on STDs describes recommendations for the treatment of diseases characterized by vaginal discharge, pelvic inflammatory disease, epididymitis, human papillomavirus infection, proctitis, proctocolitis, enteritis and ectoparasitic diseases. Single-dose therapies are recommended for the treatment of several of these diseases. A single 1-g dose of oral azithromycin is as effective as a seven-day course of oral doxycycline, 100 mg twice a day, for the treatment of chlamydial infection. Erythromycin and ofloxacin are alternative agents. Four single-dose therapies are now recommended for the management of uncomplicated gonococcal infections, including 400 mg of cefixime, 500 mg of ciprofloxacin, 125 mg of ceftriaxone or 400 mg of ofloxacin. Advances in the treatment of bacterial vaginosis also have been made. A seven-day course of oral metronidazole is still recommended for the treatment of bacterial vaginosis in pregnant women, but intravaginal clindamycin cream and metronidazole gel are now recommended in nonpregnant women. Single-dose therapy with 150 mg of oral fluconazole is a recommended treatment for vulvovaginal candidiasis. Two new topical treatments, podofilox and imiquimod, are available for patient self-administration to treat human papillomavirus infection. Permethrin cream is now the preferred agent for the treatment of pediculosis pubis and scabies.

Drug treatment of common STDs: part I. Herpes, syphilis, urethritis, chlamydia and gonorrhea

In 1998, the Centers for Disease Control and Prevention released guidelines for the treatment of sexually transmitted diseases. Several treatment advances have been made since the previous guidelines were published. Part I of this two-part article describes current recommendations for the treatment of genital ulcer diseases, urethritis and cervicitis. Treatment advances include effective single-dose regimens for many sexually transmitted diseases and improved therapies for herpes infections. Two single-dose regimens, 1 g of oral azithromycin and 250 mg of intramuscular ceftriaxone, are effective for the treatment of chancroid. A three-day course of 500 mg of oral ciprofloxacin twice daily may be used to treat chancroid in patients who are not pregnant. Parenteral penicillin continues to be the drug of choice for treatment of all stages of syphilis. Three antiviral medications have been shown to provide clinical benefit in the treatment of genital herpes: acyclovir, valacyclovir and famciclovir. Valacyclovir and famciclovir are not yet recommended for use during pregnancy. Azithromycin in a single oral 1-g dose is now a recommended regimen for the treatment of nongonococcal urethritis.

Inhibition of Fas receptor (CD95)-induced hepatic caspase activation and apoptosis by acetaminophen in mice

The mechanism of liver cell injury induced by an overdose of the analgesic acetaminophen (AAP) remains controversial. Recently, it was hypothesized that a significant number of hepatocytes die by apoptosis. Since caspases have been implicated as critical signal and effector proteases in apoptosis, we investigated their potential role in the pathophysiology of AAP-induced liver injury. Male C3Heb/FeJ mice were fasted overnight and then treated with 500 mg/kg AAP. Liver injury became apparent at 4 h and was more severe at 6 h (plasma ALT activities: 4110 +/- 320 U/liter; centrilobular necrosis). DNA fragmentation increased parallel to the increase of plasma ALT values. At 6 h there was a 420% increase of DNA fragmentation and a 74-fold increase of terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL)-positive cells located predominantly around central veins. However, the activity of the proapoptotic caspase-3 was not increased at any time after AAP. In contrast, injection of the anti-Fas antibody Jo-2 (positive control) caused a 28-fold increase of caspase-3 activity and severe DNA fragmentation before significant ALT release. Treatment with the caspase inhibitor ZVAD-CHF2 had no effect on AAP toxicity but completely prevented Jo-mediated apoptosis. In contrast, Jo-induced caspase activation and apoptosis could be inhibited by AAP treatment in a time- and dose-dependent manner. We conclude that AAP-induced DNA fragmentation does not involve caspases, suggesting a direct activation of endonucleases through elevated Ca2+ levels. In addition, electrophilic metabolites of AAP may inactivate caspases or their activation pathway. This indicates that AAP metabolism has the potential to inhibit signal transduction mechanisms of receptor-mediated apoptosis.

Hepatitis B vaccine and liver problems in U.S. children less than 6 years old, 1993 and 1994

Data to assess the benefits and risks of hepatitis B vaccine for the general population of U.S. children are sparse. This study addressed the problem of external validity found in previous studies of high risk populations by evaluating the benefit of hepatitis B vaccination for the general population of American children. We calculated the risk of liver problems among hepatitis B vaccinated and non-hepatitis B vaccinated children using logistic regression. Hepatitis B vaccinated children had an unadjusted odds ratio of 2.94 and age-adjusted odds ratio of 2.35 for liver problems compared with non-hepatitis B vaccinated children in the 1993 National Health Interview Survey. Hepatitis B vaccinated children had an unadjusted odds ratio of 2.57 and age-adjusted odds ratio of 1.53 for liver problems compared with non-hepatitis B vaccinated children in the 1994 National Health Interview Survey dataset.

