Clinical phenotypes of cardiac sarcoidosis by latent class analysis

Background

Sarcoidosis is a systemic granulomatous disease with cardiac involvement reported in 20–27% of patients [1]. Cardiac sarcoidosis (CS) can lead to atrial or ventricular arrhythmias, various conduction system disorders, heart failure or sudden cardiac death, depending on the location of myocardial involvement [2]. Previous studies have investigated the possible types of CS based on the distribution of myocardial involvement on imaging as well as the role of genetic factors [3,4]. However, there are no studies describing the clinical heterogeneity of CS patients.

Purpose

In order to determine if clinical clusters exist in CS, we carried out a latent class analysis (LCA) to explore potential phenotypes in a large sample of CS patients from the National Inpatient Sample (NIS).

Methods

We identified 848 patients with a diagnosis of CS from the NIS in 2016–2018. A LCA was performed based on comorbidities. Utilizing the Bayesian information criterion and Akaike's information criterion we divided our study population into 3 cohorts. We subsequently applied the LCA model for our study population to fit each patient into one of the 3 cohorts. Finally, we compared the clinical outcomes among the 3 groups.

Results

Following LCA, patients in cohort 3 were strongly associated with a cardiometabolic syndrome profile with the highest prevalence of congestive heart failure (CHF, 95.1%), chronic kidney disease (CKD, 69.7%), diabetes mellitus (68.9%), hyperlipidemia (52.5%) and obesity (45.1%). Patients in cohort 2 had an intermediate prevalence of cardiometabolic syndrome with a universal diagnosis of hypertension (100%) but with the lowest number of CHF (32.5%) patients and none with CKD. Finally, patients in cohort 1 had the least comorbidities in comparison to the other groups but there was a higher prevalence of CHF (71.7%). There was no significant difference in mortality among the 3 groups, but acute respiratory failure was the highest in cohort 3. However, ventricular arrhythmias were more prevalent in cohort 1 patients (Table).

Conclusion

We identified 3 different types of CS based on their clinical phenotype. The clinical outcomes varied among the cohorts with ventricular arrhythmias being the most prevalent in patients with the least cardiometabolic comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Postpartum atypical hemolytic uremic syndrome: Evaluating thrombotic microangiopathy in the pregnant woman

Acute kidney injury in women during pregnancy and the puerperium is often ascribed to hypertensive complications of pregnancy, especially pre-eclampsia. However, rarer causes, including atypical hemolytic uremic syndrome (aHUS) can be triggered by pregnancy. We present a case of a woman with post-partum acute kidney injury due to aHUS, which was successfully treated with the C5a inhibitor eculizumab. We also present a summary of the evaluation and management of thrombotic microangiopathy in pregnancy.

Solid pseudopapillary tumour of pancreas

Solid pseudopapillary tumour of pancreas (SPT) is an extremely rare pancreatic tumour, which has a low malignant potential and occurs mainly in young women. Pathologic and imaging findings include a well defined encapsulated pancreatic mass with cystic and solid components with evidence of haemorrhage. This is a case of a 16 years old girl who presented with upper abdominal pain of long duration and epigastric mass on palpation. Computed Tomography (CT) scan demonstrated a large well defined heterogenous attenuation mass of solid enhancing and cystic non enhancing areas, arising from the head of the pancreas. Radiologically it was diagnosed as a case of pancreatic neoplasm. Fine needle aspiration cytology (FNAC) and histopathology of the biopsy material diagnosed as solid pseudopapillary tumour of pancreas.

Light induced toxicity of merocyanine 540-silica nanoparticle complex

The electrostatic binding between the negatively charged lipophilic dye Merocyanine 540 and silica nanoparticles having 3-amino propyl groups at the surface has been characterized using absorption and fluorescence spectroscopy. The binding of the dye with the nanoparticle resulted in significant changes in its absorption spectra. Further the fluorescence intensity and lifetime gets enhanced by more than an order of magnitude. The results obtained suggest that this is due to the reduced photoisomerization rate of the dye bound to the nanoparticle. Consistent with the expectation that a reduction in the photoisomerization rate should enhance the singlet oxygen yield of the dye via intersystem crossing, the light induced toxicity of the dye-nanoparticle complex (tested with MCF cells) was observed to be higher compared to the free dye.

SilkSatDb: a microsatellite database of the silkworm, Bombyx mori

The SilkSatDb (silkmoth microsatellite database) (http://www.cdfd.org.in/silksatdb) is a relational database of microsatellites extracted from the available expressed sequence tags and whole genome shotgun sequences of the silkmoth, Bombyx mori. The database has been rendered with a simple and robust web-based search facility, developed using PHP. The SilkSatDb also stores information on primers developed and validated in the laboratory. Users can retrieve information on the microsatellite and the protocols used, along with informative figures and polymorphism status of those microsatellites. In addition, the interface is coupled with Autoprimer, a primer-designing program, using which users can design primers for the loci of interest.

