Topographical and quantitative assessment of white matter injury following a focal ischaemic lesion in the rat brain

Axonal injury following cerebral ischaemia has attracted less attention than damage in grey matter. However, it is becoming increasingly recognised that axons are highly vulnerable to focal ischaemia [D. Dewar, D.A. Dawson, Changes of cytoskeletal protein immunostaining in myelinated fibre tracts after focal cerebral ischaemia in the rat, Acta. Neuropathol., 93 (1997) 71-77] [2]; [L. Pantoni, J.H. Garcia, J.A. Gutierrez, Cerebral white matter is highly vulnerable to ischemia, Stroke, 27 (1996) 1641-1647] [10]; [P. S. Yam, T. Takasago, D. Dewar, D.I. Graham, J. McCulloch, Amyloid precursor protein accumulates in white matter at the margin of a focal ischaemic lesion, Brain Res., 760 (1997) 150-157] [15]. Since white matter does not contain neuronal cell bodies or synapses it is likely that the mechanisms of injury and strategies for its protection are different from those in grey matter. In order that the effect of therapeutic intervention on the protection of axons can be assessed, a method by which axonal injury can be mapped and quantified is required. For this purpose, we investigated immunocytochemical methods using amyloid precursor protein (APP) following permanent middle cerebral artery occlusion in the rat. APP is transported by fast anterograde axonal transport [E.H. Koo, S.S. Sisodia, D.R. Archer, L.J. Martin, A. Weidemann, K. Beyreuther, P. Fischer, C.L. Masters, D.L. Price, Precursor of amyloid protein in Alzheimer disease undergoes fast anterograde axonal transport, Proc. Natl. Acad. Sci. U.S.A. 87 (1990) 1561-1565] [7] and has been shown to accumulate following a variety of insults to axons, indicative of dysfunction of axonal transport [R.N. Kalaria, S.U. Bhatti, E.A. Palatinsky, D.H. Pennington, E.R. Shelton, H.W. Chan, G. Perry, W.D. Lust, Accumulation of the beta amyloid precursor protein at sites of ischemic injury in rat brain, Neuroreport, 4 (1993) 211-214] [4]; [T. Kawarabayashi, M. Shoji, Y. Harigaya, H. Yamaguchi, S. Hirai, Expression of APP in the early stage of brain damage, Brain Res., 563 (1991) 334-338] [5]; [N. Otsuka, M. Tomonaga, K. Ikeda, Rapid appearance of beta-amyloid precursor protein immunoreactivity in damaged axons and reactive glial cells in rat brain following needle stab injury, Brain Res., 568 (1991) 335-338] [9]; [K. Shigematsu, P. L. McGeer, Accumulation of amyloid precursor protein in neurons after intraventricular injection of colchicine, Am. J. Pathol., 140 (1992) 787-794] [12]. We have been able to map the topographical relationship between APP accumulation and region of infarction using immunocytochemistry and image analysis techniques. Additionally, using a semi-quantitative scoring system, we have demonstrated that there is a relationship between the amount of APP accumulation and the volume of infarction following middle cerebral artery occlusion. These methods will be useful in the future for the assessment of therapeutic interventions on the protection of axons following ischaemic injury.

Discovery of ritonavir, a potent inhibitor of HIV protease with high oral bioavailability and clinical efficacy

The structure-activity studies leading to the potent and clinically efficacious HIV protease inhibitor ritonavir are described. Beginning with the moderately potent and orally bioavailable inhibitor A-80987, systematic investigation of peripheral (P3 and P2') heterocyclic groups designed to decrease the rate of hepatic metabolism provided analogues with improved pharmacokinetic properties after oral dosing in rats. Replacement of pyridyl groups with thiazoles provided increased chemical stability toward oxidation while maintaining sufficient aqueous solubility for oral absorption. Optimization of hydrophobic interactions with the HIV protease active site produced ritonavir, with excellent in vitro potency (EC50 = 0.02 microM) and high and sustained plasma concentrations after oral administration in four species. Details of the discovery and preclinical development of ritonavir are described.

Discovery of ritonavir, a potent inhibitor of HIV protease with high oral bioavailability and clinical efficacy

The structure-activity studies leading to the potent and clinically efficacious HIV protease inhibitor ritonavir are described. Beginning with the moderately potent and orally bioavailable inhibitor A-80987, systematic investigation of peripheral (P3 and P2') heterocyclic groups designed to decrease the rate of hepatic metabolism provided analogues with improved pharmacokinetic properties after oral dosing in rats. Replacement of pyridyl groups with thiazoles provided increased chemical stability toward oxidation while maintaining sufficient aqueous solubility for oral absorption. Optimization of hydrophobic interactions with the HIV protease active site produced ritonavir, with excellent in vitro potency (EC50 = 0.02 microM) and high and sustained plasma concentrations after oral administration in four species. Details of the discovery and preclinical development of ritonavir are described.

Stroke without dissection from a neck holding manoeuvre in martial arts

Carotid artery trauma is a known cause of stroke in young people. The vessel may occlude, dissect or shower thrombotic emboli into intracranial vessels. This paper reports the use of single photon emission computed tomography (SPECT) imaging in a 29 year old man who developed an embolic stroke after neck holding manoeuvres at a martial arts class. Awareness of the potential consequences of these procedures is matched by the need for rapid and accurate diagnosis of stroke now that thrombolytic and neuroprotective treatments are emerging, which are effective only within a short time window.

EPA's neurotoxicity risk assessment guidelines

The proposed Neurotoxicity Risk Assessment Guidelines (U.S. EPA, 1995c Fed. Reg. 60(192), 52032-52056) of the U.S. Environmental Protection Agency (EPA) were the subject of a workshop at the 1997 Meeting of the Society of Toxicology. The workshop considered the role of guidelines in the risk assessment process, the primary features, scientific basis, and implications of the guidelines for EPA program offices, as well as for industrial neurotoxicologists from the perspectives of both pesticides and toxic substances regulation. The U.S. National Academy of Sciences (NAS, 1983, Risk Assessment in the Federal Government: Managing the Process) established a framework for distinguishing risk management from risk assessment, the latter being the result of integrating hazard identification, hazard characterization, and exposure assessment data. The guidelines are intended to establish operating principles that will be used when examining data in a risk assessment context. The proposed neurotoxicity risk assessment guidelines provide a conceptual framework for deciding whether or not a chemically induced effect can be considered to be evidence of neurotoxicity. Topics in the proposed guidelines include structural and functional effects, dose-response and -duration considerations, and relationships between effects. Among the issues that must be considered are the multiplicity of chemical effects, the levels of biological organization in the nervous system, and the tests, measurements, and protocols used. Judgment of the adversity of an effect depends heavily on the amount and types of data available. The attribution of a chemically induced effect to an action on the nervous system depends on several factors such as the quality of the study, the nature of the outcome, dose-response and time-response relationships, and the possible involvement of nonneural factors. The guidelines will also serve as a reference for those conducting neurotoxicity testing, as well as establish a consistent approach to neurotoxicity risk assessment by regulators. Extending this approach through international harmonization would be advantageous to the development of products for a worldwide market. Thus, both risk assessors and regulated industries have a large stake in the guidelines to provide a framework that will lead to accurate risk assessment decisions.

