The Kenya cancer research and control stakeholder program: Evaluating a bilateral partnership to strengthen national cancer efforts

Background

In response to a growing cancer burden and need for improved coordination among stakeholders in Kenya, the US National Cancer Institute and the Kenya Ministry of Health collaboratively hosted a stakeholder meeting in 2014 which identified four priority areas of need (research capacity building, pathology and cancer registries, cancer awareness and education, and health system strengthening) and developed corresponding action plans.

Methods

Surveys were conducted with participants to collect input on the progress and impact of the 2014 stakeholder meeting.

Findings

Of 69 eligible participants, 45 responded from academia, healthcare institutions, civil society, government, and international agencies. Of the four technical focus areas, three have continued to conduct working group meetings and two have conducted in-person meetings to review and update their respective action plans. Accomplishments linked to or enhanced by t meeting include: Kenyan and international support for expansion of population-based cancer registries, increased availability of prioritized diagnostic tests in selected regional referral hospitals, a greater focus on development of a national cancer research agenda, strategic planning for a community education strategy for cancer awareness, and improved coordination of partners through in-country technical assistance.

Interpretation

The Stakeholder Program has successfully united individuals and organizations to improve cancer control planning in Kenya, and has enhanced existing efforts and programs across the country. This model of partners working in parallel on prioritized track activities has supported development of long term coordination of cancer research and control activities sustainable by the Kenyan government and Kenyan institutions.

Effect of different alcohols on stratum corneum kallikrein 5 and phospholipase A2 together with epidermal keratinocytes and skin irritation

OBJECTIVES

The aim of this exploratory study was to investigate the effect of ethanol, isopropanol and n-propanol on stratum corneum (SC) enzymes and keratinocytes in vitro together with their effects on skin condition and function.

METHODS

Activities of kallikrein 5 (KLK5) and phospholipase A2 (PLA2) as well as keratinocyte metabolic activity, interleukin-1α (IL-1α) and tumor necrosis factor-α (TNF-α) were measured in vitro in the presence and absence of the different alcohols. We also measured transepidermal water loss (TEWL), skin capacitance, visual dryness and visual redness on the volar forearms of 25 Caucasian women following application of the alcohols 20 and 100 times per day over a period of 14 days in a clinical study.

RESULTS

Reduced activities of KLK5 and PLA2 were observed in the presence of the alcohols. The greatest denaturing effect was always observed for n-propanol (P < 0.001), and in the case of PLA2, the effect of isopropanol was greater than ethanol (P < 0.001). Equally, ethanol had the mildest effects on keratinocyte metabolic activity and cytokine secretion (P < 0.001) and n-propanol always produced the most severe changes in normal and differentiated keratinocytes. These in vitro findings supported the clinical results where the major effects were on the induction of skin irritation (increased dropout rates) and ranked the intolerance of the different alcohols as follows: n-propanol > isopropanol > ethanol. At the high application frequencies, the effect of the different alcohols on transepidermal water loss (TEWL) and skin capacitance was similar, but at the low application frequencies, n-propanol had a significant effect on TEWL and capacitance values (P < 0.05). Equally, n-propanol and isopropanol produced significantly more skin redness at the low application frequencies.

CONCLUSIONS

Clearly, isopropanol and n-propanol caused significant SC and keratinocyte perturbation in vitro together with damage to skin condition and function in vivo whereas ethanol did not. As a result, we show that ethanol-based sanitizers are better tolerated by skin, particularly in high-use settings, than other alcohols and should be the active ingredient of choice.

Reliable change assessment with practice effects in sport concussion research: a comment on Hinton-Bayre

In his comments on our previous article, Hinton-Bayre advocates the use of the regression based approach in most cases of determining reliable change. This article comments on Hinton-Bayre's argument, discusses cases where the regression method might not be the preferred method, and presents adjustments that make the method more generally preferable.

Characterization of molecules mediating cell-cell communication in human cardiac valve interstitial cells

Cell-cell interactions and adhesion determine cellular architectural organization, proliferation, signaling, differentiation, and death. We have identified the molecular components of different cell-cell junctions in human valve interstitial cells (ICs) both in situ and in culture. ICs were isolated, cultured, and phenotyped for cell surface and cytoplasmic markers by flow cytometry and immunocytochemistry. Western blotting was used to identify and quantify the molecular components of these cell-cell junctions in human valve ICs and compared with expression in smooth muscle and fibroblast cell types. N-cadherin and desmoglein were weakly detected on a low percentage of ICs, and the other classical cadherins were not detected. alpha- and beta-catenin, but not gamma-catenin, were expressed at equivalent levels by all valve ICs. Valve ICs did not express connexin-32 and -40; however, connexin-26 and -43 were equally expressed by a low percentage of ICs, demonstrating cell surface and cytoplasmic expression ,and connexin-45 was weakly expressed. The other cell types also expressed N-cadherin, alpha- and beta-catenin, desmoglein and connexin-43. The expression of these junctional molecules was predominantly by valve ICs on the inflow side of the valves. Human valve ICs have the ability to communicate with other valve ICs and mediate cell-cell adhesion via N-cadherin, connexin-26 and -43, and desmoglein. The junctions between valve ICs could support an interconnecting and coordinated cellular unit capable of controlling the functionality of the valve.

