Ofatumumab plus fludarabine and cyclophosphamide in relapsed chronic lymphocytic leukemia: results from the COMPLEMENT 2 trial

In this multicenter, open-label, phase III study, patients with relapsed chronic lymphocytic leukemia (CLL) were randomized (1:1) to receive ofatumumab plus fludarabine and cyclophosphamide (OFA + FC) or FC alone; the primary endpoint being progression-free survival (PFS) assessed by an independent review committee (IRC). Between March 2009 and January 2012, 365 patients were randomized (OFA + FC: n = 183; FC: n = 182). Median IRC-assessed PFS was 28.9 months with OFA + FC versus 18.8 months with FC (hazard ratio = 0.67; 95% confidence interval, 0.51-0.88; p = .0032). Grade ≥3 adverse events (≤60 days after last dose) were reported in 134 (74%) OFA + FC-treated patients compared with 123 (69%) FC-treated patients. Of these, neutropenia was the most common (89 [49%] vs. 64 [36%]). OFA + FC improved PFS with manageable safety for patients with relapsed CLL compared with FC alone, thus providing an alternative treatment option for patients with relapsed CLL.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT00824265).

Health-related quality of life and patient-reported outcomes of ofatumumab plus chlorambucil versus chlorambucil monotherapy in the COMPLEMENT 1 trial of patients with previously untreated CLL

BACKGROUND

Patients diagnosed with chronic lymphocytic leukemia (CLL) are usually elderly and frequently have a number of comorbidities. Health-related quality of life (HRQoL) for these patients is of utmost importance and should be taken into consideration when assessing new treatment options. The combination of ofatumumab with chlorambucil has shown longer progression-free survival compared with chlorambucil alone. In this study, we aim to assess how this treatment combination affects patients' health-related quality of life and patient-reported symptoms.

MATERIAL AND METHODS

In this open-label phase III trial, patients with previously untreated CLL for whom fludarabine-based treatment was contra-indicated, were randomized 1:1 to receive oral chlorambucil (10 mg/m²) on Days 1-7 of a 28-day treatment cycle or to receive chlorambucil by this schedule plus intravenous ofatumumab (Cycle 1: 300 mg on Day 1 and 1000 mg on Day 8; subsequent cycles: 1000 mg Day 1) for 3-12 cycles. The EORTC QLQ-C30 and QLQ-CLL16 questionnaires were administered to patients before and during treatment, in follow-up and at the time of disease progression. The primary specified patient-reported outcomes were HRQoL and fatigue.

RESULTS

Patient-reported improvements from baseline in Global Health Status (GHS)/HRQoL scores and fatigue scores were recorded during treatment with both chlorambucil monotherapy and ofatumumab in combination with chlorambucil. There were no significant differences between the two treatment arms for GHS/HRQoL (p = 0.667) or fatigue (p = 0.103). Following treatment, numerical improvements to GHS/HRQoL and fatigue scores were reported, with no significant differences between the two treatment arms.

CONCLUSION

Small but detectable improvements in patients' quality of life were reported as a result of treatment. The addition of ofatumumab to chlorambucil did not negatively impact HRQoL. Quality of life was maintained in the months following treatment.

A phase 2, multicenter study investigating ofatumumab and bendamustine combination in patients with untreated or relapsed CLL

The purpose of this study is to assess the safety and efficacy of the combination of ofatumumab and bendamustine in patients with previously untreated or relapsed chronic lymphocytic leukemia. Patients received IV ofatumumab (cycle 1: 300 mg day 1 and 1,000 mg day 8; cycles 2-6: 1,000 mg on day 1 every 28 days) and IV bendamustine 90 mg m(-2) (previously untreated) or 70 mg m(-2) (relapsed) on days 1 and 2 of each 28-day cycle, for up to 6 cycles. Forty-four previously untreated and 53 relapsed patients were enrolled. Median age was 62.5 years (previously untreated) and 68 years (relapsed); relapsed patients had received a median of 1 (range 1-11) prior therapy. The investigator-assessed overall response rate was 95% (43% complete response [CR]) for the previously untreated, and 74% (11% CR) for the relapsed patients. The regimen was well tolerated with 89% (previously untreated) and 85% (relapsed patients) receiving all 6 cycles. No unexpected toxicities were reported. Grade 3/4 events occurred in 57% of previously untreated, and 72% of relapsed patients. At ∼29 months' follow-up, the median progression-free survival (PFS) was not reached for the previously untreated population, and the 28-month PFS estimate was 72.3%. The median PFS for the relapsed population was 22.5 months (95% CI: 14.0-27.3 months). The combination of ofatumumab and bendamustine was well tolerated and effective in these previously untreated or relapsed populations. Am. J. Hematol. 91:900-906, 2016. © 2016 Wiley Periodicals, Inc.

Chlorambucil plus ofatumumab versus chlorambucil alone in previously untreated patients with chronic lymphocytic leukaemia (COMPLEMENT 1): a randomised, multicentre, open-label phase 3 trial

BACKGROUND

Treatment for patients with chronic lymphocytic leukaemia who are elderly or who have comorbidities is challenging because fludarabine-based chemoimmunotherapies are mostly not suitable. Chlorambucil remains the standard of care in many countries. We aimed to investigate whether the addition of ofatumumab to chlorambucil could lead to better clinical outcomes than does treatment with chlorambucil alone, while also being tolerable for patients who have few treatment options.

METHODS

We carried out a randomised, open-label, phase 3 trial for treatment-naive patients with chronic lymphocytic leukaemia in 109 centres in 16 countries. We included patients who had active disease needing treatment, but in whom fludarabine-based treatment was not possible. We randomly assigned patients (1:1) to receive oral chlorambucil (10 mg/m(2)) on days 1-7 of a 28 day treatment course or to receive chlorambucil by this schedule plus intravenous ofatumumab (cycle 1: 300 mg on day 1 and 1000 mg on day 8; subsequent cycles: 1000 mg on day 1) for three to 12 cycles. Assignment was done with a randomisation list that was computer generated at GlaxoSmithKline, and was stratified, in a block size of two, by age, disease stage, and performance status. The primary endpoint was progression-free survival in the intention-to-treat population and assessment was done by an independent review committee that was masked to group assignment. The study is registered with ClinicalTrials.gov, number NCT00748189.

FINDINGS

We enrolled 447 patients, median age 69 years (range 35-92). Between Dec 22, 2008, and May 26, 2011, we randomly assigned 221 patients to chlorambucil plus ofatumumab and 226 patients to chlorambucil alone. Median progression-free survival was 22·4 months (95% CI 19·0-25·2) in the group assigned to chlorambucil plus ofatumumab compared with 13·1 months (10·6-13·8) in the group assigned to chlorambucil only (hazard ratio 0·57, 95% CI 0·45-0·72; p<0·0001). Grade 3 or greater adverse events were more common in the chlorambucil plus ofatumumab group (109 [50%] patients; vs 98 [43%] given chlorambucil alone), with neutropenia being the most common event (56 [26%] vs 32 [14%]). Grade 3 or greater infections had similar frequency in both groups. Grade 3 or greater infusion-related adverse events were reported in 22 (10%) patients given chlorambucil plus ofatumumab. Five (2%) patients died during treatment in each group.

INTERPRETATION

Addition of ofatumumab to chlorambucil led to clinically important improvements with a manageable side-effect profile in treatment-naive patients with chronic lymphocytic leukaemia who were elderly or had comorbidities. Chlorambucil plus ofatumumab is therefore an important treatment option for these patients who cannot tolerate more intensive therapy.

