P4465Acute Cardio-Selective Functional Modulation via a Small-Molecule Direct Myosin-Attenuator (MYK-581) Preserves Diaphragmatic Function in vivo: Comparison versus Disopyramide

Background

Hypertrophic cardiomyopathy (HCM) is a heritable cardiac disease characterized by hyper-contractility, hindered relaxation, and impaired exercise capacity. Conventional negative inotropes can alleviate enhanced inotropy in HCM, but do not improve ventricular filling and have the potential to further decrease exercise capacity due to their off/on-target systemic effects. Recently, a novel small molecule cardiac-myosin attenuator, Mavacamten, has been shown to normalize hyper-contractility in the setting of HCM. This study evaluated and compared the in vivo functional selectivity of MYK-581, a mavacamten analog, with those of disopyramide (DISO), a commonly-used negative inotrope.

Methods

In vivo, the acute cardiac (left ventricular pressures) and neuro-muscular (force of diaphragmatic and skeletal muscle contractions) responses to MYK-581 (up to 0.5 mg/kg IV) and DISO (up to 10 mg/kg IV) were simultaneously evaluated using anesthetized and mechanically-ventilated Sprague-Dawley rats; diaphragmatic (both intrinsic and phrenic nerve stimulated) and skeletal contractions (stimulated quadriceps) were measured via strain gauges.

Results

MYK-581 decreased indices of systolic function (dP/dtmax: −32±2% and vmax: −14±2%, P<0.05 vs. pre-dose) and increased LV EDV (+9±2%, P<0.05), while preserving EDP (6±1 to 6±1 mmHg), suggesting improved ventricular distensibility. Despite these marked cardiac effects, MYK-581 preserved both diaphragmatic (23.7±2.0 to 23.3±2.2 g) and skeletal in situ function (14.9±1.4 to 13.9±0.8 g). In contrast, DISO at matched levels of negative inotropy (dP/dtmax: −25±2% and vmax: −19±2%, P<0.05 vs. pre-dose) depressed diaphragmatic force (−16±3%, 23.8±1.9 to 19.8±1.2 g, P<0.05). Finally, the cardiac selectivity of MYK-581 was confirmed in kinetic experiments evaluating the Ca2+-activated ATPase activity of both cardiac and diaphragmatic myofibrils.

Conclusions

Direct myosin modulation with MYK-581, a mavacamten analog, is characterized in vivo by reductions in systolic function with preserved filling pressures and improved LV compliance. Moreover, this cardiovascular profile was devoid in vivo of diaphragmatic/skeletal off-target effects that could further hinder exercise capacity in patients with HCM.

Abstract P1-01-09: BMP4 suppresses the progression of breast cancer through altered expression of metastasis regulating genes

Metastasis is a lethal manifestation of cancer, the development of which is the major cause of death in cancer patients. During a search for metastasis-regulating elements, an inverse correlation was identified between the in vivo tumor expression of bone morphogenetic protein-4 (BMP4) and spontaneous metastasis in a panel of isogenic mammary tumors of varying metastatic capacity. BMP4 is an essential morphogen in development, regulating cellular mechanisms akin to those in metastasis, including cellular differentiation, pluripotency and apoptosis. We therefore initiated an investigation of the impact of BMP4 expression on the metastatic process.

We studied the effect of enforced expression of BMP4 in a highly metastatic mammary tumour model called 4T1.2, comparing in vitro properties and tumour progression in mice. There were no differences in proliferation in vitro or when implanted into the mammary gland of immunocompetent mice. In contrast, mice bearing equivalent-sized 4T1.2-BMP4 tumors revealed dramatically reduced metastasis to lung, lymph node and bone. In a parallel study where the established orthotopic primary tumor was resected, survival was significantly extended in mice bearing 4T1.2-BMP4 tumors. Enforced BMP4 expression in tumor cells introduced intravenously resulted in a 2.5-fold decrease in lung metastatic burden, consistent with the impaired capacity of tumor cells to survive in circulation and colonize the lung. Conversely, silencing BMP4 expression in separate weakly metastatic tumours enhanced their ability to colonize the lung and shortened the survival of the mice. No changes were found in the ability of tumor cells expressing BMP4 or treated with recombinant BMP4 to migrate or invade through Matrigel in chemotactic assays but BMP4 enhanced anoikis in both mouse and human breast cancer cells, indicating that BMP4 sensitizes disseminated cells to anoikic stresses induced by cell-substrate detachment and shear flow during systemic transit. BMP4 activated canonical BMP-SMAD signaling in our mammary tumours, leading to altered expression of known metastasis-regulating genes, including SMAD7. SMAD7 depletion in metastasis-deficient 4T1.2-BMP4 tumors accelerated the onset of metastatic disease.

In a meta-analysis of 3,587 breast cancer patients in publically available datasets, low BMP4 mRNA expression was significantly associated with reduced relapse-free survival (RFS) (HR = 0.85, P = 0.01). In an independent analysis using the BreastMark algorithm, low levels of BMP4 mRNA were associated with reduced RFS (HR = 0.88, P = 0.035), distant metastasis-free survival (HR = 0.83, P = 0.035) and overall survival (HR = 0.78, P = 0.006). At the protein level, in a tissue microarray from 415 treatment naïve patients, improved overall survival was observed in multivariate analysis for both BMP4 (HR = 0.66, P = 0.037) and SMAD7 expression (HR = 0.64, P = 0.035) individually. Expression of both proteins compared to neither further improved OS (HR = 0.55, P = 0.005).

In summary, we found strong evidence that BMP4 is a metastasis suppressor correlating inversely with metastatic potential in preclinical breast cancer models and predicting improved relapse-free and overall survival in breast cancer patients.

Citation Format: Redfern AD, Eckhardt BL, Cao Y, Sloan EK, Parker BS, Loi S, Ueno NT, Lau PK, Latham B, Anderson RL. BMP4 suppresses the progression of breast cancer through altered expression of metastasis regulating genes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-01-09.

Abstract P5-14-03: Withdrawn

This abstract was withdrawn by the authors.

