Recommendations for change in infection prevention programs and practice

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

The Quebec Parkinson Network: A Researcher-Patient Matching Platform and Multimodal Biorepository

BACKGROUND

Genetic, biologic and clinical data suggest that Parkinson's disease (PD) is an umbrella for multiple disorders with clinical and pathological overlap, yet with different underlying mechanisms. To better understand these and to move towards neuroprotective treatment, we have established the Quebec Parkinson Network (QPN), an open-access patient registry, and data and bio-samples repository.

OBJECTIVE

To present the QPN and to perform preliminary analysis of the QPN data.

METHODS

A total of 1,070 consecutively recruited PD patients were included in the analysis. Demographic and clinical data were analyzed, including comparisons between males and females, PD patients with and without RBD, and stratified analyses comparing early and late-onset PD and different age groups.

RESULTS

QPN patients exhibit a male:female ratio of 1.8:1, an average age-at-onset of 58.6 years, an age-at-diagnosis of 60.4 years, and average disease duration of 8.9 years. REM-sleep behavior disorder (RBD) was more common among men, and RBD was associated with other motor and non-motor symptoms including dyskinesia, fluctuations, postural hypotension and hallucinations. Older patients had significantly higher rates of constipation and cognitive impairment, and longer disease duration was associated with higher rates of dyskinesia, fluctuations, freezing of gait, falls, hallucinations and cognitive impairment. Since QPN's creation, over 60 studies and 30 publications have included patients and data from the QPN.

CONCLUSIONS

The QPN cohort displays typical PD demographics and clinical features. These data are open-access upon application (http://rpq-qpn.ca/en/), and will soon include genetic, imaging and bio-samples. We encourage clinicians and researchers to perform studies using these resources.

Towards prevention of post-traumatic osteoarthritis: report from an international expert working group on considerations for the design and conduct of interventional studies following acute knee injury

OBJECTIVE

There are few guidelines for clinical trials of interventions for prevention of post-traumatic osteoarthritis (PTOA), reflecting challenges in this area. An international multi-disciplinary expert group including patients was convened to generate points to consider for the design and conduct of interventional studies following acute knee injury.

DESIGN

An evidence review on acute knee injury interventional studies to prevent PTOA was presented to the group, alongside overviews of challenges in this area, including potential targets, biomarkers and imaging. Working groups considered pre-identified key areas: eligibility criteria and outcomes, biomarkers, injury definition and intervention timing including multi-modality interventions. Consensus agreement within the group on points to consider was generated and is reported here after iterative review by all contributors.

RESULTS

The evidence review identified 37 studies. Study duration and outcomes varied widely and 70% examined surgical interventions. Considerations were grouped into three areas: justification of inclusion criteria including the classification of injury and participant age (as people over 35 may have pre-existing OA); careful consideration in the selection and timing of outcomes or biomarkers; definition of the intervention(s)/comparator(s) and the appropriate time-window for intervention (considerations may be particular to intervention type). Areas for further research included demonstrating the utility of patient-reported outcomes, biomarkers and imaging outcomes from ancillary/cohort studies in this area, and development of surrogate clinical trial endpoints that shorten the duration of clinical trials and are acceptable to regulatory agencies.

CONCLUSIONS

These considerations represent the first international consensus on the conduct of interventional studies following acute knee joint trauma.

