Spinal Cord Sarcoidosis Occurring at Sites of Spondylotic Stenosis, Mimicking Spondylotic Myelopathy: A Case Series and Review of the Literature

Sarcoidosis is a multisystem granulomatous disease, with intramedullary spinal cord involvement seen in <1% of cases. This case series illustrates the clinical presentations and imaging findings of 5 patients with intramedullary spinal neurosarcoidosis occurring at sites of spondylotic spinal canal stenosis, which can be indistinguishable from spondylotic myelopathy with cord enhancement. Both entities are most common in middle-aged men and present with weeks to months of motor and sensory symptoms. On imaging, both can have focal spinal cord enhancement and longitudinally extensive signal abnormality centered at or just below the level of spinal canal stenosis. On the basis of our experience, we suggest that in patients with cord enhancement centered at or just below a site of spinal canal stenosis, consideration should be given to chest imaging and lymph node biopsy when applicable, to assess for the possibility of underlying sarcoidosis before surgical decompression.

Quantitative susceptibility mapping using plug-and-play alternating direction method of multipliers

Quantitative susceptibility mapping employs regularization to reduce artifacts, yet many recent denoisers are unavailable for reconstruction. We developed a plug-and-play approach to QSM reconstruction (PnP QSM) and show its flexibility using several patch-based denoisers. We developed PnP QSM using alternating direction method of multiplier framework and applied collaborative filtering denoisers. We apply the technique to the 2016 QSM Challenge and in 10 glioblastoma multiforme datasets. We compared its performance with four published QSM techniques and a multi-orientation QSM method. We analyzed magnetic susceptibility accuracy using brain region-of-interest measurements, and image quality using global error metrics. Reconstructions on glioblastoma data were analyzed using ranked and semiquantitative image grading by three neuroradiologist observers to assess image quality (IQ) and sharpness (IS). PnP-BM4D QSM showed good correlation (β = 0.84, R² = 0.98, p < 0.05) with COSMOS and no significant bias (bias = 0.007 ± 0.012). PnP-BM4D QSM achieved excellent quality when assessed using structural similarity index metric (SSIM = 0.860), high frequency error norm (HFEN = 58.5), cross correlation (CC = 0.804), and mutual information (MI = 0.475) and also maintained good conspicuity of fine features. In glioblastoma datasets, PnP-BM4D QSM showed higher performance (IQ_Grade = 2.4 ± 0.4, IS_Grade = 2.7 ± 0.3, IQ_Rank = 3.7 ± 0.3, IS_Rank = 3.9 ± 0.3) compared to MEDI (IQ_Grade = 2.1 ± 0.5, IS_Grade = 2.1 ± 0.6, IQ_Rank = 2.4 ± 0.6, IS_Rank = 2.9 ± 0.2) and FANSI-TGV (IQ_Grade = 2.2 ± 0.6, IS_Grade = 2.1 ± 0.6, IQ_Rank = 2.7 ± 0.3, IS_Rank = 2.2 ± 0.2). We illustrated the modularity of PnP QSM by interchanging two additional patch-based denoisers. PnP QSM reconstruction was feasible, and its flexibility was shown using several patch-based denoisers. This technique may allow rapid prototyping and validation of new denoisers for QSM reconstruction for an array of useful clinical applications.

The Updated Neuroradiology Milestones: Synapsing from 1.0 to 2.0

The Accreditation Council for Graduate Medical Education is currently in the process of specialty-by-specialty revision of the Milestones. As a result, the Neuroradiology Milestones 2.0 Workgroup was created to refine a system of competency-based assessments for fellow educational growth and development. Strengths of the new Milestones include decreased complexity and uniformity within a subcompetency as it relates to a specific educational development trajectory. The Supplemental Guide serves to decrease clutter in the Milestones 2.0 document and provides a more practical resource for guidance. This article serves to review the history of the Neuroradiology Milestones, followed by a summary of the timeline of events and discussions of the workgroup for development of Neuroradiology Milestones 2.0 and a synopsis of major changes. The plan is for the updated Neuroradiology Milestones to take effect in 2021 or 2022 based on public commentary.

Tentorial Dural Arteriovenous Fistulas as a Cause of Thalamic Edema: 2 Cases of an Important Differential Diagnosis to Consider

The differential diagnosis for bilateral thalamic edema is extensive and includes vascular, neoplastic, metabolic, and infectious causes. Of the vascular causes of thalamic edema, arterial and venous infarctions are well-documented, but dural arteriovenous fistulas (dAVFs) are a relatively uncommon and widely underrecognized cause of thalamic edema. Dural AVFs are notoriously difficult to diagnose clinically, especially in the absence of hemorrhage, and cross-sectional imaging findings can be subtle. This can result in a delayed diagnosis, and occasionally, an invasive biopsy for further clarification of a purely vascular disease. In this review, we detail our experience with the imaging diagnosis of dAVF as a cause of thalamic edema and present a short differential of other vascular causes.

Data-Driven Quantitative Susceptibility Mapping Using Loss Adaptive Dipole Inversion (LADI)

BACKGROUND

Quantitative susceptibility mapping (QSM) uses prior information to reconstruct maps, but prior information may not show pathology and introduce inconsistencies with susceptibility maps, degrade image quality and inadvertently smoothing image features.