FUNDING

GlaxoSmithKline, Genmab A/S.

Assessment of angiographic vascularity of meningiomas with dynamic susceptibility contrast-enhanced perfusion-weighted imaging and diffusion tensor imaging

BACKGROUND AND PURPOSE

The roles of DTI and dynamic susceptibility contrast-enhanced-PWI in predicting the angiographic vascularity of meningiomas have not been studied. We aimed to investigate if these 2 techniques could reflect the angiographic vascularity of meningiomas.

MATERIALS AND METHODS

Thirty-two consecutive patients with meningiomas who had preoperative dynamic susceptibility contrast-enhanced-PWI, DTI, and conventional angiography were retrospectively included. The correlations between angiographic vascularity of meningiomas, classified with a 4-point grading scale, and the clinical or imaging variables-age and sex of patient, as well as size, CBV, fractional anisotropy, and ADC of meningiomas-were analyzed. The meningiomas were dichotomized into high-vascularity and low-vascularity groups. The differences in clinical and imaging variables between the 2 groups were compared. Receiver operating characteristic curve analysis was used to determine the diagnostic performance of these variables.

RESULTS

In meningiomas, angiographic vascularity correlated positively with CBV but negatively with fractional anisotropy. High-vascularity meningiomas demonstrated significantly higher CBV but lower fractional anisotropy as compared with low-vascularity meningiomas. In differentiating between the 2 groups, the area under the curve values were 0.991 for CBV and 0.934 for fractional anisotropy on receiver operating characteristic curve analysis.

CONCLUSIONS

CBV and fractional anisotropy correlate well with angiographic vascularity of meningiomas. They may differentiate between low-vascularity and high-vascularity meningiomas.

Solitary intraventricular tuberculoma in adults

Intracranial tuberculoma is typically located in the parenchyma. Lesions limited to the ventricular system are uncommon. It is difficult to make a differential diagnosis from other lesions if no systemic tuberculosis is present. This study investigates a case of solitary intraventricular tuberculoma in a 19-year-old female patient with an initial clinical symptom of progressive headache. Cranial computed tomography revealed a strongly enhanced lesion in the lateral ventricle. Histopathology of the tumor demonstrated chronic inflammation, caseous necrosis, epithelioid cells and Langhans' giant cell. The culture study grew M. Tuberculosis. Solitary intraventricular tuberculoma in adults is extremely rare. Medical treatment is the preferred management method of this disease, and surgical intervention should be considered in certain situations.

Effects of heat, acid, and freeze-thaw challenges on survival of starved Vibrio parahaemolyticus in minimal salt medium, tryptic soy broth, and filtered oyster homogenate medium

Vibrio parahaemolyticus is a ubiquitous gram-negative enteropathogenic bacterium. To evaluate the risk of stress-adapted V. parahaemolyticus cells in food, we investigated the survivability of starvation-adapted and starvation-low salinity-adapted cells of this pathogen in different media against different stresses. Logarithmically grown bacterial cells were starved at 25 degrees C in a minimal salt medium with 0.5 or 3.0% NaCl for 24 h. Resistances against challenges of heat, acid, and freeze-thaw treatment exhibited by the starvation-adapted cells were similar to those exhibited by the starvation-low salinity-adapted cells but substantially higher than those of the unadapted control cells. The increased stress resistance of the adapted cells against freeze-thaw challenge was lower in tryptic soy broth than in the starving medium. Resistance of the adapted bacteria against heat and freeze-thaw treatment was completely eliminated in filter-sterilized oyster homogenate medium. Practically, these results help to assess the risk of stress-adapted V. parahaemolyticus in food.

Effectiveness of fluticasone propionate and salmeterol combination delivered via the Diskus device in the treatment of chronic obstructive pulmonary disease

This randomized controlled trial examined the benefits of combining an inhaled corticosteroid, fluticasone propionate (F), with an inhaled long-acting beta(2)-agonist, salmeterol (S), to treat the inflammatory and bronchoconstrictive components of chronic obstructive pulmonary disease (COPD). A total of 691 patients with COPD received the combination of F and S (FSC), S (50 mcg), F (500 mcg), or placebo twice daily via the Diskus device for 24 weeks. A significantly greater increase in predose FEV(1) at the endpoint was observed after FSC (156 ml) compared with S (107 ml, p = 0.012) and placebo (-4 ml, p < 0.0001). A significantly greater increase in 2-hour postdose FEV(1) at the endpoint was observed after treatment with FSC (261 ml) compared with F (138 ml, p < 0.001) and placebo (28 ml, p < 0.001). There were greater improvements in the Transition Dyspnea Index with FSC (2.1) compared with F (1.3, p = 0.033), S (0.9, p < 0.001), and placebo (0.4, p < 0.0001). The incidence of adverse effects (except for an increase in oral candidiasis with FSC and F) was similar among the treatment groups. We conclude that FSC improved lung function and reduced the severity of dyspnea compared with individual components and placebo.

Lateralization and prognostic value of proton magnetic resonance spectroscopy in patients with intractable temporal lobe epilepsy

BACKGROUND

The aims of this prospective study were to investigate the stability of hippocampal metabolite ratios obtained by proton magnetic resonance spectroscopy (MRS), to evaluate the ability of MRS to determine the pre-surgical lateralization of seizure focus, and to assess the relationship between MRS results and postoperative outcomes in patients with intractable temporal lobe epilepsy.

METHODS

Within- and between-acquisition variations were evaluated in 30 control subjects, using the chemical-shift imaging technique. The most stable metabolite ratio was then applied for pre-surgical evaluation of 14 patients with intractable temporal lobe epilepsy.

RESULTS

The ratio between N-acetylaspartate (NAA) and choline-containing compounds (Cho) plus creatine-phosphocreatine (Cr), i.e., NAA/(Cho+Cr), had an overall smaller percentage change between measurements (13%-28%) than did the other ratios: NAA/Cho (18%-37%), NAA/Cr (11%-60%), and Cho/Cr (19%-51%). With a mean follow-up period of 27 months (range, 12-55 months) after an anterior temporal lobectomy, 10 patients were in Engel s class I (71%), 2 were in class II (14%), and 2 were in class III (14%). Lateralization by MRS was consistent with the operation side in 11 (79%) patients, including class I in 8 patients, class II in 1 patient, and class III in 2 patients. Ranges of reduced NAA/(Cho+Cr) values were similar between patients with different post-surgical outcomes: 0.26-0.47 for class I, 0.40-0.45 for class II, and 0.34-0.40 for class III (p=0.651).

CONCLUSIONS

Proton MRS may be helpful in pre-surgical lateralization of the seizure focus in patients with intractable temporal lobe epilepsy; however, it cannot provide prognostic information about postoperative seizure control.

Hyperbaric oxygen treatment decreases post-ischemic neurotrophin-3 mRNA down-regulation in the rat hippocampus

The therapeutic effect of hyperbaric oxygen (HBO) on ischemic injury was investigated using in situ hybridization to detect the mRNA expression of neurotrophin-3 (NT-3), which is thought to play a crucial role in protecting against neuronal death induced by brain ischemia. The rats under investigation were subjected to 10 min transient forebrain ischemia, and subsequently exposed to HBO (100% oxygen, 2.5 atm absolute) for 2 h. Levels of NT-3 mRNA in the CA1, CA2 and CA3 regions, and the dentate gyrus of the hippocampus were measured after various reperfusion periods. Neuronal death in the hippocampal CA1 region was also measured by Nissl staining, seven days post ischemia. The results demonstrated that HBO treatment significantly reduced the ischemia-induced down-regulation of the NT-3 mRNA level at 4 h post ischemia, and significantly increased cell survival 7 days after reperfusion. The findings suggest that an HBO treatment maintaining the NT-3 mRNA level in the hippocampus can be beneficial to the ischemic brain within a certain time frame.