Predictors of responses to immune checkpoint blockade in advanced melanoma

Immune checkpoint blockers (ICB) have become pivotal therapies in the clinical armamentarium against metastatic melanoma (MMel). Given the frequency of immune related adverse events and increasing use of ICB, predictors of response to CTLA-4 and/or PD-1 blockade represent unmet clinical needs. Using a systems biology-based approach to an assessment of 779 paired blood and tumor markers in 37 stage III MMel patients, we analyzed association between blood immune parameters and the functional immune reactivity of tumor-infiltrating cells after ex vivo exposure to ICB. Based on this assay, we retrospectively observed, in eight cohorts enrolling 190 MMel patients treated with ipilimumab, that PD-L1 expression on peripheral T cells was prognostic on overall and progression-free survival. Moreover, detectable CD137 on circulating CD8⁺ T cells was associated with the disease-free status of resected stage III MMel patients after adjuvant ipilimumab + nivolumab (but not nivolumab alone). These biomarkers should be validated in prospective trials in MMel.The clinical management of metastatic melanoma requires predictors of the response to checkpoint blockade. Here, the authors use immunological assays to identify potential prognostic/predictive biomarkers in circulating blood cells and in tumor-infiltrating lymphocytes from patients with resected stage III melanoma.

Differential in vivo tumorigenicity of diverse KRAS mutations in vertebrate pancreas: A comprehensive survey

Somatic activation of the KRAS proto-oncogene is evident in almost all pancreatic cancers, and appears to represent an initiating event. These mutations occur primarily at codon 12 and less frequently at codons 13 and 61. While some studies have suggested that different KRAS mutations may have variable oncogenic properties, to date there has been no comprehensive functional comparison of multiple KRAS mutations in an in vivo vertebrate tumorigenesis system. We generated a Gal4/UAS-based zebrafish model of pancreatic tumorigenesis in which the pancreatic expression of UAS-regulated oncogenes is driven by a ptf1a:Gal4-VP16 driver line. This system allowed us to rapidly compare the ability of 12 different KRAS mutations (G12A, G12C, G12D, G12F, G12R, G12S, G12V, G13C, G13D, Q61L, Q61R, and A146T) to drive pancreatic tumorigenesis in vivo. Among fish injected with one of five KRAS mutations reported in other tumor types but not in human pancreatic cancer, 2/79 (0.25%) developed pancreatic tumors, with both tumors arising in fish injected with A146T. In contrast, among fish injected with one of seven KRAS mutations known to occur in human pancreatic cancer, 22/106 (20.8%) developed pancreatic cancer. All eight tumorigenic KRAS mutations were associated with downstream MAPK/ERK pathway activation in preneoplastic pancreatic epithelium, while non-tumorigenic mutations were not. These results suggest that the spectrum of KRAS mutations observed in human pancreatic cancer reflects selection based upon variable tumorigenic capacities, including the ability to activate MAPK/ERK signaling.

Predictors of adjuvant chemotherapy (AT) decision-making in referred patients (pts) with stage II and III colon cancer (CC)

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Background: Randomized clinical trials have demonstrated a robust survival benefit of AT for node positive (stage III) CC patients; similar evidence for node-negative (stage II) patients is lacking. While guidelines recommend AT for stage III colon cancer but AT is not a routine recommendation for stage II. Actual practice of the evidence varies and suggests the interplay of additional variables. We sought to identify factors associated with practice patterns which vary from conventional AT guidelines, ie no AT in stage III CC and receipt of AT in.stage II CC. Methods: Data pertaining to pt demographics, tumor characteristics, and treatment for pts with resected stage II (n=176) and III CC (n=235) referred to the British Columbia Cancer Agency in 2004 was collected by retrospective chart review. One-sided Fisher's exact test was used to assess statistical significance (p<0.05) by univariate analysis. Results: 28% (n=49) of stage II pts received AT. Compared to untreated pts, stage II pts who received AT were significantly more often younger than 66 years (57% vs 21%), lived in a city with a regional cancer center (71% vs 51%), had T4 disease (33% vs 9%), vascular invasion (22% vs 5%), perineural invasion (10% vs 2%) and high grade (26% vs 2%). Marital status, ethnicity, lymphatic invasion and high CEA were not associated with AT in stage II. 29% (n=69) of stage III pts did not receive AT. Compared to treated pts, stage III pts who did not receive AT were significantly more often older than 65 years (91% vs 51%), had low grade disease (96% vs 84%) and presented for oncology consultation greater than 42 days from surgery (29% vs 11%). Marital status, ethnicity, residence, T4 status or N2 status were not associated with no AT in stage III. Conclusions: For pts with stage II CC, subgroups associated with high risk for relapse were more likely to receive AT although the majority of stage II pts in this cohort remained untreated. For stage III disease, almost one-third of referred pts did not receive AT. Older age and delayed presentation were strongly associated with failure to receive AT. Within the limitations of a retrospective review, these data highlight the significant and commonly observed implications of factors other than stage in AT decision-making for high risk resected CC.