PURPOSE

To develop a local field data-driven QSM reconstruction that does not depend on spatial edge prior information.

STUDY TYPE

Retrospective.

SUBJECTS, ANIMAL MODELS

A dataset from 2016 ISMRM QSM Challenge, 11 patients with glioblastoma, a patient with microbleeds and porcine heart.

SEQUENCE/FIELD STRENGTH

3D gradient echo sequence on 3T and 7T scanners.

ASSESSMENT

Accuracy was compared to Calculation of Susceptibility through Multiple Orientation Sampling (COSMOS), and several published techniques using region of interest (ROI) measurements, root-mean-squared error (RMSE), structural similarity index metric (SSIM), and high-frequency error norm (HFEN). Numerical ranking and semiquantitative image grading was performed by three expert observers to assess overall image quality (IQ) and image sharpness (IS).

STATISTICAL TESTS

Bland-Altman, Friedman test, and Conover multiple comparisons.

RESULTS

Loss adaptive dipole inversion (LADI) (β = 0.82, R² = 0.96), morphology-enabled dipole inversion (MEDI) (β = 0.91, R² = 0.97), and fast nonlinear susceptibility inversion (FANSI) (β = 0.81, R² = 0.98) had excellent correlation with COSMOS and no bias was detected (bias = 0.006 ± 0.014, P < 0.05). In glioblastoma patients, LADI showed consistently better performance (IQ_Grade = 2.6 ± 0.4, IS_Grade = 2.6 ± 0.3, IQ_Rank = 3.5 ± 0.4, IS_Rank = 3.9 ± 0.2) compared with MEDI (IQ_Grade = 2.1 ± 0.3, IS_Grade = 2 ± 0.5, IQ_Rank = 2.4 ± 0.5, IS_Rank = 2.8 ± 0.2) and FANSI (IQ_Grade = 2.2 ± 0.5, IS_Grade = 2 ± 0.4, IQ_Rank = 2.8 ± 0.3, IS_Rank = 2.1 ± 0.2). Dark artifact visible near the infarcted region in MEDI (Inf_MEDI = -0.27 ± 0.06 ppm) was better mitigated by FANSI (Inf_FANSI-TGV = -0.17 ± 0.05 ppm) and LADI (Inf_LADI = -0.18 ± 0.05 ppm).

CONCLUSION

For neuroimaging applications, LADI preserved image sharpness and fine features in glioblastoma and microbleed patients. LADI performed better at mitigating artifacts in cardiac QSM.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY STAGE: 1 J. Magn. Reson. Imaging 2020;52:823-835.

Biomechanical Model of Corneal Transplantation

PURPOSE

Refractive consequences of corneal transplants are analyzed using corneal biomechanical models assuming homogeneous and inhomogeneous stiffness distributions across the cornea. Additionally, refractive effects of grafts combined with volume removal procedures are also evaluated to develop methods to reduce postoperative refractive management of patients.

METHODS

Refinements of a two-dimensional finite element model are applied to simulate the biomechanical and refractive effects of different corneal transplant procedures: anterior lamellar keratoplasty, posterior lamellar keratoplasty, and penetrating keratoplasty. The models are based on a nonlinearly elastic, isotropic formulation. Predictions are compared with published clinical data.

RESULTS

The model simulating the penetrating keratoplasty procedure predicts more change in the postoperative corneal curvature than models simulating anterior lamellar keratoplasty or posterior lamellar keratoplasty procedures. When a lenticle-shaped tissue with a central thickness of 50 microns and a diameter of 4 mm is removed from the anterior corneal surface along with the anterior lamellar keratoplasty or posterior lamellar keratoplasty, the models predict a refractive correction of -8.6 and -8.9 diopters, respectively.

CONCLUSIONS

Simulations indicate that a posterior lamellar keratoplasty procedure is preferable for obtaining a better corneal curvature profile, eliminating the need for specific secondary treatments.

A finite element model for ultrafast laser-lamellar keratoplasty

A biomechanical model of the human cornea is employed in a finite element formulation for simulating the effects of Ultrafast Laser-Lamellar Keratoplasty. Several computer simulations were conducted to study curvature changes of the central corneal zone under various physiological and surgical factors. These factors included the combined effect of corneal flap and residual stromal bed thickness on corneal curvature; the effect of the shape of the lenticle on the surgical procedure outcomes and the effect of flap thickness on stress distribution in the cornea. The results were validated by comparing computed refractive power changes with clinical results. The effect of flap thickness on the amount of central flattening indicates that for flap thickness values 28% over the corneal thickness, central corneal flattening decreases. Moreover, the change in corneal curvature induced by subtraction of a plano-convex lenticle under a uniform flap, naturally imply a smaller change in the structure of the anterior layers of the cornea, but a bigger deformation in the structure of the posterior layers that are left behind the resection of the lenticle. In addition, the model also verified that the corneal curvature increased peripherally with simultaneous thinning centrally after subtraction of corneal tissue. This result shows that not only the treated zone is affected by the surgery, indicating the important role of the biomechanical response of the corneal tissue to refractive surgery, which is unaccounted for in current ablation algorithms. The results illustrate the potentialities of finite element modeling as an aid to the surgeon in evaluating variables.