Perioperative Microembolism is not Associated with Cognitive Outcome Three Months after Carotid Endarterectomy

OBJECTIVE

To investigate the association between perioperative microembolism and cognitive outcome 3 months after carotid endarterectomy (CEA).

DESIGN

Prospective study.

MATERIALS AND METHODS

Patients were tested 1 day before and 3 months after surgery with neuropsychological tests measuring a wide range of cognitive functions. Number of microemboli was monitored with transcranial Doppler ultrasonography in 58 patients during the operation and in a random subgroup of 27 patients directly following the procedure.

RESULTS

Forty patients (69%) had intraoperative embolism, varying from 1 to 33 isolated microemboli and/or 1 to 11 embolic showers. Postoperative emboli were present in 22 of the 27 patients (81%), ranging from 1 to 142 isolated microemboli. More than 10 microemboli (including showers) were detected in 13 patients (22%) intraoperatively and in 6 patients (22%) postoperatively. Twenty-two patients (38%) showed deterioration in three or more cognitive function variables at 3 months. There were no significant associations between any cognitive change or deterioration score and presence or number of intraoperative and/or postoperative emboli.

CONCLUSIONS

The degree of microembolism during and immediately following CEA is generally small and seems to be of no significance with respect to postoperative cognitive functioning. Future research should include a larger group of patients to allow reliable subgroup analysis.

Left or right carotid endarterectomy in patients with atherosclerotic disease: Ipsilateral effects on cognition?

We evaluated hemispheric functions ipsilateral to the side of carotid endarterectomy (CEA) in patients with a severe stenosis in the left or right carotid artery. Assessments took place 1 day before and 3 months after CEA. Only right-handed males were included. Nineteen patients underwent surgery of the left carotid artery and 17 of the right. Valid instruments for hemispheric function were included, such as verbal dichotic listening, finger tapping, and a lateralised test for motor planning. Results showed that, preoperatively, patients had lower scores compared to norms on the laterality tests, and on a visuoconstructive test. There was no evidence of ipsilateral improvement related to side of surgery. Left ear dichotic listening improved, which was seen in both left and right surgery groups. Also in both groups, left- and right-hand movement speed in the motor planning test decreased. Conclusion is that beneficial ipsilateral cognitive change after CEA in patients with severe stenosis in one of the carotid arteries may not be demonstrated, even if valid instruments for hemispheric function are included.

Trauma-related phenomena in anxious dental patients

OBJECTIVES

The main purpose of this descriptive study was to investigate whether dental anxiety is associated with the occurrence of trauma-related symptoms (i.e. recurrent memories and a tendency to avoid these memories) associated with earlier traumatic dental experiences.

METHODS

A sample of 37 consecutive anxious patients attending a dental fear clinic was assessed prior to dental treatment. The results were compared with those of a sample of 32 consecutive patients of a general dental practice, who served as a reference group.

RESULTS

The proportion of patients who indicated they had had a horrific dental experience at least once in their life did not significantly differ between the anxious group and the reference group. Conversely, significantly more patients (76%) in the anxious group reported suffering from memories of these events. They also showed a higher level of trauma-related symptomatology as indexed by the Impact of Event Scale (IES). About half of the anxious patients suffered from symptoms typically reported by patients with posttraumatic stress disorder (PTSD). Severity of dental anxiety showed a high correlation with both frequency of intrusions (r = 0.64, P < 0.001) and avoidance of the memories (r = 0.62, P < 0.001).

CONCLUSIONS

The results suggest that in anticipation of treatment dentally anxious individuals suffer from a high level of intrusive recollections of earlier dental experiences.

Investigation of the pharmaceutical and pharmacological equivalence of different Hawthorn extracts

Seven Hawthorn extracts were tested in isolated guinea pig aorta rings. The effect on noradrenaline- (10 microM) induced contraction was investigated. The extracts were prepared using ethanol (40 to 70% v/v), methanol (40 to 70% v/v), and water as the extraction solvents. The aqueous-alcoholic extracts displayed similar spectra of constituents. They were characterised by similar procyanidin, flavonoid, total vitexin and total phenols content and by similar TLC fingerprint chromatograms. The aqueous extract, however, showed a different fingerprint and a noticeably lower concentration of procyanidins, flavonoids and total phenols but a similar total vitexin content. All 7 extracts had a relaxant effect on the aorta precontracted by noradrenaline and led to relaxations to 44 until 29% of the initial values. The EC50 values of the aqueous-alcoholic extracts varied between 4.16 and 9.8 mg/l. The aqueous extract produced a similarly strong maximal relaxation as the other extracts, but the EC50, at 22.39 mg/l, was markedly higher. The results show that Hawthorn extracts with comparable quality profiles were obtained by using aqueous-alcoholic extraction solvents (40 to 70% ethanol or methanol). The extracts exerted comparable pharmacological effects. When using water as the extraction solvent, both, the spectrum of constituents and the pharmacological effect, deviated remarkably. It is thus possible to obtain bioequivalent extracts with comparable effect profiles by using 40 to 70% ethanol or methanol as the extraction solvent.

The development of the fetal vermis: an in-utero sonographic evaluation

OBJECTIVE

To establish a nomogram for fetal vermis measurements during gestation.