Clipping of cerebral aneurysm under hypothermic cardiac arrest and simultaneous coronary artery bypass grafting: case report

This report describes a case where joint neurological and cardiac surgery teams cooperated to perform simultaneous procedures of clipping a complex internal carotid artery under hypothermic cardiac arrest and coronary artery bypass grafting. A 69 year old man was evaluated for complaints of double vision, pain behind his right eye, and progressively worsening headaches. Examination showed bilateral upgoing toes and difficulty performing a tandem gait. The patient had a history of myocardial infarction. Brain MRI showed a 1.6 cm diameter, partially thrombosed aneurysm of the right internal carotid artery and posterior communicating artery. Cardiac catheterisation showed critical coronary artery disease of the distal segment of the right coronary artery with 90% stenosis of the midcircumflex artery and an ejection fraction of 40%. After initial exposure of the aneurysm, the cardiac team instituted hypothermic cardiac arrest (21 degree C). The aneurysmal sac was collapsed and dissected from the surrounding perforators. An encircling fenestrated clip was applied and a small part of the neck of the aneurysm was further clipped with straight clips. The cardiac surgery team performed the coronary artery bypass grafting procedure. The patient recovered fully, returned to his normal activities, and is functioning independently.

Induction of phr gene expression in E. coli strain KY706/pPL-1 by He-Ne laser (632.8 nm) irradiation

We have observed that He-Ne laser irradiation of E. coli strain KY706/pPL-1 leads to induction of photolyase gene, phr. The magnitude of induction was found to depend on the He-Ne laser fluence, fluence rate and post-irradiation incubation period in the nutrient medium. The optimum values for fluence and fluence rate were 7x10(3) J/m(2) and 100 W/m(2), respectively, and the induction of phr gene was observed to saturate beyond an incubation period of approximately 2 h. Experiments carried out with singlet oxygen quenchers and with D(2)O suggest that the effect is mediated via singlet oxygen. Photoreactivation studies carried out after UVC exposure of both the He-Ne laser-exposed as well as unexposed cells showed a larger surviving fraction in the He-Ne laser pre-irradiated cells. This can be attributed to He-Ne laser irradiation-induced induction of phr expression. However, since even without photoreactivating light He-Ne laser pre-irradiated cells show higher survival against UVC radiation it appears that He-Ne laser irradiation induces both light-dependent as well as dark DNA repair processes.

Absorption and accumulation of nitrate in plants: influence of environmental factors

Plants adopt various strategies to fulfill their nitrogen nutrition requirement, the most important being the uptake of nitrate from the soil and its subsequent assimilation in to amino acids. The uptake of nitrate is energy dependent and is an active process involving high affinity and low affinity transport systems. The net uptake of the anion depends upon both influx as well as on its passive efflux. When the uptake far exceeds over its assimilation in the plant, there is considerable accumulation of nitrate in the plant parts making them unfit for human and cattle consumption. Various environmental factors affect the uptake and accumulation of nitrate, which along with the genetic component of the plant affecting the net uptake and accumulation of the nitrate, need to be considered and carefully manipulated for effective nitrogen management in the plant, soil and aquatic environment.

Anterior cervical instrumentation enhances fusion rates in multilevel reconstruction in smokers

This retrospective consecutive case study evaluated the effect of anterior plating on multilevel anterior cervical decompressions and fusions in smokers and non-smokers. Multilevel anterior cervical decompression and fusion surgery in smokers provides an important challenge. Higher nonfusion rates in smokers have been reported. Cigarette smoking has been shown to interfere with bone metabolism and revascularization and to suppress bone formation. One hundred six patients underwent anterior cervical decompression and fusion using autografts or allografts and anterior plating. The minimum follow-up was 12 months. The mean age was 50.12 years (+/- 11.72; range, 27 to 80 years). Autografts were used in 90 patients and allograft in 16. The mean level fused was 2.74 (+/- 0.61). Forty-six (45.5%) patients were smokers. Successful fusion was achieved in all but three patients (97.17%). C5 root weakness was seen in four patients (3.8%); two patients experienced acute airway obstruction, of which one required tracheotomy. Temporary recurrent laryngeal nerve palsy developed in three (2.8%) patients. A fusion rate of 97% was achieved in multilevel anterior cervical decompression and fusions using anterior plating. No difference in fusion rates between smokers and nonsmokers was seen. Anterior cervical plating markedly improved the fusion rate in smokers.