Abstract P5-04-03: Bone morphogenic protein-4: A novel metastasis suppressor gene in breast cancer

Background: The combination of large-scale screening platforms and animal models of cancer, have provided much insight into the genetic mechanisms that control metastatic progression. Indeed, several studies have unraveled an essential role for genes that encode growth factors and extracellular matrix proteins in the progression of breast cancer. We have found that one such growth factor, bone morphogenic protein-4 (BMP4), to be significantly reduced in tumors with a high proclivity to metastasize. BMP4 is known to regulate tissue polarity and differentiation during embryogenesis, however it is not known whether BMP4 can functionally affect tumor progression.

Methods and results: In a panel of mammary tumor lines, we demonstrate an inverse correlation between metastatic propensity and the expression of BMP4 through a combination of RT-PCR, immunohistochemistry (IHC) and ELISA. These findings were extended to publicly available gene expression data sets, where low BMP4 expression was found to be associated with ER-negative breast tumors and in those tumors with high histologic grade. Low BMP4 expression also correlated with poorer survival from distant metastases (HR 0.82, p = 0.013). IHC analysis on a tissue microarray consisting of tumor specimens from 535 patients with invasive breast cancer demonstrated that, compared to normal breast epithelium, BMP4 positivity was significantly less common in both DCIS (HR 0.59, p = 0.00046) and invasive carcinoma (HR = 0.56, p&lt;0.0000001), and was inversely associated with axillary lymph node-positivity (HR = 1.53, p = 0.055). Using surrogate in vitro assays of metastasis, we determined that BMP4 can suppress the ability of highly metastatic 4T1.2 tumor cells to resist anoikis. When BMP4 was overexpressed in 4T1.2 cells (4T1.2-BMP4) and orthotopically implanted in mice, we did not observe an effect on primary tumor growth, however elevated BMP4 expression did block the ability of these tumors to metastasize to the lymph node, lung and bone. In a reverse-complimentary approach, we confirmed that silencing of BMP4 expression by RNAi in weakly metastatic 4T07 and 168FARN cells, can enhance lung colonization. Mechanistically, we establish that BMP4 can induce canonical BMP-SMAD signaling in multiple breast cancer cells, leading to an up-regulation of genes known to suppress metastasis, and a down-regulation of metastasis promoting genes. Specifically, we link the anti-metastatic function of BMP4 to its ability to induce the expression of the known metastasis suppressor, Smad7. Through RNAi-mediated suppression of Smad7 in 4T1.2-BMP4 tumors, we were able to restore the metastatic phenotype of this tumor line. Finally, we demonstrate that administration of recombinant BMP4 protein in 4T1.2 tumor challenged mice elevates Smad7 expression within the primary tumor, and leads to a pronounced decrease in spontaneous bone and lung metastasis.

Conclusion: Utilizing animal models of cancer, and clinically sourced tissues, we provide correlative and functional data to prove that BMP4 is a bona fide metastasis suppressor gene in breast cancer. Furthermore, we demonstrate that BMP4 may be therapeutically viable, and can prevent breast tumor progression through the modulation of known ‘metastasis virulence’ genes.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-04-03.

Mice with reduced NMDA receptor expression: more consistent with autism than schizophrenia?

Reduced NMDA-receptor (NMDAR) function has been implicated in the pathophysiology of neuropsychiatric disease, most strongly in schizophrenia but also recently in autism spectrum disorders (ASD). To determine the direct contribution of NMDAR dysfunction to disease phenotypes, a mouse model with constitutively reduced expression of the obligatory NR1 subunit has been developed and extensively investigated. Adult NR1(neo-/-) mice show multiple abnormal behaviors, including reduced social interactions, locomotor hyperactivity, self-injury, deficits in prepulse inhibition (PPI) and sensory hypersensitivity, among others. Whereas such phenotypes have largely been interpreted in the context of schizophrenia, these behavioral abnormalities are rather non-specific and are frequently present across models of diseases characterized by negative symptom domains. This study investigated auditory electrophysiological and behavioral paradigms relevant to autism, to determine whether NMDAR hypofunction may be more consistent with adult ASD-like phenotypes. Indeed, transgenic mice showed behavioral deficits relevant to all core ASD symptoms, including decreased social interactions, altered ultrasonic vocalizations and increased repetitive behaviors. NMDAR disruption recapitulated clinical endophenotypes including reduced PPI, auditory-evoked response N1 latency delay and reduced gamma synchrony. Auditory electrophysiological abnormalities more closely resembled those seen in clinical studies of autism than schizophrenia. These results suggest that NMDAR hypofunction may be associated with a continuum of neuropsychiatric diseases, including schizophrenia and autism. Neural synchrony abnormalities suggest an imbalance of glutamatergic and GABAergic coupling and may provide a target, along with behavioral phenotypes, for preclinical screening of novel therapeutics.

Abstract P3-10-09: Peptide-based molecular targeting of inflammatory breast cancer

Inflammatory breast cancer (IBC) is a subtype of breast cancer that has a frequent association with metastatic disease and a poorer prognosis than comparative non-inflammatory breast cancers. While IBC is now considered a distinct subclass of breast cancer, the lack of molecular characterization, both at the genomic and proteomic levels, has hampered the development of rationalized and targeted therapies. Inherent receptor/ligand interactions that can occur on the surface of tumor cells can act as a dynamic molecular address that can enable targeted delivery of drugs and imaging agents to tumors. We hypothesize that such molecular addresses within IBC can be exploited for ligand-based imaging and early detection of disease sites. To this end, it is our goal to generate targeted imaging and therapeutic agents by combining ligand-directed targeting with efficient transduction of IBC cells by hybrid gene delivery vectors. Our strategy utilizes a hybrid vector with genomic elements from adeno-associated virus (AAV) and an M13-derived phage. Ligand-targeted, AAV/phage (AAVP) chimeras can display tumor-homing peptides that mediate selective internalization of viral particles through specific ligand-receptor interactions in vitro and in vivo. Such targeted vehicles are suited for the delivery of different reporter genes that can be used for imaging, diagnosis and therapy of breast cancer