METHODS

A prospective cross-sectional study of normal singleton pregnancies. Measurements of the fetal vermis width (in the axial plane) and height (in the sagittal plane) were performed by high-resolution transabdominal ultrasonography between 18 and 38 weeks of gestation in 256 fetuses.

RESULTS

Adequate vermis measurements were obtained in 256 fetuses. Vermian width and height as a function of gestational age and biparietal diameter were expressed by regression equations and the correlation coefficients were found to be highly statistically significant (P < 0.0001). The normal mean (+/- SD) for each gestational week was defined.

CONCLUSIONS

The present data offer the normal range of the vermian measurements throughout gestation. These values may allow intrauterine assessment of the development of the cerebellar vermis, as well as the posterior fossa.

Neuronal sodium-channel alpha1-subunit mutations in generalized epilepsy with febrile seizures plus

Generalized epilepsy with febrile seizures plus (GEFS+) is a familial epilepsy syndrome characterized by the presence of febrile and afebrile seizures. The first gene, GEFS1, was mapped to chromosome 19q and was identified as the sodium-channel beta1-subunit, SCN1B. A second locus on chromosome 2q, GEFS2, was recently identified as the sodium-channel alpha1-subunit, SCN1A. Single-stranded conformation analysis (SSCA) of SCN1A was performed in 53 unrelated index cases to estimate the frequency of mutations in patients with GEFS+. No mutations were found in 17 isolated cases of GEFS+. Three novel SCN1A mutations-D188V, V1353L, and I1656M-were found in 36 familial cases; of the remaining 33 families, 3 had mutations in SCN1B. On the basis of SSCA, the combined frequency of SCN1A and SCN1B mutations in familial cases of GEFS+ was found to be 17%.

Vacuolating megalencephalic leukoencephalopathy in 12 Israeli patients

Leukodystrophy with macrocephaly as the main features of infantile neurodegenerative disease are characteristics of Canavan's disease, L-2-hydroxyglutaric aciduria, type I glutaric aciduria, and Alexander's disease. Also occasionally described are occidental congenital muscular dystrophy, G(M)2-gangliosidosis, metachromatic leukodystrophy, Krabbe's disease, and mucopolysaccharidosis. Since 1995, over 60 patients with a new syndrome, vacuolating megalencephalic leukoencephalopathy, have been described. The syndrome is characterized by macrocephaly, a slowly progressive clinical course of ataxia, spastic paraparesis, and seizure disorder with relatively spared cognition. Unlike other leukodystrophies with macrocephaly (except Alexander's disease), no metabolic marker has been found. We describe a similar group of 12 patients from two different Jewish ethnic origins in whom consanguinity is prominent. These patients have neuroimaging features and magnetic resonance spectroscopy findings indicating that there is an initial increase in white-matter edema with subsequent cystic formation. Consistent with loss of tissue in these areas, brain metabolites are reduced. The familial incidence in this group of patients is suggestive of autosomal-recessive inheritance.

Quality of life after laparoscopic adjustable gastric banding for severe obesity: postoperative and retrospective preoperative evaluations

BACKGROUND

The aim of this study was to examine postoperative as well as retrospective preoperative evaluations of multiple dimensions of quality of life of patients with morbid obesity after laparascopic adjustable gastric banding (LAGB).

METHODS

12 to 38 months after LAGB, 74 consecutive patients (64 female, 10 male, mean age 36.6 years, age range 23-56) filled out the RAND-36 Health Survey questionnaire to evaluate their current postoperative as well as their past preoperative quality of life.

RESULTS

Pre- to 1 year postoperative weight reduction (127.5 to 100.7 kg) and change of BMI (45.2 to 35.6 kg/m2) were highly significant (p<0.001). As compared to age reference groups, the preoperative quality of life was evaluated very poor (p<0.002), postoperative psychological and social quality of life were about normal (all p's >0.10), and postoperative physical functioning (p=0.04), vitality (p=0.01) and general health (p=0.03) were below normal. No differences were found between postoperative evaluations of patient groups with varying postoperative follow-up duration, but patients in the second year after surgery evaluated some aspects of their preoperative quality of life as poorer than patients in the third year after surgery.

CONCLUSION

Postoperative psychosocial quality is at a level that may be expected to motivate patients to consolidate the surgically established weight reduction, but attention should be paid to the physical condition. Since the relative gain in quality of life as experienced by patients tends to be evaluated less with a longer duration of the postoperative interval, the risk of relapse may increase with passage of time.

Chronic stress affects blood pressure and speed of short-term memory

Subjects high and low on chronic stress (daily hassles) were engaged in a short-term memory-scanning task with (n = 12) or without (n = 12) an active listening task. Blood pressure and heart rate were obtained before and during the experiment. Subjects with high stress were slower in short-term memory processing, had higher systolic blood pressure and heart rate (at baseline and during task performance), and reported more health complaints than those low in stress. The processing efficiency theory may predict slower memory scanning in subjects with high chronic stress, as part of these subjects' working memory capacity is taken up by more worries than that of the other subjects. Speed of short-term memory was even lower for subjects with high stress when performing the memory task in the active listening condition.