Proton magnetic resonance spectroscopy of cerebral glioma after irradiation

BACKGROUND

Conventional magnetic resonance imaging (MRI) is commonly employed to assess cerebral gliomas after radiotherapy, but it cannot always differentiate tumor regrowth from post-irradiation changes. In this study, we utilized magnetic resonance spectroscopy (MRS) to evaluate changes in cerebral metabolites in patients with a cerebral glioma after irradiation.

METHODS

Over a period of 3 years, we performed MRS after MRI whenever soft tissue masses were found on magnetic resonance (MR) images. A total of 122 MR spectra of 58 patients was used for analysis. Spectral interpretations were based on integral values of the N-acetylaspartate (NAA) and choline (Cho) compounds relative to phosphocreatine/creatine (Cr).

RESULTS

Our MRS study showed that higher Cho/Cr ratios occurred in regrowing gliomas than for stable diseases (range, 0.9 to 9.5 vs. 0.4 to 2.1; mean, 3.0 vs. 1.2). A greater increment in the Cho/Cr ratio between successive studies was also noted in regrowing gliomas than for stable disease (range, 41% to 87% vs. < 32%). No significant differences in NAA/Cr ratios or lactate were found between these 2 groups. None of our patients exhibited abnormal MR spectra in the mirror area of the contralateral brain.

CONCLUSION

MRS provides valuable information about the metabolism of irradiated gliomas and can be used to exclude radiation encephalopathy of the contralateral brain. Cho is the most reliable indicator of a regrowing glioma. A high Cho/Cr ratio or substantial elevation in the Cho/Cr ratio between serial studies increases the likelihood of tumor regrowth. However, lower Cho/Cr ratios were inconclusive for determining if tumor regrowth or a stable process was occurring.

Membranous obstruction of the fourth ventricle outlet. A case report

We report the case of a 15-year-old girl with amenorrhea and a several-week history of headache. After the diagnosis of membranous obstruction of the foramen of Magendie suggested by MRI, suboccipital craniotomy for removal of the membrane was carried out. The patient made an excellent postoperative recovery, and postoperative phase-contrast MRI demonstrated patent cerebrospinal fluid (CSF) pathways at the level of the foramina of Magendie and Luschka. We believe that this case is of interest because of the unequivocal evidence on MRI studies of the occlusion of the foramen of Magendie preoperatively, and because of the dramatic postoperative MRI findings demonstrating the effectiveness of the surgical procedure both in terms of ventricular size and CSF flow characterization.

The study of Central Taiwan particles concentration variations during earthquake period

Ambient particle concentration was taken on the traffic sampling site over the Chung-Chi Road over the bridge (CCROB) in front of Hungkuang Institute of Technology (HKIT). The sampling time was from August 1999 to December 1999. During the sampling period, Taiwan's biggest earthquake in more than a century registered 7.3 on the Richter scale (Taiwan Chi-Chi Earthquake). Besides, there are more than 20,000 aftershocks following the Taiwan Chi-Chi Earthquake within 3 months. Thus, the mass concentration of particles with aerodynamic diameters smaller than 2.5 microm (PM2.5) and PM2.5-10 was also collected then compared with the total mass concentration of suspended particles (TSP) in this study. The average TSP, PM2.5-10, and PM2.5 concentrations are 106, 24.6, and 58.0 microg/m3, respectively, after the Taiwan Chi-Chi Earthquake. The average TSP concentrations before and after Taiwan Chi-Chi Earthquake were 69.6 and 127 microg/ m3, respectively. In addition, statistical analysis of the PM10 data from this study and EPA in 1999 yielded a Tstatistic of 0.147, which is smaller than t(0.975,18) = 2.101. It is indicated that there was no significant difference. So, the PM10 concentrations measured after Taiwan Chi-Chi Earthquake in this study were also greater than those data previously obtained from Taiwan EPA in the same region of this area. The relationships between TSP, PM10, PM2.5-10, and PM2.5 particle concentrations and wind speed (R2) are .77, .59, .58, .58, respectively. And the ratios of PM2.5/PM25-10, PM2.5/PM10, and PM10/TSP are 221%, 67.2%, 58.0%, respectively. The average ratios of PM2.5/PM2.5-10 and PM2.5/PM10 increase by about 120% and 17%. It indicated that the fine-particles concentration increases compared to the coarse-particles concentration after 921 Taiwan Chi-Chi Earthquake. And the proposed reasons are that local motor vehicle emissions combined the fine particles transported from the Chi-Chi epicenter. More importantly, the wind direction was mainly blown from southeastern part. These two main factors enhance the fine-particles concentration in this area.

Breast uptake of iodine-131 mimicking lung metastases in a thyroid cancer patient with a pituitary tumour

We report a case of a 44-year-old female thyroid cancer patient with a pituitary tumour. 131I whole body scanning showed a change of chest uptake from a unilateral crescent uptake to a bilateral full breast uptake pattern. Hyperprolactinaemia and a pituitary tumour were diagnosed as a result of observing the 131I breast uptake.

Cerebellar metastasis from papillary serous adenocarcinoma of the ovary mimicking Ménière's disease. A case report

BACKGROUND

In rare cases, cerebellar metastasis originating in serous papillary adenocarcinoma of the ovary can mimick Ménière's disease.

CASE

A 51-year-old woman, with complete remission after optimal maximal debulking and chemotherapy for an International Federation of Gynecology and Obstetrics IIIc primary ovarian carcinoma, presented with nausea, vomiting, vertigo and headache 18 months after surgery. Investigations revealed a solitary cerebellar cystic mass, 4.6 x 4.0 x 3.2 cm. Gross total excision of the cerebellar lesion followed by brain irradiation resulted in complete resolution of her symptoms. Histology showed a metastatic tumor consistent with the primary ovarian carcinoma.

CONCLUSION

In an atypical presentation in patients with metastatic ovarian carcinoma, thorough investigations should be done to rule out or confirm brain metastasis, which can be aggressively managed to prevent serious consequences and improve outcome.

Development of a real-time control strategy with artificial neural network for automatic control of a continuous-flow sequencing batch reactor

The purpose of this study is to develop a reliable and effective real-time control strategy by integrating artificial neural network (ANN) process models to perform automatic operation of a dynamic continuous-flow SBR system. The ANN process models, including ORP/pH simulation models and water quality ([NH4(+)-N] and [NOx(-)-N]) prediction models, can assist in real-time searching the ORP and pH control points and evaluating the operation performances of aerobic nitrification and anoxic denitrification operation phases. Since the major biological nitrogen removal mechanisms were controlled at nitrification (NH4(+)-N-->NO2(-)-N) and denitritification (NO2(-)-N-->N2) stages, as well as the phosphorus uptake and release could be completely controlled during aerobic and anoxic operation phases, the system operation performances under this ANN real-time control system revealed that both the aeration time and overall hydraulic retention time could be shortened to about 1.9-2.5 and 4.8-6.2 hrs/cycle respectively. The removal efficiencies of COD, ammonia nitrogen, total nitrogen, and phosphate were 98%, 98%, 97%, and 84% respectively, which were more effective and efficient than under conventional fixed-time control approach.