Outcomes after posterolateral lumbar fusion with instrumentation in patients treated with adjunctive pulsed electromagnetic field stimulation

Fusion success and clinical outcome were determined in 48 high-risk patients who underwent posterolateral lumbar fusions with internal fixation and were treated with adjunctive pulsed electromagnetic field (PEMF) stimulation postoperatively. An independent radiographic assessment demonstrated a success rate of 97.9%. Following treatment, 59% of the working patients returned to their employment. Overall clinical assessment was excellent in 4.2% of patients, good in 79.2%, and fair in 16.7%; no patient had a poor clinical assessment.

N2 laser-induced oxidation of hemoproteins in red blood cell lysate

Irradiation of red blood cell lysate with a N(2) laser (337 nm) was observed to induce oxidation of hemoproteins. This process showed a strong dependence on the concentration of red blood cell lysate and the dose of radiation. Studies of mechanisms and experiments with deoxygenated red blood cell lysate rule out involvement of any reactive oxygen species and suggest that the process is not a photodynamic reaction.

Activation of expression of the c-fos oncogene by UVA irradiation in cultured human skin fibroblasts

Both broad-spectrum and near-monochromatic (334 nm, 365 nm and 405 nm) UVA (320-380 nm) and near-visible radiations strongly activate accumulation of mRNA corresponding to the nuclear oncogene and transcription factor, c-fos, in cultured human skin fibroblasts within a dose-range encountered in the environment. The oxidizing component of UVA is clearly of central importance to the activation observed because the absence of reduced glutathione strongly enhances the response. In contrast to observations in rodent cells, we observe negligible activation of the gene in human cells after UVB (290-320 nm) radiation. The results of this study provide evidence that UVA radiation strongly activates c-fos gene expression in human dermal fibroblasts, a phenomena that is likely to be reflected in UVA-mediated modulation of genes containing active AP-1-based enhancer elements in the promoter region.

An overview of cerebral aneurysms. Which factors affect the outcome of microsurgical treatment

There is a higher incidence of subarachnoid hemorrhage (SAH) with advancing age. Considerable controversy exists as to whether aggressive therapy is indicated in the elderly. With increased life expectancy, a greater number of elderly patients with SAH will require treatment in the future. This study was undertaken to evaluate the effect of age, aneurysm characteristics, Hunt-Hess grade on admission, race, and smoking status to the eventual outcome. The results of 76 consecutive aneurysms clipped in 67 patients by a single surgeon (B.B.) were analyzed. Among the variables, Hunt-Hess grade at admission seemed to be the only significant factor influencing the outcome in this series (X2MH = 17.136, p < 0.001). Advancing age did not worsen the prognosis after SAH and therefore age should not be a contraindication for aggressive management.

Catalytic mechanism and specificity for hydrolysis and transglycosylation reactions of cytosolic beta-glucosidase from guinea pig liver

Cytosolic beta-glucosidase (CBG) from mammalian liver is known for its broad substrate specificity and has been implicated in the transformation of xenobiotic glycosides. CBG also catalyzes a variety of transglycosylation reactions, which have been been shown with other glycosylhydrolases to function in synthetic and genetic regulatory pathways. We investigated the catalytic mechanism, substrate specificity, and transglycosylation acceptor specificity of guinea pig liver CBG by several methods. These studies indicate that CBG employs a two-step catalytic mechanism with the formation of a covalent enzyme-sugar intermediate and that CBG will transfer sugar residues to primary hydroxyls and equatorial but not axial C-4 hydroxyls of aldopyranosyl sugars. Kinetic studies revealed that correction for transglycosylation reactions is necessary to derive correct kinetic parameters for CBG. Further analyses revealed that for aldopyranosyl substrates, the activation energy barrier is affected most by the presence of a C-6 carbon and by the configuration of the C-2 hydroxyl, whereas the binding energy is affected modestly by the configuration and substituents at C-2, C-4, and C-5. These data indicate that the transglycosylation activity of CBG derives from the formation of a covalently linked enzyme-sugar intermediate and that the specificity of CBG for transglycosylation reactions is different from its specificity for hydrolysis reactions.

Anterior cervical fusion using Caspar plating: analysis of results and review of the literature

BACKGROUND

Ninety-seven patients underwent anterior cervical fusions after discectomy and/or corpectomy. Fibular allograft was used in 13 cases and iliac crest was used in the remaining 84 patients.

METHODS

Lateral cervical spine X-rays were reviewed for evaluation of fusion and instrumentation failures.

RESULTS

Solid fusion was achieved in all but two patients (97.91%). Nineteen patients developed instrumentation related failures. Seven patients developed fracture of one screw each (one superior and six inferior). Ten patients developed screw back out (inferior screw) and in one patient the superior screws were found to be 2 mm posterior to the posterior cortex but did not cause any neurological deficits. Seven of these patients underwent revision surgery. No complications related to the instrumentation were encountered in the last 34 cases. There were no infections in this series. Five patients developed temporary dysphagia. Two developed temporary deltoid weakness and three patients developed transient recurrent laryngeal nerve palsy. One developed acute airway obstruction but the patient had a pre-existing epiglottic anomaly and sleep apnea disorder.