Finite element analysis applied to cornea reshaping

A 2-D finite element model of the cornea is developed to simulate corneal reshaping and the resulting deformation induced by refractive surgery. In the numerical simulations, linear and nonlinear elastic models are applied when stiffness inhomogeneities varying with depth are considered. Multiple simulations are created that employ different geometric configurations for the removal of the corneal tissue. Side-by-side comparisons of the different constitutive laws are also performed. To facilitate the comparison, the material property constants are identified from the same experimental data, which are obtained from mechanical tests on corneal strips and membrane inflation experiments. We then validate the resulting models by comparing computed refractive power changes with clinical results. Tissue deformations created by simulated corneal tissue removal using finite elements are consistent with clinically observed postsurgical results. The model developed provides a much more predictable refractive outcome when the stiffness inhomogeneities of the cornea and nonlinearities of the deformations are included in the simulations. Finite element analysis is a useful tool for modeling surgical effects on the cornea and developing a better understanding of the biomechanics of the cornea. The creation of patient-specific simulations would allow surgical outcomes to be predicted based on individualized finite element models.

An analytically solvable model for biomechanical response of the cornea to refractive surgery

An analttically solvable model that considers the elasticity of the cornea is developed for use in the current and novel corneal refractive surgery procedures. The model assumes that the cornea is a thin spheroid shell with an elastic response to intraocular pressure. The value of the Young's modulus of the post-operative cornea and its dependence on the geometric parameters of the ablation zone are estimated employing "best-fit" approach to nomograms currently used in corneal refractive surgery. These elasticity parameters are applied for quantitative modeling of different types of refractive surgery for myopia.

Efficacy of induction and difficulty level in durability of post-hypnotic suggestions

We examined whether participants instructed to reenter a hypnotic state as part of the post-hypnotic suggestion (PHS) show less decay in responding over an 8-week period than participants who do not receive such instructions. We also attempted to replicate Trussell, Kurtz, and Strube's (1996) finding on impact of difficulty level of suggestion on response curve. Fifty-nine highly susceptible participants were selected by the Stanford Hypnotic Susceptibility Scale: Form C (SHSS:C) and were assigned to one of four groups (two levels of Difficulty [easy-hard] x two levels of Condition [hypnotic PHS, non-hypnotic PHS]). Participants were tested for PHS at 1, 3, 6, and 8 weeks. A 2 x 2 x 4 (Difficulty x Condition x Time) factorial ANOVA was conducted, with Time as a repeated-measure. The outcome variable at each time was either pass or fail for relevant suggestion. None of the effects containing Condition as a term were significant indicating there is no advantage to using Berrigan, Kurtz, Stabile, and Strube's (1991) atypical induction technique to influence the durability of PHS. We found a significant Time effect but failed to replicate Trussell et al.'s findings for Difficulty level. The differing results found in these three recent studies (Berrigan et al., Trussell et al., and the current study) suggest the effects for durability of PHS may be quite fragile in spite of rigorous experimental controls used in all three studies.

Body attitude, gender, and self-concept: a 30-year perspective

Two comparable samples of college men and women from 1966 and 1996 were compared using the Kurtz Body Attitude Scale (BAS; R. M. Kurtz, 1966). As predicted, women in 1996 reported a significantly more negative body attitude than women in 1966 did. No significant differences in the 2 samples of men were found. With the 1996 sample, the relationship between body attitude and self-esteem was also examined using Marsh's Self-Description Questionnaire-III (SDQ-III; H. W. Marsh & R. O'Neill, 1984). There was a significant relationship between body attitude and general self-esteem, and there were also complex gender differences in the relationships of various SDQ-III facets to body attitudes.

An in vivo model of femtosecond laser intrastromal refractive surgery

BACKGROUND AND OBJECTIVE

To develop an animal model for evaluation of femtosecond laser intrastromal refractive surgery.

METHODS

Intrastromal photodisruption was performed in New Zealand Albino rabbits using a femtosecond laser system. This surgical pattern consisted of a 100 microm-tick pyramid of laser pulses starting 180 microm below the corneal surface. Animals underwent serial slit lamp examinations and corneal thickness measurements at 1,3,7,14, and 28 days, then monthly up to 1 year.

RESULTS

Approximately 70 microm of central corneal thinning were seen at 1 week, remaining stable up to 7 months.

CONCLUSIONS

Intrastromal photodisruption with femtosecond lasers produced consistent changes in corneal thickness without loss of corneal transparency. These changes were more stable than those produced with excimer laser procedures in a similar animal model.

Filled versus empty intervals in prospective hypnotic time estimation with a real-simulator design

While interest in hypnotic time perception dates back to the 19th century (St. Jean, 1989) only recently have researchers focused on hypnosis and time estimation under more controlled conditions. Following the work of Jasinski (1986) and Mozenter and Kurtz (1992) we predicted a 2-way interaction between Group (high hypnotizable, low hypnotizable, and simulator) and Condition (waking, hypnotized) across 3 time intervals (30, 60, and 120 seconds). It was further hypothesized that "filled" intervals (with white noise) would be perceived as longer than "empty" intervals across all conditions. Sixty-two undergraduates were screened on the Stanford Hypnotic Susceptibility Scale: Form C and verbally estimated time intervals of 30, 60, and 120 seconds, 5 times each, both while in a waking and a hypnotic condition. Support was found for the predicted 2-way interaction for women only. High hypnotizable women showed a significant increase in overestimation from the waking to hypnosis condition, men did not. The predicted difference between "filled" versus "empty" intervals was not found.

