Fever, Rash, and Cough in a 7-Year-Old Boy

A 7-year-old boy presented to the emergency department with fever, cough, congestion, abdominal pain, myalgias, and morbilliform rash. Several aspects of the patient's history, including recent travel, living on a farm, exposure to sick contacts, and new medications, resulted in a wide differential diagnosis. Initial laboratory testing revealed leukocytosis with neutrophilia and elevated atypical lymphocytes, but did not reveal any infectious causes of illness. He was discharged from the hospital, but then represented to the emergency department a day later with worsening rash, continued fever, abdominal pain, and poor intake. He was then admitted. A more comprehensive laboratory evaluation was initiated. During this hospital course, the patient's physical examination changed when he developed head and neck edema, and certain laboratory trends became clearer. With the assistance of several specialists, the team was able to reach a more definitive diagnosis and initiate treatment to appropriately manage his condition.

Acute appendicitis in four children with SARS-CoV-2 infection

We describe 4 children (11-17 years in age) at our institution with acute appendicitis in the setting of SARS-CoV-2 infection, suggesting a possible association. Providers should consider testing for this infection in patients with severe gastrointestinal symptoms, in order to take appropriate transmission based precautions, until more is understood.

Retrospective Application of BRUE Criteria to Patients Presenting With ALTE

OBJECTIVES

To apply recently published brief resolved unexplained events (BRUE) guidelines to patients who presented with apparent life-threatening event (ALTE) to determine: (1) characteristics of these patients; (2) which patients meet BRUE criteria, including risk stratification; and (3) patient outcomes.

METHODS

A retrospective chart review of patients presenting to the emergency department or directly to the inpatient unit of a community hospital was performed over the 3 years preceding publication of BRUE guidelines. International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision billing data for infants <1 year of age were used to screen for patients. After 2-physician review, patients presenting with ALTE diagnostic criteria were identified. Characteristics of the patients and event were analyzed.

RESULTS

A total of 321 charts were screened, of which 87 patients were determined to have been diagnosed with ALTE. Twenty patients (23%) met criteria for diagnosis of BRUE. Only 1 patient met criteria for lower-risk BRUE. Of patients with ALTE, 79% of patients presented to the emergency department, of which 65% were admitted, 25% were discharged from the hospital, and 9% were transferred to a tertiary care hospital. Of the 63 inpatients, most were discharged from the hospital after brief observation, and 5% required transfer to a higher level of care.

CONCLUSIONS

The majority of patients with ALTE presenting to this institution did not meet the BRUE definition primarily because of ongoing symptoms and/or a specific diagnosis explaining the event. With this finding, we highlight the importance of characterizing the events on the basis of history and physical examination when diagnosing and caring for these patients.

BIOLAP: biological versus synthetic mesh in laparo-endoscopic inguinal hernia repair: study protocol for a randomized, multicenter, self-controlled clinical trial

Background

Inguinal hernia repair is one of the most common surgical operations globally; more than 20 million groin herniae are repaired annually worldwide. Recurrence after an inguinal hernia operation is a considerable clinical problem. Another remaining problem after hernia surgery is the occurrence of chronic pain. Up to now, the use of synthetic meshes is the standard procedure, but there is increasing evidence that biological meshes could be advantageous concerning the occurrence of chronic pain due to different postoperative remodeling, without the disadvantages of a life-long implant.

We hypothesize that the use of a biological mesh reduces postoperative pain without being inferior in terms of recurrence rate compared with a synthetic mesh.

Methods/design

The trial compares possible the advantages of biological matrices to synthetic meshes in laparo-endoscopic inguinal hernia repair. Four hundred and ninety-six patients with primary bilateral inguinal herniae in 20 German hernia centers will be enrolled. Biological mesh is used for one of the bilateral herniae, the other side will be operated on with a synthetic mesh. Randomization will preset which side is repaired with which material and trial participants will not be informed about the location of each mesh type. The primary endpoints will be intensity of postoperative local pain and the incidence of recurrent hernia after 2 years.

Discussion

There is no reasonably sized trial that assesses the use of biological meshes in laparo-endoscopic inguinal hernia repair.

Our self-controlled trial design allows a direct comparison of the two meshes with very few confounding factors as well as minimizing the exclusion criteria. As we compare CE-certified medical devices in their designated indication the medical risk is not different compared to routine clinical care. Due to the common nature of bilateral inguinal hernia, a high recruitment rate is achievable. Because guidelines for hernia repair have stressed the need for reliable data on the already frequent use of biological meshes, we can expect our trial to have a direct implication on hernia-repair standards.

Trial registration

German Clinical Trials Register, ID: DRKS00010178. Registered on 16.June.2016. BIOLAP underwent full external peer review as part of the funding process with the German Research Foundation.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3122-5) contains supplementary material, which is available to authorized users.

Measuring environmental stress in East Greenland polar bears, 1892-1927 and 1988-2009: what does hair cortisol tell us?

Hair sampled from 96 East Greenland polar bears (Ursus maritimus) over the periods 1892-1927 and 1988-2009 was analyzed for cortisol as a proxy to investigate temporal patterns of environmental stress. Cortisol concentration was independent of sex and age, and was found at significantly higher (p<0.001) concentrations in historical hair samples (1892-1927; n=8) relative to recent ones (1988-2009; n=88). In addition, there was a linear time trend in cortisol concentration of the recent samples (p<0.01), with an annual decrease of 2.7%. The recent hair samples were also analyzed for major bioaccumulative, persistent organic pollutants (POPs). There were no obvious POP related time trends or correlations between hair cortisol and hair POP concentrations. Thus, polar bear hair appears to be a relatively poor indicator of the animal's general POP load in adipose tissue. However, further investigations are warranted to explore the reasons for the temporal decrease found in the bears' hair cortisol levels.

Associations between complex OHC mixtures and thyroid and cortisol hormone levels in East Greenland polar bears

The multivariate relationship between hair cortisol, whole blood thyroid hormones, and the complex mixtures of organohalogen contaminant (OHC) levels measured in subcutaneous adipose of 23 East Greenland polar bears (eight males and 15 females, all sampled between the years 1999 and 2001) was analyzed using projection to latent structure (PLS) regression modeling. In the resulting PLS model, most important variables with a negative influence on cortisol levels were particularly BDE-99, but also CB-180, -201, BDE-153, and CB-170/190. The most important variables with a positive influence on cortisol were CB-66/95, α-HCH, TT3, as well as heptachlor epoxide, dieldrin, BDE-47, p,p'-DDD. Although statistical modeling does not necessarily fully explain biological cause-effect relationships, relationships indicate that (1) the hypothalamic-pituitary-adrenal (HPA) axis in East Greenland polar bears is likely to be affected by OHC-contaminants and (2) the association between OHCs and cortisol may be linked with the hypothalamus-pituitary-thyroid (HPT) axis.