Image quality versus statistical power

We investigated whether SPET studies of neuroactivation might benefit from a similar approach used in PET; that is, increase the number of scans per task and accept poorer individual scan quality. Different study paradigms were simulated by varying the scanning parameters: (1) administered radiation activity per scan, (2) number of scans per task and (3) scan acquisition time. The maximum total dose received by each simulated subject remained the same. Areas of activation of varying signal strength were added to the scans using a customized graphics package. To establish the statistical benefits of a replication paradigm versus a non-replication paradigm, the datasets were analysed using SPM95 statistics software. This simulation was able to show that, when an SPM investigation is used for data analysis, study replication is more important than the individual image quality typically available from a high-performance SPET system.

Histamine H2 receptor antagonist-refractory oesophagitis: the efficacy of long-term omeprazole maintenance treatment

BACKGROUND

Erosive oesophagitis refractory to high dose histamine H2 receptor antagonists (definition: failure to heal fully after > or = 3 months' treatment with cimetidine 3.2 g or ranitidine 0.9 g) responds well to omeprazole 40 mg daily but frequently relapses when the patients are put back on maintenance H2 receptor antagonists at medium or even high dose (e.g. cimetidine 1.6 g and 3.2 g, respectively).

AIM

To investigate the efficacy of maintenance omeprazole 20 mg daily in refractory erosive oesophagitis.

PATIENTS & METHODS

In this open, sequential study, patients with H2 receptor antagonist-refractory oesophagitis were healed on omeprazole 40 mg daily and then put on maintenance H2 receptor antagonists (cimetidine 1.6 g or 3.2 g). Relapses were re-treated with omeprazole 40 mg; upon rehealing, patients were put on maintenance omeprazole 20 mg daily for up to 4.5 years.

RESULTS

Healing on omeprazole occurred in 38 out of 39 patients (97%) at 12 weeks. Only six of the 38 patients (16%) relapsed (asymptomatic in half) during subsequent maintenance treatment, whereas all had relapsed earlier on high dose H2 receptor antagonists.

CONCLUSION

Within the limits of interpretation of an open study, omeprazole 20 mg daily seems effective in maintaining prolonged remission in this group of patients with H2 receptor antagonist-refractory oesophagitis.

123Iodo-MK-801: a spect agent for imaging the pattern and extent of glutamate (NMDA) receptor activation in Alzheimer's disease

Glutamate, and the NMDA glutamate receptor, may be involved in Alzheimer's Disease (AD). Reductions in NMDA receptors are found in AD, possibly contributing to memory deficits. However the NMDA receptor is involved in excitotoxicity, which may play a role in cell death and the production of neurofibrillary tangles in AD; although with lower levels of glutamate than occur in cerebral ischaemia. Therefore reductions in the NMDA receptor may worsen memory deficit in AD, but increased stimulation of the receptor may contribute to the progress of the disease. MK-801 has been used to image excessive glutamate activation following ischaemia in rats. However, it is unclear how effective MK-801 is in conditions with lower levels of glutamate release. This study attempts to gain insight into the utility of the tracer in these conditions, exploring glutamatergic mechanisms in AD. It describes the retention and elimination of 123iodo-MK-801 in five AD and five control subjects, comparing this to regional cerebral blood flow (rCBF). The initial uptake of 123I-MK-801 is dominated by delivery of the ligand. However, despite significant reductions in rCBF in the AD patients, there is no significant difference in the uptake of 123I-MK-801. This suggests increased retention of 123I-MK-801 in the AD patients. In addition the washout of 123I-MK-801 was less in the AD patients, again suggesting increased retention, although this only reached significance in one region. Theses data hint at possible increases in NMDA activation in AD but ultimately 123I-MK-801 does not provide a sufficiently accurate measurement to demonstrate this conclusively. Further NMDA ligands are now at a late stage of development and may provide more conclusive answers to the role of glutamate in AD.

A new method for rapid fluid bolus infusion into a peripheral vein

OBJECTIVE

To compare the flow rates achieved by a new short-tubed infusion device with those obtained with a conventional apparatus, using gravity, manual pressure, and pneumatic inflation as the driving forces.

METHODS

Ten paramedic volunteers were recruited for this prospective, randomized, controlled laboratory study. For the short-tubing setup, a new device, the port, was used to adapt standard 18-cm extension tubing directly to an i.v. bag [short tubing/port (STP) setup]. For the conventional (CON) setup, 280-cm tubing was used. Both study setups were tested on each of the volunteers with flow from a standard 250-mL bag of normal saline subjected to three types of driving force: 1) gravity alone, 2) pressure supplied by two hands squeezing the i.v. bag, and 3) a pneumatic pressure bag continuously inflated to 300 mm Hg. The mean flow rates for each driving force were compared between the two setups.

RESULTS

Using gravity flow, no significant difference was noted between the STP setup and the CON setup (0.40 vs 0.45 mL/sec, respectively, p > 0.4). However, when flow was augmented by pressure supplied by two hands squeezing the bag, mean flow was greater for the STP setup than for the CON setup (4.5 vs 2.7 mL/sec, respectively, p < 0.001). When flow was augmented by a pneumatic bag at 300 mm Hg, mean flow was again greater for the STP setup (5.6 mL/sec) than for the CON setup (3.3 mL/sec, p < 0.001).

CONCLUSION

Flow of crystalloid under pressure into a peripheral vein is markedly increased with the new STP setup as compared with the CON setup. Incorporation of this new setup in prehospital care would allow EMS personnel to infuse fluid more rapidly and conveniently during transport.

Ictal regional cerebral blood flow in frontal lobe seizures

99mTC (single photon emission computed tomography) (HMPAO SPECT) was carried out during 16 frontal-lobe seizures in 15 patients. Focal changes in regional cerebral blood flow were seen during all seizures. In 9 of 16 seizures SPECT showed hyperperfusion localized to one frontal lobe. In 1 of 16 seizures ictal hypoperfusion was seen in one frontal lobe. In 2 of 16 seizures there was hyperperfusion in both frontal lobes, and in 4 of 16 seizures hyperperfusion involved the frontal lobe or lobes plus other lobes of the brain. These changes were accompanied by hyperperfusion of subcortical structures in 13 seizures. SPECT thus localized to one frontal lobe in 10 of 16 seizures, and localized to the frontal lobes without lateralizing in two further seizures. No seizure showed a pattern of perfusion similar to that reported in mesial-temporal-lobe seizures. We conclude that ictal SPECT may provide useful localizing information in frontal-lobe seizures.