No significant financial relationships to disclose.

Sensorimotor adaptation in Parkinson's disease: evidence for a dopamine dependent remapping disturbance

Sensorimotor adaptation is thought to involve a remapping of the kinematic and kinetic parameters associated with movements performed within a changing environment. Patients with Parkinson's disease (PD) are known to be affected on this type of learning process, although the specific role of dopamine depletion in these deficits has not yet been elucidated. The present study was an attempt to clarify whether dopamine depletion in PD may directly affect the capacity to internally reorganize the visuomotor remapping of a distorted environment. Fourteen PD patients were tested twice, while they were treated and while they were withdrawn from their regular levodopa treatment. Fourteen control subjects were also enrolled and tested twice. Two parallel forms of the Computed Mirror Pointing Task (CMPT), requiring making a reaching movement in a visually transformed environment (mirror inversion), were administered to each participant. Each of them had to perform 40 trials at each of the 2 testing sessions. At each trial, sensorimotor adaptation was evaluated by the initial direction angle (IDA), which reflects the direction of movement before any visually guided readjustment. Results revealed no IDA difference at baseline, between control subject and PD patients, whether they were treated or not. In all group, IDA values at that time were large, reflecting a tendency to make movements according to the real life visuomotor mapping (based on the natural direct vision). However, striking differences appeared during sensorimotor learning, in that IDA reduction along trials was poorer in patient not treated with levodopa than both control subjects and the same PD patient treated with levodopa. No difference was observed between the treated PD patients and control subjects. Given that IDA is thought to reflect the internal representation of the visuomotor mapping, it is concluded that dopamine depletion in PD would affects sensorimotor adaptation, in that it facilitates old and poorly adapted movements (real life mapping), instead of new and more adapted ones (mirror transformed mapping).

Raclopride-induced motor consolidation impairment in primates: role of the dopamine type-2 receptor in movement chunking into integrated sequences

Results obtained in patients with schizophrenia have shown that antipsychotic drugs may induce motor learning deficits correlated with the striatal type-2 dopamine receptors (D(2)R) occupancy. Other findings suggest that the role of the striatum in motor learning could be related to a process of "chunking" discrete movements into motor sequences. We therefore hypothesized that a D(2)R blocking substance, such as raclopride, would affect motor learning by specifically disrupting the grouping of movements into sequences. Two monkeys were first trained to perform a baseline-overlearned sequence (Seq. A) drug free. Then, a new sequence was learned (Seq. B) and the overlearned sequence was recalled OFF-drug (Seq. A recall OFF-drug). The effect of raclopride was then assessed on the learning of a third sequence (Seq. C), and on the recall of the overlearned sequence (Seq. A recall ON-drug). Results showed that performance related to the overlearned sequence remained the same in the three experimental conditions (Seq. A, Seq. A recall OFF-drug, Seq. A recall ON-drug), whether the primates received raclopride or not. On the other hand, new sequence learning was significantly affected during raclopride treatment (Seq. C), when compared with new sequence learning without the effect of any drug (Seq. B). Raclopride-induced disturbances consisted in performance fluctuations, which persisted even after many days of trials, and prevented the monkeys from reaching a stable level of performance. Further analyses also showed that these fluctuations appeared to be related to monkeys' inability to group movements into single flowing motor sequences. The results of our study suggest that dopamine is involved in the stabilization or consolidation of motor performances, and that this function would involve a chunking of movements into well-integrated sequences.