Lamellar Refractive Surgery with Scanned Intrastromal Picosecond and Femtosecond Laser Pulses in Animal Eyes

PURPOSE

To evaluate the use of scanned intrastromal picosecond and femtosecond laser pulses in lamellar refractive surgical procedures.

METHODS

Intrastromal corneal photodisruption was performed in fresh porcine and primate cadaver eyes with a solid-state femtosecond laser. Laser pulses were focused 150 to 200 microns below the epithelial surface and scanned in a spiral pattern to create a plane. A flap was made by scanning an arc pattern from the plane of the spiral to the surface of the cornea. Tissue plane separation was graded using a standard scale, while internal surfaces were analyzed by scanning electron microscopy. Comparison was made to a picosecond laser system using the same delivery system device. Creation of a stromal lenticule for in situ keratomileusis was also demonstrated and compared with both laser systems.

RESULTS

For femtosecond pulses, tissue separation was achieved best with pulse energies from 4 to 8 microJ and spot separations from 10-15 microns. Picosecond pulses accomplished less complete separations with pulse energies of 25 microJ and spot separations from 10 to 20 microns. Surface quality corresponded to dissection results, with high-grade dissections resulting in a smooth surface appearance, versus a more irregular surface for low-grade dissections. Although high-grade dissections could be created with picosecond pulses (with optimal parameters) in ex vivo porcine eyes, only femtosecond parameters produced similar results in ex vivo primate eyes.

CONCLUSION

In contrast to previous attempts using picosecond lasers which require additional mechanical dissection, high precision lamellar refractive surgery may be practical with femtosecond laser pulses.

Hypnotic susceptibility order effects in waking analgesia

This study reexamined Spanos, Hodgins, Stam, and Gwynn's (1984) contention that susceptibility testing order effects generated a relationship between waking analgesia pain reduction and level of hypnotic responsiveness. Undergraduate volunteers with no previous hypnosis experience were randomly assigned to two groups. Group 1 (n = 69) first received a cold pressor pain protocol, and then was administered the Standford Hypnotic Susceptibility Scale, Form C (SHSS:C). Group 2 (n = 69) was administered the SHSS:C prior to the cold pressor pain protocol. Our findings do not support Spanos, Hodgins et al.'s contention that susceptibility testing order effects generate the often reported relationship between waking analgesia and level of hypnotic responsiveness. We found significant partial correlation coefficients between the SHSS:C and nonhypnotic pain reduction regardless of order of susceptibility testing. Implications regarding the adequacy of design-generated expectancies to explain hypnotic analgesia phenomena were examined.

Ofloxacin penetration into the eye after intravenous and topical administration

PURPOSE

To determine the aqueous and vitreous fluid penetration of ofloxacin after a combined topical and single intravenous dose protocol before vitrectomy surgery.

MATERIALS AND METHODS

Before undergoing vitrectomy surgery, patients were given two drops of ofloxacin 0.3% topically and a single intravenous dose of ofloxacin 400 mg. Aqueous (mean, 43 minutes) and vitreous (mean, 53 minutes) fluid samples were collected at the start of the surgical procedure. The samples were analyzed for ofloxacin penetration.

RESULTS

The mean aqueous fluid concentration was 1.083 micrograms/mL +/- 0.406. The mean +/- SD vitreous fluid concentration in nondiabetic patients with intact vitreous was 0.352 microgram/mL +/- 0.301. Vitreous levels obtained more than 50 minutes after administration (0.414 microgram/mL +/- 0.336) were generally higher than those obtained after less than 50 minutes (P = 0.12). Eyes with prior vitrectomies achieved better ofloxacin penetration (0.984 microgram/mL +/- 0.680) than did nonvitrectomized eyes.

CONCLUSION

Ofloxacin achieved measurable aqueous fluid penetration after topical and intravenous administration. Aqueous levels were above the minimum inhibitory concentration for most ocular pathogens. Vitreous levels were adequate in vitrectomized eyes to achieve inhibitory concentrations against many common ocular pathogens. Combined preoperative topical and a single dose of intravenous ofloxacin may provide inhibitory aqueous and vitreous antibiotic levels in vitrectomized eyes in cases where intravitreal antibiotics are not considered and oral administration is not practical.

Photodisruption in the Human Cornea as a Function of Laser Pulse Width

BACKGROUND

We investigated the role of laser pulse width in determining fluence thresholds and efficiency for corneal photodisruption.

METHODS

A laser system that delivers a wide range of pulse energies and pulse widths was used to produce ablations at pulse widths from 100 femtoseconds (fs) to 7 nanoseconds (ns). The laser-induced breakdown fluence threshold at each pulse width was determined by monitoring individual plasma emissions. Using multiple shots, the photodisruption threshold and cutting depth at each pulse width were determined histologically.