The feasible sequential control strategy of treating high strength organic nitrogen wastewater with sequencing batch biofilm reactor

The bio-kinetics and feasible sequential control strategy of treating high strength organic carbon and nitrogen wastewater were investigated by conducting the ABS manufacturing wastewater in a series of Sequencing Batch Biofilm Reactors (SBBRs). The on-line ORP, pH, and DO monitoring parameters were applied to identify the feature-points when ammonification, nitrification, and denitrification ends. The carbonaceous matter removal kinetics in the anaerobic and aerobic reaction stages can be expressed by the Michaelis-Menten equation. High efficiency of organic carbon removal and organic nitrogen ammonification in the anaerobic stage can eliminate the substrate competition and activation inhibition to nitrifying organisms in the following aerobic stage. In the sequencing nitrogen removal processes, the producing time and system ORP values of these feature-points have good function relationships with the influent COD loading rates of SBBR, which can be integrated into a set-point (set-time and set-ORP) sequential control strategy of nitrogen removal. The automatic control operation results revealed ORP was one of the major control parameters of the sequencing nitrogen removal process in SBBR system and high overall removal efficiency were obtained.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses

BACKGROUND AND PURPOSE

Craniofacial resection provides multidirectional approaches to remove nasal and paranasal tumors that involve the skull base. The purpose of this study was to determine the survival and local control rate in patients undergoing craniofacial resection for tumors of the nasal cavity, paranasal sinuses, and adjacent areas.

METHODS

The medical records of 30 consecutive patients who had undergone craniofacial resection for tumors of the nasal cavity, paranasal sinuses, and adjacent areas were reviewed. The extent of disease, treatment results, complications, and prognoses were analyzed.

RESULTS

Lesions were malignant in 28 patients and benign in two. Sixteen of the patients had dural or intradural involvement. There was no surgical mortality, and the rate of surgical morbidity was 7%. The 2-year survival of the 28 patients with malignancies was 46% and the mean follow-up time was 35 months. Local control was achieved in 53% of patients. Nine of 16 patients with dural or intradural invasion had a mean survival time of 17 months. There was no significant difference in the frequency of local control between previously treated and untreated patients. Patients who had a clear margin showed significantly better local control than those with an involved or questionable margin.

CONCLUSIONS

Tumors of the nasal cavity and paranasal sinus that involve the skull base can be effectively treated using craniofacial resection, with a reasonable survival and low complication rate.

The study of TSP, PM(2.5-10) and PM2.5 during Taiwan Chi-Chi Earthquake in the traffic site of central Taiwan, Taichung

Ambient particle concentration was taken on the traffic sampling site over the Chung-Chi Road over bridge (CCROB) in front of Hungkuang Institute of Technology (HKIT). The sampling time was from August 1999 to December 1999. During the sampling period, Taiwan's biggest earthquake in more than a century registered 7.3 on the Richter scale (Taiwan Chi-Chi Earthquake). Besides, there were more than 20,000 aftershocks that followed the Taiwan Chi-Chi Earthquake within three months. Thus, the PM2.5, PM(2.5-10) particle concentrations were also collected then and compared with total suspended particle (TSP) in this study. The average PM(2.5-10), PM2.5 and TSP concentrations are 24.6, 58.0 and 106 microg/m3, respectively, after the Taiwan Chi-Chi Earthquake. The average TSP concentrations before and after Taiwan Chi-Chi Earthquake were 70 and 127 microg/m3, respectively. It is clearly shown that the average concentration of TSP after Taiwan Chi-Chi Earthquake was about 1.8 times as that of TSP concentration before Taiwan Chi-Chi Earthquake in the traffic site of central Taiwan. And the ratios of PM2.5/PM(2.5-10), PM2.5/PM10 and PM2.5/TSP are 2.2%, 67.2%, 38.9%, respectively. The results also indicated about Chi-Chi fine particle concentration (PM25) and the TSP increases in the traffic site of central Taiwan after Taiwan Chi-Chi Earthquake.

Comparison of particulate mass, chemical species for urban, suburban and rural areas in central Taiwan, Taichung

Aerosol samples for PM2.5, PM(2.5-10) and TSP were collected from June to September 1998 and from February to March 1999 in central Taiwan. Ion chromatography was used to analyze the acidic anions: sulfate, nitrate and chloride in the Universal samples. The ratios of fine particle concentrations to coarse particle concentrations displayed that the fine particle concentrations are almost greater than that of coarse particle concentrations in Taichung area. The average concentrations of PM2.5, PM(2.5-10) and TSP in urban sites are higher than in suburban and rural sites at both daytime and night-time. Chloride dominated in the coarse mode in daytime and in fine mode in night-time. Nitrate can be found in both the coarse and fine modes. Sulfate dominated in fine mode in both daytime and night-time.

Engineering autogenous cartilage in the shape of a helix using an injectable hydrogel scaffold

OBJECTIVE

Previous successful efforts to tissue engineer cartilage for an auricle have used an immunocompromised nude mouse xenograft model. Subsequent efforts in an immunocompetent autogenous animal model have been less successful because of an inflammatory response directed against the foreign scaffold polymer used to provide an auricular shape. We studied an alternative polymer material and surgical technique to engineer autogenous cartilage in the shape of a human ear helix using injectable hydrogel scaffolding, Pluronic F-127 (polyethylene oxide and polypropylene oxide).

SUBJECT

Yorkshire swine.

MATERIAL AND METHODS

Fresh autogenous chondrocytes were suspended in a biodegradable, biocompatible co-polymer hydrogel, Pluronic F-127, at a concentration of 3 x 10(7) cells/mL. To support the contour of the implant, a skin fold channel in the shape of the helix of a human ear was created in the skin in three sites on the ventral surface of the animal. The cell-hydrogel suspension was injected through the skin fold channel. For controls, injections were made into identical channels using either cells alone or the Pluronic F-127 without cells. After 10 weeks, the specimens were excised and examined both grossly and histologically.

RESULTS

Grossly, all implants retained a helical-like shape. Excised specimens possessed flexible characteristics consistent with elastic cartilage. The specimens could be folded and twisted and on release of mechanical pressure would instantly return to the original shape. Histological evaluation of the implants using H&E, Safranin O, trichrome blue, and Verhoeff's stains demonstrated findings consistent with mature elastic cartilage. Control injection of hydrogel alone demonstrated no evidence of cartilage formation and control injection of chondrocytes alone showed evidence only of disassociated elastic cartilage.

CONCLUSION

Injection of autologous porcine auricular chondrocytes suspended in a biodegradable, biocompatible hydrogel of Pluronic F-127 resulted in the formation of cartilage tissue in the approximate size and shape of a human ear helix. This preliminary method extends the concept of auricular tissue engineering from an immunocompromised xenograft animal model to an immunocompetent autologous animal model.

The study of fine and coarse particles, and metallic elements for the daytime and night-time in a suburban area of central Taiwan, Taichung

Daily average concentrations of fine and coarse particulates, and TSP samples have been measured simultaneously at daytime and night-time periods by using Universal and PS-1 sampler in a suburban area of central Taiwan from June to August 1998. The samples were analyzed by atomic absorption spectrometry to determine the fine and coarse particulate concentrations of metallic elements (Ca, Fe, Mn, Pb, Cu, Zn and Cr). The concentration of PM2.5 and TSP showed a decreased trend for the daytime period. The fine particle concentrations were about two times as that of coarse particulate concentrations. The averaged fine particulate concentrations at daytime are higher than at night-time. Ca and Fe were mostly in the coarse particulate mode. The correlation coefficients were 0.63 and 0.69 for elements Ca and Fe in the coarse particle mode for day and night periods. Pb showed a similar distribution ratio with Mn for the fine to coarse particle ratios at both day and night period. Pb and Mn are highly correlated for the day (R = 0.78) and night period (R = 0.61) at particle size <2.5 microm. Cu and Zn were mainly in fine particles at both day and night period. Fe and Ca consist of the major parts of all the elements. Elemental Mn is the lowest among the rest of the heavy metals.