Expression of the self-marker CD47 on dendritic cells governs their trafficking to secondary lymphoid organs

Dendritic cells (DCs) capture and process Ag in the periphery. Thus, traffic through lymphatic vessels is mandatory before DCs relocate to lymph nodes where they are dedicated to T-cell priming. Here, we show that the ubiquitous self-marker CD47 selectively regulates DC, but not T and B cell trafficking across lymphatic vessels and endothelial barriers in vivo. We find an altered skin DC migration and impaired T-cell priming in CD47-deficient mice at steady state and under inflammatory conditions. Competitive DC migration assays and active immunization with myeloid DCs demonstrate that CD47 expression is required on DCs but not on the endothelium for efficient DC trafficking and T-cell responses. This migratory defect correlates with the quasi-disappearance of splenic marginal zone DCs in nonmanipulated CD47-deficient mice. Nonetheless, CCR7 expression and CCL19-driven chemotaxis remain intact. Our data reveal that CD47 on DCs is a critical factor in controlling migration and efficient initiation of the immune response.

Kyste du défilé spinoglénoïdien. À propos d'un cas et revue de la littérature

INTRODUCTION

Entrapment of the suprascapular nerve at the spinoglenoid notch due to a ganglion cyst is an uncommon event and remains a challenge for clinicians.

EXEGESIS

We describe the findings in a 35-year-old patient with nonspecific pain in the shoulder and in whom MR revealed a ganglion cyst in the spinoglenoid notch, confirmed surgically.

CONCLUSION

Entrapment of the suprascapular nerve at the spinoglenoid notch due to a ganglion cyst must be considered in the differential diagnosis of nonspecific shoulder pain. MR imaging and electromyography can reach a positive, topographic, and etiologic diagnosis of suprascapular neuropathy.

Newly generated neurons in the amygdala and adjoining cortex of adult primates

The subventricular zone remains mitotically active throughout life in rodents. Studies with tritiated thymidine, which is incorporated into the DNA of mitotic cells, have revealed that the rodent subventricular zone produces neuroblasts that migrate toward the olfactory bulb along the rostral migratory stream. A similar migratory stream has been documented in monkeys by using the thymidine analogue BrdUrd. The same approach showed that neurogenesis occurred in the dentate gyrus of adult primates, including humans. In the present study, experiments combining injections of BrdUrd and the dye 1,1'-dioctadecyl-3,3,3',3'-tetramethylindo-carbocyanine, with the immunostaining for molecular markers of neurogenesis (polysialylated neural cell adhesion molecule, beta-tubulin-III, collapsin response mediator protein-4, neuronal nuclear protein) in New World (Saimiri sciureus) and Old World (Macaca fascicularis) monkeys have revealed that new neurons are produced in the amygdala, piriform cortex, and adjoining inferior temporal cortex in adult primates. These newborn neurons expressed the antiapoptotic protein Bcl-2 and formed a more-or-less continuous pathway that extended from the tip of the temporal ventricular horn to the deep portion of the temporal lobe. The production of newborn neurons in the amygdala, piriform cortex, and inferior temporal cortex seems to parallel the continuing addition of neurons in the olfactory bulb. These two concomitant phenomena may ensure structural stability and functional plasticity to the primate olfactory system and temporal lobe.

Do wine polyphenols modulate p53 gene expression in human cancer cell lines?

BACKGROUND

The p53 gene is an established tumor suppressor and an inducer of apoptosis. We here attempt to determine whether the putative anticarcinogenic properties attributed to red wine and its polyphenolic constituents depend, at least in part, upon their ability to modulate p53 expression in cancer cells.

METHODS

Three human breast cancer cell lines (MCF-7, T47D; MDA-MB-486) and one human colon cancer cell line [Colo 320 HSR (+)] were treated for 24-h with each of four polyphenols [quercetin; (+)-catechin, trans-resveratrol; caffeic acid] at concentrations ranging from 10(-7) M to 10(-4) M, after which, p53 concentrations were measured in cell lysates by a time-resolved fluorescence immunoassay.