RESULTS

Corneal breakdown thresholds decreased at a faster rate from 7 ns to approximately 10 picoseconds (ps), compared to further reductions in pulse width below 10 ps, where little variation was seen. Breakdown for pulse widths below 10 ps showed little intershot variability, resulting in highly reproducible fluence thresholds. Corneal tissue examined histologically showed similar fluence dependency.

CONCLUSIONS

Corneal tissue photodisruption thresholds demonstrate pulse width dependence. At pulse widths less than 10 ps and with fluences near the breakdown threshold, ablations are maximally precise and efficient. These findings suggest optimal laser parameters for corneal surgery.

Human retinal pigment epithelial cell interleukin-8 and monocyte chemotactic protein-1 modulation by T-lymphocyte products

PURPOSE

The purpose of the study was to examine the effect of T-lymphocyte products on human retinal pigment epithelial (HRPE) cell interleukin-8 (IL-8) and monocyte chemotactic protein-1 (MCP-1) secretion and gene expression.

METHODS

HRPE cells were stimulated for 2, 4, 8, or 24 hours with 20% conditioned media (CM) from T-lymphocytes stimulated with CD3 or CD28 monoclonal antibodies (mAbs) or phorbol myristic acid. In some experiments, CM from CD3 mAb-stimulated T-lymphocytes was preincubated with neutralizing anti-(alpha)-tumor necrosis factor (TNF), alpha-interferon-gamma (IFN-gamma), or alpha-interleukin-1 (IL-1) mAb (control) to determine the contributions of each of these cytokines to HRPE chemokine induction by stimulated T-lymphocyte CM. HRPE cells were stimulated for 8 and 24 hours with IL-1 beta (0.2 to 20.0 ng/ml) (positive control), TNF-alpha (0.2 to 20.0 ng/ml) (positive control), IFN-gamma (1 to 1000 U/ml), IFN-gamma + IL-1 beta, IFN-gamma + TNF-alpha. Interleukin-2 (IL-2; 100 ng/ml) alone or in combination with IL-1 beta, TNF-alpha, or IFN-gamma also was tested. Enzyme-linked immunosorbent assay (ELISA) and Northern blot analyses were performed to determine secreted IL-8 and MCP-1 and their steady state mRNA expression, respectively.

RESULTS

ELISA showed significant increases in HRPE IL-8 and MCP-1 secretion by CM from T-lymphocytes stimulated with CD3 or CD3 + CD28 mAb. Smaller, but significant, increases in IL-8 and MCP-1 resulted from CM phorbol myristic acid-stimulated T-lymphocytes. CM preincubated with neutralizing alpha-TNF or alpha-IFN-gamma mAb induced significantly less HRPE IL-8 and MCP-1, whereas preincubation of CM with neutralizing alpha-IL-1 mAb failed to inhibit CM-induced IL-8 or MCP-1. Northern blot analysis showed increased HRPE IL-8 and MCP-1 mRNA expression within 2 hours of stimulation and was maintained up to 24 hours. CM from T-lymphocytes stimulated with CD3 mAb or CD3 + CD28 mAb produced the greatest increases in IL-8 and MCP-1 mRNA. IFN-gamma induced dose-dependent increases in HRPE MCP-1, but not IL-8, IFN-gamma potentiated IL-1 beta and TNF-alpha-induced MCP-1 production, but showed little modulation of IL-1 beta and TNF-alpha-induced IL-8 production. IL-2 did not induce HRPE IL-8 or MCP-1, nor did it modulate the effects of the other cytokines. Northern blot analysis confirmed the ELISA results.

CONCLUSIONS

T-lymphocyte secretions induce HRPE IL-8 and MCP-1 gene expression and secretion. TNF and IFN-gamma appear to be necessary components of T-lymphocyte CM for the induction of HRPE IL-8 and MCP-1. IFN-gamma alone induces HRPE MCP-1, albeit to a lesser extent than would IL-1 beta or TNF-alpha, and potentiates IL-1 beta- and TNF-alpha-induced HRPE MCP-1. IL-2 does not appear to modulate cytokine-induced HRPE IL-8 or MCP-1.

Dexamethasone and cyclosporin A modulation of human retinal pigment epithelial cell monocyte chemotactic protein-1 and interleukin-8

PURPOSE

To examine the modulation of interleukin-1 beta (IL-1 beta)- and tumor necrosis factor-alpha (TNF-alpha)-stimulated monocyte chemotactic protein-1 (MCP-1) and interleukin-8 (IL-8) secretion and transcription in human retinal pigment epithelial (HRPE) cells by dexamethasone (DEX) and cyclosporin A (CSA).

METHODS

Cultured HRPE cells were stimulated with IL-1 beta (0.2 to 20 ng/ml) or TNF-alpha (0.2 to 20 ng/ml) for 8 or 24 hours without (control) and with DEX (10(-8) to 10(-6) M) or with CSA (0.3 to 30 ng/ml). Secreted levels of HRPE MCP-1 and IL-8 were measured in the media using enzyme-linked immunosorbent assay (ELISA). Both MCP-1 and IL-8 mRNA were analyzed by Northern blot.