Profiles of gonadal development, sex steroids, aromatase activity, and gonadotropin II in the controlled sex change of protandrous black porgy, Acanthopagrus schlegeli Bleeker

The objectives of the present study were to investigate the effects of oral administration of estradiol-17 beta (E(2)) on the sex steroids and gonadotropin II (GTH II) in plasma, aromatase activity in gonad and brain, and sex change in protandrous black porgy, Acanthopagus schlegeli Bleeker. Two-year-old black porgy were divided into two groups, one fed a control diet and the other a diet mixed with E(2) (4.0 mg/kg feed) for 7 months. Significantly higher GSI was observed in the E(2) group. Fish treated with E(2) showed complete suppression of spermatogenesis and spermiation and induced sex change with vitellogenic oocytes and large primary oocytes. Lower levels of plasma 11-ketotestosterone and higher levels of plasma vitellogenin were shown in the E(2) group. Higher gonadal aromatase activity in concordance with elevated plasma levels of GTH II was observed in the E(2) group. The highest aromatase activity in the forebrain in the control group was observed in January. Higher aromatase activity in forebrain, midbrain, and hindbrain was also detected in the E(2) group than the control group. The change of aromatase activity in brain was more susceptible than that in gonad. The data showed that the increase of plasma GTH II levels and gonadal aromatase activity may be important to the controlled sex change by administration in black porgy.

Characterization of chemical species in PM2.5 and PM10 aerosols in suburban and rural sites of central Taiwan

Aerosol samples for PM2.5 (particulate matter with aerodynamic diameters less than 2.5 microns), PM2.5-10 (particulate matter with aerodynamic diameters between 2.5 and 10 microns) and TSP were collected from June to September 1998 at THU (suburban) and HKIT (rural) sites in central Taiwan. The ratios of PM2.5/PM10 averaged 0.70 for the daytime and 0.63 for the nighttime at THU, respectively. At HKIT, the PM2.5/PM10 ratios averaged 0.56 for the daytime and 0.72 in the nighttime, respectively. These results indicated that the PM2.5 concentrations contribute the majority of the PM10 concentration and PM10 concentrations contribute the majority of the TSP at both sites. The averaged PM2.5 concentrations at THU are higher than those measured at HKIT during the daytime period. However, the average PM2.5-10 concentrations in THU are lower than those measured at HKIT during nighttime. The samples collected were also analyzed by atomic absorption spectrophotometry for the elemental analysis of Ca, Fe, Pb, Zn, Cu, Mn and Cr. Meanwhile ion chromatography was used to analyze for the water-soluble ions: sulphate, nitrate and chloride in the Universal samples. The concentrations of heavy metals in PM10 during daytime were all higher than nighttime at THU. However, the averaged concentrations of metal elements in PM10 during day and night period were distributed irregularly at HKIT. The results indicated that for metal elements collected at HKIT have different emission sources. The concentrations of metal elements during daytime in PM10 at THU were generally higher than HKIT. The phenomena owing to the averaged PM2.5 particle concentrations at THU (suburban) were higher than those measured at HKIT (rural) and PM2.5 occupied the major portions of PM10 for both sites during the day period. For anion species, there are no significant differences between day and night period in PM10 concentrations at both suburban and rural sites.

The characteristic study of TSP, PM2.5-10 and PM2.5 in the rural site of central Taiwan

The total suspended particle (TSP), PM2.5-10 (aerodynamic diameter less than 10 microns) and PM2.5 concentration (aerodynamic diameter less than 2.5 microns) concentrations were sampled by PS-1 and Universal sampler on the roof (25 m) of the Medical and Engineering Building in the campus of Hungkuang Institute of Technology (HKIT) which is located at a height of 500 m on Da Du Mountain. The results indicated that average TSP, PM2.5-10 and PM2.5 concentrations are 0.42, 0.34 and 0.019 mg/m3 in the day time, respectively and are 0.32, 0.26 and 0.017 mg/m3 in the night time, respectively. The ratios of PM2.5-10/TSP were from 76% to 85% and from 50% to 91% for day and night period, respectively. It indicated that the major composition in the total suspended particles was PM2.5-10 in the rural site. The relationship between TSP and PM2.5-10 is TSP = 1.16PM2.5-10 + 0.027 and TSP = 1.01 PM2.5-10 + 0.058 in the day and night time, respectively. The correlation coefficient (R2) is 0.98 and 0.97 for day and night period, respectively. The relationship between PM2.5-10 and PM2.5 is PM2.5 = 0.0005PM2.5-10 + 0.019 and PM2.5 = 0.037PM2.5-10 + 0.0076 in the day and night period, respectively. The correlation coefficient (R2) is 3E-5 and 0.67 for day and night period, respectively. The relationships between TSP, PM2.5-10, PM2.5 particle concentrations and wind speed (R2) in the day time are 0.71, 0.64, 0.43, respectively and are 0.83, 0.79, 0.57, respectively in the night time. The proposed reasons are that there are more activities caused by people (students) and natural living animals which absorbed some of the particles during the day time. Thus, the correlation coefficients for the night time are better than those of day time. The particle size distributions are both bimodel in the day and night time. The major peaks in the day time appear in the particle diameter between 0.031-0.056 micron and 3.16-5.62 microns in the day period and appear between 0.017-0.031 micron and 1.78-3.16 microns in the night period. The results indicate that the particle size distribution in the day time tends to be of larger particle size mode than the night time.

Epitope mapping of CCR5 reveals multiple conformational states and distinct but overlapping structures involved in chemokine and coreceptor function

The chemokine receptor CCR5 is the major coreceptor for R5 human immunodeficiency virus type-1 strains. We mapped the epitope specificities of 18 CCR5 monoclonal antibodies (mAbs) to identify domains of CCR5 required for chemokine binding, gp120 binding, and for inducing conformational changes in Env that lead to membrane fusion. We identified mAbs that bound to N-terminal epitopes, extracellular loop 2 (ECL2) epitopes, and multidomain (MD) epitopes composed of more than one single extracellular domain. N-terminal mAbs recognized specific residues that span the first 13 amino acids of CCR5, while nearly all ECL2 mAbs recognized residues Tyr-184 to Phe-189. In addition, all MD epitopes involved ECL2, including at least residues Lys-171 and Glu-172. We found that ECL2-specific mAbs were more efficient than NH2- or MD-antibodies in blocking RANTES or MIP-1beta binding. By contrast, N-terminal mAbs blocked gp120-CCR5 binding more effectively than ECL2 mAbs. Surprisingly, ECL2 mAbs were more potent inhibitors of viral infection than N-terminal mAbs. Thus, the ability to block virus infection did not correlate with the ability to block gp120 binding. Together, these results imply that chemokines and Env bind to distinct but overlapping sites in CCR5, and suggest that the N-terminal domain of CCR5 is more important for gp120 binding while the extracellular loops are more important for inducing conformational changes in Env that lead to membrane fusion and virus infection. Measurements of individual antibody affinities coupled with kinetic analysis of equilibrium binding states also suggested that there are multiple conformational states of CCR5. A previously described mAb, 2D7, was unique in its ability to effectively block both chemokine and Env binding as well as coreceptor activity. 2D7 bound to a unique antigenic determinant in the first half of ECL2 and recognized a far greater proportion of cell surface CCR5 molecules than the other mAbs examined. Thus, the epitope recognized by 2D7 may represent a particularly attractive target for CCR5 antagonists.