Cortisol levels in hair of East Greenland polar bears

To demonstrate the ability to assess long-term hypothalamic-pituitary-adrenocortical (HPA) axis activity in polar bears (Ursus maritimus), a pilot study was conducted in which cortisol concentrations was analyzed in hair from 7 female (3-19 years) and 10 male (6-19 years) East Greenland polar bears sampled in 1994-2006. The hair was chosen as matrix as it is non-invasive, seasonally harmonized, and has been validated as an index of long-term changes in cortisol levels. The samples were categorized according to contamination: eight were clean (2 females, 6 males), 5 had been contaminated with bear blood (2 F, 3 M), and 4 with bear fat (3 F, 1 M). There was no significant difference in cortisol concentration between the three categories after external contamination was removed. However, contaminated hair samples should be cleaned before cortisol determination. Average hair cortisol concentration was 8.90 pg/mg (range: 5.5 to 16.4 pg/mg). There was no significant correlation between cortisol concentration and age (p=0.81) or sampling year (p=0.11). However, females had higher mean cortisol concentration than males (females mean: 11.0 pg/mg, males: 7.3 pg/mg; p=0.01). The study showed that polar bear hair contains measurable amounts of cortisol and that cortisol in hair may be used in studies of long-term stress in polar bears.

Lacune-associated cerebral hypoperfusion correlates with cognitive testing

The hypothesis was tested among 83 patients with multiple lacunar infarctions that cerebral hypoperfusion will correlate with cognitive impairments. Patients were subdivided according to Cognitive Capacity Screening Examination (CCSE) scores into a cognitively impaired group (Group D, n = 40; mean age, 68.2 years) with CCSE scores between 6 and 25 (mean, 19.9) and a cognitively intact group (Group I, n = 43; mean age, 66.0) with normal scores (mean, 29.4). Gray and white matter tissue densities were measured by plain computed tomography (CT), and their compartmental perfusions were estimated during stable xenon inhalation. Eighty infarcts in basal ganglia and white matter were detected in Group D and 62 in Group I. Cognitive impairments correlated with (a) multiplicity and bilaterality of lacunes; (b) hypertension, diabetes mellitus, and multiplicity of risk factors for stroke; (c) hypoperfusion of white and gray matter, but particularly of frontal white matter; (d) leuko-araiosis; (e) aging; and (f) lower education. The conclusion was that hypertension and diabetes mellitus are potent risk factors for cerebral small vessel disease or arteriolosclerosis ultimately resulting in lacunar infarcts, leuko-araiosis, white matter hypoperfusion, and impaired cognitive test performance.

Emergent Lorentz symmetry with vanishing velocity in a critical two-subband quantum wire

We consider a quantum wire with two subbands of spin-polarized electrons in the presence of strong interactions. We focus on the quantum phase transition when the second subband starts to get filled as a function of gate voltage. Performing a one-loop renormalization group analysis of the effective Hamiltonian, we identify the critical fixed-point theory as a conformal field theory having an enhanced SU(2) symmetry and central charge 3/2. While the fixed point is Lorentz invariant, the effective "speed of light" nevertheless vanishes at low energies due to marginally irrelevant operators leading to a diverging critical specific heat coefficient.

Noninvasive technique for the repeated sampling of salivary free cortisol in awake, unrestrained squirrel monkeys

The use of noninvasive measures of hypothalamic-pituitary-adrenal (HPA) axis function is of growing interest among preclinical and clinical investigators. This report describes a method for the repeated assessment of salivary free cortisol in awake, unrestrained squirrel monkeys (Saimiri sciureus) based on a saliva sampling technique previously developed for rhesus monkeys. Individually housed adult male squirrel monkeys were trained to chew on dental rope attached to a pole, from which saliva was extracted by centrifugation and analyzed for cortisol by radioimmunoassay (RIA). Eight of nine monkeys readily acquired the task, reliably providing adequate saliva samples for the assay. Salivary free cortisol levels were examined in these subjects under basal conditions and in response to two types of neuroendocrine challenge. Levels of salivary free cortisol showed relatively low intra- and interindividual variability, with mean individual morning levels ranging between 17.1 and 37.9 microg/dl. Squirrel monkeys demonstrated a consistent daily rhythm in salivary free cortisol ranging from a high of 27.4 +/- 5.2 microg/dl (mean +/- SEM) at 12 P.M. to a low of 7.5 +/- 1.6 microg/dl at 6 P.M. Intravenous (IV) challenges with 1 microg/kg ACTH, or 10 and 50 microg/kg CRF resulted in significant increases in salivary free cortisol. The described sampling technique provides a reliable and sensitive means for repeated measurement of HPA activity in unrestrained, awake squirrel monkeys. In addition, our findings illustrate several features of HPA system rhythmicity and reactivity using salivary cortisol instead of blood plasma or serum.

Bioavailability and toxicity of dietborne copper and zinc to fish

To date, most researchers have used dietborne metal concentrations rather than daily doses to define metal exposure and this has resulted in contradictory data within and between fish species. It has also resulted in the impression that high concentrations of dietborne Cu and Zn (e.g. > 900 mg kg(-1) dry diet) are relatively non-toxic to fish. We re-analyzed existing data using rations and dietborne metal concentrations and used daily dose, species and life stage to define the toxicity of dietborne Cu and Zn to fish. Partly because of insufficient information we were unable to find consistent relationships between metal toxicity in laboratory-prepared diets and any other factor including, supplemented metal compound (e.g. CuSO(4) or CuCl(2)), duration of metal exposure, diet type (i.e. practical, purified or live diets), or water quality (flow rates, temperature, hardness, pH, alkalinity). For laboratory-prepared diets, dietborne Cu toxicity occurred at daily doses of > 1 mg kg(-1) body weight d(-1) for channel catfish (Ictalurus punctatus), 1-15 mg kg(-1) body weight d(-1) (depending on life stage) for Atlantic salmon (Salmo salar) and 35-45 mg kg(-1) body weight d(-1) for rainbow trout (Oncorhynchus mykiss). We found that dietborne Zn toxicity has not yet been demonstrated in rainbow trout or turbot (Scophthalmus maximus) probably because these species have been exposed to relatively low doses of metal ( < 90 mg kg(-1) body weight d(-1)) and effects on growth and reproduction have not been analyzed. However, daily doses of 9-12 mg Zn kg(-1) body weight d(-1) in laboratory-prepared diets were toxic to three other species, carp Cyprinus carpio, Nile tilapia Oreochromis niloticus, and guppy Poecilia reticulata. Limited research indicates that biological incorporation of Cu or Zn into a natural diet can either increase or decrease metal bioavailability, and the relationship between bioavailability and toxicity remains unclear. We have resolved the contradictory data surrounding the effect of organic chelation on metal bioavailability. Increased bioavailability of dietborne Cu and Zn is detectable when the metal is both organically chelated and provided in very low daily doses. We have summarized the information available on the effect of phosphates, phytate and calcium on dietborne Zn bioavailability. We also explored a rationale to understand the relative importance of exposure to waterborne or dietborne Cu and Zn with a view to finding an approach useful to regulatory agencies. Contrary to popular belief, the relative efficiency of Cu uptake from water and diet is very similar when daily doses are compared rather than Cu concentrations in each media. The ratio of dietborne dose:waterborne dose is a good discriminator of the relative importance of exposure to dietborne or waterborne Zn. We discuss gaps in existing data, suggest improvements for experimental design, and indicate directions for future research.

Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast

Fractures of the hip in children have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). Over a period of 20 years, we have treated displaced fractures by early anatomical reduction, internal fixation and immobilisation in a spica cast to try to reduce these complications. We have reviewed 18 patients who had a displaced non-pathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (2 to 13). They returned for examination and radiography at a mean follow-up of eight years (2 to 17). Each patient had been treated by early (" 24 hours) closed or open reduction with internal fixation and 16 had immobilisation in a spica cast. By Delbet's classification, there was one type-I, eight type-II, eight type-III, and one type-IV fractures. There were no complications in 15 patients. Avascular necrosis occurred in one patient (type-III), nonunion in one (type-II, one of the two patients who did not have a cast) and premature physeal closure in one (type-I). There were no cases of infection or complications as a result of the cast. Our treatment of displaced hip fractures in children by early reduction, internal fixation, and immobilisation in a spica cast gave reduced rates of complications compared with that of large published series in the literature.

Naturalized salmonid populations occur in the presence of elevated trace element concentrations and temperatures in the Firehole River, Yellowstone National Park, Wyoming, USA

We investigated the effects of geothermally influenced waters on the distribution of rainbow trout, Oncorhynchus mykiss, and brown trout, Salmo trutta, in the Firehole River and its tributaries in Yellowstone National Park (WY, USA) from June 1997 to June 1998. Geothermal features in the Firehole River basin elevate mineral content and temperature in portions of the river and its tributaries. We found concentrations of boron and arsenic to be elevated in geothermally influenced areas compared with upstream sites. Boron concentrations occasionally exceeded 1,000 microg/L, a proposed limit for the protection of aquatic organisms. Arsenic concentrations occasionally exceeded 190 microg/L, the chronic ambient water quality criterion. Temperatures in geothermally influenced sites ranged up to 30 degrees C and were consistently 5 to 10 degrees C higher than upstream sites unaffected by geothermal inputs. Rainbow trout occurred at sites with elevated concentrations of boron, arsenic, and other trace elements and elevated water temperatures. Rainbow trout inhabited and spawned at sites with the most elevated trace element concentrations and temperatures; however, brown trout were absent from these sites. Water temperature may be the major factor determining brown trout distributions, but we cannot exclude the possibility that brown trout are more sensitive than rainbow trout to boron, arsenic, or other trace elements. Further investigations are needed to determine species-specific tolerances of boron, arsenic, and other trace elements among salmonids.

Biotic ligand model of the acute toxicity of metals. 2. Application to acute copper toxicity in freshwater fish and Daphnia

The biotic ligand model (BLM) was developed to explain and predict the effects of water chemistry on the acute toxicity of metals to aquatic organisms. The biotic ligand is defined as a specific receptor within an organism where metal complexation leads to acute toxicity. The BLM is designed to predict metal interactions at the biotic ligand within the context of aqueous metal speciation and competitive binding of protective cations such as calcium. Toxicity is defined as accumulation of metal at the biotic ligand at or above a critical threshold concentration. This modeling framework provides mechanistic explanations for the observed effects of aqueous ligands, such as natural organic matter, and water hardness on metal toxicity. In this paper, the development of a copper version of the BLM is described. The calibrated model is then used to calculate LC50 (the lethal concentration for 50% of test organisms) and is evaluated by comparison with published toxicity data sets for freshwater fish (fathead minnow, Pimephales promelas) and Daphnia.

Biotic ligand model of the acute toxicity of metals. 1. Technical basis

The biotic ligand model (BLM) of acute metal toxicity to aquatic organisms is based on the idea that mortality occurs when the metal-biotic ligand complex reaches a critical concentration. For fish, the biotic ligand is either known or suspected to be the sodium or calcium channel proteins in the gill surface that regulate the ionic composition of the blood. For other organisms, it is hypothesized that a biotic ligand exists and that mortality can be modeled in a similar way. The biotic ligand interacts with the metal cations in solution. The amount of metal that binds is determined by a competition for metal ions between the biotic ligand and the other aqueous ligands, particularly dissolved organic matter (DOM), and the competition for the biotic ligand between the toxic metal ion and the other metal cations in solution, for example, calcium. The model is a generalization of the free ion activity model that relates toxicity to the concentration of the divalent metal cation. The difference is the presence of competitive binding at the biotic ligand, which models the protective effects of other metal cations, and the direct influence of pH. The model is implemented using the Windermere humic aqueous model (WHAM) model of metal-DOM complexation. It is applied to copper and silver using gill complexation constants reported by R. Playle and coworkers. Initial application is made to the fathead minnow data set reported by R. Erickson and a water effects ratio data set by J. Diamond. The use of the BLM for determining total maximum daily loadings (TMDLs) and for regional risk assessments is discussed within a probabilistic framework. At first glance, it appears that a large amount of data are required for a successful application. However, the use of lognormal probability distributions reduces the required data to a manageable amount.

Dichotomy in phasic-tonic neuromuscular structure of crayfish inhibitory axons

Crustacean muscles are unique in their innervation by both excitatory and inhibitory neurons; therefore, they exhibit polyneuronal and multiterminal innervation. Because excitatory motoneurons are broadly divided into phasic and tonic types, we hypothesized that inhibitory neurons would follow a similar dichotomy. The abdominal extensor muscles in crayfish are separated into parallel deep and superficial bundles; the former has fast muscle fibers innervated by phasic excitatory motoneurons, and the latter has slow fibers supplied by tonic excitatory motoneurons. Each muscle also is innervated by a single, separate inhibitory neuron that uses gamma-aminobutyric acid (GABA) as the inhibitory neurotransmitter. The pattern of axonal branching by the separate inhibitory axons in phasic and tonic abdominal extensor muscles was visualized with confocal microscopy in preparations labeled for GABA-like immunoreactivity. Initial observations indicated that the phasic muscle was covered by extensive GABAergic, filiform axon terminals, whereas innervation of the tonic muscle was comprised of more localized and varicose terminals. With quantitative analyses, we found that the phasic axon has a more highly branched nature than the tonic in first- and second-order branches. The phasic axon branches also were significantly longer than the tonic branches in the second- and third-order branches. Synaptic varicosities in the phasic branches were smaller and less frequent than those in the tonic branches. The fine structure of the inhibitory nerve terminals near synaptic contacts examined with thin-serial-section electron microscopy revealed distinct differences between the phasic system and the tonic system. The phasic terminals were smaller in cross-sectional area than the tonic terminals, and they had smaller synapses and fewer mitochondria. The presynaptic active zone dense bodies were similar in length and number between phasic and tonic synapses. However, their number per synaptic area was two-fold higher in phasic synapses compared with tonic synapses because of the smaller size of the phasic synapses. Thus, within the same neuromuscular system, inhibitory synaptic terminals revealed unique phasic and tonic identities similar to those observed for the excitatory axons.