RESULTS

Although DEX (10(-8) to 10(-6) M) inhibited IL-1 beta-stimulated MCP-1 and IL-8 production, it did not inhibit TNF-alpha-stimulated chemokine secretion. In contrast, CSA significantly inhibited TNF-alpha-stimulated, but not IL-1 beta-stimulated, HRPE MCP-1 and IL-8 secretion. Both DEX and CSA inhibitions showed dose dependence. Northern blot analysis of HRPE steady state MCP-1 and IL-8 mRNA corroborated the ELISA measurements of secreted MCP-1 and IL-8.

CONCLUSIONS

Although DEX and CSA inhibit HRPE MCP-1 and IL-8 secretion, this is dependent on whether the inducing inflammatory mediator is IL-1 beta or TNF-alpha. IL-1 beta-induced chemokine secretion is sensitive to DEX, whereas MCP-1 and IL-8 induced by TNF-alpha are inhibited by CSA. This information may be useful in explaining in vivo observations and in suggesting targeted clinical treatments and combinations of immunosuppressive agents.

Cellular pharmacology and molecular biology of the trabecular meshwork inducible glucocorticoid response gene product

Studies of the effects of glucocorticoid (GC) and oxidative stress stimuli in differentiated cultures of human trabecular meshwork (HTM) cells have provided the rationale for our studies of a major new gene termed TIGR (trabecular meshwork inducible GC response). The TIGR clone was isolated by differential library screening using selection criteria based on the induction pattern of a new protein/glycoprotein found in HTM cultures after prolonged but not brief exposure to GCs. This GC induction pattern matched the time course and dose response required for intraocular pressure elevation in patients receiving corticosteroids. The very large, progressive induction of TIGR combined with specific structural features of its cDNA suggested that TIGR should be considered a candidate gene for outflow obstruction in glaucoma. Among the properties of TIGR cDNA were a signal sequence for secretion, several structural features for interactions with glycosaminoglycans and other glycoproteins and putative sites for cell surface interactions. In addition, the leucine zippers in the structure were related to TIGR-TIGR oligomerization that was shown to occur with native and recombinant TIGR protein. The verification that TIGR was a major stress response protein in HTM cells following hydrogen peroxide (or phorbol esters) exposure provided a potential link between GC and oxidative mechanisms thought to be involved in glaucoma pathogenesis. Pharmacological evaluation showed that basic fibroblast growth factory and transforming growth factor beta decreased the GC induction of TIGR, and certain nonsteroidal anti-inflammatory drugs protected against both GC- and oxidation-induced stress responses in HTM cells. Our recent studies of TIGR's genomic structure have shown motifs in the promoter region that suggest a basis by which multiple hormonal/environmental stimuli can regulate TIGR production and by which putative genetic alterations could lead to an overexpression of the protein. Further application of cell biology/biochemistry, molecular biology, genetic and histological approaches will be helpful in understanding the role of TIGR in different glaucoma syndromes.

Durability of posthypnotic suggestions: type of suggestion and difficulty level

This study investigated the impact of Difficulty Level and Type of Suggestion upon the durability of posthypnotic suggestion over an 8-week period. Seventy-eight highly susceptible subjects selected by both the Harvard Group Scale of Hypnotic Susceptibility: Form A (HGSHS:A) and Stanford Hypnotic Scale of Susceptibility: Form C (SHSS:C) were assigned to six groups (two levels of Difficulty x three Types of Suggestion). S's were tested for posthypnotic suggestion at 1, 3, 6, and 8 weeks. A 2 x 3 x 4 (Difficulty x Suggestion x Time) factorial ANOVA was conducted, with Time treated as a repeated-measure. The outcome variable at each time was either pass or fail for relevant suggestion. We found a significant Time effect, a significant Difficulty effect, and a significant Time x Difficulty interaction. Fewer subjects passed the difficult suggestions than passed the easy suggestions; fewer passed suggestions at a latter time; and the decay in pass rate was more pronounced for the easy suggestion condition, due largely to the higher initial pass rate. Type of Suggestion was not significant, nor were any of the other interactions. Clinical implications were discussed.

The endogenous eyeblink and hypnotic susceptibility in a real-simulator design

This study investigated the relationship between hypnotic susceptibility and the endogenous eyeblink with 27 subjects who were assigned to groups of high susceptibles, low susceptibles and simulators on the basis of cutoff scores from the Harvard Group Scales of Hypnotic Susceptibility: Form A and the Stanford Hypnotic Susceptibility Scales: Form C. Using a repeated-measures design, oculomotor data were collected during two separate conditions, waking and hypnotized, while subjects performed a visual task requiring the discrimination of short light flashes (200 ms) from long light flashes (400 ms). Although results partially replicated previous studies, with high susceptibles blinking significantly less than low susceptibles across both conditions, no effect was found for the hypnotic state. Failure of the simulating group to meet assumptions in the waking condition allowed no conclusions regarding impact of task demands on the endogenous eyeblink.

Multiple susceptibility testing: is it helpful?