Proton MR spectroscopy in patients with complex partial seizures: single-voxel spectroscopy versus chemical-shift imaging

BACKGROUND AND PURPOSE

Proton MR spectroscopy has recently been applied to the evaluation of seizures, but few comparisons have been made between different clinical spectroscopic techniques. Our goal was to determine whether there is a significant difference between hippocampal NAA/(Cho+Cr) ratios obtained by single-voxel spectroscopy (SVS) and by chemical-shift imaging (CSI).

METHODS

Twelve healthy adults and eight patients with complex partial seizures were studied on a 1.5-T MR scanner using a proton SVS method. Another 12 healthy adults and 10 patients with complex partial seizures were recruited for a proton CSI study, which was performed on a different 1.5-T MR system. The NAA/(Cho+Cr) ratio was calculated from the integral peak areas by curve fitting. The two-tailed t-test was used for statistical analysis.

RESULTS

The mean value +/- standard deviation of the hippocampal NAA/(Cho+Cr) ratio in healthy control subjects was 0.63 +/- 0.07 by SVS, with 0.62 +/- 0.15 for the anterior hippocampus and 0.65 +/- 0.11 for the posterior hippocampus by CSI. There was no significant difference between the control group data obtained by SVS and those by CSI, nor was there a regional difference in the CSI NAA/(Cho+Cr) ratio in the hippocampus. Relative to the control group, the patients with seizures had a significant decrease in the NAA/(Cho+Cr) ratio in the abnormal hippocampus: -28% by SVS, and -24% in the anterior hippocampus and -18% in the posterior hippocampus by CSI. Proton SVS and CSI detected hippocampal abnormalities, unilateral or bilateral, in all patients of each group.

CONCLUSION

Under similar measurement conditions, proton SVS and CSI provide similar NAA/(Cho+Cr) ratios among healthy control subjects, and they possess comparable ability for detecting hippocampal abnormalities in patients with complex partial seizures.

Proton chemical shift imaging of the hippocampus in patients with complex partial seizures

BACKGROUND

Cerebral metabolites can be evaluated non-invasively using in vivo proton magnetic resonance spectroscopy (MRS). Decreased N-acetylaspartate (NAA) and increased choline-containing compounds (Cho) and creatine-phosphocreatine (Cr) have been found in the hippocampus of patients with complex partial seizures (CPS).

METHODS

We prospectively studied hippocampal proton MRS of 10 patients with CPS and 12 control subjects by using the chemical shift imaging (CSI) technique. The spectral data were analyzed in terms of the ratio between the integral peak area of NAA and that of (Cho + Cr).

RESULTS

Compared with the control group, patients with CPS showed a significantly lower NAA/(Cho + Cr) ratio, both in the anterior and posterior hippocampus (p value = 0.001 and 0.002, respectively). Metabolic abnormalities of the hippocampus were detected using proton CSI in all the patients with normal MRI results (4 patients) and those with normal EEG results (3 patients). Lateralizations using proton CSI were obtained in all the 10 patients in this study, including concordant lateralization in the 6 patients with MRI-detectable abnormalities.

CONCLUSION

The hippocampal abnormalities in patients with CPS can be detected early using proton CSI than using MRI or surface EEG. Lateralization of the seizure focus using proton CSI is possible, but further correlation with the surgical outcome in a larger study group is necessary.

Dexamethasone inhibits ischemia-induced transient reduction of neurotrophin-3 mRNA in rat hippocampal neurons

Dexamethasone (DEX) increases the expression of neurotrophin-3 (NT-3) in normal rat hippocampal neurons, whereas transient forebrain ischemia reduces the NT-3 mRNA level. The effect of DEX on the expression of NT-3 mRNA in injured brain cells after ischemia has not been investigated, however. Using in situ hybridization and ribonuclease protection assay methods, we studied NT-3 mRNA expression in rats with and without DEX administration after transient forebrain ischemia. Without DEX treatment, NT-3 mRNA was down-regulated in the hippocampal neurons at 2, 4, 12 h and returned to basal levels 24 h following ischemia. With DEX treatment, however, NT-3 mRNA showed no change at 2, 4 and 12 h and increased 24 h after ischemia. The results indicate that DEX inhibits ischemia-induced NT-3 mRNA down-regulation during the first 12 h and up-regulates NT-3 mRNA 24 h after ischemia. DEX administration might be effective in influencing some of the pathophysiological effects of ischemia in the hippocampus.

Nuclear multiparameter flow cytometric DNA analysis of human brain tumors: correlation of DNA content with tumor histology and clinical behavior

BACKGROUND

Using fresh surgical specimens of brain tumors to investigate cellular DNA content is uncommon. The aim of this study is to elucidate the relationship among cellular nuclear DNA content, tumor histology, and tumor clinical behavior of various tumors of the central nervous system.

METHODS

Multiparameter flow cytometry (FACStar, Becton-Dickinson, San Jose, CA) was randomly applied to analyze 40 fresh surgical specimens from brain tumors. Histologically, there were 19 cases of benign tumors and 21 cases of malignant tumors.

RESULTS

DNA distribution profiles in the benign tumors revealed 15 cases of diploidy and four cases of aneuploidy, while the malignant tumors had eight cases of diploidy and 13 cases of aneuploidy (p < 0.01). The mean DNA index (DI) in benign tumors was 1.13 +/- 0.27 and in malignant tumors 1.43 +/- 0.48 (p < 0.05). The mean proliferative index (PI) in benign tumors was 10.27 +/- 5.46% and 18.44 +/- 8.98% in malignant tumors (p < 0.05). Clinically, 10 patients had postoperative recurrence. The PI in recurrent and nonrecurrent tumors was 17.83 +/- 11.13% and 13.20 +/- 7.19%, respectively (p < 0.05). The 1-year cumulative survival rate in benign tumors was 78.9%, and 57.1% in malignant tumors (p < 0.05).

CONCLUSIONS

Malignant tumors had a significantly higher incidence of aneuploid DNA histograms, a higher DNA index, and a higher proliferative index. Tumors with a high PI had a higher incidence of recurrence and a lower survival rate. Multiparameter DNA analysis by flow cytometry provides a valuable diagnostic aid for the histopathologic differentiation of human brain tumors.

The endocrine mechanism of sex reversal in the protandrous black porgy, Acanthopagrus schlegeli: a review

Black porgy, Acanthopagrus schlegeli Bleeker, a marine protandrous hermaphrodite, is a functional male for the first 2 years of life but begin to sexually reverse to female after the third year. This sex pattern provides a very good model to study the mechanism of sex reversal in fish. The gonad at 5 month of age consisted of testicular tissue with few primary oocytes at 5 month of age. The ovarian tissue became dominant at 18 months of age during the non-spawning season. Testicular and ovarian tissues were separated by connective tissue. Plasma estradiol-17 beta(E2), vitellogenin and 11-ketotestosterone (11-KT) profiles in males were significantly different from those in the 3-year-old reversing females. Peak levels of plasma E2 in the reversing females occurred during the early prespawning season (in October). Lower levels of plasma E2 were, however, observed in the males. Plasma 11-KT levels significant decreased but no changes of plasma testosterone were detected in the reversing females. Exogenous E2 suppressed the testicular development but induced the gonadal aromatase activity, ovarian development and sex reversal in 2-year-old black porgy. Exogenous T and LHRH analog did not have effects on the sex reversal. Higher concentrations of pituitary GtH II and mRNA of GtH II-beta subunit were detected in the reversed females. These data suggested that E2 and gonadal aromatase closely associated to the occurrence of sex reversal. A working model of the sex reversal in black porgy is proposed.