The interaction "light, Fe(III)" as a tool for pollutant removal in aqueous solution: degradation of alcohol ethoxylates

The photoinduced degradation of an alcohol ethoxylate (AE) (Brij 30) by Fe(III) in aqueous solution has been investigated. The study was carried out with the major fraction of ethoxymers having an alkyl chain length of 12 carbon atoms and n ethoxy units E (C12En). The Fe(III) sensitised degradation of this fraction occurs efficiently at 365 nm. The rate of degradation depends on the concentration of Fe(OH)2+, the most photoreactive species in terms of .OH radical formation. Formate ethoxylates were identified as photoproducts and shortening of the ethoxylated chain all along the degradation process was observed. The mechanism of Brij 30 degradation implies a major .OH radicals attack on the polyethoxylated chain. For prolonged irradiations, the total degradation of Brij 30 and of the photoproducts is obtained. Consequently, the degradation photoinduced by iron (III) could be an efficient method of AEs removal in water.

Plasma glutathione peroxidase deficiency and platelet insensitivity to nitric oxide in children with familial stroke

In a previous report by Freedman et al (J Clin Invest. 1996;97:979-987), plasma from 2 brothers with stroke or transient ischemic attack inactivated the antiplatelet effects of nitric oxide (NO), and this effect was found to be a consequence of a deficiency of plasma glutathione peroxidase (GSH-Px). In this study, we attempted to define the generalizability of this deficiency by studying NO-mediated antiplatelet effects in 7 families with familial childhood stroke. Seven families with familial childhood stroke that consecutively presented to a large referral center were included in the study. We monitored ADP-induced aggregation of normal gel-filtered platelets (GFP) in platelet-poor plasma (PPP) from normal individuals and from patients in the presence or absence of an NO donor (S-nitroso-glutathione). Surface P-selectin expression of normal GFP in patients' PPP was analyzed by flow cytometry after incubation with a P-selectin-specific monoclonal antibody in the presence or absence of the NO donor. We also measured GSH-Px activity in plasmas from family members and normal controls using standard methods. In 6 of 7 families, NO failed to inhibit platelet P-selectin expression and platelet aggregation in PPP from the affected family members and some of their relatives. Of 4 families studied, 3 probands and their corresponding affected parent had 50% decrease in plasma GSH-Px activity. In some patients with childhood stroke, impaired metabolism of reactive oxygen species as a result of reduced GSH-Px activity results in NO insufficiency that affects normal platelet inhibitory mechanisms and predisposes to arterial thrombosis.

Long term neurological outcome of herpes encephalitis

Twenty eight children with herpes simplex encephalitis were followed up for a mean of 5.5 years. Two children died and 26 survived, of whom 16 were left with no neurological sequelae and 10 had persistent neurological sequelae. Mean (SD) Glasgow coma score was significantly lower in the patients with neurological sequelae (7.7 (1.5)) and the patients who died (4.5 (0.7)), compared with the patients without neurological sequelae (11 (1.7)).

3-Methyl glutaconic aciduria in Iraqi Jewish children may be misdiagnosed as cerebral palsy

It is generally accepted that patients with cerebral palsy suffer from a static encephalopathy causing a non-progressive disorder of posture and/or movement. We describe 7 patients from 5 families who were initially diagnosed with cerebral palsy. Eventually, excessive excretion of urinary 3-methyl glutaconic acid (3-MGA) was found. The data of our 7 patients are quite similar to the clinical description of Costeff et al (1989): Jewish-Iraqi origin (7/7), consanguinity (2/7), involuntary movements (5/7), ataxia (6/7), pyramidal involvement (6/7) and optic atrophy (6/7). The cognitive functions were intact in 5/7 and 2/7 showed mild to moderate mental retardation. The mean delay in the definitive diagnosis was 9 years. Cerebral palsy-like symptoms accompanied by optic atrophy and extrapyramidal signs should call for extensive metabolic evaluation including the determination of urinary 3-MGA.

Induced mood and selective attention

Subjects (N = 60) were randomly assigned to an elated, depressed, or neutral mood-induction condition to assess the effect of mood state on cognitive functioning. In the elated condition film fragments expressing happiness and euphoria were shown. In the depressed condition some frightening and distressing film fragments were presented. The neutral group watched no film. Mood states were measured using the Profile of Mood States, and a Stroop task assessed selective attention. Both were presented by computer. The induction groups differed significantly in the expected direction on the mood subscales Anger, Tension, Depression, Vigour, and Fatigue, and also in the mean scale response times, i.e., slower responses for the depressed condition and faster for the elated one. Differences between conditions were found in the errors on the Stroop: in the depressed condition were the fewest errors and significantly longer error reaction times. Speed of error was associated with self-reported fatigue.