CONCLUSIONS

In selected cases, the Caspar plating system affords an effective means of improving the fusion rate (97.91%) with acceptable instrumentation-related morbidity that improves with experience, (10.7% in the first 38 cases and 1.69% in the last 59 with an overall rate of 7.2%). Temporary neurological deficits seen in this series were probably not related to the Caspar plating procedure itself. Intraoperative fluoroscopic films can be misleading. Therefore regular lateral cervical spine X-rays postplating in the operating room prior to closure are recommended. Lower screws backed out in all failures and this was circumvented by using the bigger (rescue) screws at the inferior end of long constructs.

Correlation between UVA-induced changes in microviscosity, permeability and malondialdehyde formation in liposomal membrane

The lipid peroxidation, 14C-glucose leakage and microviscosity of liposomal membrane increased linearly with increasing UVA fluence. A positive and highly significant correlation was found between these properties of the UVA-exposed liposomal membrane. The possible involvement of singlet oxygen in the UVA-induced damage of liposomal membrane is discussed.

On the induction of protective responses in Salmonella typhimurium strain TA1535/pSK1002 by UVA (365 nm)

Exposure to UVA (365 nm) led to growth delay, loss of viability and inhibition of 3H-thymidine incorporation into the cells of Salmonella typhimurium strain TA1535 containing multiple copies of a plasmid pSK1002 carrying a umuC'-'lacZ fusion gene. Ultraviolet-A induced umu gene expression, as monitored by the estimation of beta-galactosidase, in a linear fluence-dependent manner. The induction of umu gene expression increased with the increase of postirradiation incubation period of the cells in the LB-ampicillin (LBA) medium at 37 degrees C and leveled off from 2 h onward. The induction of gene expression depended on concomitant protein synthesis and represented the induction of the SOS response in the particular S. typhimurium cells used. The exposure to low fluences (sublethal) of UVA also led to the induction of an adaptive response in the same bacterial cells, which made them resistant to subsequent challenge by a much higher fluence of the same radiation. The adaptive response, as monitored by the assays of viability and beta-galactosidase units, increased with the period of exposure to sublethal fluences of UVA, attained a maximum at the UVA exposure of 4.5 kJ/m2 (15 min) and thereafter gradually decreased with further increase of UVA exposure period. Modulation studies involving D2O, LBA growth medium, different scavengers of free radicals and quenchers of activated oxygen species indicated the involvement of both hydroxyl free radicals and singlet oxygen in the UVA-induced umu gene expression.

UVA-induced peroxidation of lipid in the dried film state

Exposure of a dried lipid thin film to UVA produced a dose-dependent linear increase in the three peroxidation products, conjugated diene, lipid hydroperoxide and malondialdehyde (MDA). All three lipid peroxidation products exhibited an inverse dose rate effect. Identical amounts of malondialdehyde were produced when the lipid film was exposed to UVA either directly or through the thickness of the Corning glass on which the film was cast. Antioxidants, alpha-tocopherol, butylated hydroxytoluene (BHT) and the singlet oxygen quencher beta-carotene significantly inhibited the UVA-induced peroxidation of the lipid film. The biological implications of the UVA-induced peroxidation of the dried lipid film are discussed.

Effect of UV-A on the linolenic acid micelles

UV-A produced a dose-dependent linear increase of peroxidation in linolenic acid micelles as detected by the assay of (i) conjugated dienes, (ii) hydroperoxides, (iii) malondialdehyde (MDA), and (iv) the fluorescent adduct formed by the reaction of MDA with the amino acid, glycine. While sodium formate, dimethyl sulfoxide, superoxide dismutase, and ethylenediamine-tetraacetic acid produced no significant inhibition, some generally used singlet oxygen quenchers, beta-carotene, dimethylfuran, L-histidine, and sodium azide, caused significant inhibition of the UV-A-induced peroxidation of the linolenic acid micelles. alpha-Tocopherol and butylated hydroxytoluene produced more than 90% inhibition of the UV-A-induced peroxidation. ESR spectrometry revealed the formation of 2,2,6,6-tetramethylpiperidine oxide in the UV-A-irradiated aqueous solution of 2,2,6,6-tetramethylpiperidine. The involvement of singlet oxygen (1O2) in the UV-A-induced peroxidation of linolenic acid micelles is discussed.