Influence of ischemia and reperfusion on the course of brain tissue swelling and blood-brain barrier permeability in a rodent model of transient focal cerebral ischemia

Brain swelling is a serious complication associated with focal ischemia in stroke and severe head injury. Experimentally, reperfusion following focal cerebral ischemia exacerbates the level of brain swelling. In this study, the permeability of the blood-brain barrier has been investigated as a possible cause of reperfusion-related acute brain swelling. Blood-brain barrier disruption was investigated using Evans Blue dye and [14C]aminoisobutyric acid autoradiography in a rodent model of reversible middle cerebral artery (MCA) occlusion. Acute brain swelling and cerebral blood flow (CBF) during ischemia and reperfusion were analyzed from double-label CBF autoradiograms after application of the potent vasoconstrictor peptide endothelin-1 to the MCA. Ischemia was apparent within ipsilateral MCA territory, 5 min after endothelin-1 application to the exposed artery. Reperfusion, examined at 30 min and 1, 2, and 4 h, was gradual but incomplete within this time frame in the core of middle cerebral artery territory and associated with significant brain swelling. Ipsilateral hemispheric swelling increased over time to a maximum (>5%) at 1-2 h after endothelin-1 but was not associated with a significant increase in the ipsilateral transfer constant for [14C]aminoisobutyric acid over this time frame. These results indicate that endothelin-1 induced focal cerebral ischemia is associated with an acute but reversible hemispheric swelling during the early phase of reperfusion which is not associated with a disruption of the blood-brain barrier.

Ictal single photon emission computed tomography in occipital lobe seizures

PURPOSE

Ictal single photon emission computed tomography (SPECT) has been evaluated as an adjunctive localizing technique in temporal lobe epilepsies and, to a lesser degree, in some extratemporal epilepsies. The purpose of this study was to determine whether occipital lobe seizures are associated with distinctive ictal cerebral blood perfusion (rCP) patterns.

METHODS

SPECT was used with the tracer 99mTc HMPAO to image ictal rCP in 6 patients in whom clinical, EEG, and imaging data indicated occipital lobe seizures.

RESULTS

Two patterns of rCP were seen. Four patients had hyperperfusion that was restricted to the occipital lobe, and two patients had hyperperfusion of the occipital lobe and the ipsilateral mesial temporal lobe, with hypoperfusion of the lateral temporal lobe. The latter 2 patients had clinical and surface EEG evidence of temporal lobe involvement in the seizure discharge.

CONCLUSIONS

Ictal rCP patterns in occipital lobe seizures are distinct from those in temporal lobe seizures and may vary according to whether or not ipsilateral temporal lobe structures are involved in the ictal discharge.

SPECT, CT, and MRI in head injury: acute abnormalities followed up at six months

Neuroimaging with single photon emission computed tomography (SPECT) using the cerebral blood flow tracer 99Tc(m)-HMPAO has been used to study acute functional alterations after head injury and residual abnormalities at six month follow up in 32 patients. Comparison has been made with anatomical abnormalities defined acutely with CT and on follow up with MRI. SPECT showed slightly more abnormalities than CT in the acute phase (49 regions of abnormally low tracer uptake on SPECT and 45 lesions on CT). Twenty two of the acute SPECT abnormalities were in normal regions on CT. At follow up MRI showed more abnormalities than SPECT (30 on SPECT and 48 on MRI). Ten of the SPECT deficits were in regions with normal MRI. Comparison of the intensity of late and early SPECT deficits showed that only four early deficits deteriorated whereas 28 improved. Only five of 27 lesions seen on both acute SPECT and CT resolved compared with 16 of 22 lesions seen on SPECT but not on CT. Regions of abnormally high tracer uptake were detected in the acute stage in five of the patients. No high focal uptake was evident on follow up. Ten patients with a residual SPECT abnormality and eight with residual MRI lesions were graded clinically in the upper band of good recovery.

Biochemical and morphological expression of early prenatal caprine beta-mannosidosis

Lysosomal storage diseases associated with early-onset pathological changes may require prenatal therapy to avert the profound effects of the metabolic error on organs, especially the central nervous system. The present investigation determined the extent of expression of beta-mannosidase deficiency in the caprine fetus at 62 days of gestation, near the end of the period of immunotolerance when donor cells can engraft in various organs without immune rejection and supply missing enzyme. Three pairs of obligate carrier goats from the beta-mannosidosis colony were mated. Out of six fetuses delivered at 62 days of gestation, one (V385) was identified by measurement of beta-mannosidase activity as the only fetus affected with beta-mannosidosis. Thin-layer chromatography and quantitation of oligosaccharides revealed the presence of tri- and disaccharides, typical of beta-mannosidosis, only in V385. Morphological analysis revealed cytoplasmic vacuolation typical of beta-mannosidosis in V385; in thyroid, spinal cord, and kidney, the pattern of vacuolation was similar to, but less severe than, that observed previously in newborn affected goats. On the basis of these results, it will be possible to determine the effects of prenatal cell transplantation therapeutic strategies performed during the period of immunotolerance by monitoring phenotypic characteristics after treatment.

Paramedic interpretation of prehospital lead-II ST-segments

OBJECTIVE

To determine the reliability of ST-segment interpretation by paramedics from lead-II rhythm strips obtained in the prehospital setting.

DESIGN

Prospective, blinded study of 127 patients transported by an urban/rural emergency medical services system with complaints consistent with ischemic heart disease.

METHODS

Emergency department physicians asked emergency medical technician-paramedics (EMT-P) via radio to evaluate ST-segments for elevation or depression and grade it as "mild," "moderate," or "severe." Then, this rhythm strip was interpreted blindly by emergency physicians who also interpreted the lead-II obtained from a 12-lead electrocardiogram (ECG) obtained in the emergency department (ED). The field interpretation was compared with the subsequent readings and the final in-patient diagnosis using positive predictive value (PPV), negative predictive value (NPV), and the Kappa statistic. Markedly discrepant interpretations were analyzed separately.

RESULTS

Using physician interpretation as the reference standard, paramedic interpretation of the lead-II ST-segments obtained in the prehospital setting was correct (within +/- 1 gradation) in 113 out of 127 total cases (89%). Of 105 patients for whom final hospital diagnosis was available, the ST-segment on the rhythm strip obtained in the prehospital setting, had a positive predictive value of 74% and a negative predictive value of 85% for myocardial ischemia or myocardial infarction (MI) (p < 0.001, Kappa = 0.59). Discordant interpretations between the paramedics and emergency physicians often were related to a basic misunderstanding of rhythm strip morphology.

CONCLUSION

Field interpretation of ST-segments by paramedics is fairly accurate as judged both by emergency physicians and correlation with final patient outcome, but its clinical utility is unproved. A small but clinically significant number of outliers, consisting of markedly discrepant false positives, reflects paramedic uncertainty in identifying the deviations of the ST-segment.