Imaging of musculoskeletal infections

Imaging studies play a critical role in the diagnosis and management of musculoskeletal infections in children. Conventional radiography is usually the first imaging study performed with other imaging modalities as needed. Ultrasound is helpful in detecting joint effusions and fluid collections in the soft tissue and subperiosteal regions, and may guide localization for aspiration or drainage. CT can demonstrate osseous and soft tissue abnormalities and is ideal for detecting gas in soft tissues. Nuclear scintigraphy and MR imaging are valuable because of their high sensitivity. Scintigraphy is particularly useful in identifying multifocal involvement, which is an important consideration in neonatal osteomyelitis and CRMO. MR imaging provides accurate information on both the soft tissues and bones and is our imaging study of choice for evaluating the local extent of musculoskeletal infections.

Longitudinal follow-up of depressive symptoms among normal versus cognitively impaired elderly

OBJECTIVES

This prospectively designed longitudinal study assesses prevalence, incidence and prognosis of depressive symptoms among cognitively normal elderly volunteers compared with patients with mild cognitive impairment (MCI), dementia of Alzheimer type (DAT), and vascular dementia (VAD). Possible relationships between depressive symptoms, cognitive performance, disease types, and effects of antidepressant treatment were analyzed.

METHODS

Two hundred and ninety four subjects exhibiting different levels of cognitive performance were admitted to this study. Demographics, cardiovascular and neurodegenerative risk factors, together with measures of neuropsychological test performance, were obtained at sequential visits. Depressive symptoms were selectively treated with antidepressant medications.

RESULTS

One hundred and forty six subjects with normal cognition, 19 subjects with MCI, 42 patients with DAT, and 32 patients with VAD were followed for a mean of 3.5 years. With the passage of time, there were trends showing prevalence of depressive symptoms to decrease among DAT and to increase among VAD patients. VAD patients exhibited the highest incidences of new-onset depressive symptoms, followed in incidence by DAT and MCI groups. Depressive symptoms among VAD and MCI patients were more persistent and refractory to antidepressant medications than for DAT patients. Trends suggested that antidepressant treatment might benefit MCI and VAD subjects more than DAT patients. Motivationally related depressive symptoms accounted for major components of elevated Hamilton depression rating scale scores.

CONCLUSIONS

Depressive symptoms among DAT patients have higher rates of spontaneous resolution, without requiring intensive drug treatment, than among VAD patients in whom depressive symptoms are more persistent and refractory to drug treatment. Early depressive symptoms among subjects with MCI may represent a preclinical sign and should be considered as a risk factor for impending DAT or VAD among the elderly.

Cell Proliferation in Ovarian Carcinoma: Superior Accuracy of S-Phase Fraction (SPF) by DNA Labeling Index versus Flow Cytometric SPF, Lack of Independent Prognostic Power for SPF and DNA Ploidy, and Limited Effect of SPF on Tumor Growth Rate

OBJECTIVES

The goal of this work was to test the hypotheses that S-phase fraction (SPF) by DNA labeling index (SPF-LI) would predict the course of the disease for ovarian/peritoneal carcinomas and that SPF-LI would correlate better with pathologic classification and outcome than SPF by DNA flow cytometry (SPF-F).

METHODS

Tritiated thymidine (1985-1988) and bromodeoxyuridine (1988-1999) DNA labeling (SPF-LI) was evaluated in vitro on 178 tumors. Cellular DNA and SPF-F were measured flow cytometrically. During this time, 90% of ovarian/peritoneal tumors accessioned in surgical pathology were studied.

RESULTS

Tumors of low malignant potential (LMP, "borderline") had low SPF-LI (median = 1.2%). High-grade invasive carcinomas of various types and carcinosarcomas all had high SPF-LI (medians = 11.2-23.4%). Serous low-grade invasive carcinomas (median = 1.05) resembled LMP tumors. SPF-LI of ovarian carcinomas other than LMP tumors increased slightly as FIGO stage increased (P = 0.07). Survival of patients with high-grade ovarian carcinomas was not predicted by SPF-LI or SPF-F, nor was DNA ploidy predictive. SPF-LI produced tighter distributions for various tumor types than did SPF-F. Neither SPF nor DNA ploidy contributed to prediction of outcome when tumor type and stage were included in multivariate models. We calculated the mean cell loss rate of high-grade carcinomas to be 94%.

CONCLUSIONS

LMP ovarian/peritoneal tumors have low proliferation rates in contrast to high-grade carcinomas. Proliferation correlated with tumor type and stage, but neither it nor DNA ploidy predicted survival independently. Proliferation rate is growth limiting only when low. At higher levels cell loss limits growth. SPF-LI measures proliferation more accurately than SPF-F; SPF-F is not sufficiently reliable for clinical use.

Depressive symptoms among cognitively normal versus cognitively impaired elderly subjects

OBJECTIVES

The present cross-sectional study analyzed the prevalence and severity of depressive symptoms among patients with Alzheimer's disease (DAT), vascular dementia (VAD), and among the cognitively normal elderly. Putative risk factors contributing to depression were likewise evaluated.

METHODS

Seventy-six DAT patients, 51 VAD patients, and 121 cognitively normal subjects were admitted to the study. Questionnaires concerning demography and their vascular and familial risk factors together with results of neuropsychological testing by combined Mini-Mental Status Examinations (MMSE), Cognitive Capacity Screening Examinations (CCSE), and Hamilton Depression Rating Scales (HDRS) were obtained so that resulting data would be statistically analyzed.

RESULTS

Prevalence of depressive symptoms among VAD, DAT, and cognitively normal elderly were 31.4%, 19.9%, and 13.2%, respectively. 25.5% of VAD and 13.2% of DAT patients had depression of mild to moderate degrees. Regression analysis revealed that diagnosis of VAD and DAT, heart disease, and past history of depression was significantly associated with high HDRS scores. There was no correlation between degree of depression and severity of cognitive impairments.

CONCLUSION

Mild to moderate depression is a common comorbidity with organic dementia, especially VAD, but associated depression is independent of severity of cognitive impairments.

Validating mini-mental status, cognitive capacity screening and Hamilton depression scales utilizing subjects with vascular headaches

INTRODUCTION

The Mini-Mental State Examination (MMSE) and Cognitive Capacity Screening Examination (CCSE) are easily and rapidly administered tests for quantifying the general cognitive status of young as well as geriatric subjects. Likewise, the Hamilton Depression Rating Scale (HDRS) is a brief instrument for quantifying depression that may confound cognitive test performances. Testing by means of all three scales concurrently provides useful information for longitudinal research among the elderly.