An audit of preschool vision screening

An audit was carried out to clarify the dispute surrounding the vision screening test at 3.5 years. The uptake was 53.5%, sensitivity 77%, specificity 96%, and positive predictive value 50%. In particular the uptake was poor and the test needed a clear policy for the future.

Membrane lipid peroxidation by UV-A: mechanism and implications

UV-A produced a dose-dependent linear increase of lipid peroxidation in liposomal membrane, as detected by the assay of (i) conjugated dienes, (ii) lipid hydroperoxides, (iii) malondialdehydes (MDA), and (iv) the fluorescent adducts formed by the reaction of MDA with glycine and also a linear dose-dependent increase of [14C]glucose efflux from the liposomes. UV-A-induced MDA production could not be inhibited by any significant degree by sodium formate, dimethyl sulfoxide, EDTA, or superoxide dismutase but was very significantly inhibited by butylated hydroxytoluene, alpha-tocopherol, sodium azide, L-histidine, dimethylfuran, and beta-carotene. MDA formation increased with an increase in the D2O content in water, leading to a maximal amount of nearly 50% enhancement of lipid peroxidation in 100% D2O vis-à-vis water used as dispersion medium. The experimental findings indicate the involvement of singlet oxygen as the initiator of the UV-A-induced lipid peroxidation.

An approach towards understanding the genesis of sunlight-induced skin cancer

The molecular basis of the sunlight-induced skin carcinogenesis has been elucidated. Of the two ultraviolet components of sunlight that reach the earth's surface the UV-B is known to be carcinogenic but the mode of action of UV-A, the predominant component of sunlight, is ill understood. Using the liposomes as a model system, it has been shown here that UV-A causes dose-dependent lipid peroxidation as estimated by measurements of conjugated dienes, lipid hydroperoxides, malondialdehydes and the fluorescent adducts (Schiff bases) produced by the reaction of MDA with glycine. Direct exposure to sunlight has also been shown to cause dose-dependent lipid peroxidation. The UV-A induced lipid peroxidation has also been shown to be dependent on dose rate. While the sodium formate, dimethyl sulphoxide, superoxide dismutase and EDTA do not have any significant effect, sodium azide, histidine, beta-carotene and dimethylfuran were shown to inhibit significantly the UV-A induced lipid peroxidation, thereby providing significant evidence of the involvement of singlet oxygen (1O2) as the initiating agent. The use of D2O in place of H2O as the liposome dispersing medium enhanced to great extent the UV-A induced lipid peroxidation, thereby lending additional support to the finding that singlet oxygen was the initiating agent. The possible mode of formation of 1O2 on exposure to UV-A was discussed. This study also highlighted the role of environmental factors on the sunlight-induced cutaneous damage. Finally, the relation between lipid peroxidation, DNA damage and carcinogenesis has been discussed in a way to suggest the possible link between sunlight exposure and causation of skin cancer.

CO2 reactivity and heterogeneity of cerebral blood flow in ischemic, border zone, and normal cortex

Regional arterial CO2 tension (PaCO2) reactivity of cerebral blood flow (CBF) and the effect of PaCO2 on the spatial and temporal heterogeneity of CBF were investigated by using autoradiographically determined CBF in the rat middle cerebral artery occlusion model after a 2-h period under pentobarbital anesthesia to clarify the relation between PaCO2 reactivity, CBF heterogeneity, and the temporal cycling of CBF. PaCO2 was adjusted to one of four levels. CBF was determined in four cortical areas and white matter using the tissue fractionation of [14C]iodoantipyrine [( 14C]IAP) in combination with vessel mapping using in vivo 4% thioflavine S. Specific PaCO2 reactivity and CBF were normal in the nonischemic cortex, normal, although slightly depressed, in the border zone far from the ischemic core area, and depressed in the border zone adjacent to the ischemic core area (P less than 0.001) and the ischemic core (P less than 0.001). In normocapnic and hypocapnic animals, CBF heterogeneity in the form of regularly spaced CBF columns perpendicular to the cortical surface was observed in the nonischemic hemisphere but was absent in the ischemic core area. In hypercapnic rats, flow columns were present in the ischemic core areas and border zones but were absent on the nonischemic side. There was a highly significant interaction (P less than 0.0001) in observer-determined heterogeneity grades between PaCO2 level and each of three areas, normal, border zone, and ischemic core. In normal cortex, comparison of the thioflavine S-stained vessels with the flow columns provided evidence supporting the concept of capillary recruitment and cycling as a mode of normal cerebral blood flow control. The presence of flow columns in severely ischemic areas in hypercapnic animals indicates that a short period of high PaCO2 transiently augments microregional flow and could enhance the delivery of a therapeutic agent to these microregions of the ischemic core. The regional analysis of PaCO2 reactivity suggests an index of future tissue viability.