First SPET images of glutamate (NMDA) receptor activation in vivo in cerebral ischaemia

This report describes the initial clinical assessment of (+)-3-[123I]Iodo-MK-801 and its potential to provide single photon emission tomographic (SPET) images in vivo of NMDA receptor activation during cerebral ischaemia. Multiple SPET images were obtained in the 120 min after the administration of 150 MBq of (+)-3-[123I]Iodo-MK-801 to five patients with cerebral ischaemia (due to cerebral haemorrhages) and to five normal volunteers. In normal subjects, (+)-3-[123I]Iodo-MK-801 has a rapid uptake into the brain. The tracer has a high non-specific retention in the central nervous system due to its lipophilicity, which was made evident by the retention of tracer in the cerebellum and white matter (brain areas with few NMDA receptors). In all patients with cerebral haemorrhages, the initial uptake of (+)-3-[123I]Iodo-MK-801 into the ipsilateral hemisphere was markedly reduced, consistent with a reduced level of cerebral blood flow. In two of five patients, relatively increased tracer retention at later time points (60-120 min after tracer administration) could be seen in cortical areas adjacent to the site of the haemorrhage, consistent with activated NMDA receptors. In three of the patients, no relatively enhanced tracer retention could be identified. Using (+)-3-[123I]Iodo-MK-801, it may be possible to image excessive glutamate (NMDA) receptor activation during an ischaemic episode in living human patients. The utility of (+)-3-[123I]Iodo-MK-801 as a SPET ligand for assessing modest alterations in NMDA receptor activity may ultimately be limited by its lipophilicity and consequent high non-specific binding.

Severe hyperphosphatemia following phosphate administration for bowel preparation in patients with renal failure: two cases and a review of the literature

Two cases of severe hyperphosphatemia following phosphate bowel preparation are described and a review of the literature is presented. Impairment of renal function appears to be a risk factor in those patients without primary bowel pathology. One of our patients died, and the mortality rate combining our cases with all other reported cases is 33%. Repeated doses of phosphate bowel preparations/purgatives can be dangerous in patients with renal impairment.

Relative effects of inhaled corticosteroids on immunopathology and physiology in asthma: a controlled study

BACKGROUND

Although corticosteroids are recognised as the most efficacious treatment for bronchial asthma, their mode of action remains unclear. A placebo controlled trial was undertaken of the effect of inhaled corticosteroids on physiological and immmunopathological parameters in asthmatic patients in whom the correlations between these indices were tested after treatment.

METHODS

Sixteen patients (two women) with asthma entered a double blind, placebo controlled, parallel study during which they inhaled either budesonide 800 micrograms twice daily or matching placebo for six weeks. Spirometric parameters and bronchial reactivity to histamine and terbutaline were measured and endobronchial biopsy samples were taken before and after treatment. Patients recorded morning and evening flow rates during the treatment period. The biopsy samples were subjected to immunohistological analysis to determine the disposition of inflammatory cells within the bronchial wall.

RESULTS

Treatment with budesonide resulted in a significant improvement in the 25-75% forced expiratory flow (FEF25-75) from a mean of 133 l/min before treatment to 169 l/min after treatment, and in the morning peak expiratory flow rate (PEFR) from a mean of 384 l/min before treatment to 415 l/min after treatment. No changes were seen in the placebo group. Comparison between the changes in the immunopathological indices after six weeks of treatment with placebo or budesonide showed a significant reduction in the numbers of mast cells (0.5/unit area to 0.2/ unit area), activated eosinophils, and the expression of HLA-DR antigens (relative density -1.9 before to 1.02 after treatment) on inflammatory cells in response to treatment with budesonide. Although reductions in the numbers of other inflammatory cells within the bronchial wall were recorded using immunohistological analysis, these changes were not statistically significant. Significant correlations were found between changing immunological indices and lung physiology.

CONCLUSIONS

This controlled study shows that inhaled corticosteroids cause improvement in physiological and immunopathological parameters in patients with stable asthma that are not seen with placebo, and that cause and effect relationships may exist between these two measures of disease status.

Risk and resilience among children and youth with disabilities

OBJECTIVE

To review the literature on risk and protective factors as applied to children with chronic and disabling conditions so as to assist the health care professional in developing clinical strategies and interventions.

DESIGN

Literature review.

MAIN OUTCOME VARIABLES

Risk factors (eg, emotional problems, school failure) and protective variables (eg, family cohesion, school involvement).

RESULTS

Both risk and protective factors can be identified at multiple levels: the condition, the child, the family, and the community. Conditions that are invisible have remitting-relenting courses, and where the prognosis is uncertain, these conditions are associated with the greatest emotional problems. Males with chronic conditions appear to have more emotional sequelae than do females. Likewise, personality characteristics of sociability and flexibility and physical characteristics of attractiveness are protective. Families with clear boundaries and a capacity to balance competing family needs, maintain flexibility, and ascribe positive meanings to life events all are protective.

CONCLUSIONS

As increasing numbers of children with chronic conditions survive through adolescence to adulthood, the creation of environments where children can optimally develop becomes ever more pressing. It is evident that a range of factors, many amenable to interventions, can influence outcomes for these young people.

HMPAO as a regional cerebral blood flow tracer at high flow levels

HMPAO is being used extensively to image rCBF during focal seizures in humans. It is, however, theoretically possible that back-diffusion of tracer causes retention to fall as flow rises at high levels.

METHODS

We used a double label 99mTc-HMPAO/14C-IAP autoradiographic technique to compare HMPAO retention and regional cerebral blood flow in penicillin induced focal seizures in rats.

RESULTS

Using this protocol, flows of up to 717 ml/100 g per min were observed. The same pattern of uptake was seen on IAP and HMPAO autoradiographs, with the exception of relatively high HMPAO uptake in the choroid plexus, in the fissures and, in one animal only, the supramammilary nucleus. Correlation of HMPAO retention and blood flow showed a linear relationship up to 200 ml/100 g per min all animals. HMPAO retention then showed a falloff in its rise with blood flow, but was still increasing, even at the highest flows seen. At 700 ml/100 g/min, HMPAO retention was 20% of that expected from a linear relationship.

CONCLUSION

HMPAO is a suitable tracer of rCBF at high flows and is unlikely to produce anomalous images in human focal seizures.