RESULTS

None of the polyphenols tested affected p53 expression in the breast cancer cell lines T-47D and MDA-MB-486. p53 content of MCF-7 breast cancer cells (wild-type) was increased by caffeic acid, decreased by resveratrol, and showed a twofold increase with catechin, that reached borderline statistical significance; however, none of these effects were dose-responsive. Colo 320 HSR (+) cells (with a mutant p53 gene) had lower p53 content upon stimulation, reaching borderline statistical significance, but without being dose-responsive, in the presence of caffeic acid and resveratrol. Apart from toxicity at 10(-4) M, quercetin had no effect upon these four cell lines.

CONCLUSIONS

The observed p53 concentration changes upon stimulation by polyphenols are relatively small, do not follow a uniform pattern in the four cell lines tested, and do not exhibit a dose-response effect. For these reasons, we speculate that the putative anticarcinogenic properties of wine polyphenols are unlikely to be mediated by modulation of p53 gene expression.

[Post-traumatic fracture and migration in the pulmonary artery of the catheter of a totally implantable venous access device. Unusual complication]

The case of a 59 year-old patient, who sustained a post-traumatic fracture of the silastic catheter of his totally implantable venous access device that migrated in the right pulmonary artery, is reported. The venous device was placed six months earlier for the treatment of metastatic spread of a primary unknown adenocarcinoma. The venous device was placed on the left side in consideration of a recent right supraclavicular node biopsy. The catheter was introduced through the left internal jugular vein and its peripheral end was positioned subcutaneously across the clavicle to be connected to the port chamber placed in the infraclavicular region. The accidental fracture of the catheter was attributed to a closed trauma occurred during the transport of a refrigerator on the homolateral shoulder. Treatment involved extraction of the migrated fragment through a percutaneous transfemoral angioradiological procedure. A few days later the chamber was removed and a new totally implantable venous access device was placed on the other side.

Association of macrophagic myofasciitis and fibromuscular dysplasia with renal fibromuscular dysplasia: first case report

Two rare muscular diseases, macrophagic myofasciitis and fibromuscular dysplasia, are associated in the patient reported here. Their respective etiologies are unknown. The possible link has to be discussed.

Axonal branching pattern of neurons of the subthalamic nucleus in primates

Axonal projections arising from the subthalamic nucleus (STN) in cynomolgus monkeys (Macaca fascicularis) were traced after labeling small pools (5-15 cells) of neurons with biotinylated dextran amine. Seventy-five single axons were reconstructed from serial sagittal sections with a camera lucida. Most of the STN labeled cells displayed five to eight long, sparsely spined dendrites that arborized mostly along the main axis of the nucleus. Based on their axonal targets, five distinct types of STN projection neurons have been identified: 1) neurons projecting to the substantia nigra pars reticulata (SNr), the internal (GPi) and external (GPe) segments of the globus pallidus (21.3%); 2) neurons targeting SNr and GPe (2. 7%); 3) neurons projecting to GPi and GPe (48%); 4) neurons targeting GPe only (10.7 %); and 5) neurons with axons that coursed toward the sriatum, but whose terminal arborization could not be visualized in detail (17.3%). Axons of the first two types bifurcated into rostral subthalamopallidal and caudal pallidonigral branches. However, the majority of STN axons had only a single branch that coursed rostrally toward the pallidum and striatum. These results reveal that, in contrast to current beliefs, the primate STN is not a monolithic entity. This nucleus harbors several subtypes of projection neurons, each endowed with a highly patterned set of collaterals. This organization allows STN neurons to exert a multifarious effect not only on the GPe, with which the STN is reciprocally connected, but also on the two major output structures of the basal ganglia, the SNr and the GPi.