Evolving focal cerebral ischemia in cats: spatial correlation of nuclear magnetic resonance imaging, cerebral blood flow, tetrazolium staining, and histopathology

The spatial correlation of nuclear magnetic resonance imaging (NMRI) and cerebral blood flow (CBF) may improve our ability to identify ischemic brain lesions and may provide further insight into the pathophysiology of early cerebral ischemia. Eleven pentobarbital-anesthetized adult cats underwent exposure of the common carotid arteries bilaterally and the right middle cerebral artery through a transorbital approach. Baseline NMRI images were obtained with a single spin-echo, multislice technique using a 0.6-T field, 0.4-cm slice thickness, and a surface coil. Focal ischemia was produced with right middle cerebral artery occlusion and potentiated with bilateral common carotid artery ligation. Sequential NMRI studies were then performed at 1, 2, 4, 6, and 12 hours or until CBF was determined in the same cats using [14C]iodoantipyrine at either 2 (n = 2), 4 (n = 2), 6 (n = 2), or 12 (n = 1) hours after the time of occlusion. This protocol allowed temporal and spatial correlation of NMRI and CBF. Alternate 5-mm brain slices were incubated with 1% 2,3,5-triphenyltetrazolium chloride (TTC) for 45 minutes at 37-41 degrees C and frozen in liquid Freon for later autoradiographic CBF determination. Four cats were studied only with NMRI and TTC (not CBF). The correlation between areas of increased NMRI signal intensity observed in T2-weighted images (repetition time 2,000 msec, echo time 120 msec), vital staining with TTC, low CBF, and routine histology was evaluated. During the early phase (less than 6 hours), T2-weighted NMRI changes were localized to the central ischemic gray matter areas, as defined in the later CBF images, with no involvement of the white matter. By the twelfth hour the NMRI changes involved the entire ischemic area including gray and white matter. The initial visible changes seen on T2-weighted NMRI are suggestive of cellular edema, and the later changes are characteristic of vasogenic edema. The spread of NMRI changes compared with the ischemic area determined from autoradiographic CBF is consistent with the previously described biphasic evolution of ischemic injury. These data suggest that T2-weighted NMRI could be used clinically to delineate areas of acute ischemic stroke.

A once daily theophylline preparation in prevention of nocturnal symptoms in childhood asthma

Twenty school children with chronic asthma who despite regular prophylactic therapy continued to have troublesome nocturnal wheeze or cough entered a double-blind cross-over study in which a once daily theophylline preparation was compared with placebo to assess control of these symptoms. Seventeen children completed both phases of the study. Significant improvement was noted in the day and night symptom scores, the morning dip index and daily peak flow readings with a significant reduction in rescue bronchodilator inhaler usage during the active treatment period. Satisfactory serum theophylline concentrations were obtained 11-12 h post dose in all children using a standard dose of 18 mg/kg per day at 2000 hours. Three children were withdrawn because of minor side-effects. The theophylline preparation studied in conjunction with other conventional anti-asthma therapy was thus effective in controlling nocturnal symptoms.

Small intestinal permeability in pediatric clinical practice

Passive permeability of small intestine to lactulose and mannitol was studied in children suspected of having intestinal disease, using a hypertonic differential sugar absorption test. Children with coeliac disease and cows' milk intolerance were shown to have an elevated urinary lactulose/mannitol recovery ratio when compared with controls, children with normal jejunal biopsy, or children in whom alternative explanations for failure to thrive had been demonstrated. The abnormality in permeability ratio principally reflects a reduced urinary recovery of mannitol following oral administration. This study demonstrates that a hypertonic sugar absorption test is well tolerated even by young children, is practicable in routine clinical pediatric practice, and is capable of demonstrating abnormal intestinal function in children with small intestinal disease.

Features of di George syndrome in a child with 45,XX,-3,-22,+der(3),t(3;22)(p25;q11)

A child with an unbalanced translocation resulting in monosomy for chromosomes 22 (q11----pter) and 3(p25----pter) is described. Although no immunological dysfunction could be demonstrated, the abnormalities found are similar to those seen in the di George syndrome which has been associated with monosomy for the same region of chromosome 22.