Immune globulins are effective in severe pediatric Guillain-Barré syndrome

The effect of high-dose intravenous immune globulins was evaluated in an open prospective multicenter study of 26 children with severe Guillain-Barré syndrome. They presented with mild to moderate flaccid weakness of extremities, with cranial nerve involvement (20) and sensory impairment (22). All children rapidly deteriorated in 2-16 days (mean 6) to become bedridden, and 2 children also developed respiratory failure requiring artificial ventilation (Disability Grading Scale 4-5). Immune globulins were then administered at a total dose of 2 gm/kg, on 2 consecutive days, without adverse effects requiring discontinuation of therapy. Marked and rapid improvement was noted in 25 children, who improved by 1 to 2 Disability Grade Scales < or = 2 weeks after the infusion. Twenty were able to walk independently by 1 week, and 1 could be weaned off a ventilator. Eighteen children recovered by 2 weeks. The rest recuperated in a period of four months, including a child who was artificially ventilated for 4 weeks. The uniform rapid improvement and recovery associated with immune globulins contrasts with the slow recovery course in severe natural cases. We conclude that immune globulins are effective and safe in severe childhood-onset Guillain-Barré syndrome and therefore may serve as the initial treatment of choice.

Tethered cord syndrome presenting as a nonhealing cutaneous ulcer

The usual clinical presentations of tethered cord syndrome include pain in the lumbosacral region, gait difficulty, weakness, and bladder abnormalities. We describe an unusual presentation of tethered cord - a nonhealing gluteal ulcer in an anesthetic cutaneous territory supplied by the S2-4 segments. Unexplained cutaneous lesions may be the presenting sign of an underlying neurological condition.

Epileptic blindness in children: a localizing sign of various epileptic disorders

The ictal manifestations, EEG, CT, and MRI correlates, as well as the management and outcome of 11 children with epileptic blindness are presented. Seven males and four females, aged 3 months to 12 years, experienced single or recurrent episodes of acute visual obscuration. Ictal blindness was the solitary epileptic phenomenon in only two children. The rest had other focal or generalized motor epileptic manifestations. Six children had either focal motor phenomena and/or unilateral EEG disturbances, with a normal head CT. The drug of choice in this group was carbamazepine and all became asymptomatic. Two patients had structural abnormalities of the brain, of which one had a low-grade occipital astrocytoma which was resected. His blindness abated shortly following initiation of carbamazepine, even prior to surgery. Status epilepticus amauroticus and focal motor seizures, secondary to focal cortical dysplasia, was detected in another 3-month-old infant. These required cortical resection and she regained full vision. Three patients had generalized epileptiform discharges on EEG, of which two were photic-induced. Blindness was accompanied with motor seizures and myoclonic jerks. Full seizure control could be achieved in only one child.

CONCLUSION

our data suggest a relatively benign nature and a favorable outcome in most children with ictal blindness. Resection of a secondary temporo-parietal focus, as occurred in an infant with status epilepticus amauroticus which originated in the occipital region, may result in complete cessation of seizures and visual recovery.

Leukemia translocation gene, PLZF, is expressed with a speckled nuclear pattern in early hematopoietic progenitors

The PLZF gene was discovered by studying a rearrangement of the RAR alpha locus in a patient with acute promyelocytic leukemia and a t(11;17) chromosomal translocation. To understand further the potential role(s) of the PLZF gene product in hematopoiesis, we have examined its expression levels in a variety of murine tissues and in established cell lines that are representative of various stages of myeloid and lymphoid development. We show that murine PLZF(mPLZF) is expressed at the highest levels in undifferentiated, multipotential hematopoietic progenitor cells and that its expression declines as cells become more mature and committed to various hematopoietic lineages. Data obtained with established cell lines are corroborated by results showing the lack of human PLZF protein expression in mature peripheral blood mononuclear cells and high PLZF levels in the nuclei of CD34+ human bone marrow progenitor cells. Interestingly, unlike many transcription factors, PLZF protein in these cells possesses distinct punctate nuclear distribution, suggesting its compartmentalization in the nucleus. Taken together, our data suggest a role for PLZF protein in early hematopoiesis and the requirement of downregulation of its expression for proper differentiation of most hematopoietic lineages.

Expression of the zinc-finger gene PLZF at rhombomere boundaries in the vertebrate hindbrain

To investigate the potential biological role(s) of the PLZF gene, discovered as a fusion with the RARA locus in a patient with acute promyelocytic leukemia harboring a t(11;17) chromosomal translocation, we have isolated its murine homologue (mPLZF) and studied its patterns of developmental expression. The levels of mPLZF mRNAs increased perinatally in the liver, heart, and kidney, but with the exception of the heart, they were either absent or very low in the adult tissues. In situ analysis of mPLZF expression in mouse embryos between 7.0 and 10.5 days of development revealed that mPLZF mRNAs and proteins were coexpressed in spatially restricted and temporally dynamic patterns in the central nervous system. In the hindbrain region, a segmental pattern of expression correlated with the development of the rhombomeres. From 9.0 days of development, starting first in rhombomeres 3 and 5, there was an ordered down-regulation of expression in the center of each rhombomere, so that 1 day later elevated levels of mPLZF mRNAs and proteins were restricted to cells surrounding the rhombomeric boundaries. The chicken homologue of the PLZF gene, which we have also cloned, demonstrated a similar segmental pattern of expression in the hindbrain. To date, PLZF represents the only example of a transcription factor with elevated expression at rhombomeric boundaries. The high degree of evolutionary conservation between the patterns of PLZF expression during mammalian and avian central nervous system development suggests that it has an important functional role in the regionalization of the vertebrate hindbrain, potentially regulating boundary cell interactions.