As a part of our ongoing studies we have identified, characterized and evaluated a peptide (WIFPWIQL, amino acid sequence) that can target GRP78, a stress-response protein that is expressed in IBC tumors and elevated during metastatic progression. Indeed, we found that this GRP78-targeting peptide can bind to, and internalize within IBC cells. As a result, we sought to characterize the ability of this peptide to mediate the delivery of fluorescent-based compounds and toxic moieties in preclinical models of IBC and breast cancer metastasis. Using amine-based chemical coupling, we conjugated near-infrared dyes on both WIFPWIQL-phage and on a WIFPWIQL-peptide engrafted antibody. When these fluorescent construct were administered into mice bearing IBC or IBC-like tumors, we could visualize tumor-specific targeting of the vectors in vivo. To demonstrate efficacy of GRP78-targeted therapeutics, we conjugated the tumor-homing, GRP78 ligand to a cell-death inducing domain (creating a compound called BMTP-78, βone metastasis targeting peptide-78), which can selectively kill cells upon internalization. We show here that BMTP78 therapy in mice with established GRP78-positive tumors, but not matched GRP78-negative tumors, could effectively reduce tumor growth and metastatic burden. Finally, we demonstrate a WIFPWIQL-AAVP construct that expresses a suicide gene (HSVtk) under the control of either CMV or GRP78 promoter, could sensitize IBC tumor xenografts to the pro-drug ganciclovir. Collectively, our results demonstrate an in vivo receptor/ligand system that has the potential for imaging and therapeutic targeting of IBC and aggressive breast tumors.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-10-09.

Delta cell secretory responses to insulin secretagogues are not mediated indirectly by insulin

AIMS/HYPOTHESIS

Somatostatin from islet delta cells inhibits insulin and glucagon secretion, but knowledge of the regulation of pancreatic somatostatin release is limited. Some insulin secretagogues stimulate somatostatin secretion, and here we investigated whether delta cell secretory responses are indirectly regulated in a paracrine manner by insulin released from beta cells.

METHODS

Hormone release from static incubations of primary mouse islets or somatostatin-secreting TGP52 cells was measured by RIA. mRNA expression was assessed by RT-PCR.

RESULTS

Glucose and a range of other physiological and pharmacological agents stimulated insulin and somatostatin release, and insulin receptor mRNA was expressed in islets, MIN6 beta cells and TGP52 cells. However, exogenous insulin did not modulate basal or glucose-induced somatostatin secretion from islets, nor did pre-incubation with an antibody against the insulin receptor or with the insulin receptor tyrosine kinase inhibitor, HNMPA(AM)(3). Glucose and tolbutamide stimulated somatostatin release from TGP52 cells, whereas a range of receptor-operating agents had no effect, the latter being consistent with a lack of corresponding receptor mRNA expression in these cells. Parasympathetic activation stimulated insulin, but inhibited somatostatin release from mouse islets in accordance with differences in muscarinic receptor mRNA expression in islets, MIN6 and TGP52 cells. The inhibitory effect on somatostatin secretion was reversed by pertussis toxin or the muscarinic receptor 2 antagonist, methoctramine.

CONCLUSIONS/INTERPRETATIONS

A number of insulin secretagogues have analogous effects on insulin and somatostatin release, but this similarity of response is not mediated by an indirect, paracrine action of insulin on delta cells.

Vitamin D homeostasis is compromised due to increased urinary excretion of the 25-hydroxycholecalciferol-vitamin D-binding protein complex in the Zucker diabetic fatty rat

Altered serum concentrations of the major circulating form of vitamin D [25-hydroxycholecalciferol (25D(3))] and its active hormone derivative [1,25-dihydroxycholecalciferol (1,25D(3))] have been linked to non-insulin-dependent diabetes mellitus (NIDDM). However, a mechanistic basis for this occurrence has not been fully elucidated. Normally, renal reabsorption of vitamin D-binding protein-bound 25D(3) absolutely requires receptor-mediated endocytosis via a receptor complex containing megalin, cubilin, and disabled-2 (Dab2), whereas an absence of megalin or its endocytic partners can lead to a marked urinary loss of 25D and severe vitamin D deficiency. Therefore, we hypothesized that reduced serum vitamin D status in NIDDM may be due to reduced expression of megalin and/or its endocytic partners and increased urinary excretion of protein-complexed 25D(3). In the present study, we utilized Zucker diabetic fatty Rats (ZDF) to demonstrate that renal reuptake of the 25D(3)-DBP complex was compromised in ZDF animals, which was reflected by a reduction in expression of megalin and Dab2. Moreover, serum levels of both 25D(3) and 1,25D(3) were reduced, and urinary 25D(3), 1,25D(3), and DBP excretion were elevated in the ZDF animals compared with their lean controls regardless of vitamin D levels in the diet. Taken together, these are the first reports to our knowledge that associate compromised renal reabsorption of the 25D(3)-DBP complex with expression of megalin and its endocytic partners in NIDDM, which in turn can lead to compromised vitamin D status.

Intrinsic bacterial contamination of a commercial iodophor solution: investigation of the implicated manufacturing plant

After an outbreak of peritoneal infections attributed to intrinsic contamination of a poloxamer-iodine solution with Pseudomonas aeruginosa, the manufacturer of the contaminated solution permitted investigation and sampling of materials within the plant. Pseudomonas spp. were recovered from two different unopened lots of solution and from numerous water samples obtained at the plant. The isolates from water identical to those of an isolate recovered from Prepodyne solution (West-Agro Chemical Co., Inc., Westwood, Kans., manufactured for AMSCO Medical Products Div., Erie, Pa.) manufactured 1 month earlier at the same plant. P. aeruginosa was not recovered from incoming city water. P. aeruginosa was recovered from sterile water and poloxamer-iodine after 48 h of incubation in a plant polyvinyl chloride pipe. Scanning electron micrographs of polyvinyl chloride pipe used in the plant showed massive concentrations of rod-shaped and coccobacillary cells apparently embedded in interior deposits of the pipe. Manufacturers of iodophors should be aware that pipes or other surfaces colonized with bacteria may be a source of contamination of their products.