Glutathione peroxidase-deficient mice are more susceptible to neutrophil-mediated hepatic parenchymal cell injury during endotoxemia: importance of an intracellular oxidant stress

Neutrophils contribute to hepatocellular injury in a number of acute inflammatory reactions. However, the molecular mechanism of parenchymal cell injury remains controversial. To address the issue of whether or not reactive oxygen species (ROS) are important in the injury process, we used the galactosamine/endotoxin (Gal/ET) model of acute liver failure, which involves a neutrophil-mediated parenchymal cell injury. In C3Heb/FeJ mice, Gal/ET induced a significant increase of hepatic and plasma levels of glutathione disulfide (GSSG), an indicator of oxidant stress, selectively during the neutrophil-mediated injury phase. In glutathione peroxidase-deficient mice (Gpx1(-/-)), Gal/ET or Gal/tumor necrosis factor alpha (TNF-alpha) caused more severe neutrophil-mediated liver injury compared with wild-type animals. However, there was no significant difference in other critical parameters, e.g., activation of the transcription factor, nuclear factor-kappaB (NF-kappaB), and soluble intercellular adhesion molecule-1 (sICAM-1), parenchymal cell apoptosis, and neutrophil sequestration in the liver. Our results suggest that neutrophil-derived ROS are responsible for an intracellular oxidant stress in hepatocytes after Gal/ET treatment. Because of the higher susceptibility of Gpx1(-/-) mice to a neutrophil-mediated injury, we conclude that peroxides generated by neutrophils diffused into hepatocytes and contributed to parenchymal cell death in vivo. Thus, strengthening defense mechanisms against ROS in target cells can attenuate excessive inflammatory injury without affecting host defense reactions.

Conduction velocity versus amplitude analysis: evidence for demyelination in diabetic neuropathy

Motor conduction velocities (CVs) were correlated with distal compound muscle action potential (CMAP) amplitudes for tibial, peroneal, and median nerves in patients with biopsy-proven chronic inflammatory demyelinating polyneuropathy (CIDP), diabetic neuropathy, and amyotrophic lateral sclerosis. Only in the diabetic patients did CV significantly correlate with CMAP amplitude. The data show that diabetic neuropathy produces conduction velocity slowing that cannot be explained by axon loss alone, and that differentiation between diabetic neuropathy and CIDP in an individual nerve is difficult.

Parenchymal cell apoptosis as a signal for sinusoidal sequestration and transendothelial migration of neutrophils in murine models of endotoxin and Fas-antibody-induced liver injury

Endotoxin (ET) induces neutrophil sequestration in hepatic sinusoids, the activation of proinflammatory transcription factors (nuclear factor KB [NF-kappaB]) with up-regulation of adhesion molecules on sinusoidal endothelial cells and hepatocytes. However, if galactosamine (Gal) is co-administered with ET, neutrophils transmigrate and attack parenchymal cells. This suggests that a signal from parenchymal cells triggers neutrophil transmigration. In this study, we tested the hypothesis that parenchymal cell apoptosis may induce neutrophil transendothelial migration in the Gal/ET model. Treatment of C3Heb/FeJ mice with 700 mg/kg Gal and 100 microg/kg ET induced tumor necrosis factor alpha (TNF-alpha) formation (13.25 +/- 0.75 ng/mL) and hepatic NF-kappaB activation at 90 minutes; the generation of the C-X-C chemokine KC (2.86 +/- 0.30 ng/mL at 5 hours); sinusoidal neutrophil sequestration (380 +/- 21 polymorphonuclear leukocytes/50 high-power fields) and apoptosis (925% +/- 29% increase of DNA fragmentation; and a 45-fold increase of terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL)-positive cells) at 6 hours, followed by transmigration of neutrophils and development of substantial necrosis (38% +/- 3% of hepatocytes; alanine transaminase [ALT]: 1,500 +/- 300 U/L) at 7 hours. Administration of uridine (1,000 mg/kg) did not reduce plasma levels of TNF-alpha and KC, NF-kappaB activation, or polymorphonuclear leukocyte sequestration, but attenuated apoptosis by 90% to 94%. In these livers, neutrophils did not transmigrate and liver injury was prevented (necrosis: < 5%; ALT: 40 +/- 3 U/L). However, massive apoptosis and liver injury initiated by the anti-Fas antibody, Jo2, did not recruit neutrophils into the liver. We conclude that excessive parenchymal cell apoptosis represents an important signal for transmigration of primed neutrophils sequestered in sinusoids during endotoxemia in vivo. However, apoptosis per se does not cause neutrophil sequestration in the liver vasculature.

Toxic methemoglobinemia: a rare but serious complication of transesophageal echocardiography

Cyanosis occurring during a transesophageal echocardiogram (TEE) is usually related to the respiratory depressant effect of the administered sedative. However, acute toxic methemoglobinemia related to topical benzocaine is a rare and not well recognized but potentially life threatening cause of cyanosis during or after TEE. A case of this condition is presented and the literature on its frequency, diagnosis and management is briefly reviewed.