Consequences of transient focal cerebral ischaemia for second messenger and neurotransmitter binding in the rat: quantitative autoradiographic analysis of forskolin, dopamine D1 receptor binding and cerebral blood flow changes

In order to study the consequences of reperfusion for ischaemic brain injury, quantitative ligand binding autoradiography was carried out in a model of reversible focal cerebral ischaemia. Endothelin-1 applied to the abluminal surface of the middle cerebral artery in anaesthetized Sprague-Dawley rats induced severe focal ischaemia and subsequent reperfusion (assessed by blood flow tracers [99mTc]HMPAO and [14C]iodoantipyrine respectively) by 2 h after insult. Ligand binding autoradiography on consecutive sections demonstrated these blood flow changes to be associated with a significant reduction in forskolin binding throughout the middle cerebral artery territory (e.g. 25% in parietal cortex, 11% in dorsolateral caudate nucleus). The most marked losses in forskolin binding were in areas where ischaemia was severe and reperfusion was poor. However, the same changes in cerebral blood flow had no significant effect on D1 dopamine receptor binding (e.g. < 2% reduction in the caudate nucleus). These data demonstrate that ligand binding characteristics are significantly affected as early as 2 h after insult, with evidence of differential sensitivity for forskolin and D1 dopamine binding. With regard to the consequences of reperfusion, comparison with our previous study of 2 h maintained ischaemia demonstrates reperfusion-related salvage of dopamine and forskolin binding in the caudate nucleus but possible exacerbation of forskolin binding loss in the cortex.

Longitudinal changes in cognitive function and regional cerebral function in Alzheimer's disease: a SPECT blood flow study

In Alzheimer's disease (AD), SPECT imagining of regional cerebral blood flow (rCBF) has emphasized deficits in the posterior association cortex. Previous studies have shown an association between these deficits and cognitive performance, both on overall cognitive tests and more specific tests such as praxis and language. Frontal deficits have been reported in more severe patients. This has led to the conclusion that the deficit in AD, at least with functional neuroimaging, starts in the posterior association cortex, and later in the disease process "spreads" to involve the frontal cortex. This study set out to measure, in a group of AD patients, the change over time of cognitive performance and the pattern of functional deficit measured by neuroimaging. Change in function was measured using 99TCm-HMPAO and SPECT and change in cognitive function using the CAMCOG. Two time points were used, 0 and 2 years. Twenty-four patients satisfying the DSM-III R criteria for probable AD were studied, nine of whom were subsequently diagnosed as having AD at post-mortem. The most striking finding was the effect that decreases in frontal lobe function had on cognitive function. A similar study by the same group, using the same techniques and many of the same patients but at only one time point, showed a correlation between cognitive function and rCBF in the parietal and posterior temporal lobes. This suggests that as AD patients deteriorate from unaffected to mild or moderately affected, the posterior association cortex exerts the greatest effect on cognitive deficit. In this longitudinal study, we found, using a MANOVA, that there were significant decreases over time for all the cortical regions studied, but that no region decreased significantly more than any other. In addition we found a correlation between change in frontal rCBF and change in cognitive function (both overall cognitive function and the CAMCOG sub tests of language and praxis). These data suggest, in contrast to the previous study, that as the disease progresses from mild or moderate to moderate or severe, the frontal cortex exerts the greatest effect on cognitive decline. These data support the concept of the deficit in functional imaging spreading from posterior to anterior as the disease progresses. However, both the initial pattern of deficit and the change over time were very heterogeneous when examined qualitatively. A posterior to anterior spread is the predominant pattern for the group as a whole, but individual patients, and possibly groups of patients, may well show alternative patterns.

A randomised trial comparing mesalazine and prednisolone foam enemas in patients with acute distal ulcerative colitis

Distal ulcerative colitis can be treated with oral or rectal mesalazine, or both. A foam enema preparation has been developed and its efficacy investigated. The aim of this study was to evaluate the efficacy and safety of mesalazine foam enemas compared with prednisolone foam enemas in the treatment of patients with acute distal ulcerative colitis. Patients aged over 18 years presenting with a relapse of distal ulcerative colitis were randomly allocated treatment with mesalazine foam enema (n = 149 evaluable patients) and prednisolone foam enema (n = 146 evaluable patients) for four weeks. A randomised multicentre investigator blind parallel group trial was conducted. It was found that after four weeks of treatment, clinical remission was achieved by 52% of mesalazine treated patients and 31% of patients treated with prednisolone (p < 0.001). There was a trend in favour of more patients in the mesalazine group achieving sigmoidoscopic remission (40% v 31%, p = 0.10). Histological remission was achieved by 27% and 21% of patients receiving mesalazine and prednisolone respectively. Symptoms improved in both treatment groups. Significantly more mesalazine patients had no blood in their stools after four weeks of treatment (67% v 40%, p < 0.001). Prednisolone treated patients had significantly fewer days with liquid stools than mesalazine patients, with a median of 0 and 1 days respectively by week 4 (p = 0.001). In this study mesalazine foam enema was superior to prednisolone foam enema with regards to clinical remission, this was supported by favourable trends in sigmoidoscopic and histological remission rates. Both treatments were well tolerated.

Interictal temporal hypoperfusion is related to early-onset temporal lobe epilepsy

Previous studies of interictal regional cerebral blood flow (rCBF) in temporal lobe epilepsy have shown variable correlations with clinical measures. We used high spatial resolution hexamethyl propyleneamine oxime single photon emission computed tomography (HMPAO SPECT) in 80 consecutive patients with complex partial seizures (CPS), comparing results with those from a large series of normal subjects. Visual image analysis detected abnormalities of rCBF in 41 of 80 (51%; numeric analysis detected abnormalities in 38 of 80). Age at epilepsy onset was significantly younger in patients with temporal hypoperfusion (p = 0.002), and the frequency distribution of hypoperfusion versus age at epilepsy onset was reverse exponential. The results of numerical image analysis showed that degree of hypoperfusion did not vary with age at epilepsy onset. These data suggest a single insult operating early in life as a cause of temporal hypoperfusion, as has been shown for mesial temporal sclerosis (MTS). We could not demonstrate relationships with other clinical variables, including time since last seizure.

Eye patch treatment for the pain of corneal abrasion

The traditional use of patching and topical antibiotics in the treatment of corneal abrasion has recently been challenged, particularly after foreign body removal. In a prospective, controlled, randomized study of 33 patients treated in the emergency department for eye pain and corneal abrasion, we attempted to determine whether eye patching affected the pain of simple corneal abrasions. After fluorescein examination with magnification (x 5), a visual analog pain score was recorded and the patient was randomized to either the patched or nonpatched group. A standard analgesic was supplied, and all patients had follow-up at 24 hours, when repeat pain scores and analgesic use were recorded. The groups were compared by using the Wilcoxon's rank sum test, Student's t test, and analysis of covariance as required. There was no significant difference in the mean changes in pain scores between the patched and nonpatched groups. Analgesic use was also similar. We conclude that routine eye patching does not favorably affect the pain associated with the treatment of simple corneal abrasion.