TRAIL-induced apoptosis is enhanced by heat shock protein 70 expression

Heat shock protein 70 (Hsp70) is a well-known inhibitor of apoptotic pathways; however, a role for Hsp70 in the modulation of death receptor-mediated apoptosis remains largely unexplored. In this study, the ability of Hsp70 to modulate tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL)-induced apoptosis was examined in SW480 and CCRF-CEM cells. These lines exhibit the characteristics of type I cells (SW480, human colon adenocarcinoma), with no requirement for mitochondrial involvement to exhibit apoptosis following death receptor engagement and type II cells (CCRF-CEM, human leukemic T cell), which do require amplification of the signal through the mitochondria. Unexpectedly, expression of Hsp70 in the type II CCRF-CEM cells enhanced the extent of TRAIL-induced apoptosis, but in SW480, Hsp70 had no impact on TRAIL-induced apoptosis. The enhanced TRAIL-induced apoptosis was accompanied by an up-regulation of TRAIL receptors, R1 and R2, at the cell surface as determined by flow cytometry and at the transcriptional level as assessed by real-time polymerase chain reaction (PCR). Increased expression of Hsp70 led to up-regulated expression of p53, and chromatin immunoprecipitation combined with real-time PCR revealed increased binding of p53 to its consensus sequence in the TRAIL-R2 gene. In contrast, expression of Hsp70 in SW480 cells did not increase p53 or TRAIL-R1 or TRAIL-R2 surface expression. This result is in marked contrast to most apoptotic stresses, including TNFalpha and Fas ligand, where Hsp70 has been shown to inhibit apoptosis in type II cells. These findings suggest that in tumors retaining functional p53 and expressing high levels of Hsp70, TRAIL may be an effective therapy.

ST7-mediated suppression of tumorigenicity of prostate cancer cells is characterized by remodeling of the extracellular matrix

Multiple lines of evidence have provided compelling evidence for the existence of a tumor suppressor gene (TSG) on chromosome 7q31.1. ST7 may be the target of this genetic instability but its designation as a TSG is controversial. In this study, we show that, functionally, ST7 behaves as a tumor suppressor in human cancer. ST7 suppressed growth of PC-3 prostate cancer cells inoculated subcutaneously into severe combined immunodeficient mice, and increased the latency of tumor detection from 13 days in control tumors to 23 days. Re-expression of ST7 was also associated with suppression of colony formation under anchorage-independent conditions in MDA-MB-231 breast cancer cells and ST7 mRNA expression was downregulated in 44% of primary breast cancers. Expression profiling of PC-3 cells revealed that ST7 predominantly induces changes in genes involved in re-modeling the extracellular matrix such as SPARC, IGFBP5 and several matrix metalloproteinases. These data indicate that ST7 may mediate tumor suppression through modification of the tumor microenvironment.

Presynaptic alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors modulate release of inhibitory amino acids in rat spinal cord dorsal horn

Local inhibition within the spinal cord dorsal horn is mediated by the neurotransmitters GABA and glycine and strongly influences nociceptive and temperature signaling. Alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors are expressed by inhibitory interneurons and have been shown to modulate GABA release in other regions of the CNS. In the spinal cord, there is morphological evidence for presynaptic AMPA receptor subunits in GABAergic dorsal horn neurons, but functional data are lacking. To determine if AMPA receptors are indeed functional at presynaptic terminals of inhibitory neurons, we recorded evoked and miniature inhibitory postsynaptic currents (mIPSPs) in the superficial dorsal horn of the rat spinal cord. We show that AMPA receptor activation enhances spontaneous release of inhibitory amino acids in the presence of tetrodotoxin onto both lamina II neurons and NK1 receptor-expressing (NK1R+) lamina I neurons. This effect is sensitive to the concentration of extracellular Ca2+, yet is not fully blocked in most neurons in the presence of Cd2+, suggesting possible Ca2+ entry through AMPA receptors. Postsynaptic Ca2+ elevation is not required for these changes. AMPA-induced increases in mIPSP frequency are also seen in more mature dorsal horn neurons, indicating that these receptors may play a role in nociceptive processing in the adult. In addition, we have observed AMPA-induced depression of evoked release of GABA and glycine onto lamina I NK1R+ neurons. Taken together these data support a role for presynaptic AMPA receptors in modulating release of GABA and glycine in the superficial dorsal horn. Because inhibition in the dorsal horn is important for controlling pain signaling, presynaptic AMPA receptors acting to modulate the inhibitory inputs onto dorsal horn neurons would be expected to impact upon pain signaling in the spinal cord dorsal horn.

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement

BACKGROUND

Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California.

METHODS

Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews.

RESULTS

On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients.

CONCLUSIONS

SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

Characterizing blood pressure control in individuals with Type 2 diabetes: the relationship between clinic and self-monitored blood pressure

AIMS

To determine the relationship between blood pressure (BP) measurement in the clinic and self-monitored blood pressure (SMBP); and to evaluate the accuracy of self-reported data in patients with Type 2 diabetes treated intensively for hypertension.

METHODS

Seventy subjects had baseline and 1-week follow-up clinic BP measured using an Omron 907 automated device. During a contemporaneous 14-day period these subjects measured their BP at least four times each day using an Omron IC semiautomatic portable monitor which, unknown to them, contained an onboard memory capable of storing BP with corresponding time and date.

RESULTS

There was no significant difference between mean clinic and mean self-monitored BP. Correlations between clinic BP and SMBP were r=0.61 (P<0.0001) for systolic BP and r=0.69 (P<0.0001) for diastolic BP. Clinic BP classified 56 subjects as uncontrolled hypertension (BP > or = 130/80 mmHg, adjusted for diabetes) and 14 subjects as controlled hypertension. Using World Health Organization-International Society of Hypertension criteria for SMBP (> or = 125/75 mmHg), 55 cases of clinic classified uncontrolled hypertension were confirmed, resulting in 98% sensitivity. Clinic and SMBP agreed in one case of controlled hypertension, resulting in 7% specificity. For all subjects, the median percent of values exceeding SMBP criteria for controlled hypertension was systolic 92% and diastolic 70%. Self-reporting precision averaged 89+/-10% (range 45-100%); under-reporting was 25+/-16% (ranging from 0 to 56%) and over-reporting was 12+/-15% (ranging from 0 to 46%). The overall logbook mean was not significantly different from the downloaded data from the Omron IC(R) monitors.

CONCLUSIONS

SMBP was able to identify 13 patients with uncontrolled hypertension who, by clinic BP measurement, had been classified as controlled.