Effects of nimodipine on acute focal cerebral ischemia

Nimodipine is a calcium slow channel blocker with several pharmacologic properties suggesting the potential to favorably modify outcome in focal cerebral ischemia. Thirty adult cats underwent unilateral middle cerebral artery (MCA) occlusion for 4 hours. Seventeen cats were treated with an ipsilateral intracarotid infusion of nimodipine (1 microgram kg-1 min -1) beginning 15 minutes before MCA occlusion and continuing throughout the occlusion period. Eight nimodipine treated cats maintaining MAP greater than 90 mmHg were assigned to a Higher Pressure Nimodipine (HPN) group. The remaining nine treated cats with MAP less than 90 mmHg were assigned to the Lower Pressure Nimodipine (LPN) group. Thirteen cats were untreated, receiving an isovolumetric amount of vehicle through the ipsilateral carotid artery. Local cerebral blood flow (ICBF) was continuously monitored using thermal diffusion probes. The brains, assessed for colloidal carbon perfusion, fluorescein and Evans blue staining, electroencephalographic activity (EEG), and histological changes, revealed no significant differences by any of these methods between the HPN and control animals with the exceptions of: HPN treated cats exhibited a preservation of EEG activity at 15 minutes post-occlusion compared to the untreated cats, and Post-ischemic surface colloidal carbon perfusion was better preserved in the treated cats than in the untreated cats. Mild hypotension, as demonstrated by the LPN group, negated these two positive effects. Prior to MCA occlusion, ICBF was bilaterally significantly increased after nimodipine infusion in the HPN group as compared to vehicle infusion. Intra-arterially infused nimodipine did not reduce infarct size.

Preservation of neuronal function during prolonged focal cerebral ischemia by ventriculocisternal perfusion with oxygenated fluorocarbon emulsion

The left middle cerebral artery and both carotid arteries of 17 cats were occluded to evaluate the effects of oxygenated fluorocarbon emulsion on brain ischemia. Carotid and middle cerebral arteries were occluded concurrently for 2 hours, followed by occlusion of the middle cerebral artery only for another 24 hours. Six animals were treated with oxygenated fluorocarbon emulsion delivered by ventriculocisternal perfusion, 5 received ventriculocisternal perfusion with mock cerebrospinal fluid, and 6 were untreated. Perfusions were started 3 hours after the initial ischemic insult. Infarct size judged by tetrazolium staining and standard neuropathological stains was significantly smaller in the treated animals. The mechanism of protection is as yet unknown, but most likely reflects oxygen/nutrient diffusion into the ischemic middle cerebral artery zone from the ventricular fluorocarbon, or removal of harmful metabolites. The results imply that ventriculocisternal perfusion with fluorocarbon emulsion can preserve neuronal function during a major cerebral vessel occlusion. In the cat, therapy is effective if begun within 3 hours after ischemia starts.

Ganglioside-induced regeneration and reestablishment of axonal continuity in spinal cord-transected rats

In this study we examined the effect of chronic GM-1 ganglioside treatment on the reestablishment of axonal continuity and functional recovery in spinal cord-transected rats. Previous studies have shown that chronic treatment with GM-1 ganglioside is effective in producing regeneration of lesioned mesostriatal dopaminergic neurons in the central nervous system [1, 2]. In addition, GM-1 ganglioside advances peripheral nerve regeneration following nerve crush injury [12]. Axonal continuity was determined by the ability of the spinal cord to transport horseradish peroxidase across the region of transection. Comparisons between ganglioside-treated and saline-treated controls showed that ganglioside treatment resulted in the reestablishment of axonal continuity between the spinal cord distal to the level of the transection and the brainstem. Saline-treated controls showed little evidence of axonal continuity between these two regions. Thus gangliosides induce reestablishment of axonal continuity and thereby could advance functional recovery in rats following spinal cord transection.

Management of lumbar translocation injuries: case reports

Lumbar translocation (complete lumbar dislocation) injuries constitute a severe and highly unstable form of thoraco-lumbar spinal injury and are uncommon. Adequate management of such injuries includes removing the neural tissue compression and realigning and stabilizing the spine. Computerized axial tomographic scans of the spine are very dramatic in demonstrating encroachment on the spinal canal by bony fragments. We report two cases of lumbar translocation injuries with favorable outcomes. The patients were initially managed with halo-femoral traction, resulting in spinal reduction and eliminating the need for acute surgical intervention, and subsequently underwent posterior fusion for stability. Anterior decompression was done at a later date as computed tomography showed retropulsed intracanalicular bone fragments. The use of Harrington rod instrumentation and realignment of the spine did not free the canal of bony fragments and, hence, decompression was required.

Wiedemann-Beckwith syndrome in one of monozygotic twins

A pair of monozygotic twins discordant for Wiedemann-Beckwith syndrome is described. The probability of monozygosity is 0.995. This observation suggests that the syndrome is unlikely to be under single gene control and genetic counselling should be based on multifactorial inheritance.