Proton magnetic resonance spectroscopy in patients with complex partial seizures

We prospectively studied eight patients with complex partial seizures, using single-voxel proton magnetic resonance spectroscopy (MRS). Control data from 12 healthy volunteers were obtained with the same MRS protocol. The ratios between the peak areas of N-acetylaspartate, creatine and phosphocreatine (Cr), and choline-containing compounds (Cho) were analyzed. The results showed statistically significant lower N-acetylaspartate:Cr, N-acetylaspartate:Cho, and N-acetylaspartate: Cho + Cr ratios, and a higher Cho:Cr ratio in the mesial temporal lobes of the patient group than in healthy controls. Because N-acetylaspartate is located in the neurons and Cho and Cr in the glial cells, these observations represent the underlying neuronal loss and reactive astrocytosis in the epileptogenic foci. MRS can detect abnormal metabolic changes in most complex partial seizure patients with normal electroencephalography and magnetic resonance images. MRS can also identify bitemporal abnormalities which are a common feature in patients with complex partial seizures. Proton MRS could not confirm the specific location of seizure foci. Further investigation with quantitative spectral analysis and correlation with surgical outcome is needed to improve the contribution of MRS to the diagnosis and localization of seizure foci.

An antibody reactive with domain 4 of the platelet-derived growth factor beta receptor allows BB binding while inhibiting proliferation by impairing receptor dimerization

A panel of murine monoclonal antibodies was generated against the extracellular domain of the human platelet-derived growth factor (PDGF) beta receptor (PDGFRbeta). These antibodies were assayed for both the ability to inhibit binding of PDGF BB to PDGFRbeta+ cells as well as the capacity to inhibit PDGF BB-mediated mitogenesis. As expected, all antibodies that could prevent PDGF BB binding also inhibited mitogenesis. However one antibody (M4TS.11), with no detectable ability to inhibit PDGF BB binding, was a potent inhibitor of proliferation induced by PDGF BB. Further characterization indicated that M4TS.11 impaired PDGFRbeta dimerization, revealing the mechanism by which it prevented PDGF BB-mediated mitogenesis. Using domain deletion mutants of the extracellular portion of PDGFRbeta, the determinant recognized by this antibody was localized to the fourth extracellular domain of PDGFRbeta, indicating that this domain, which is not involved in ligand binding, actively participates in receptor dimerization and signal transduction. The M4TS.11 antibody could also inhibit PDGF BB-mediated proliferation of responsive cells from both the baboon and the rabbit, indicating the determinant recognized by the antibody is not limited to humans and making it possible to use this antibody to evaluate the therapeutic benefit of interfering with PDGF in animal models of human disease.

Reoperation for recurrent trigeminal neuralgia after microvascular decompression

BACKGROUND

Microvascular decompression (MVD) is an effective technique for those who have trigeminal neuralgia (TN) but cannot tolerate, or show no response to medicine. Though the initial success rate is high, some patients may develop severe recurrent neuralgia, especially after a longer period of follow-up. The efficacy of reoperation needs to be evaluated. To know the possible risk factors of recurrence after initial MVD is mandatory to the management of recurrent TN.

METHODS

Among the 80 cases of TN treated with MVD, five cases showed severe recurrent symptoms within a follow-up period from 9 months-4 years. The symptoms recurred on the same side of the face, and were unresponsive to medical treatment. Brain computed tomography (CT) and magnetic resonance imaging (MRI) may reveal the etiology of recurrence. Repeat decompression of the trigeminal nerve was the main goal of reoperation, which was done via a suboccipital approach.

RESULTS

Over the past 17 years, 80 MVDs for TN have been performed at Chang Gung Memorial Hospital. There were five cases of serious postoperative recurrence, which could not be relieved by medicine. Recurrence occurred 1 day-12 months after the initial surgery. Three cases were due to vascular compression, while two were caused by the local effect of Teflon felt. Reoperation produced complete remission in four patients, and partial remission in one.

CONCLUSIONS

An increasing number of patients may experience severe recurrent TN after initial MVD during a long period of follow-up. Reoperation is safe and beneficial for these patients, but the results are dependent on the etiology of the recurrence. Further vascular compression of the trigeminal nerve can be relieved by MVD. Otherwise, in cases of severe adhesion caused by Teflon, complete microneural lysis can achieve satisfactory results.

Treatment of frontal sinus osteoma using a craniofacial approach

Osteoma is one of most common benign tumors of the nose and paranasal sinuses, with the frontal sinus being its most frequent location. It may be locally destructive and aggressive with possible intracranial complications. Osteoma of the frontal sinus comprises 57% of all osteomas in the paranasal sinuses. In 1939, Childrey reviewed 3,510 consecutive sinus radiographs taken for any reason and found an incidence of 0.43% of paranasal sinus osteomas. There are many operative approaches for frontal sinus osteomas, such as external frontoethmoidal approach and osteoplastic frontal sinusectomy, both with high recurrence rates. Those traditional operative methods cannot radically eradiate the osteoma grown in the posterior table of the frontal sinus. From July 1991 to June 1992, three patients with symptomatic frontal sinus osteomas were operated by a craniofacial approach. One patient is presented here in detail. A coronal incision is used and is found to be beneficial both in surgical exposure and in reconstruction with a calvarial bone graft. The patient has been followed for 3.5 years without osteoma recurrence.

Optic nerve decompression in fibrous dysplasia: indications, efficacy, and safety

Optic nerve decompression is controversial in posttraumatic visual loss and as a prophylactic therapy in fibrous dysplasia involving the optic canal. It is less controversial for the treatment of optic nerve compression in fibrous dysplasia. Thirteen patients with craniomaxillofacial fibrous dysplasia who underwent 16 optic nerve decompressions at the Chang Gung Craniofacial Centre for both therapeutic (10) and prophylactic (6) indications are reported. One patient sustained a clinically useful improvement in vision in response to two therapeutic decompressions, and another demonstrated marked improvement after therapeutic decompression, with visual acuity improving from 0.4 to 1.0 in the affected eye. No patient underwent a permanent deterioration of vision as a result of either therapeutic or prophylactic decompression. One patient suffered extraocular muscle dysfunction that was corrected with strabismus surgery. A review of the literature clarifies the controversies and allows establishment of indications for optic nerve decompression.

Neuroimaging in intractable complex partial seizures

We retrospectively analyzed 19 patients with intractable complex partial seizures who underwent temporal lobectomy and compared the usefulness of various imaging techniques in diagnosis and localization. Pathologic findings consistent with mesial temporal sclerosis were found in 12 patients arteriovenous malformations in four, tumors in three, and coexistence of a tumor and mesial temporal sclerosis in one. Electroencephalography and single photon emission computed tomography detected lateralized functional abnormality in two patients when computed tomography (CT) and magnetic resonance imaging (MRI) showed equivocal results. Both CT and MRI showed all arteriovenous malformations and tumors. CT detected only four cases of mesial temporal sclerosis, while MRI showed nine cases. Detection, delineation and diagnosis of lesions responsible for complex partial seizures are essential for good surgical results. Thus, the importance of image studies, especially MRI, should be emphasized in patients with complex partial seizures.