Genes involved in breast cancer metastasis to bone

Metastasis to bone occurs frequently in advanced breast cancer and is accompanied by debilitating skeletal complications. Current treatments are palliative and new therapies that specifically prevent the spread of breast cancer to bone are urgently required. While our understanding of interactions between breast cancer cells and bone cells has greatly improved, we still know little about the molecular determinants that regulate specific homing of breast cancer cells to the bone. In this review, we focus on genes that have been implicated in migration and adhesion of breast cancer cells to bone, as well as genes that promote tumor cell proliferation in the bone microenvironment. In addition, the review discusses new technologies, including better animal models, that will further assist with the identification of the molecular determinants of bone metastasis and will guide the development of new therapies.

Use of hard palate grafts for treatment of postsurgical lower eyelid retraction: a technical overview

Lower eyelid retraction occasionally occurs following the repair of fractures involving the orbital rims, orbital floor, or complex zygomatic maxillary complex fractures. The surgical repair of these scarred eyelids has been historically difficult. The authors have utilized the principle of releasing the scar tissue and attempting to reposition the eyelid in its normal anatomic position by employing a hard palate mucosal graft spacer to correct the eyelid malposition. In this article, the authors discuss the excellent success they have experienced utilizing hard palate autologous grafts as spacers performing revision of scarred contracted lower eyelid retractors and tightening of the lateral canthal tendon complex. Adherence to the principles delineated in the article can yield excellent functional and cosmetic results.

Predicting level of mental health care among children served in a delivery system in a rural state

The purpose of this study was to establish benchmark data to assist in identifying factors associated with mental health service needs and level of care for children living in a rural state. Clinical and psycho-social needs and strengths were assessed using retrospective chart review for all children and adolescents (n=150) with symptoms or a diagnosis of reactive attachment disorder who presented to a comprehensive treatment facility between January 1997 and December 1999. Logistic regression was used to predict factors associated with inpatient admission (n=15) vs. community-based care (n=135). Significant individual contributors to the prediction of inpatient care were more limited clinical/psycho-social strengths, history of inpatient use and history of sexual abuse. Although 80 percent of children admitted to inpatient care had a history of hospitalization, two-thirds had no history of receiving community-based services and presented to current treatment with a two-year or longer history of symptoms. Approximately two-thirds of children admitted to inpatient care had a history of sexual abuse; however, one-third of these children had no history of mental health service use and presented to current treatment with a two-year or longer history of symptoms. Findings raise concerns about current efforts in public health education, community awareness and health prevention and early intervention programs for children with mental/behavioral health challenges and children and families at risk for abuse and/or neglect living in rural areas.

MMP-9 secretion and MMP-2 activation distinguish invasive and metastatic sublines of a mouse mammary carcinoma system showing epithelial-mesenchymal transition traits

We have investigated the gelatinase profiles and invasiveness of clonal tumour sublines derived from a spontaneously arising mammary tumour in a Balb/cfC3H mouse. The 67NR. 66c14 and 4T1.2 sublines have low, intermediate and high metastatic potential respectively. In Boyden chamber studies, Matrigel invasion was seen to be progressively higher in the more metastatic lines 4T1.2>66c14>67NR, consistent with MMP-2 activation potential, MMP-9 secretion, and migration over either type I or IV collagen, which were low in both 67NR and 66c14 cells compared to 4T1.2 cells. These attributes are consistent with those seen in human breast cancer cell lines which appear to have undergone an epithelial-mesenchymal transition (EMT) as indicated by vimentin expression. We were, however, surprised to find vimentin expression, MT1-MMP expression and stellate Matrigel outgrowth in the non-invasive, non-metastatic 67NR cells. indicating that they had undergone an EMT despite not being invasive. We conclude that the EMT is manifested to differing degrees in these three clonal cell lines, and that the 67NR cells have either undergone a partial EMT or have since lost certain important attributes of the EMT-derived phenotype. This model should prove useful in further characterizing the regulation of MTI-MMP mediated MMP-2 activation and delineating the EMT in breast cancer progression.

Orbicularis myectomy with levator advancement in Schwartz-Jampel syndrome

PURPOSE

Schwartz-Jampel syndrome is a disorder of continuous myotonia causing blepharospasm, acquired ptosis, and blepharophimosis. We report the management of the associated eyelid anomalies with orbicularis oculi myectomy, levator aponeurosis resection, and lateral canthopexy.

METHODS

Interventional case reports. Two patients with Schwartz-Jampel syndrome presented with blepharospasm, acquired ptosis, and blepharophimosis. Orbicularis myectomy, levator aponeurosis resection, and lateral canthopexy were performed to relieve the blepharospasm and to correct the ptosis and blepharophimosis.

RESULTS

Significant functional and cosmetic improvements were achieved by increasing the palpebral fissure height and length while greatly decreasing the blepharospasm of the patients. No recurrence of the blepharospasm or eyelid anomalies has been noted after 1 and 15 years of follow-up, respectively.

CONCLUSION

The blepharospasm and eyelid alterations caused by Schwartz-Jampel syndrome should be treated to provide functional and cosmetic improvements. Our technique of myectomy, levator resection, and lateral canthopexy provides an excellent, long-lasting result.

A new groove director for simplified nasolacrimal intubation

Silicone intubation is commonly performed to maintain patency of the lacrimal drainage system. We describe a new lacrimal groove director, designed to simplify retrieval of the metal Crawford probe with minimal trauma to the nasal mucosa. This instrument can also be used to infracture or medialize the inferior turbinate in both pediatric and adult populations during nasolacrimal duct intubation or external or endoscopic dacryocystorhinostomy.

Solitary fibrous tumor of the orbit in a child

PURPOSE

Solitary fibrous tumor is a rare spindle-cell tumor that usually is seen in the pleura. The orbit is one of the most common extrapleural sites. It is frequently misdiagnosed as hemangiopericytoma and is seen in older patients. We present the youngest case of this tumor, which was apparent in family photographs by age 10 and removed at age 15. The first reported echography findings are presented.

METHODS

Case report and literature review.

RESULTS

Solitary fibrous tumor was diagnosed by microscopy and immunohistochemical study that showed cells reactive with vimentin and CD34.