Focal cerebral ischemia: reduction in size of infarcts by ventriculo-subarachnoid perfusion with fluorocarbon emulsion

A new method for brain resuscitation following acute focal ischemic insult has been developed in this laboratory. The technique utilizes a surrogate route to supply cerebral metabolites and employs highly oxygenated fluorocarbons (OFNS), which are efficient gas transport and exchange agents, perfused through the ventriculo-subarachnoid spaces. We previously described a return of aerobic metabolism and EEG after severe global ischemia by oxygenated perfusions and now report treatment-induced reduction in the size of experienced cerebral infarction. Twenty-eight cats were anesthetized (choralose and urethane), tracheotomized and placed in a stereotactic frame. Physiologic adjustments assured arterial blood pCO2 28-35 Torr, pO2 100-150 Torr pH 7.4 and glucose less than 200 mg%. The left middle cerebral artery was exposed transorbitally and temporarily clipped along with both common carotids for 2 h. One hour later (3 h after ischemic onset) the treated group were perfused by the ventriculo-cisternal route either with OFNS [pO2 = 600 Torr; 3 ml/min 6 h, 2 ml/min 2 h, 1 ml/min 2 h, 0.5 ml/min 2 h at 10 mm Hg intracranial pressure (ICP)] or with the vehicle perfusate. Eighteen to twenty hours after the ischemic insult the animals were sacrificed. Sections of fresh brain of 0.5 mm thickness were incubated in 1% triphenyl tetrazolium chloride. The infarcted areas were confirmed with classic neuropathologic techniques. Areas of infarction (expressed in cm3 and as % of the brain) were measured using a planimeter. OFNS-treated brains contained 80% less infarcted tissue than the vehicle-perfused or untreated stroked animals. The infarcted areas were significantly treatment reduced (P less than 0.05 ANOVA and Bonferroni tests).(ABSTRACT TRUNCATED AT 250 WORDS)

A reproducible experimental model of focal cerebral ischemia in the cat

In the past experimental methods used for producing focal cerebral ischemia have had considerable difficulty with regard to reproducibility of the size of the infarcted region. In this study we have developed an experimental model which enables us to consistently produce focal regions of cerebral ischemia (resulting in infarction) which vary little in size in a number of animals. Thirty-seven cats (3-4 kg b. wt.) anesthetized with chloralose and urethane were used. Physiologic monitoring and adjustments maintained arterial blood values as follows: pCO2 27-35 Torr, pO2 100-150 Torr, pH +/- 7.4, glucose 200 mg%, hematocrit greater than 25. The left middle cerebral artery was exposed via a transorbital approach and occluded for 1-2 h with and without left and/or both carotid artery occlusion. Sixteen hours following the ischemic episode, the animals were sacrificed and sections of fresh brain tissue were processed for vital staining using 1% tetrazolium solution. With this method normal brain areas appear dark red, ischemic regions (without infarction) appear gray and irreversibly infarcted areas appear pinkish-white. The volumetric dimensions of the lesioned area were measured using a planimeter. The same tissue was also evaluated histologically by means of standard histopathologic techniques on paraffin-embedded material. Infarcted areas as delineated macroscopically by the tetrazolium correlated well with the light microscopic findings. Ten animals subjected to a 2-h occlusion of the left middle cerebral artery (LMCA) and both carotid arteries resulted in a reproducible infarct which was 3.2 +/- 0.7 ml in volume. This represents 13.3 +/- 2.9% of the total volume of both cerebral hemispheres (above the level of the inferior colliculus.(ABSTRACT TRUNCATED AT 250 WORDS)

Reanalysis of central cervical cord injury management

Early investigators indicated that conservative management was superior to operative intervention in the treatment of central cord injuries. Their clinical data suggested that operative treatment, in fact, worsened the condition. Recent experience with this clinical entity, however, indicates that in selected patients operative intervention may be of value in improving the rate and degree of motor recovery. A retrospective study of all individuals admitted to our hospital (Delaware Valley Spinal Cord Injury Center) with central cervical spinal cord injury was done (28 patients). One-half had been treated with medical therapy alone (Group I); the others were treated both medically and surgically (Group II). Medical therapy consisted of intravenous mannitol, dexamethasone, and sodium bicarbonate given during the acute phase of the injury. Both groups were immobilized using either a halo or a Philadelphia collar. Criteria for entry into the surgical group were one or both of the following: (a) failure to improve progressively after an initial period of improvement, with persistent compression of neural tissue visualized on myelography and (b) unacceptable instability of the spinal bony elements. The patients were given neurological scores based on the motor power of the major muscle groups. The stability of the spine was scored using the Panjabi-White scale. The two groups were compared using Student's t-test and the two-factor analysis of variance. There was no significant difference in initial neurological scores between the groups. The surgical groups had a higher incidence of instability of the bony elements of the cervical spine, as judged by the Panjabi-White scale.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidermal cyst of the breast

Two cases of epidermal cyst of the breast are presented. Mammography and ultrasonography merely confirmed that the masses were solid. As is usual with these extremely rare lesions, the initial diagnoses (fibroadenoma and carcinoma) were incorrect.