Predictors of outcome of stroke in infants and children based on clinical data and radiologic correlates

Outcome predictors were analyzed in 45 infants and children with cerebrovascular disorders (CVD), based on clinical features and radiological correlates. The clinical features at presentation could be categorized into three major groups: (1) generalized: alteration of consciousness with or without seizures--24 patients (54%); (2) focal: acute hemiplegia or monoplegia with or without focal seizures--18 patients (40%); (3) cerebellar disturbances--3 patients (6%). The underlying etiology was detected in 80% of children. Thirty-seven patients (82%) survived the initial debilitating event, of whom 11 (29.7%) recovered completely and the rest had either motor or cognitive handicaps during an average follow-up period of 4.2 years (range 1.5-11 years). A head CT performed in all children revealed ischemic infarction in 29 patients (64.4%), while the others had hemorrhagic infarction. Of those with an initial generalized neurological presentation, as many as 50% had multi-focal lesions on CT. All children with focal neurological findings had a solitary localized lesion on CT, mainly in the distribution of the middle cerebral artery. Statistical analysis for outcome prediction showed that the following variables were associated with increased risk of immediate death: (1) hemorrhagic infarction demonstrated by brain CT (p = 0.031); (2) patients who presented with a generalized neurological disorder, namely alteration of consciousness, with or without seizures (p = 0.036). No other clinical or laboratory variables were predictive of imminent death, motor or cognitive handicaps. These may therefore serve as outcome predictors of stroke in the pediatric age group.

Surgical morbidity in the North Coast Health Region

A comparison of morbidity following 20 selected surgical procedures was conducted in the North Coast Health Region of NSW in 1988. Morbidity rates between procedures, hospitals and hospital levels were compared and the effects of age, gender and the American Society of Anesthesiologists rating on morbidity were examined. The respective perceptions of doctors and patients regarding complications were also compared. The study gives conditional support to the continuation of a surgical programme in Level 3 hospitals in the North Coast Health Region.

Origins of hyperphenylalaninemia in Israel

Mutations and polymorphisms at the phenylalanine hydroxylase (PAH) gene were used to study the genetic diversity of the Jewish and Palestinian Arab populations in Israel. PAH mutations are responsible for a large variety of hyperphenylalaninemias (HPAs), ranging from the autosomal recessive disease phenylketonuria to various degrees of nonclinical HPA. Seventy-two Jewish and 36 Palestinian Arab families with various HPAs, containing 115 affected genotypes, were studied by haplotype analysis, screening for previously known PAH lesions and a search for novel mutations. Forty-one PAH haplotypes were observed in this sample. Four mutations previously identified in Europe (IVS10nt546, R261Q, R408W and R158Q) were found, and were associated with the same haplotypes as in Europe, indicating possible gene flow from European populations into the Jewish and Palestinian gene pools. Of particular interest is a PAH allele with the IVS10nt546 mutation and haplotype 6, that might have originated in Italy more than 3,000 years ago and spread during the expansion of the Roman Empire. These results, together with previous identification of three PAH mutations unique to Palestinian Arabs [IVSnt2, Edel(197-205) and R270S], indicate that the relatively high genetic diversity of the Jewish and Palestinian populations reflects, in addition to genetic events unique to these communities, some gene flow from neighboring and conquering populations.

Delayed parkinsonism associated with hypotension in a child undergoing open-heart surgery

An eight-year-old boy developed acute parkinsonism four days after open-heart surgery for repair of a ventriculo-septal defect. During the procedure he experienced a hypotensive episode which required administration of positive-inotropic agents. Complementing the clinical signs of parkinsonism, CT scan showed symmetrical hypodensities in the basal ganglia, and decreased regional cerebral blood flow was demonstrated using 99mTc HMPAO SPECT. These findings were suggestive of a hypoxic-ischaemic insult to the basal ganglia. The child was treated with levodopa/carbidopa and subsequently completely recovered within a follow-up period of eight months. CT scan appearances and cerebral blood flow findings returned to normal. Parkinsonism secondary to a hypoxic-ischaemic insult to basal ganglia in children is a rare but reversible disorder, in contrast to its progressive course which results in severe disability in adults.

Hereditary motor-sensory neuropathy (Charcot-Marie-Tooth disease) with nerve deafness: a new variant

Hereditary motor-sensory neuropathy with sensorineural deafness is described in a family; the neurologic features and deafness were apparent in early childhood and infancy. The clinical syndrome in the family was not closely linked to the Duffy blood group, nor was duplication demonstrated at the disease-associated locus 17 p11.2. This family may represent a different form of this heterogeneous disease.