Biodegradation of pentachlorophenol in a continuous anaerobic reactor augmented with Desulfitobacterium frappieri PCP-1

In this work, a strain of anaerobic pentachlorophenol (PCP) degrader, Desulfitobacterium frappieri PCP-1, was used to augment a mixed bacterial community of an anaerobic upflow sludge bed reactor degrading PCP. To estimate the efficiency of augmentation, the population of PCP-1 in the reactor was enumerated by a competitive PCR technique. The PCP-1 strain appeared to compete well with other microorganisms of the mixed bacterial community, with its population increasing from 10(6) to 10(10) cells/g of volatile suspended solids within a period of 70 days. Proliferation of strain PCP-1 allowed for a substantial increase of the volumetric PCP load from 5 to 80 mg/liter of reaction volume/day. A PCP removal efficiency of 99% and a dechlorination efficiency of not less than 90.5% were observed throughout the experiment, with 3-Cl-phenol and phenol being observable dechlorination intermediates.

Moderate alcohol consumption: the gentle face of Janus

OBJECTIVES

The regular consumption of alcohol in moderate amounts (defined in North America as up to 2 drinks per day for men and 1 drink per day for females) has been recognized in the last decade as a negative risk factor for atherosclerosis and its clinical sequelae: coronary heart disease (CHD), ischemic stroke, and peripheral vascular disease. Mortality and morbidity attributable to CHD are 40-60% lower in moderate drinkers than among abstainers. Among the mechanisms accounting for these reductions, increased circulating concentrations of HDL-cholesterol and inhibition of blood coagulation appear to be paramount. Additional benefits are, in certain beverages, conferred by the presence of constituents other than alcohol (e.g., flavonoids and hydroxystilbenes), which prevent oxidative damage, free radical formation, and elements of the inflammatory response.

CONCLUSIONS

A number of other diseases appear to be beneficially modulated by moderate alcohol consumption based on epidemiologic surveys and, in some instances, experimental evidence. These include duodenal ulcer, gallstones, enteric infections, rheumatoid arthritis, osteoporosis, and diabetes mellitus (type II). Compared with abstainers, moderate drinkers exhibit improved mental status characterized by decreased stress and depression, lower absenteeism from work, and decreased incidence of dementia (including Alzheimer's disease). Although limits of safe drinking have been conservatively defined, it is regrettable that political considerations are hampering the clinical application of this knowledge and its dissemination to the lay public.

Quality care for cardiology patients

To evaluate outcome measures in a cardiology unit, patient satisfaction was measured. Patients consistently related problems in two areas: pain management and the waiting period before their procedure. After a major system change, patient satisfaction increased 16% and 29% respectively.

Frequency of expression of prostate-specific antigen mRNA in lung tumors

The presence of prostate-specific antigen (PSA) protein and messenger RNA (mRNA) was studied in 52 primary lung tumor tissues. The PSA protein was detected more frequently and at higher levels in lung tumor extracts from men. The levels of PSA protein in tumor extracts correlated with preoperative and postoperative serum PSA levels, suggesting a possible contamination of the tumor extracts with PSA from residual blood in the tumor vasculature. The PSA mRNA was detected by reverse transcription-polymerase chain reaction (RT-PCR) and Southern blot hybridization in 24 (68%) of 35 tumors from men, in 9 (53%) of 17 tumors from women, and in 5 (71%) of 7 adjacent normal lung tissue specimens. The levels of PSA protein did not associate with patient age, the tumor stage, grade, or histologic type, or the nodal status. Similarly, PSA mRNA was not associated with any clinicopathologic variables, but squamous cell carcinomas, especially in men, were more frequently positive. A by-product of the RT-PCR procedure was cloned and sequenced and found to be a 450-base pair sequence not previously deposited in the data bank. We conclude that PSA mRNA and protein frequently can be detected in lung tumors and normal tissues from men and women but at levels much lower than those seen in breast carcinomas in women. The significance of the new 450-base pair sequence remains to be determined.