This study explored whether or not the use of combined group and individually administered susceptibility tests improve the predictive power over the use of a singly administered test. Two hundred and eighty undergraduates were assigned to one of five groups: Group 1 received the HGSHS: A and then the SHSS:C; Group 2 the CIS and SHSS:C; Group 3 the HGSHS: A and the SHCS:A; Group 4 received the CIS and the SHCS:A; and Group 5 was tested on the SHSS:C alone. After the susceptibility screening the subjects were hypnotized and tested on four types of target hypnotic behaviors. From the RSPSHS:I&II the following four factors were chosen (1) cognitive distortion, (2) positive hallucination, (3) negative hallucination, (4) dreams and regression. The items were matched on difficulty level. The data were subjected to a series of stepwise multiple regression and logistic regression analyses. The results confirmed previous research; i.e., (1) The SHSS:C is the best single measure, (2) the SHCS:A is a poor substitute for the SHSS:C; (3) the HGSHS:A is not adequate substitute for SHSS:C; (4) the CIS is weak in predictive power compared to the HGSHS:A; (5) Only for a weak measure such as SHCS:A does combined testing produce an advantage; (6) There appear to be no warm-up effects for SHSS:C when preceded by HGSHS:A.

Differential effects of hypnotic suggestion on multiple dimensions of pain

Within the framework of multidimensional pain assessment, this study extended an earlier finding that hypnotic analgesia and relaxation suggestions have differential effects on pain reduction by evaluating these strategies in subjects undergoing a cold pressor protocol. Thirty-two highly susceptible subjects were randomly assigned to an analgesia or a relaxation suggestion treatment group. Six pain reports were taken at 10-sec intervals for each experimental condition. The baseline measures served as covariates. A 2 x 2 x 2 x 6 repeated-measures analysis of covariance (ANCOVA) revealed a significant group (analgesia, relaxation) by pain dimension (intensity, unpleasantness), by condition (suggestion alone, hypnotic induction plus suggestion) interaction. Analysis of the simple-simple main effects, holding both group and condition constant, revealed that application of hypnotic analgesia reduced report of pain intensity significantly more than report of pain unpleasantness. Conversely, hypnotic relaxation reduced pain unpleasantness more than intensity. The clinical implications of the study are discussed.

Hypnotic analgesia, expectancy effects, and choice of design: a reexamination

Previous research by Stam and Spanos suggests that if waking analgesia is followed by hypnotic analgesia, subjects refrain from maximally responding during the waking trial so they report less pain under hypnosis (i.e., a "holdback effect"). This hypothesis was re-examined using more stringent controls. Thirty-six highly susceptible subjects chosen by a combination of the Harvard Group Scale of Hypnotic Susceptibility, Form A and the Stanford Hypnotic Susceptibility Scale, Form C were randomly assigned to one of three treatment groups (waking analgesia followed by hypnotic analgesia, waking analgesia followed by waking analgesia, or hypnotic analgesia followed by waking analgesia). Each group received three 60-second immersions of cold pressor pain stimulation (baseline, Immersion 1, Immersion 2) and rated pain using a magnitude estimation and a category rating scale. The obtained results failed to support the hypotheses of a holdback effect or a "reverse-order holdback effect." Properties of within-subjects and between-subjects designs were considered in explaining the superiority of hypnotic analgesia over waking analgesia typically found in within-subjects models.

Hypnotic susceptibility and the endogenous eyeblink: a brief communication

This study investigated the relationship between hypnotic susceptibility, hypnotic state, and the endogenous eyeblink with 36 undergraduates, who were assigned to four independent groups (waking-low, hypnotized-low, waking-high, and hypnotized-high susceptibles) on the basis of combined cutoff scores on both the Creative Imagination Scale and the Stanford Hypnotic Clinical Scale for Adults. The auditory vigilance task required subjects to discriminate between 200 ms and 300 ms tones over a 35-minute period. Hypnotic depth was controlled across trials using the Long Stanford Scale of Hypnotic Depth. As predicted, high-susceptible subjects had a significantly lower blink rate than low-susceptible subjects. The predicted interaction between susceptibility and hypnotic state was also confirmed. High-susceptible subjects showed a significant decrease in blinking for the hypnotized condition, whereas low-susceptible subjects did not. The need for replication with more adequate measures of susceptibility is discussed.

Prospective time estimation and hypnotizability in a simulator design

The present study of prospective time estimation examined the effects of hypnosis on short time intervals using a real-simulator design. The major hypothesis predicted a 2-way interaction between group (high hypnotizable, low hypnotizable, and simulator) and condition (waking and hypnotic) across all 4 time intervals (30, 60, 120, and 240 seconds). It was further hypothesized that on a "suggested" task (a measure of hypnotic depth), high hypnotizable Ss and simulators would not differ from each other but would differ from low hypnotizable Ss. 42 undergraduates were screened on both the Creative Imagination Scale (Wilson & Barber, 1977) and the Stanford Hypnotic Clinical Scale for Adults (Morgan & J. R. Hilgard, 1975, 1979) and assigned to 1 of 3 groups (high hypnotizable, low hypnotizable, simulator) based on combined hypnotizability scores. Ss verbally estimated time intervals of 30, 60, 120, and 240 seconds, 3 times each, both while in a waking and a hypnotic condition. Hypnotic depth was assessed once following each time interval. Partial support was found for the first hypothesis where, for both the 60- and 120-second intervals, high hypnotizable Ss increased their overestimation in the hypnotic condition. Low hypnotizable and simulator Ss showed no such increase. The second hypothesis, that high hypnotizable and simulator Ss would differ from low hypnotizables on the "suggested" task, was confirmed. The partial replication of previous research was examined in the context of choice of hypnotizability measure and reliability of time estimation.