OBJECTIVES

To validate the combined longitudinal use of MMSE, CCSE and HDRS among a specific cohort of normal subjects with vascular headaches characterized by known well-established temporary cognitive decline occurring only during temporary intervals with headache.

METHODS

The MMSE, CCSE and HDRS were serially tested at 3-12 monthly intervals among 196 healthy subjects attending our out-patient headache clinic who suffered from migraine or cluster headaches. Stability and specificity of MMSE, CCSE and HDRS were evaluated by comparing consecutive normative scores during headache-free intervals. Sensitivity of MMSE and CCSE for detecting temporary cognitive decline were evaluated by comparing scores during headache and headache-free intervals.

RESULTS

CCSE, MMSE and HDRS gave stable headache-free normative values over intervals of 3-10 years among 182 subjects. Among 77 subjects during headache intervals, temporary cognitive decline were confirmed by both CCSE and MMSE (p < 0.0001). When cutoff points for both CCSE and MMSE normal scores were placed at >/= 27, specificity for detecting cognitively normal values for CCSE and MMSE when headache-free were 92.2 and 89.6%, respectively (p > 0.05), while sensitivity for detecting cognitively decline during headache intervals were 83.7 and 49%, respectively (p < 0.001). Compared with scoring by a single rater, reliability estimates for all three rating scales were slightly lower when tested by different raters, but these differences were not significant.

CONCLUSIONS

CCSE is reliable and more sensitive than MMSE for detecting cognitive decline.

Clinical relevance of urokinase-type plasminogen activator, its receptor, and its inhibitor type 1 in endometrial cancer

OBJECTIVE

Tumor invasion involves degradation of extracellular matrix. The urokinase plasminogen activation system participates in this process. Urokinase-type plasminogen activator (uPA), its receptor (uPAR), and its inhibitor, plasminogen activator inhibitor type 1 (PAI-1), are proposed to be prognostic factors in some cancers. There are conflicting data regarding the prognostic role of this system in endometrial cancer.

METHODS

To determine the prognostic value of the urokinase plasminogen activation system, contents of uPA, uPAR, and PAI-1 were measured in extracts of endometrial cancer tissue using ELISAs. uPA, uPAR, and PAI-1 levels were determined in 91, 54, and 92 extracts, respectively, and correlated with tumor histology, stage, grade, lymph node involvement, prevalence of metastasis, and recurrence as well as with estrogen (ER), progesterone (PR), epidermal growth factor (EGFR) receptor and HER-2/neu contents.

RESULTS

Patients with cancers exhibiting advanced stage, high grade, unfavorable tumor histology, nodal involvement, recurrence, and lower PR levels determined by ligand binding had significantly higher uPA content than others. PAI-1 was significantly elevated in patients with advanced stage, high-grade tumor, recurrence, decreased ER content, and lower PR levels determined by ligand binding. uPAR did not show any relation to any of clinical and laboratory parameters. Elevated expression of PAI-1 was associated with significantly shorter disease-free (P = 0.005) and overall (P = 0.0003) survival. Multivariate analysis revealed that PAI-1 was a predictor of survival although stage was the strongest independent factor.

CONCLUSION

Elevated uPA and PAI-1 levels appear to correlate with unfavorable prognosis in endometrial cancer.

Physiological correlates of self-injurious behavior in captive, socially-reared rhesus monkeys

This study examined the relationship between self-injurious behavior (SIB) in rhesus monkeys and several biological variables, including monoamine metabolites in cerebrospinal fluid (CSF) and circulating levels of ACTH, cortisol, and testosterone. Cisternal CSF and blood plasma samples were obtained from 23 individually housed male rhesus macaques, 14 of which had a veterinary record of self-inflicted wounding. CSF samples were analyzed for 5-hydroxyindole-3-acetic acid (5-HIAA), homovanillic acid (HVA) and 3-methoxy-4-hydroxyphenylglycol (MHPG) using isocratic high-performance liquid chromatography with electrochemical detection (HPLC-EC). Plasma samples were analyzed for ACTH, cortisol, and testosterone using commercially available radioimmunoassays (RIAs). Rates of self-directed biting were determined by systematic observation of all monkeys. Monkeys with SIB did not differ from controls in their basal monoamine or gonadal activity. However, the SIB group showed consistently lower mean plasma cortisol levels than the control group. Plasma cortisol was negatively correlated with rates of self-directed biting. These results suggest a persistent dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis in monkeys with SIB. It is not yet clear whether this phenomenon of low cortisol represents chronically reduced adrenocortical secretion under basal conditions or a difference in response to the mild stress of capture and chemical restraint. The implications of these findings will be discussed with respect to SIB in humans as well as post-traumatic stress disorder (PTSD), a condition characterized by pituitary-adrenocortical hypoactivity.

Risk factors for cerebral degenerative changes and dementia

It is concluded that the most important determinants for cerebral neurodegenerative changes and cognitive decline during aging are neuronal shrinkage and/or loss, which are accelerated by certain risk factors: e.g. TIAs, hypertension, heart disease, hyperlipidemia, smoking, heavy alcohol consumption, male gender, low educational status, family history of cerebrovascular disease and absence of estrogen replacement therapy among women. Some of these risk factors are remediable by therapeutic interventions, including prevention of TIAs and medications that control hypertension, heart disease, hyperlipidemia and estrogen replacement in postmenopausal women, as well as abstention from abuse of tobacco and alcohol. Cerebral neurodegenerative changes measured by neuroimaging appear to be premorbid markers for depleted neuronal and synaptic reserves which predispose to the onset of dementias of both VAD and DAT types. Normal subjects at risk for cognitive decline include those with TIAs, hypertension and heart disease since these risk factors measurably accelerate cerebral atrophy, ventricular enlargement, leukoaraiosis, and decline in cortical perfusion.

Techniques for collecting saliva from awake, unrestrained, adult monkeys for cortisol assay

Cortisol levels serve as an index of pituitary-adrenal activity in nonhuman primates. In adult monkeys, cortisol is normally measured in blood (typically requiring restraint or sedation) or urine (reflecting a state rather than point estimate). In contrast, saliva collection is less invasive than drawing blood and allows for repeated sampling within a short period of time. Although protocols exist for collecting saliva from young monkeys, these procedures are inadequate for awake, unrestrained adult animals. Our laboratory has developed two methods for collecting saliva from adult rhesus monkeys: a "screen" method, which involves licking screen-covered gauze, and a "pole" method, which involves sucking and chewing on an attached rope. Twenty-three adult male rhesus monkeys were used to evaluate these two methods. After a period of adaptation, saliva samples were collected from 21 of 23 subjects. Saliva collection was faster with the pole than with the screen method (P < 0.01), but the pole method was not suitable for some animals because of their tendency to bite off the attached rope. An analysis of 19 saliva samples revealed a mean cortisol concentration of 0.84 microg/dl (range 0.27-1.77 microg/dl). There was no statistically significant difference in cortisol value between methods used (P > 0.22). The influence of the flavoring on the cortisol assay was tested, and was found to have no significant effect (P > 0.28). Our results indicate that either technique can be used to safely collect saliva from unrestrained adult monkeys. Choice of technique will depend on the proclivities of individual monkeys.