CONCLUSIONS

Solitary fibrous tumor of the orbit has been diagnosed with increasing frequency in recent years as the result of improved methods of pathologic examination. It is important to be aware of this tumor and recognize that it must be included in the differential diagnosis of highly vascular spindle-cell tumors even in young children.

Development of electrophysiological and morphological diversity in autonomic neurons

The generation of neuronal diversity requires the coordinated development of differential patterns of ion channel expression along with characteristic differences in dendritic geometry, but the relations between these phenotypic features are not well known. We have used a combination of intracellular recordings, morphological analysis of dye-filled neurons, and stereological analysis of immunohistochemically labeled sections to investigate the development of characteristic electrical and morphological properties of functionally distinct populations of sympathetic neurons that project from the celiac ganglion to the splanchnic vasculature or the gastrointestinal tract of guinea pigs. At early fetal stages, neurons were significantly more depolarized at rest compared with neurons at later stages, and they generally fired only a single action potential. By mid fetal stages, rapidly and slowly adapting neurons could be distinguished with a topographic distribution matching that found in adult ganglia. Most rapidly adapting neurons (phasic neurons) at this age had a long afterhyperpolarization (LAH) characteristic of mature vasomotor neurons and were preferentially located in the lateral poles of the ganglion, where most neurons contained neuropeptide Y. Most early and mid fetal neurons showed a weak M current, which was later expressed only by rapidly-adapting and LAH neurons. Two different A currents were present in a subset of early fetal neurons and may indicate neurons destined to develop a slowly adapting phenotype (tonic neurons). The size of neuronal cell bodies increased at a similar rate throughout development regardless of their electrical or neurochemical phenotype or their topographical location. In contrast, the rate of dendritic growth of neurons in medial regions of the ganglion was significantly higher than that of neurons in lateral regions. The apparent cell capacitance was highly correlated with the surface area of the soma but not the dendritic tree of the developing neurons. These results demonstrate that the well-defined functional populations of neurons in the celiac ganglion develop their characteristic electrophysiological and morphological properties during early fetal stages of development. This is after the neuronal populations can be recognized by their neurochemical and topographical characteristics but long before the neurons have finished growing. Our data provide strong circumstantial evidence that the development of the full phenotype of different functional classes of autonomic final motor neurons is a multi-step process likely to involve a regulated sequence of trophic interactions.

Nodular cutaneous amyloid tumors of the eyelids in the absence of systemic amyloidosis

A patient was referred with recurrent bilateral, slow-growing, painless, nodular tumors of the upper eyelid margins. The tumors were excised and the base of each lesion was ablated with the CO2 laser. Histological examination of the excised tissue revealed amyloid. Despite the fact that cutaneous, amyloid lesions of the eyelid have been previously described as essentially pathognomonic for systemic amyloid disease, no evidence of systemic amyloidosis was found in this patient. We believe that this represents only the second reported case of bilateral cutaneous amyloid of the eyelids without systemic involvement. We agree with previous authors that this lesion be added to the list of painless slow-growing bilateral eyelid tumors.

Neuropeptide Y immunoreactivity in cutaneous sympathetic and sensory neurons during development of the guinea pig

Different levels of the cutaneous vasculature are innervated selectively by subpopulations of sympathetic neurons distinguished by the presence or absence of immunoreactivity (-IR) for neuropeptide Y (NPY). This study used multiple-labelling immunohistochemistry to examine the appearance of NPY-IR in neurons innervating cutaneous vessels in the ear pinna of embryonic, fetal, and neonatal guinea pigs. NPY-immunoreactive axons were detected in the ear bud at embryonic day 25. However, these axons lacked IR for tyrosine hydroxylase (TH) and often ran in bundles with substance P (SP)-immunoreactive axons close to the epidermis. Many neuronal somata in the cervical dorsal root ganglia (DRG) at late embryonic stages contained NPY-IR with or without SP-IR, but no NPY-IR was detected in DRG or subepidermal axons by late fetal stages. IR for calcitonin gene-related peptide increased in DRG neurons from midfetal to late fetal stages, after the decrease in NPY-IR. Populations of TH-IR neurons with or without NPY-IR were present in the superior cervical ganglion (SCG) from midembryonic stages. TH-immunoreactive axons were not detected in the ear pinna until midfetal stages, when axons with TH-IR and NPY-IR innervated proximal arteries and TH-immunoreactive axons without NPY-IR innervated distal vessels. Vasoactive intestinal peptide-IR was detected transiently in most fetal SCG neurons with TH-IR and NPY-IR but was not detected in cutaneous axons. These results demonstrate that selective expression of NPY by subpopulations of sympathetic neurons occurs prior to innervation of their targets. This suggests that target contact is not required to establish appropriate patterns of expression of peptide neurotransmitters by cutaneous sympathetic neurons.

Management of eyelid anomalies associated with Blepharo-cheilo-dontic syndrome

PURPOSE

To describe the previously unreported management of the eyelid anomalies associated with blepharocheilo-dontic syndrome. Blepharo-cheilo-dontic syndrome is a syndrome of congenital cleft lip/palate, oligodontia, euryblepharon, eyelid ectropion, and lagophthalmos.

METHODS

Case report. A 3-month-old male presented with bilateral upper and lower eyelid ectropion with eyelid retraction, marked euryblepharon, severe lagophthalmos, and a right side cleft lip/palate. Lateral tarsal strips, lower eyelid retractor disinsertion, myocutaneous advancement of the cheek and eyelids, and lateral tarsorrhaphy were performed.

RESULTS

Correction of the ectropion, eyelid retraction, euryblepharon, and marked improvement in his lagophthalmos were achieved postoperatively. No recurrence of the ectropion or euryblepharon has been noted after 6 months of follow-up.

CONCLUSION

Appropriate reconstructive surgery of the eyelids reduces the morbidity associated with the eyelid anomalies and provides an excellent cosmetic result for patients with blepharo-cheilo-dontic syndrome.