Durability of "posthypnotic suggestions" as a function of type of suggestion and trance depth

3 types of "posthypnotic suggestion," based upon factor analytic studies, were administered to high hypnotizable Ss (reals) and to low hypnotizable Ss instructed to simulate hypnosis (simulators) (N = 12 high and 6 low hypnotizable Ss per suggestion). The "posthypnotic suggestions" consisted of instructions given to Ss following a hypnotic induction that, when the posthypnotic cue was later given, they would re-enter the hypnotic state and perform a certain task at that time. Ss were then tested 6 times for durability of "posthypnotic response" during an 8-week period. Responses to the "suggestions" were rated by research assistants (objective scores) and by Ss themselves (subjective scores). There was a significant Trials x Type of "Suggestion" interaction for both types of scores for the reals but not for the simulators, indicating different rates of decline with time for the different "suggestions" for the hypnotic Ss. Depth of reported hypnotic trance during the assessment sessions was found to be strongly related to performance of the "posthypnotic suggestion" for both real and simulating Ss.

Hypnotic susceptibility and experimental pain reduction

We exposed 24 subjects high in hypnotic susceptibility and 24 subjects low in hypnotic susceptibility to a cold-pressor pain stimulus under either hypnotic or waking conditions, using each of two pain-reduction strategies (analgesia and distraction) separately. Trance depth level was held constant for hypnotized subjects. We used pain-tolerance levels as measures of pain, and we analyzed them by survival analysis. High susceptibles reported significantly lower pain ratings and kept their hands immersed longer in the cold water than low-susceptible subjects. There were no significant differences between hypnotic and waking condition subjects or between the different strategies. We have discussed the results in terms of a relationship in the literature between choice of experimental design (between-subjects or within-subjects) and the effectiveness of a hypnotic induction for suggested pain reduction.

The effects of hypnotic suggestion on pain report

Forty-five highly susceptible volunteers rated a series of shocks using 32 pain descriptors. Descriptors were given numerical values using magnitude estimation procedures. We assigned the subjects to one of three conditions, analgesia suggestion, relaxation suggestion, or no suggestion. All subjects were administered the shocks and the suggestion appropriate to the group, in both the waking and hypnotic state. The results support the existence of two dimensions of pain which are differentially responsive to suggestion. Hypnotic-analgesia suggestion altered subjects' perceptions of the intensity without changing their perceptions of the unpleasantness of the shocks. Hypnotic-relaxation suggestion reduced the unpleasantness but not the perceived intensity of the stimuli. These findings imply that research into hypnotic pain relief is more easily interpreted if pain is viewed as multidimensional in nature.

Changes in body attitude as a function of posthypnotic suggestions

This study hypothesized that highly hypnotizable Ss who remained amnesic for posthypnotic suggestions to improve body attitude would show greater changes than Ss who were not amnesic. Ss given simulating instructions were used as a comparison group to assess experimental demands. 48 females were screened with the Harvard Group Scale of Hypnotic Susceptibility, Form A (Shor & E. Orne, 1962) and assigned to one of 4 conditions: (a) high hypnotizable with amnesia suggestions, (b) high hypnotizable without suggested amnesia, (c) low hypnotizable simulators with amnesia, and (d) low hypnotizable simulators without suggested amnesia. A fifth group was formed of those high hypnotizable Ss who remembered the suggestion despite instructions to the contrary. The Body Attitude Scale (Kurtz, 1966) was administered prior to and 3 days after the experimental suggestions. Results generally demonstrated that high hypnotizable amnesic Ss manifested the greatest attitudinal and phenomenological changes as a result of the posthypnotic suggestion, although conclusions were tempered by performance of simulating Ss. The implications for hypnosis research and clinical practice are discussed.

Hypnosis and its effects on left and right hemisphere activity

Recent research suggests a relationship between hypnosis and the right cerebral hemisphere in man. With several major modifications in the 1978 study of Frumkin, Ripley, and Cox, the following hypothesis was investigated: Hypnosis creates a shift towards relatively greater left ear accuracy, suggesting greater participation of the right hemisphere during a trance. Two studies were undertaken with 36 right-handed male volunteers in each; 12 of low susceptibility to hypnosis, 12 of medium susceptibility, and 12 of high susceptibility. Study 1 investigated the affect hypnosis had on the processing of musical stimuli while Study 2 investigated its affects on verbal stimuli. Study 1 found that the more susceptible an individual was to hypnosis the greater the shift towards the left ear. Study 2 found no such relationship. Possible differences in stimulus characteristics which might have caused these different results were discussed.

Psychiatric residents and lower class patients: Conflict in training

A special outpatient clinic was established to pioneer newer and more appropriate methods of treating poor personality resource patients. While the clinic apparently served its clientele, the psychiatrists in training felt angry and frustrated in their clinic experience. Analysis of interview data revealed that the trainees were subject to forces that placed them in conflict. The characteristics of the patients, the clinic structure that required subservience of individual gratifications to institutional values, the need to develop a personal sense of competence, and the residents' perception of conflicting values on the part of the staff all contributed to the residents' experience of conflict and frustration. Patterns of conflict resolution were discerned in criticism directed toward the staff but more effectively in apathetic withdrawal of personal investment.