Time course of training-induced changes in maximal exercise of short duration in men and women

The purpose of the present study was to test the hypothesis that gender differences are present in the extent and time course of exercise training-induced changes in maximal 10- and 90-s performance test. Thirty-six sedentary subjects (19 women and 17 men) were submitted to 15 weeks of training involving both continuous and interval ergocycle exercise sessions, while 13 other subjects (5 women and 8 men) served as a control group. Maximal power output after 10 s (P10) and 90s (P90) of cycling exercise was measured before and at each 5-week interval of the 15-week training period in both groups. Significant (p < 0.01) training-induced increases in performance were noted after 5 weeks, 10 weeks and 15 weeks of training for P10, and after 5 and 10 weeks for P90 in both genders. P10 and P90 were significantly increased in both genders (about 25% in men and 35% in women) following the 15-week training program and overall absolute increases were not statistically different between men and women. Slight increases (about 5%) in performance tests were observed in control subjects, but only during the first 5-week interval. P10 and P90 of women expressed as a percentage of that of men remained the same throughout the 15-week program. No significant relationship between pre-training values of P10 and their responses to training was found in men and women. In conclusion, results of the present study indicate that women have the same capacity to increase maximal short-term performance in response to training in comparison to men.

Glutamate currents in morphologically identified human dentate granule cells in temporal lobe epilepsy

Glutamate-receptor-mediated synaptic transmission was studied in morphologically identified hippocampal dentate granule cells (DGCs; n = 31) with the use of whole cell patch-clamp recording and intracellular injection of biocytin or Lucifer yellow in slices prepared from surgically removed medial temporal lobe specimens of epileptic patients (14 specimens from 14 patients). In the current-clamp recording, low-frequency stimulation of the perforant path generated depolarizing postsynaptic potentials that consisted of excitatory postsynaptic potentials and phase-inverted inhibitory postsynaptic potentials mediated by the gamma-aminobutyric acid-A (GABA(A)) receptor at a resting membrane potential of -62.7 +/- 2.0 (SE) mV. In the voltage-clamp recording, two glutamate conductances, a fast alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA)-receptor-mediated excitatory postsynaptic current (EPSC; AMPA EPSC) and a slowly developing N-methyl-D-aspartate (NMDA)-receptor-mediated EPSC (NMDA EPSC), were isolated in the presence of a GABA(A) receptor antagonist. NMDA EPSCs showed a voltage-dependent increase in conductance with depolarization by exhibiting an N-shaped current-voltage relationship. The slope conductance of the NMDA EPSC ranged from 1.1 to 9.4 nS in 31 DGCs, reaching up to twice the size of the AMPA conductance. This widely varying size of the NMDA conductance resulted in the generation of double-peaked EPSCs and a nonlinear increase of the slope conductance of up to 37.5 nS with positive membrane potentials, which resembled "paroxysmal currents," in a subpopulation of the neurons. In contrast, AMPA EPSCs, which were isolated in the presence of an NMDA receptor antagonist (2-amino-5-phosphonovaleric acid), showed voltage-independent linear changes in the current-voltage relationship and were blocked by 6-cyano-7-nitroquinoxaline-2,3-dione. The AMPA conductance showed little variance, regardless of the size of the NMDA conductance of a given neuron. The average AMPA slope conductance was 5.28 +/- 0.65 (SE) nS in 31 human DGCs. This value was similar to AMPA EPSC conductances in normal rat DGCs (5.35 +/- 0.52 nS, mean +/- SE; n = 55). Dendritic morphology and spine density were quantified in the individual DGCs to assess epileptic pathology. Dendritic spine density showed an inverse correlation (r2 = 0.705) with a slower rise time and a longer half-width of the excitatory postsynaptic potentials mediated by the NMDA receptor. It is concluded that both AMPA and NMDA EPSCs contribute to human DGC synaptic transmission in epileptic hippocampus. However, a wide range of changes in the slope conductance of the NMDA EPSCs suggests that the NMDA-receptor-mediated conductance could be altered in human epileptic DGCs. These changes may influence the generation of chronic subthreshold epileptogenic synaptic activity and give rise to pathological excitation leading to epileptic seizures and dendritic pathology.