The prediction of mental health service use in residential care

The purpose of this study was to characterize the clinical and psychosocial factors of residents living in psychiatric nursing homes, assess residents' levels of mental health service utilization, and examine the factors that predict the utilization of mental health services. Data were collected from 200 randomly selected residents with schizophrenia living in four intermediate care facilities. Fewer than 60% of residents received mental health services beyond medication and nearly one-half of the residents were readmitted to the hospital in the course of a year. Family contact and involvement in activities were associated with mental health service utilization. Hospital readmission was predicted, not by substance use, but rather by not using substances. There is a growing need among service providers to better identify relevant factors that are important in treatment planning and service delivery. Attention to these issues may impact treatment provision and outcomes for persons with schizophrenia and their families.

Role of priming stresses and Hsp70 in protection from ischemia-reperfusion injury in cardiac and skeletal muscle

Ischemia-reperfusion injury limits the survival of muscle involved in tissue trauma or transfers during microsurgical reconstruction. Priming stresses such as ischemic preconditioning or mild hyperthermia have frequently been associated with improved survival of ischemic-reperfused cardiac muscle, such protection coinciding with induction of the stress-related heat shock protein 70 (Hsp70). Little is known about the response of skeletal muscle to priming stresses. This review summarizes the current knowledge on the use of priming stresses as protective strategies against the consequences of ischemia-reperfusion in cardiac and skeletal muscle and the potential role of Hsp70.

Nitric oxide synthase II gene disruption: implications for tumor growth and vascular endothelial growth factor production

The expression of a primary initiator of tumor angiogenic responses, vascular endothelial growth factor (VEGF), may be induced by nitric oxide (NO) in carcinoma cells. However, the net impact of NO on carcinogenesis remains unclear, because manipulation of NO levels has been shown to either stimulate or inhibit tumor growth. We have investigated the relationship between inducible NO synthase (NOS II), VEGF expression, and growth of B16-F1 melanoma over 14 days in wild-type (NOS II+/+) mice and in those in which the gene for NOS II has been deleted (NOS II-/-). B16-F1 tumor growth was measured as wet weight of the excised tissue. Tumor NOS II and VEGF localization were evaluated by immunohistochemistry, and VEGF mRNA levels were measured by Northern blot analysis. In NOS II+/+ mice inoculated with B16-F1 melanoma cells, macroscopic tumors were always observed at 14 days; however, 22% of NOS II-/- mice had no detectable tumor mass. Immunoreactive NOS II was detected in tumor cells of tumors grown in NOS II+/+ but not in NOS II-/- mice. Although immunoreactive VEGF was detected in the granules of tumor-associated mast cells from both NOS II+/+ and NOS II-/- mice, VEGF mRNA expression in tumors from NOS II-/- was half that in NOS II+/+ mice. Neither NOS II inhibition, exogenous NO, nor peroxynitrite influenced DNA synthesis in culture B16-F1 melanoma cells. The NO donor did not alter either VEGF mRNA levels or degranulation in cultures of the mast cell line RBL-2H3, but peroxynitrite increased both VEGF mRNA expression and degranulation. We conclude that host expression of NOS II contributes to induction of NOS II in the tumor and to melanoma growth in vivo, possibly by regulating the amount and availability of VEGF.

Systemic corticosteroid use in orbital lymphangioma

PURPOSE

To describe the clinical results of systemic corticosteroid use in a series of patients with orbital lymphangioma.

METHODS

Four patients (two adults and two children) were treated with corticosteroids using intravenous, oral, or both routes for 2 days to a month. Corticosteroids were used with and without other therapies for symptomatic exacerbations.

RESULTS

The adults showed more improvement with pain than with swelling, whereas the children had improvement with both the signs and symptoms. There were no complications in any patient.

CONCLUSIONS

Systemic corticosteroids are a useful therapeutic option for patients with orbital lymphangioma and can be used as an adjuvant treatment to surgery and other modalities. Resolution of symptoms with corticosteroids was expedited compared with the natural history of the disease in the patients studied.

A family study of outpatients with borderline personality disorder and no history of mood disorder

While several studies have examined psychiatric disorders in the relatives of individuals with borderline personality disorder, many of these studies have not employed a family study methodology and suffer from other methodological shortcomings. Thus, the conclusions from family data addressing the validity of borderline personality disorder, its relation to other conditions, and its distinction from mood disorders, continue to be debated. The present investigation employed a family study design with direct interviews with relatives, structured diagnostic interviews with both probands and relatives, and blind assessment of relatives. Rates of psychiatric disorders were examined in 563 relatives of outpatients with mood disorders (n = 119), 54 relatives of outpatients with borderline personality disorder and no history of mood disorder (n = 11), and 229 relatives of never psychiatrically ill controls (n = 45). Results indicate increased rates of mood disorders and personality disorders in the relatives of borderline probands compared with never psychiatrically ill controls. Familial aggregation of psychiatric disorders was generally similar for borderline personality and the mood disorder comparison group. The results suggest there may be common etiological factors between borderline personality disorder and mood disorders.

Needs-based planning for persons with serious mental illness residing in intermediate care facilities

This study examined the association of clinical status to mental health service use among persons with mental illness living in residential care. Two hundred residents with a chart diagnosis of schizophrenia were randomly selected from four intermediate care facilities. The severity of psychiatric illness-community mental health (SPI-CMH) scale was used to assess clinical status and symptom severity according to three dimensions: symptoms and functioning, risk behaviors, and complication to illness. Lower levels of severity of psychiatric illness were associated with participation in workshops, family contact, and admitting to mental health problems. Results suggest that residents of the intermediate care facilities have clinical needs consistent with habilitation and rehabilitation services. While residents infrequently engage in high-risk behavior such as suicide and violence, they have considerable living skills and vocational needs. Future research should consider the relationship over time of mental health service utilization, severity of psychiatric illness, and psychosocial factors.