Topographic profile of reperfusion into MCA territory following endothelin-1-induced transient focal cerebral ischaemia

This study examines the topographic profile of reperfusion into ischaemic tissue following reversible middle cerebral artery (MCA) occlusion. Autoradiographic images of both ischaemia and reperfusion were prepared from brain sections following transient ischaemia induced by endothelin-1 application to the exposed MCA in anaesthetised rats. Blood flow changes were assessed using double tracer autoradiography with 99mTc-exametazime during ischaemia (5 min) and 14C-iodoantipyrine during reperfusion (2 h). Following a significant ischaemic insult, reperfusion was relatively homogeneous within MCA territory but incomplete at 2 h. There was evidence for differential reperfusion in the cortex and caudate nucleus, and increased collateral supply from the anterior cerebral artery.

Molecular order and dynamics of phosphatidylcholine bilayer membranes in the presence of cholesterol, ergosterol and lanosterol: a comparative study using 2H-, 13C- and 31P-NMR spectroscopy

We report the results of a comparative study of the molecular order and dynamics of phosphatidylcholine (PC) bilayer membranes in the absence and presence of cholesterol, ergosterol and lanosterol, using deuterium (2H) nuclear magnetic resonance (NMR) of deuterated phospholipid molecules, in addition to solid state 13C and 31P-NMR. Using dimyristoylphosphatidylcholines (DMPCs) specifically labeled at positions 2', 3', 4', 6', 8', 10' and 12' of the sn-2 chain together with the perdeuterated 2-[2H27]DMPC derivative, the order profile for 9 of the 13 methylene groups of the sn-2 chain was established at 25 degrees C for DMPC, DMPC/cholesterol, DMPC/ergosterol and DMPC/lanosterol membranes, at a fixed sterol/phospholipid mol ratio of 30%, and in the presence of excess water. The overall ordering effects were found to be ergosterol > cholesterol >> lanosterol. Transverse relaxation (T2e) studies of these systems indicated that while for DMPC, DMPC/cholesterol and DMPC/ergosterol the relative relaxation rates were in qualitative agreement with models which assume cooperative motions of the bilayer molecules as the main relaxation mechanism, those in DMPC/lanosterol were anomalously high, suggesting alterations of lipid packing. Using dipalmitoylphosphatidylcholine (DPPC) deuterated at the trimethylammonium group of the choline moiety, we found that the differential ordering and motional effects induced by the sterols in the acyl chains were also reflected in the headgroup, both in the gel (L beta) and liquid-crystalline phases. 13C and 1H spin dynamics studies of these systems, including cross-polarization, rotating frame longitudinal relaxation and dipolar echo relaxation rates showed that the mobility of the different regions of the phospholipid molecules in the binary lipid systems were inversely correlated with the ordering effects induced by the sterols. A novel combination of C-D bond order parameters (obtained by 2H-NMR) and 13C-1H cross polarization rates confirmed these results. The effects of the same sterols at the same molar proportion on the unsaturated lipid 1-[2H31]palmitoyl-2-oleoyl-sn-glycero-3-phosphatidylcholine (2H31-POPC) at 25 and 35 degrees C were different from those observed on DMPC and showed ordering effects which are largest for cholesterol, while ergosterol and lanosterol produced significantly smaller effects. Transverse relaxation studies indicate that while cholesterol does not perturb cooperative motions in POPC, both ergosterol and lanosterol do. Again, high-resolution solid state 13C-NMR studies support the conclusions of the 2H-NMR experiments.(ABSTRACT TRUNCATED AT 400 WORDS)

Breaking the news. How families first learn about their child's chronic condition

OBJECTIVE

To develop recommendations for effectively informing families about their child's chronic illness or disability.

METHODS

The sample included 43 families of infants with Down syndrome and/or congenital heart disease who were participating in Project Resilience, which is a multisite longitudinal research project. Family interviews were transcribed verbatim and coded by two raters. Qualitative techniques were used to identify the factors that influenced family caregivers' reactions to learning that their child had been diagnosed as having a chronic condition.

RESULTS

Family caregivers clearly distinguished their personal emotional reactions to the diagnosis from their reactions to how providers informed them about their child's condition. Families emphasized the quality of information that they received as well as the manner in which they were told about the condition. Although two thirds of the informing incidents were positive, families also reported negative reactions to outdated and inadequate information as well as to professionals who were insensitive to their needs.

CONCLUSIONS

Resident and continuing education programs need to prepare physicians who can sensitively and effectively "break the news" to diverse families who have children with chronic conditions. At the time of diagnosis, clinicians need to PACE the news by (1) planning the setting, (2) assessing the family's background knowledge and experience, (3) choosing strategies that best fit the family's particular situation, and (4) evaluating the family's understanding of the information.

Focal cerebral hyperemia after focal head injury in humans: a benign phenomenon?

To assess the relationship between posttraumatic cerebral hyperemia and focal cerebral damage, the authors performed cerebral blood flow mapping studies by single-photon emission computerized tomography (SPECT) in 53 patients within 3 weeks of brain injury. Focal zones of hyperemia were present in 38% of patients. Hyperemia was correlated with clinical features and early computerized tomography (CT) and magnetic resonance (MR) imaging performed within 48 hours of the SPECT study and late CT and MR studies at 3 months. The hyperemia was observed primarily in structurally normal brain tissue (both gray and white matter), as revealed by CT and MR imaging, immediately adjacent to intraparenchymal or extracerebral focal lesions; it persisted for up to 10 days, but was never seen within the edematous pericontusional zones. The percentage of patients in the hyperemic group having brief (< 30 minutes) or no loss of consciousness was significantly higher than in the nonhyperemic group (twice as high, p < 0.05). Other clinical parameters were not significantly more common in the hyperemic group. The mortality of patients with focal hyperemia was lower than that of individuals without it, and the outcome of survivors with hyperemia was slightly better than patients without hyperemia. These results differ from the literature, which suggests that global post-traumatic hyperemia is primarily an acute, malignant phenomenon associated with increased intracranial pressure, profound unconsciousness, and poor outcome. The current results agree with more recent studies which show that posttraumatic hyperemia may occur across a wide spectrum of head injury severity and may be associated with favorable outcome.

Emergency ultrasound services as perceived by directors of radiology and emergency departments

Despite widespread concern that emergency ultrasound services are not widely available after regular business hours, data supporting or refuting this concern have not been reported. To determine the availability of emergency ultrasound services as perceived by directors of emergency departments (EDs) and radiology departments, direct mail survey was sent to both ED Directors and Directors of Radiology at 100 large teaching hospitals (more than 300 beds) and 100 smaller nonteaching hospitals (fewer than 300 beds) chosen at random from the American Heart Association Guide. Questions elicited the directors' perceptions of availability of emergency ultrasound services in their own institutions as well as their attitudes toward performance of ultrasound examinations by emergency physicians. The overall response rate was 53%. It was found that 24-hour in-house ultrasound services are rarely available even in large teaching hospitals, even as reported by Directors of Radiology. ED Directors and Directors of Radiology differ significantly in perceptions of ultrasound availability, clinical importance of emergency ultrasound, and desirability of ultrasound performance by ED physicians.