Phenylketonuria: variable phenotypic outcomes of the R261Q mutation and maternal PKU in the offspring of a healthy homozygote

Phenylketonuria (PKU) and benign hyperphenylalaninaemia (HPA) result from a variety of mutations in the gene for the hepatic enzyme phenylalanine hydroxylase. PKU has been found in the Israeli population in two variants, classical and atypical. The two are clinically indistinguishable and require treatment with low phenylalanine diet to prevent mental retardation, but show differences in serum phenylalanine levels and in tolerance to this amino acid. Maternal PKU is a syndrome of congenital anomalies and mental retardation that appears in offspring of PKU mothers as a result of fetal exposure to the high phenylalanine level in the maternal blood. We studied a family in which two children with severe, classical PKU and their unaffected brother showed mild signs of maternal PKU. Their mother had no clinical signs of PKU, but the phenylalanine concentration in her serum reached a level that usually characterises PKU patients. This woman represents a rare phenotype, benign atypical PKU. Such 'hidden' PKU in women may lead to maternal PKU in the offspring, similar to overt PKU. Special attention should therefore be paid to women having children with any of the clinical hallmarks of maternal PKU, and to children born to women known to have benign HPA. The mother was also found to be homozygous for a missense mutation at the phenylalanine hydroxylase locus, R261Q, which does not abolish enzymatic activity completely. In two other families, homozygosity for this mutation resulted in atypical PKU in four children. This observation suggests that mutations that do not completely destroy phenylalanine hydroxylase activity may exhibit variable phenotypic expression which is unpredictable. Compound heterozygosity for R261Q and other mutations led in other patients either to classical PKU or to mild benign HPA.

Procedural learning of cognitive and motor skills in psychotic patients

Two kinds of procedural learning, viz. learning of a sequence of simple motor responses and learning to solve a rather complex problem (Tower of Hanoi), as well as declarative learning (word list learning) were investigated in a group of psychotic inpatients (n = 67) and a control group of non-psychotic psychiatric inpatients (n = 19). Within the psychotic group, correlations of the task variables with positive and negative symptoms were explored. There was no difference between both groups in motor procedural learning. Psychotic patients were less efficient than controls in solving the Tower problem, but both groups again showed an equal amount of procedural learning. Consistent with the literature, however, a clear difference between both groups was found in declarative learning. The memory tasks did not correlate significantly with psychotic symptoms. These findings are interpreted as another indication that automatic information processing in psychotic patients is intact. The results are discussed with reference to neuropsychological research on procedural learning in neurological patients.

Effect of add-on amantadine therapy for refractory absence epilepsy

Amantadine hydrochloride was administered as an add-on drug to four children with refractory absence epilepsy, resulting in complete resolution of absence episodes within 1 week. All patients remained free of symptoms for 27 to 36 months without adverse effects related to this drug. An attempt to discontinue the use of this medication in three children resulted in a prompt relapse. The suggestion that amantadine may be an effective drug in the treatment of refractory absence epilepsy, should be tested in a double-blind, controlled study.

Self-inflicted ocular mutilation in the pediatric age group

Three mentally retarded children with severe self-inflicted ocular injuries are presented. All three suffered from severe ocular injuries including retinal detachment resulting in progressive visual loss and even blindness. Self-inflicted injuries to the eyes, including self enucleation, is an extremely uncommon form of behavior, rarely encountered by pediatricians. The risk of ocular morbidity is high if the diagnosis is overlooked. Technical advances in ophthalmology permit much improvement in some formerly hopeless cases of ocular self-mutilation, but there is still no accurate method to repair destroyed retinal or nervous tissue. Early identification of patients at risk of ocular self-mutilation is essential in order to prevent or minimize such severe ocular injuries.

Transverse myelitis following mumps in children

Although acute transverse myelitis is a rare complication of mumps, it is relatively well documented. We describe a child who developed mumps associated acute transverse myelitis and who subsequently recovered completely. To our knowledge, only 13 cases have been reported in children. This case is compared with 13 previously reported patients.

X-linked mental retardation with bilateral clasped thumbs: report of another affected family

A Sephardi Jewish family is reported in which the two brothers had mental retardation, lower limb spasticity and bilateral clasped thumbs anomaly. This X-linked recessive disorder has only been reported twice. We believe this syndrome comprises a distinct entity among the X-linked mental retardation syndromes.

Nose tapping test inducing a generalized flexor spasm: a hallmark of hyperexplexia

The present report describes a benign disorder of neonates or young infants presenting with generalized hypertonicity accompanied by brisk muscle stretch reflexes, intermittent clonus, and exaggerated startle response. This condition is termed hyperexplexia, and may be either familial or sporadic. Two affected families are reported: Two sisters and their mother are involved in the first family; in the second family, where the parents are asymptomatic first degree cousins, all three siblings suffer from hyperexplexia of various severity. Nose tapping in infants of affected families induced a uniform reaction of facial twitching accompanied by head extension, and a generalized flexor spasm, all of which may be a hallmark of hyperexplexia. Severely hypertonic infants were treated with small doses of benzodiazepines and improved markedly, all becoming asymptomatic by two years of age. Unnecessary investigation and treatment may be avoided by sufficient awareness of possible hyperexplexia.

[High-dose immunoglobulins in children with Guillain-Barré syndrome]

High-dose intravenous immunoglobulin was effective in 3 children with severe Guillain-Barre syndrome (GBS). They presented with mild to moderate, flaccid weakness which progressively deteriorated to severe tetraparesis and weakness of ocular, facial and bulbar muscles. 1 of them was treated with steroids with no response. Serum immune globulins were infused (1g/kg/day) for 2 consecutive days. There was marked clinical improvement in all 3 after the second day of infusion, and there were no adverse affects. All became ambulatory and were able to walk within the first week. Ocular, facial and bulbar impairment gradually subsided and disappeared, as did hypertension in 1. A 6-year-old boy completely recovered after 3 weeks while the 2 girls, both aged 9 years, still have mild weakness which is gradually improving. High-dose immunoglobulin therapy may be effective in children with severe GBS, with no significant adverse effects. It presumably provides idiotypic antibodies that block the autoimmune process responsible for demyelination.