Prolonged circulatory arrest in moderate hypothermia with retrograde cerebral perfusion. Is brain ischemic?

BACKGROUND

Circulatory arrest (CA), which provides a bloodless field and good visualization without the need of aortic cross-clamp, is commonly used to facilitate repair of aortic lesions. However, extended periods of CA may impair cerebral metabolism and cause ischemic injury. Studies were performed to evaluate the efficacy of retrograde cerebral perfusion (RCP) in protecting the brain from ischemic injury during a prolonged period of CA in moderate hypothermia.

METHODS AND RESULTS

Twenty-three patients (18 men and 5 women) were operated on for aortic lesions (17 acute type A aortic dissection and 6 chronic type A aortic dissection with Marfan's syndrome). The aortic operations were performed with CA (58 to 104 minutes; mean +/- SD, 75 +/- 12 minutes) at a rectal temperature of 23.3 +/- 0.5 degrees C (21 degrees C to 25 degrees C). For RCP, cold (14 degrees C to 18 degrees C) oxygenated blood (300 mL/min) was pumped to the superior vena cava with internal jugular venous pressure of 15 +/- 5 mm Hg. The cardiopulmonary bypass time was 157 +/- 18 minutes. Cortical blood flow during RCP detected by subdural laser Doppler probe was 10 +/- 5% of baseline. Percent oxygen extraction and pyruvate and lactate levels (26 +/- 2% and 0.43 +/- 0.17 and 45 +/- 16 mg/dI) were insignificantly different from those before CA (28 +/- 3% and 0.71 +/- 0.08 and 62 +/- 20 mg/dL, P > .05). Creatine kinase-BB isoenzyme was undetectable. All but 1 patient survived the operation (95.5%) and woke up without neurological deficit. Follow-up (mean, 13 months) was complete in all survivors. There were no late deaths. Cerebral functional studies performed 3 months after discharge showed results insignificantly different from those of the normal control subjects.

CONCLUSIONS

There is no evidence of ischemia of the brain during prolonged moderate hypothermic CA with the aid of RCP. Retrograde cerebral perfusion effectively extends the safe time of CA. Deep hypothermia during CA seems unnecessary.

Serial MRI studies in pathologically verified Balò's concentric sclerosis

We report serial MRI studies in a patient with Balò's concentric sclerosis, who presented with a progressive weakness in the right limbs of 10 day duration. Serial MR images revealed several concentric lesions characterized by layer by layer of demyelinated and myelinated appearance and multiple plaques in the white matter. Pathological study of a biopsy of a concentric lesion (which was performed to rule out neoplasm) further confirmed this diagnosis. These MR findings resolved in correspondence with clinical improvement. The patient was almost completely normal 1 year later. In conclusion, in this case, we found that MRI could show the striking feature reminiscent of the histopathologic findings of Balò's concentric sclerosis and played an important role in antemortem diagnosis of this rare demyelinating disease.

p53 gene mutation in cerebral primitive neuroectodermal tumor in Taiwan

p53 mutation has been rarely reported in cerebral primitive neuroectodermal tumors (PNET). To determine the significance of p53 mutations in the development of cerebral PNET, we studied cerebral PNET samples from 14 patients, 8 females and 6 males with a mean age of 38 years (range 10 months to 77 years) who had total or subtotal surgical resection. Histological typing of PNET with neuronal (N) and non-neuronal (NN) differentiation groups revealed 8 and 6 cases, respectively. Six (43%) of the 14 patients had p53 mutation. The p53(+) and p53(-) groups had an age range of 19-77 with a mean of 49 years and 10 months to 57 years with a mean of 30 years, respectively. p53 expression between the PNET-N and PNET-NN groups was 5 of 8 (62.5%) and 1 of 6 (16.7%), respectively. The mutations contained 3 transitions, 2 transversions and 1 frameshift; none of them occurred at the site of 'hot-spot' residues (codons 175, 248, 273). The results suggest that: (1) p53 mutation in cerebral PNET tends to show a higher incidence of neuronal differentiation and occurs in the older age group in Taiwan, (2) there was no difference in survival time between the PNET-N and PNET-NN groups (7 months and 6 months) (P = 0.54), and between p53(+) and p53(-) groups (6 months and 7 months) (P = 0.57), and (3) PNET may be an entity of a heterogenous group of tumors with different genetic mechanisms controlling their trends of differential lineage. Further studies are needed to determine the significance of p53 mutations in PNET development, especially the role of carcinogens in the genesis of PNET in Taiwan.

Myocardial perfusion and function in dogs with moderate coronary stenosis

MRI studies of first-pass contrast enhancement with polylysine-Gd-DTPA and myocardial tagging using spatial modulation of magnetization (SPAMM) were performed to assess the feasibility of a combined regional myocardial blood flow and 2D deformation exam. Instrumented closed-chest dogs were imaged at a baseline control state (Cntl) followed by two interventions: moderate coronary stenosis (St) achieved by partial occlusion of the left anterior descending (LAD) and moderate coronary stenosis with dobutamine loading (StD). Hypoperfusion of the anterior region (ANT) of the myocardium (LAD distribution) relative to the posterior wall (POS) based on the upslope of the signal intensity time curve from the contrast-enhanced MR images was demonstrated only with dobutamine loading (ANT:POS Cntl = 1.077 +/- 0.15 versus ANT:POS StD = 0.477 +/- 0.11, P < 0.03) and was confirmed with radiolabeled microspheres measurements (ANT:POS Cntl = 1.18 +/- 0.2 ml/min/g versus ANT:POS StD = 0.44 +/- 0.1 ml/min/g; P < 0.002). Significant changes in regional myocardial shortening were only seen in the StD state (P < 0.02); the anterior region showed impaired myocardial shortening with dobutamine loading (P = NS), whereas the nonaffected POS region showed a marked increase in shortening when compared with Cntl (Cntl = 0.964 +/- 0.02 versus StD = 0.884 +/- 0.03; P < 0.001). These results demonstrate that an integrated quantitative assessment of regional myocardial function and semiquantitative assessment of myocardial blood flow can be performed noninvasively with ultrafast MRI.

Continuous hyperthermic peritoneal perfusion for peritoneal carcinomatosis

Continuous hyperthermic peritoneal perfusion (CHPP) with anticancer agents in warm saline was performed in 10 patients with cancer of the digestive tract and peritoneal carcinomatosis after resection of primary and metastatic lesions or both. Eight patients had colorectal cancer and one patient had recurring gastric cancer. CHPP was performed using saline containing mitomycin-C and 5-flurouracil at 42 degrees C to 43 degrees C for 60 minutes. One patient with pancreatic cancer received CHPP twice. After CHPP, the preoperative ascites of three patients disappeared. Four patients died of malignancy within 1 year of CHPP and one patient died of respiratory failure 5 months post-CHPP. The remaining five patients survived for more than 1 year after CHPP. There were no significant immediate postoperative complications, except for transient changes in liver function, white blood cell count and serum albumin level. While CHPP treatment appears to be a safe method of treatment for peritoneal carcinomatosis, its long term benefits need further investigation.

Intraoperative somatosensory evoked potentials for localization in excision of recurrent parasagittal meningioma--a case report

Removal of tumors that are located in the motor area is a challenge to neurosurgeons because of the possibility of injuring the motor cortex. We present our experience in excision of a recurrent parasagittal meningioma located in the central area. With the help of somatosensory evoked potentials (SSEP) monitoring, the tumor was removed totally without any neurologic sequela.