Effects of neonatal cocaine treatment and gender on opioid agonist-stimulated [(35)S]GTP gamma S binding in the striatum and nucleus accumbens

Prenatal cocaine exposure increases mu-opioid receptor binding in dopaminergic terminal areas and enhances behavioral responsiveness to mu-opioid agonists. We investigated the influence of early postnatal cocaine treatment on in vitro mu- and delta-opioid receptor activation in male and female weanling rats. Pups received subcutaneous injections of either 20 mg/kg cocaine HCl or saline once daily on postnatal days 1 through 5. On postnatal day 25, animals were decapitated and their brains were removed and frozen for later sectioning. Opioid receptor activation was assessed in the striatum and the shell of the nucleus accumbens by autoradiographic analysis of agonist-stimulated [(35)S]GTP gamma S binding. Brain sections were incubated in the presence of [(35)S]GTP gamma S, GDP, and either the mu-opioid agonist [D-Ala(2)-N-MePhe(4)-Gly(5)-ol]enkephalin (DAMGO) or the delta-opioid agonist D-Pen(2)-D-Pen(5)-enkephalin (DPDPE). Baseline binding was assessed in the absence of agonist, and nonspecific binding was determined by the addition of unlabeled GTP gamma S. Film images were quantified using brain mash-calibrated [(14)C] standards. Neonatal cocaine treatment had no effect on either baseline or agonist-stimulated [(35)S]GTP gamma S binding. However, males exhibited significantly greater activation than females of delta-opioid receptors in both striatum and accumbens shell, regardless of neonatal treatment. These findings indicate a gender difference in delta-opioid receptor function that could mediate behavioral differences in response to opioid agonists.

Ultrafast MR imaging of the normal posterior fossa in fetuses

OBJECTIVE

The purpose of our study was to determine if a standard imaging protocol using ultrafast MR sequences could adequately reveal normal posterior fossa anatomy in fetuses and, if so, to document a template on MR imaging for normal posterior fossa development.

MATERIALS AND METHODS

A retrospective review found 66 MR imaging studies of 63 fetuses, 16-39 weeks' gestation age (mean, 25 weeks' gestation), who were referred between June 1996 and May 1999 for evaluation of non-central nervous system anomalies revealed on prenatal sonography. All fetuses had normal brains and spines on prenatal sonography. The standard MR imaging protocol included axial, sagittal, and coronal half-Fourier acquisition single-shot turbo spin echo (HASTE); sagittal and coronal two-dimensional fast low-angle shot (FLASH); and axial turbo T1-weighted FLASH images through the fetal brain. Structures that we analyzed were the fourth ventricle, the cisterna magna, the vermis, the cerebellar hemispheres, and the brainstem. Using the HASTE sequences, we documented gestational age-specific signal intensity changes in the cerebellar hemispheres and the brainstem.

RESULTS

The posterior fossa anatomy was sufficiently well defined to exclude abnormalities of the fourth ventricle and cerebellar vermis in all cases. Because of high T2-weighting, good contrast enhancement, and good signal-to-noise ratios, HASTE images provided the best anatomic definition of the posterior fossa.

CONCLUSION

Normal posterior fossa anatomy can be adequately shown on ultrafast MR images, which can be helpful when prenatal sonography is equivocal.

Reversible cognitive decline accompanies migraine and cluster headaches

Vascular headaches, including migraine, cluster, and migrainous transformation to chronic daily headaches, are disabling. During and shortly after headache intervals, difficulties are reported in concentration, comprehension, and communication, not accounted for by nausea, photophobia, or sonophobia. These interfere with interpersonal relations and performance at work with economic loss. The hypothesis tested and reported here is that cognitive impairments comprise an important part of vascular headache diatheses. One hundred ninety-six otherwise normative subjects suffering from migraine or cluster, but not tension-type, headaches (136 women, 63 men; mean age, 46 years) participated in an outpatient prospective trial. One hundred thirty-three patients had migraine without aura, 39 migraine with aura, 11 periodic cluster (by IHS criteria), and 13 had migrainous transformation into chronic daily headaches. Neuropsychological testing was compared with and without headaches, by combined Mini-Mental Status Examination (MMSE), Cognitive Capacity Screening Examination (CCSE), and Hamilton Depression Rating Scale (HDRS). During headache intervals, significant decline was measured in both CCSE and MMSE scores (P <. 001) without HDRS change in all types of vascular headache and independent of headache severity, which often improved, or associated physical symptoms. Cognitive decline was promptly relieved by serotonin agonists and sleep. Disorders of cerebral serotoninergic projection systems appear to cause these reversible cognitive impairments.

Prenatal MRI evaluation of congenital diaphragmatic hernia

The objective of this paper is to evaluate the efficacy of various magnetic resonance imaging (MRI) sequences and the general usefulness of prenatal MRI in determining the position of the fetal liver and visualizing lung tissue in fetuses who have congenital diaphragmatic hernia (CDH). This was a retrospective review of prenatal MRI of fetuses with a confirmed diagnosis by surgery or autopsy of CDH. MRI was performed in a 1.5-Tesla magnet using fast gradient echo, half-Fourier single-shot turbo spin-echo (HASTE) and echo planar images. The presence of a chest mass, position of the stomach and liver and visualization of the lungs by MRI was noted in all fetuses. This was compared to ultrasound studies performed the same day and correlated with postnatal or autopsy studies. The fetuses were 18-36 weeks gestational age (mean 24.5 weeks). MRI diagnosed left CDH (33), right CDH (4), and bilateral CDH (1) and agreed with the postnatal diagnosis in all patients. Ultrasound (US) diagnosed left CDH (33), right CDH (2), and congenital cystic adenomatoid malformation (3). MRI changed the diagnosis in four patients. The fetal liver was easily demonstrated with MRI in all fetuses and was herniated into the chest in 25 of the 38. US diagnosed liver up in 21. Correlation with postnatal studies found MRI correctly diagnosed liver position in 37 out of 38 cases. US correctly diagnosed liver position in 32 out of 38. Both lungs could be visualized in all fetuses with MRI. MRI accurately and easily diagnoses CDH and can differentiate it from other chest masses. MRI was superior to US in demonstrating the position of the fetal liver above or below the diaphragm. MRI reliably visualized fetal lung tissue. These findings are important for counseling parents, selecting fetal surgical candidates, and estimating prognosis.