Characterization of a conjugative staphylococcal mupirocin resistance plasmid

We studied conjugative plasmids encoding high-level mupirocin resistance. These plasmids were found in Staphylococcus aureus isolates from two geographic locations in the United States. Transfer genes on three mupirocin resistance plasmids with different restriction endonuclease profiles were indistinguishable by DNA hybridization from those on pG01, a conjugative aminoglycoside resistance plasmid representative of similar plasmids that are prevalent in the United States. One mupirocin resistance plasmid, pG0400 (34 kb), was smaller than pG01 (52 kb) because of the absence from pG0400 of DNA, found on pG01, that contained genes encoding resistance to aminoglycosides, trimethoprim, and quaternary ammonium compounds flanked by directly repeated copies of the insertion sequence (IS)-like element IS431-IS257. The plasmids pG0400 and pG01 were otherwise indistinguishable except for the presence in pG0400 of a 4.5-kb HinDIII fragment encoding mupirocin resistance. The added mupirocin resistance gene was flanked by two directly repeated copies of IS431/257. The nucleotide sequence of DNA contiguous to the outside of the IS elements, as well as those of the elements themselves, was identical in both pG01 and pG0400, and there were no target site duplications flanking either copy of the element. We conclude that the mupirocin resistance gene was added to an existing conjugative plasmid in conjunction with the deletion of other resistance genes by recombination at IS elements. The construction of conjugative plasmids carrying a mupirocin resistance gene may be a model for the mobility of other resistance genes newly acquired by staphylococci.

Combining behavioral and self-help approaches in the inpatient management of dually diagnosed patients

The combination of a token economy and a self-help model made it feasible to organize and maintain an intensive dual-diagnosis treatment program in a public municipal hospital acute psychiatric ward. The program described here, which integrates the token economy and 12-step approaches, fosters voluntary and active patient participation in the process of simultaneous recovery from mental illness and addiction; it also networks the patient with community resources. Implementation of the clinical program involved addressing multiple clinical and organizational obstacles, including a multihandicapped and often nonmotivated patient population, a lack of psychiatric staff trained in managing substance abuse, and the need to integrate mental health with substance abuse clinical interventions. The program has been operating more than 5 years and has treated more than 1,000 patients. As the token economy became an integral part of the ward routine, violence on the ward declined substantially, and patient participation in group activities increased significantly.

Evaluation of technetium-99m exametazime stabilised with cobalt chloride as a blood flow tracer in focal cerebral ischaemia

A protocol has been devised to effectively extend the limited post-reconstitution shelf life of technetium-99m exametazime as a radiopharmaceutical for imaging cerebral blood flow (CBF) distribution. The potential of 99mTc-exametazime stabilised with cobalt chloride for imaging CBF distribution as late as 4 h after reconstitution has been examined in ischaemic and non-ischaemic tissue in halothane-anaesthetised cats. Focal cerebral ischaemia was produced by permanent middle cerebral artery occlusion. The relationship between 99mTc-exametazime uptake and retention and CBF (assessed with [14C]iodoantipyrine 10 min after first radiopharmaceutical administration) was determined in the same tissue section with double label autoradiography. Over the CBF range 0-80 ml 100 g-1 min-1, the uptake of 99mTc-exametazime (quantitatively and topographically) was linearly related to CBF irrespective of whether the 99mTc-labelled tracer was unstabilised (and administered within 10 min of reconstitution) or was stabilised with cobalt chloride (and administered up to 240 min after reconstitution). For levels of CBF in excess of 80 ml 100 g-1 min-1 the excellent topographical relationship between 99mTc-exametazime distribution and CBF is maintained but quantitatively, 99mTc-exametazime underestimates CBF to a similar degree in animals receiving stabilised and unstabilised 99mTc-exametazime. The presence of the stabiliser, cobalt chloride, extends greatly the period over which 99mTc-exametazime can be used after reconstitution to generate images of CBF distribution in normal and ischaemic cerebral tissue.

Effects of exercise training modality on glucose tolerance in men with abnormal glucose regulation

To determine the effects of exercise training modality on glucose tolerance in men with untreated abnormal glucose regulation, 26 untrained men (age 54 +/- 9 years; mean +/- SD) with either non-insulin-dependent diabetes mellitus (N = 8), impaired glucose tolerance (IGT) (N = 12) or hyperinsulinemia with normal glucose tolerance (N = 6) were studied before and after 20 wk of either strength training (ST) (N = 8), aerobic (treadmill walk/jog) training (AT) (N = 8), or no exercise (control group; N = 10). Plasma concentrations of glucose and insulin were measured after a 12-14 hr fast and during a standard oral glucose tolerance test (OGTT) before and after training. The ST program significantly reduced total plasma glucose area (mmol.l-1.120 min-1) under the OGTT curve (1348 +/- 251 vs 1190 +/- 329, p < 0.05), and plasma glucose levels (mmol.l-1) at 60 min (p < 0.05), 90 min (P < 0.05), and 120 min (p < 0.05) after glucose ingestion. Strength training also lowered the total plasma insulin area (pmol.l-1.120 min-1) under the OGTT curve (60082 +/- 25467 vs 46727 +/- 11273, p < 0.05) as well as plasma insulin levels (pmol.l-1) at fasting (p < 0.05) and at 90 min (p < 0.01) and 120 min (p < 0.05) after glucose ingestion. All men with IGT (four in each training group) normalized their glucose tolerance following the training. There were no significant differences in OGTT results between ST and AT and no changes were observed in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

1% lidocaine versus 0.5% diphenhydramine for local anesthesia in minor laceration repair

STUDY OBJECTIVE

Our previous study demonstrated that 1% diphenhydramine is as effective as 1% lidocaine for anesthesia in minor laceration repair, but that it also is more painful to inject. The purpose of this study was to compare 0.5% diphenhydramine to 1% lidocaine for pain of injection and adequacy of local anesthesia.

STUDY DESIGN

Randomized, double-blinded, prospective study from December 1991 through June 1992.

SETTING

University-affiliated, urban, inner-city emergency department.

PARTICIPANTS

Ninety-eight adults with linear skin lacerations without end-organ involvement were included; 48 received lidocaine and 50 received diphenhydramine.

INTERVENTIONS

Wounds were anesthetized with either diphenhydramine or lidocaine according to a random table. Both patients and physicians rated the pain of injection and suturing according to a standard, previously tested, visual analog scale.

MEASUREMENTS AND MAIN RESULTS

Patient and physician ratings were ranked without regard to treatment group, and rank sum scores were calculated for each group. General linear models and multivariate analysis of variance were used to analyze the ranked sum scores. The power of the study to detect a ranked sum difference of 15 was 0.8 with P < .05 considered statistically significant. Lidocaine was found to be significantly more effective as a local anesthetic for facial lacerations according to both patients (P < .002) and physicians (P < .004). There was no statistically significant difference between 1% lidocaine and 0.5% diphenhydramine for pain of injection or suturing for all other locations according to both patients and physicians. Overall mean and median scores for injection and suturing with diphenhydramine corresponded to the mild pain category according to patients.