Uncommon neurologic complications of burns in infants: a parkinsonian extrapyramidal disorder and massive cerebral infarction

We report uncommon neurologic complications of moderate to severe burns in two infants aged 13 and 19 months, respectively. The first patient suffered a 25% total body surface area burn to her lower limbs; 3 days later she became mute and irritable, with increasing rigidity of limbs and trunk. Her face was expressionless and she also had mild dysphagea. Muscle-stretch reflexes were brisk and accompanied by episodes of coarse jitteriness. A diagnosis of an extrapyramidal parkinsonian disorder was made. The infant was treated with amantadine hydrochloride, and she recovered completely over a period of 2 months. The second infant was admitted with an extensive burn to his trunk and limbs; 3 days later he became comatose and had intractable seizures, which were more prominent over his right side. Dysphasia and right-sided hemiplegia became apparent; these conditions were and remained permanent, accompanied by focal seizures and a marked cognitive delay. Although relatively uncommon, central nervous system involvement may be a hazardous complication of burns in infants, who thus represent a high-risk group.

Possible heterogeneity in spondyloenchondrodysplasia: quadriparesis, basal ganglia calcifications, and chondrocyte inclusions

We report on 6 patients with short stature and progressive enchondromatous-like changes of the vertebral bodies and the metaphyses of the long bones. Parental consanguinity was observed in 5 of 6 cases, supporting autosomal recessive inheritance. In spite of the similarity in radiographic changes and body proportions, genetic heterogeneity is suggested by the presence of CNS calcifications in 3 patients. Two of the latter had progressive quadriparesis. We tentatively classified these patients into 2 provisional types. An iliac crest biopsy in one of the patients with "type I" disease did not demonstrate enchondromatosis. Light and transmission electron microscopic studies demonstrated large cisterns and small inclusion bodies containing a flocculent material within the rough endoplasmic reticulum of the chondrocytes. Based on the histological and radiographic findings, we propose to classify these conditions among the spondylometaphyseal skeletal dysplasias.

Antibodies specific to the retinoic acid human nuclear receptors alpha and beta

Two cDNAs encoding two human receptors for retinoic acid (RA), RAR-alpha and RAR-beta, have been characterized recently. Synthetic peptides corresponding to the cDNA-deduced amino acid sequences unique to RAR-alpha and RAR-beta were used to generate anti-RAR-alpha antiserum (SP171) and anti-RAR-beta antisera (SP172 and SP248). The specificity of these antisera was confirmed both by immunocytochemical detection of these receptors in COS-1 cells transfected with RAR-alpha and RAR-beta expression vectors and by immunoblot analyses performed with whole extracts of these cells. We also demonstrate that these antisera recognize RAR-alpha and RAR-beta endogenously expressed in the RA-responsive human promyelocytic leukemia cell line HL-60.

Mapping of the human retinoic acid receptor to the q21 band of chromosome 17

Recombinant plasmid containing cDNA insert from the human retinoic acid receptor was radiolabeled and hybridized in situ to metaphase chromosome preparations. The results localized the human retinoic acid receptor to the q21 band of chromosome 17.

Identification of a second human retinoic acid receptor

We have previously described a human complementary DNA that encodes a novel protein which is homologous to members of the steroid/thyroid nuclear receptor multigene family. This novel protein (hap for hepatoma) exhibits strong homology with the human retinoic acid receptor (RAR) which has been recently characterized. To test the possibility that the hap protein might also be a retinoid receptor, a chimaeric receptor was created by replacing the putative DNA binding domain of hap with that of the human oestrogen receptor (ER). The resulting hap-ER chimaera was then tested for its ability to trans-activate an oestrogen-responsive reporter gene (vit-tk-CAT) in the presence of possible receptor ligands. Here we show that retinoic acid (RA) at physiological concentrations is effective in inducing the expression of this reporter gene by the hap-ER chimaeric receptor. This demonstrates the existence of two human retinoic acid receptors designated RAR-alpha and RAR-beta.

Familial carnitine deficiency: further evidence for autosomal recessive transmission with variable expression

Carnitine deficiency occurring in families has been rarely reported and the genetic transmission has not yet been clearly elucidated. Five members of one family showing marked heterogeneity of carnitine deficiency states are presented. In three patients, there was no correlation between measurable carnitine levels in serum and muscle and the clinical findings. The parents, who are remote relatives from an isolated village in Kurdistan (Iraq), had low muscle carnitine levels; however, they were asymptomatic. One son, with systemic carnitine deficiency causing muscle weakness and recurrent episodes of severe hepatic encephalopathy, died at 3 years of age. His brother had mild proximal muscle weakness associated with low muscle carnitine levels. He was successfully treated with L-carnitine and prednisone. A daughter is asymptomatic, but with low serum and muscle levels of carnitine. The marked heterogeneity of carnitine deficiency states within one family, where both parents had low muscle carnitine levels, suggests an autosomal recessive inheritance with variable expression.