Cardiovascular and other risk factors for Alzheimer's disease and vascular dementia

Factors accelerating cerebral degenerative changes represent potentially modifiable risks for cognitive decline. Putative risks accelerating subtle cognitive decline and dementia were correlated with repeated measures of cerebral atrophy, CT densitometry, perfusions, and cognitive testing among 224 neurologically and cognitively normative aging volunteers. After age 60, cerebral atrophy, ventricular enlargement, polioaraiosis, and leukoaraiosis geometrically increased as perfusions declined. Risks accelerating perfusional decline, cerebral atrophy, polioaraiosis, and leukoaraiosis were: transient ischemic attacks (TIAs), hypertension, smoking, hyperlipidemia, male gender. At age 71.5 +/- 11.9, subtle cognitive decline began, accelerated by TIAs, hypertension, and heart disease. Leukoaraiosis began before cognitive decline. TIAs, hypertension, and hyperlipidemia correlated with vascular dementias. Excessive cortical perfusional decreases and cerebral atrophy correlated with cognitive decline. Family history of neurodegenerative disease correlated with Alzheimer's disease. We concluded that TIAs, hypertension, hyperlipidemia, smoking, and male gender accelerate cerebral degenerative changes, cognitive decline, and dementia.

Anterior cruciate ligament reconstruction in adolescents with open physes

The purpose of this study was to evaluate anterior cruciate ligament reconstructions performed in adolescents with open physes and a skeletal age of at least 14 years. At one center, from 1992 to 1996, 19 adolescents (ages, 11 to 15 years) with open physes and a skeletal age of at least 14 years underwent arthroscopic anterior cruciate ligament reconstruction using an Achilles tendon allograft placed through drill holes across the open physes in both the distal femur and proximal tibia. Fifteen patients returned for reevaluation at an average of 25 months postoperatively (range, 12 to 60 months); the remaining four patients were interviewed by telephone. There were no significant leg-length discrepancies or angular deformities as determined by scanograms and anteroposterior and lateral radiographs of the femur and tibia. The mean Lysholm knee score was 97 (range, 94 to 100) and the mean KT-1000 arthrometer side-to-side difference at 20 pounds of anterior force was 1.7 mm (range, 0.0 to 3.0). All patients were satisfied with the results of surgery, and 16 of 19 patients returned to the same sport they were participating in before the injury. This study demonstrates that anterior cruciate ligament reconstruction using an Achilles tendon allograft is a viable treatment option for skeletally immature patients with a skeletal age of 14 years who have sustained midsubstance tears of the anterior cruciate ligament.

Risk factors for cerebral hypoperfusion, mild cognitive impairment, and dementia

Putative risk factors accelerating mild cognitive decline and dementia were correlated with repeated measures of cerebral atrophy, CT, densitometry, perfusions, and cognitive testing among neurologically and cognitively normative aging volunteers. A total of 224 normative subjects at increased risk for cognitive decline were admitted to the study. Mean entry age was 59.5 +/- 15.8 years. Mean follow-up is 5.8 +/- 3.3 years. At follow-up, 22 developed mild cognitive impairment (41 CCSE >/= -3), 19 became demented-8 with Vascular type (VAD), 11 with Alzheimer's type (DAT)-and 183 remain cognitively unchanged. Cerebral atrophy, tissue densities, and perfusions were measured by Xe-CT. After age 60, cerebral atrophy, ventricular enlargement, and polio- and leuko-araiosis geometrically increased as perfusions declined. Risk factors accelerating perfusional decline, cerebral atrophy, polio-araiosis, and leuko-araiosis were: transient ischemic attacks (TIAs), hypertension, smoking, hyperlipidemia, and male gender. At age 71.5 +/- 11.9, mild cognitive impairment began accelerated by TIAs, hypertension and heart disease. Leuko-araiosis began before cognitive decline. TIAs, hypertension, and hyperlipidemia correlated with VAD. Excessive cortical perfusional decrease, gray and white matter hypodensities, and cerebral atrophy correlate with cognitive decline.

Risk factors accelerating cerebral degenerative changes, cognitive decline and dementia

OBJECTIVES

Factors accelerating cerebral degenerative changes represent potentially modifiable risks for cognitive decline. Putative risk factors accelerating subtle cognitive decline and dementia were correlated with repeated measures of cerebral atrophy, CT densitometry, perfusions and cognitive testing among neurologically and cognitively normative ageing volunteers.

METHODS

Two hundred and twenty-four normative subjects at increased risk for cognitive decline were admitted to the study. Mean entry age was 59. 5+/-15.8 years. Mean follow-up is 4.3+/-3.1 years. At follow-up, 22 developed subtle cognitive decline (deltaCCSE>/=-3), 19 became demented, eight with vascular type (VAD) and 11 with Alzheimer's type (DAT) and 183 remain cognitively unchanged. Standardized questionnaires, medical, neuropsychological, neurological and blood work examinations were obtained. Cerebral atrophy, tissue densities and perfusions were measured by xenon-enhanced CT.

RESULTS

After age 60, cerebral atrophy, ventricular enlargement, polio- and leuko-araiosis geometrically increased as perfusions declined. Risk factors accelerating perfusional decline, cerebral atrophy, polio-araiosis and leuko-araiosis (thinning of grey-white matter densities) were: transient ischaemic attacks (TIAs), hypertension, smoking, hyperlipidemia, male gender. At age 71.5+/-11.9, subtle cognitive decline began, accelerated by TIAs, hypertension and heart disease. Leuko-araiosis began before cognitive decline. TIAs, hypertension and hyperlipidemia correlated with VAD. Excessive cortical perfusional decreases and cerebral atrophy correlated with cognitive decline. Family history of neurodegenerative disease correlated with DAT.

CONCLUSION

TIAs, hypertension, hyperlipidemia, smoking and male gender accelerate cerebral degenerative changes, cognitive decline and dementia.

XE-CT CBF changes during normative aging, cognitive decline and dementia

Factors accelerating cerebral degenerative changes represent potentially modifiable risks for cognitive decline. Putative risk factors accelerating mild cognitive decline and dementia were correlated with repeated measures of cerebral atrophy, CT densitometry, perfusions and cognitive testing among neurologically and cognitively normative volunteers. TIAs, hypertension, smoking and male gender accelerate cerebral degenerative changes, mild cognitive decline and dementia. Intervention by control of risk factors and cholinesterase inhibitors should prevent cerebral atropho-degenerative changes so that optimal cognitive performance is maintained.