Neurochemical differentiation of functionally distinct populations of autonomic neurons

The coeliac ganglion of guinea pigs displays a unique topographical arrangement of neurochemically and functionally distinct populations of sympathetic neurons. The authors used multiple-labeling immunohistochemistry to investigate the neurochemical differentiation of these neurons during embryonic and fetal development. Sympathoadrenal precursors, located on either side of the abdominal aorta, were intensely immunoreactive for tyrosine hydroxylase (TH-IR), neurofilament, and the human natural killer 1 antibody at midembryonic stages (Carnegie stages 16-19). During late embryonic stages (stages 20-23), a single bilobed ganglion had formed. At this time, neuropeptide Y immunoreactivity (NPY-IR) was widely expressed in sympathetic neurons (with moderate TH-IR) and chromaffin cells (with intense TH-IR). The onset of somatostatin (Som-IR) expression followed that of NPY-IR and was restricted to sympathetic neurons. However, at late embryonic stages, most TH-IR neurons with Som-IR also expressed NPY-IR (a combination of peptides not found in the mature coeliac ganglion). Between late embryonic stages and the end of the early fetal period, there was a significant increase in the proportion of neurons in lateral regions that had both NPY-IR and TH-IR. At the same time, there was an increase in the proportion of neurons in medial regions that had both Som-IR and TH-IR. Neurons expressing both Som-IR and TH-IR were rarely observed in lateral regions of the coeliac ganglion. Thus, a clear topography within the coeliac ganglion is established during late embryonic and early fetal stages of development and reflects that found in the mature animal by the end of the early fetal period.

Prior heat stress improves survival of ischemic-reperfused skeletal muscle in vivo

The ability of heat stress to improve the survival of ischemic-reperfused skeletal muscle in vivo was investigated. Ischemia-reperfusion was applied using the rat hindlimb tourniquet model. The viability of ischemic-reperfused muscle (11 +/- 1%) was increased by prior mild heat stress (86 +/- 2%). To investigate whether heat shock protein 70 (Hsp 70) expression in the muscle of the heated limb was responsible for this protection, the survival of Hsp 70-expressing transduced myoblasts and myocytes was measured after exposure to mediators of ischemia-reperfusion injury. Survival was improved in Hsp 70-positive myoblasts but not in myocytes, suggesting that the mechanism of protection conferred by heat stress in vivo cannot be explained by the expression of Hsp 70 in myocytes and may involve a more complex mechanism. In conclusion, prior heat stress is effective in protecting mature skeletal muscle in vivo against necrosis after ischemia-reperfusion and has potential for use in microsurgical procedures requiring tourniquet applications.

Burn scar malignancies of the eyelids

PURPOSE

To study the clinicopathologic characteristics and treatment of eyelid carcinomas developing in thermal burn scars.

METHODS

A review of eight cases of eyelid burn scar malignancies: two from our own experience and six from published reports.

RESULTS

Reported cases of burn scar malignancy of the eyelid are short-latency basal cell carcinomas. All carcinomas arose from small superficial burns. These potentially aggressive tumors respond well to local excision.

CONCLUSION

As with other areas of the body, eyelid burn scars may undergo neoplastic degeneration. These carcinomas are predominately short latency basal cell carcinomas, rather than long-latency squamous cell carcinomas that are more common elsewhere in the body, including the head and neck region. Clinicians should be diligent in the long-term surveillance of all eyelid burns.

Quality of life of persons with severe mental illness living in an intermediate care facility

This study examined resident characteristics, clinical factors, and mental health service utilization associated with quality of life (QOL) for residents living in an Intermediate Care Facility (ICF). This study also utilized published literature to compare the QOL of ICF residents to persons with psychiatric disorders living in other residential settings. Chart review and interviews were used to study 100 randomly selected residents living in an ICF with a chart diagnosis of schizophrenia. Multivariate analyses suggest that higher levels of QOL are associated with reports that psychological problems did not interfere with work and activities and with lower levels of being a danger to others. Also, a comparison of the QOL scores reported by ICF residents to other published mentally ill populations suggests that residents of the ICF report somewhat higher QOL scores than state hospital patients, but lower scores as compared to other community samples. Data provide insight into the types of problems faced by residents of an intermediate care facility. These findings have implications for understanding the importance of mental health service utilization on QOL.

Heat-induced alterations in the localization of HSP72 and HSP73 as measured by indirect immunohistochemistry and immunogold electron microscopy

The heat shock proteins are a family of stress-inducible proteins that act as molecular chaperones for nascent proteins and assist in protection and repair of proteins whose conformation is altered by stress. HSP72 and HSP73 are two major cytosolic/nuclear stress proteins of mammalian cells, with extensive sequence homology. HSP73 is constitutively expressed, whereas HSP72 is highly stress-inducible. However, it is unclear why two isoforms are expressed and whether these two proteins have different functions in the cell. To assist in the delineation of function, we have completed a detailed study of the localization of HSP72 and HSP73 in the cell before and after heat stress, using two different methods of detection. By indirect immunohistochemistry, the localization of these two proteins is similar, cytoplasmic and nuclear in nonstressed cells with a translocation to nucleoli immediately after heat. By the more sensitive immunogold electron microscopy technique, differences in localization were noted. In nonstressed cells, HSP72 was primarily nuclear, localized in heterochromatic regions and in nucleoli. HSP73 was distributed throughout the cell, with most cytoplasmic label associated with mitochondria. Mitotic chromosomes were also heavily labeled. After stress, HSP72 concentrated in nuclei and nucleoli and HSP73 localized to nuclei, nucleoli, and cytoplasm, with increased label over mitochondria. These differences in localization suggest that the HSP72 and HSP73 may associate with different proteins or complexes and hence have different but overlapping functions in the cell.

A novel mechanism for benign essential blepharospasm

PURPOSE

The purpose of this study is to test the hypothesis that the photophobia of benign essential blepharospasm (BEB) is caused by sympathetically maintained pain.

METHODS

Nineteen patients with photophobia and BEB were enrolled in an unblinded prospective treatment trial. The intervention was blockade of the superior sympathetic ganglion with local anesthetic. Outcome measures included the patient's subjective report of ocular surface dryness, foreign body sensation, and eyelid spasm. We also obtained video recordings of eyelid movements.

RESULTS

Of the 19 patients, 13 reported subjective improvement in BEB symptoms after cervical sympathetic blockade (CSB). Thirteen of 19 patients also had objective evidence of decreased light-induced eyelid spasm after CSB. Ocular surface disease was present in 18 of 19 patients.

CONCLUSION

These data support the hypothesis that in many patients with BEB there is a sympathetically maintained pain syndrome associated with external ocular disease. We speculate on a neurologic circuit that may explain these findings.