CONCLUSION

Although not a replacement for lidocaine, diphenhydramine is a viable alternative for anesthesia in the repair of minor lacerations.

Fluorine-19 nuclear magnetic resonance spectroscopic study of fluorophenylalanine- and fluorotryptophan-labeled avian egg white lysozymes

We report the 470-MHz (11.7 T) 19F solution nuclear magnetic resonance (NMR) spectra of 2-, 3-, and 4-fluorophenylalanine incorporated into the egg white lysozymes (EC 3.2.1.17) of chicken, pheasant, and duck, as well as spectra of 4-fluorotryptophan incorporated into chicken, California valley quail, and Bob White quail and 5- and 6-fluorotryptophan-labeled chicken lysozyme. The 19F solution NMR spectrum of [4-F]Phe hen egg white lysozyme (HEWL) consists of three sharp resonances, which span a total chemical shift range of 4.8 ppm (at p2H = 6.1). For [3-F]Phe HEWL, the chemical shift range is much smaller, 1.0 ppm (at p2H = 5.9), due presumably to the occurrence of fast phenyl ring flips about the C beta-C gamma bond axis. For [2-F]Phe HEWL, six resonances are observed, spanning a chemical shift range of 7.4 ppm (at p2H = 5.8), due to slow C beta-C gamma ring flips, i.e., both ring-flip isomers appear to be "frozen in" because of steric hindrance. Rotation of the [2-F]Phe residues remains slow up to 55 degrees C (p2H = 4.7). With the [F]Trp-labeled proteins, we find a maximal 14.6-ppm shielding range for [4-F]Trp HEWL but only a 2.8- and 2.4-ppm range for [5- and 6-F]Trp HEWL, respectively, due presumably to increased solvent exposure in the latter cases. Guanidinium chloride denaturation causes loss of essentially all chemical shift nonequivalence, as does thermal denaturation. Spectra recorded as a function of pH show relatively small chemical shift changes (< 1.4 ppm) over the pH range of approximately 1.2-7.8.(ABSTRACT TRUNCATED AT 250 WORDS)

Editing 13C-NMR spectra of membranes

We report the carbon-13 'magic-angle' sample-spinning nuclear magnetic resonance (NMR) spectra of several lipid-water systems, under a variety of radiofrequency excitation conditions. Our results show that complex lipid or membrane spectra can be greatly simplified by using 'spectral editing' techniques. For example, in a 1,2-dimyristoyl-sn-glycero-3-phosphocholine (DMPC)-water mesophase, the glycerol (C-1, C-2 and C-3) carbons are readily distinguished from the headgroup C alpha, C beta and C gamma carbons, on the basis of their mix-time behavior in a cross-polarization (CP) experiment, while in the more complex DMPC/cholesterol-water system, many of the more rigid cholesterol carbon resonances can be edited from the phospholipid peaks. In very complex systems, such as human myelin membranes, editing permits the unambiguous observation of the mobile lipid headgroup carbon resonances, as well as the much more rigid sterol ring carbons. We also report the observation of a large differential CP due to C-H vector 'magic-angle' orientational effects in the DMPC/desipramine system. Thus, both motional or orientational reduction of the C-H dipolar interaction can lead to considerable simplifications of complex membrane spectra, and are of interest from both spectral assignment and membrane dynamics aspects.

Collaboration in coronary heart disease prevention

Health visitors are ideally placed in primary care to offer effective dietary and life-style advice as part of a team approach to coronary heart disease prevention, write Alan Jones et al. Results from a dietary and life-style intervention trial programme suggest that dietitians, who are limited in numbers, should be used as a resource to provide expert dietary advice and training to the more numerous health visitors. In this way CHD risk factor identification can be developed into effective intervention.

Deficits in iodine-labelled 3-quinuclidinyl benzilate binding in relation to cerebral blood flow in patients with Alzheimer's disease

A loss of acetylcholine is one of the most consistent neurochemical findings in Alzheimer's disease (AD) post-mortem, but the debate concerning receptor abnormalities is unresolved. The aim of this investigation was to measure the density of acetylcholine muscarinic receptors in AD patients at various stages in the disease (N = 8) by synthesising a radio-iodinated version of quinuclidinyl benzilate QNB, a potent muscarinic antagonist. Deficits were identified by comparison with a control data set obtained from four elderly volunteers and then compared to the deficit in total functional activity in the same brain regions measured using the cerebral perfusion tracer technetium-99m hexamethylpropylene amine oxime. Iodine-123 (R,R)quinuclidinyl benzilate (QNB) was synthesised using a CuI assisted nucleophilic aromatic exchange reaction. 160 MBq of the radioligand (specific activity 400 Ci/mmol: dose 90 ng/kg) was administered to each subject. Diagnosis of AD was made using the CAMDEX and DSMIIIR criteria with a physical examination, full blood screen, CT and chest X-ray. All subjects were scanned at 21 h post injection on an SME810 emission tomograph. 123I(R,R)QNB activity in the controls was found to be consistent with the known distribution of muscarinic receptors with no activity in the cerebellum and low activity in the thalamus. In the AD patients deficits in 123I-QNB binding which exceeded the corresponding total functional regional perfusion deficit were not found in six of the patients and were observed only in the two most severely affected patients, both of whom were untestable on the cognitive battery.(ABSTRACT TRUNCATED AT 250 WORDS)

Ictal/postictal SPECT in the pre-surgical localisation of complex partial seizures

Single photon emission computed tomography (SPECT) used in conjunction with HM-PAO (Ceretec-Amersham International) was used to image regional cerebral blood flow (rCBF) in 28 patients with medically intractable complex partial seizures during or soon after a seizure, and interictally. Changes from interictal rCBF were seen in 26/28 (93%) patients. The main findings were; 1) During the seizure--hyperperfusion of the whole temporal lobe; 2) Up to 2m postically--hyperperfusion of the hippocampus with hypoperfusion of lateral temporal structures; 3) From 2-15m postically--hypoperfusion of the whole temporal lobe. When compared with EEG and MRI data, correct localisation to one temporal lobe was obtained in 23 patients. In one further patient bilateral temporal foci, and in a further two patients frontal foci, were correctly identified. There were no disagreements between EEG and SPECT localisation. Temporal lobe surgery was successful (by the criterion of at least 90% reduction in seizure frequency) in all but one of the 23 patients operated on. It is concluded that ictal/postictal SPECT is a reliable technique for the presurgical localisation of complex partial seizures. The data indicate a likely sequence of changes in rCBF during and after complex partial seizures of temporal lobe origin.