Why emergency XeCT-CBF should become routine in acute ischemic stroke before thrombolytic therapy

Intravenous thrombolytic therapy using recombinant tissue plasminogen activator (rtpa) has been approved for the treatment of acute ischemic stroke in the USA, if treatment is initiated within 3-hours (NINDS tpa Stroke Study Group) but not 6 hours (ECASS II) after time of onset. Favorable outcome in the placebo arm was much higher than expected possibly because patients with TIA's are likely to be included as progressive ischemic stroke subjects when a brief 3-6 hours duration of stroke is defined as the therapeutic window. Yonas' group at the University of Pittsburg demonstrated that adding stable xenon inhalation to routine CT scanning performed during emergency screening of acute stroke, predicted which cases became irreversibly infarcted if thrombolytic therapy was not administered within a few hours of stroke onset, since non-contrasted CT scans are usually normal this early. Adding a few minutes for inhalation of 26% xenon is justified in order to measure LCBF values which predict size, severity and volumes of impending cerebral infarctions and rule out TIA's which have relatively normal CT-CBF values. CT-CBF measures provide positive indications for thrombolytic therapy. This is not possible by MRI and SPECT methods which are not sufficiently quantitative to discern LCBF values persistently below ischemic thresholds of 16 mls/100 gm/min, thereby predicting impending infarction.

Distinguishing patients with senile dementia of Alzheimer type and normal elderly subjects utilizing xenon CT-CBF and multivariate analysis

Local cerebral blood flow (LCBF) was measured in 17 patients with senile dementia of Alzheimer type (SDAT) and 17 normal controls, utilizing stable xenon computed tomography (Xe CT-CBF). In patients with SDAT, LCBF values were decreased in the cerebral cortex and subcortical structures including the thalamus, basal ganglia and white matter of both hemispheres. Linear discriminant function analysis of LCBF values separated patients with SDAT from normal elderly subjects, with an error of 8.8%. Variables helpful in distinguishing SDAT patients from normal subjects were LCBF values for the frontal and temporal cortex. Multiple regression equation for predicting cognitive performance scores from LCBF values showed the best correlations with LCBF values for the frontal and occipital cortex and thalamus. Xe CT-CBF measurements provide useful information concerning diagnosis and brain function in patients with SDAT.

Cocaine up-regulates norepinephrine transporter binding in the rat placenta

We investigated the influence of 3 days of continuous cocaine exposure on norepinephrine transporter binding in the rat placenta. On gestational day 17, pregnant rats were implanted subcutaneously with two cocaine-containing Silastic capsules. There were two control groups, one that received capsules with vehicle only and was pair-fed to the cocaine-treated females, and a second group that was untreated and fed ad libitum. Placentas and fetal brains were harvested and frozen on gestational day 20, and subsequently subjected to saturation analyses for norepinephrine transporter binding using the selective ligand [3H]nisoxetine. There was a marked increase in the density (B(max)) of norepinephrine transporter binding sites in the placentas of the cocaine-treated animals compared to both control groups, but no change in the fetal brain. The mechanism underlying this up-regulation of the placental norepinephrine transporter is not yet known, but it could involve a beta-adrenoceptor- and cAMP-mediated induction of transporter gene expression.

Risk factors accelerating cerebral degenerative changes, cognitive decline and dementia

OBJECTIVES

Factors accelerating cerebral degenerative changes represent potentially modifiable risks for cognitive decline. Putative risk factors accelerating subtle cognitive decline and dementia were correlated with repeated measures of cerebral atrophy, CT densitometry, perfusions and cognitive testing among neurologically and cognitively normative ageing volunteers.

METHODS

Two hundred and twenty-four normative subjects at increased risk for cognitive decline were admitted to the study. Mean entry age was 59. 5+/-15.8 years. Mean follow-up is 4.3+/-3.1 years. At follow-up, 22 developed subtle cognitive decline (deltaCCSE>/=-3), 19 became demented, eight with vascular type (VAD) and 11 with Alzheimer's type (DAT) and 183 remain cognitively unchanged. Standardized questionnaires, medical, neuropsychological, neurological and blood work examinations were obtained. Cerebral atrophy, tissue densities and perfusions were measured by xenon-enhanced CT.

RESULTS

After age 60, cerebral atrophy, ventricular enlargement, polio- and leuko-araiosis geometrically increased as perfusions declined. Risk factors accelerating perfusional decline, cerebral atrophy, polio-araiosis and leuko-araiosis (thinning of grey-white matter densities) were: transient ischaemic attacks (TIAs), hypertension, smoking, hyperlipidemia, male gender. At age 71.5+/-11.9, subtle cognitive decline began, accelerated by TIAs, hypertension and heart disease. Leuko-araiosis began before cognitive decline. TIAs, hypertension and hyperlipidemia correlated with VAD. Excessive cortical perfusional decreases and cerebral atrophy correlated with cognitive decline. Family history of neurodegenerative disease correlated with DAT.

CONCLUSION

TIAs, hypertension, hyperlipidemia, smoking and male gender accelerate cerebral degenerative changes, cognitive decline and dementia.

Distribution of cocaine and metabolites in the pregnant rat and fetus in a chronic subcutaneous injection model

We examined the distribution of cocaine and its metabolites benzoylecgonine (BE) and norcocaine (NOR) in pregnant Sprague-Dawley rats and fetuses following twice-daily subcutaneous (s.c.) injections of 20 mg/kg cocaine HCl from gestational day (GD) 8 through GD 20. On GD 21, the animals received a single injection and maternal trunk blood, fetal blood, fetal brains, and amniotic fluid were collected 5 min, 15 min, 30 min, 1 h, 2 h, 4 h, 8 h, or 12 h later for cocaine and metabolite analyses by high-performance liquid chromatography (HPLC) with UV detection. The highest concentrations of cocaine and BE were detected in maternal plasma at 1 h and 4 h respectively. Cocaine peaked at 2 h and BE at 4 h in both fetal plasma and brain. In amniotic fluid, cocaine levels peaked at 2 h, but the highest BE levels were found at 8 h postinjection. An additional group of chronically treated dams was given both cocaine injections on GD 21 and sacrificed 2 h later. Benzoylecgonine concentrations were increased in fetal plasma, fetal brain, and amniotic fluid when compared with the 2-h results following a single cocaine treatment. Moreover, NOR, which had not been previously detected, was now measurable in the amniotic fluid.

Aggressive fibromatosis from infancy to adolescence

Aggressive fibromatosis is a rare fibroproliferative disorder with a variable biologic potential that is locally morbid but does not metastasize. Eighteen patients with extraabdominal fibromatosis were treated with a multidisciplinary approach over a 27-year period. Our observations, coupled with a review of the literature, suggest that conservative surgery with the goal of a wide margin coupled with adjuvant therapies may result in adequate control of disease from infancy to adolescence. Amputation should be reserved for cases in which the disease or its treatment have resulted in a nonfunctional or chronically painful extremity. Radiation should be used as a last resort in the skeletally immature because of the risk of growth disturbance, contracture, and secondary malignancy. Chemotherapy may have a role in children with inoperable disease, in those who have gross residual tumor after an intralesional procedure, for disease progression or recurrence, and neoadjuvant therapy should be investigated as a means to achieve a wide margin in some cases.