Electroconvulsive therapy (ECT) for intractable depression following epilepsy neurosurgery

Psychopathology following epilepsy neurosurgery is a significant risk. Treatment modalities have not been addressed in the literature. As disproportionately elevated suicide rates have been reported, it is critical to treat aggressively any psychiatric illness wherein suicidal ideation is a key component. This case reports the safe utilization of electroconvulsive therapy (ECT) for intractable depression following epilepsy neurosurgery (24 references).

Changes in health after elective percutaneous coronary revascularization. A comparison of generic and specific measures

OBJECTIVES

This study determines changes in health-related quality of life after elective percutaneous transluminal coronary angioplasty and compares generic and specific measures.

METHODS

Changes in health-related quality of life were measured in consecutive, symptomatic patients undergoing elective percutaneous coronary revascularization using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Specific Activity Scale (SAS), and the Canadian Cardiovascular Society Classification (CCSC). The patients were interviewed as outpatients before admission and at least 6 months later.

RESULTS

There were significant changes in the following SF-36 measures: physical functioning (postscore minus prescore = 19.1 +/- 24.1), role limitations due to physical-health problems (40.4 +/- 47.2), bodily pain (19.9 +/- 29.3), vitality (12.9 +/- 25.1), social functioning (20.0 +/- 33.1), role limitations due to emotional-health problems (26.7 +/- 49.0), and general mental health (7.1 +/- 21.2). General health perceptions did not change significantly. Internal-consistency reliability coefficients for these measures ranged from 0.73 to 0.91. There also was significant improvement in the CCSC class, but the SAS class did not change significantly. Overall, the SF-36 role-physical scale was the most responsive to changes after elective percutaneous coronary revascularization, followed by the CCSC and the SF-36 physical functioning scale.

CONCLUSIONS

Although this study cannot determine the causal role of elective percutaneous coronary revascularization in these changes, it provides support for the usefulness of these measures in future evaluations of this intervention.

Coronary restenosis

Return of angina within 6 months of a catheter-based treatment of coronary artery disease usually reflects restenosis due to an overly aggressive local healing response to the procedure-related arterial injury. The restenotic lesion should be treated aggressively. Patients with preexisting diabetes mellitus, renal failure requiring hemodialysis, and left anterior descending artery lesions should be considered to be at exceedingly high risk for clinically significant restenosis. Exercise testing is indicated for all patients who experience a return of their angina within 6 months of an interventional procedure. Nurse practitioners in the primary care setting may be the first clinicians to hear of the return of angina. Patients should always be reassured that repeat intervention is almost always possible and is generally effective in providing long-term relief. New devices (in particular the Palmaz-Schatz stent) may help reduce the likelihood of restenosis, to the extent that they provide a large acute post-treatment lumen diameter that is more tolerant of intimal hyperplasia without producing significant narrowing. Until adjunctive drug therapy is found that effectively reduces the local tissue response to interventional therapy, all clinicians involved in caring for patients following such procedures will need to be vigilant and knowledgeable about recognizing and treating restenosis.

Prostate specific antigen in breast cancer, benign breast disease and normal breast tissue

Prostate specific antigen (PSA) is a tumor marker used widely for the diagnosis and monitoring of prostatic adenocarcinoma. Recently, we provided evidence that PSA may also be produced by breast tumors. In this report we examined quantitatively the PSA levels in 199 breast tumors, 48 tissues with benign breast disease (BBD, 34 fibroadenomas), and 36 normal breast tissues. Significant amounts of PSA (> or = 0.030 ng of PSA per mg of total protein) were found in 28% of breast tumors, 65% of BBD tissues, and 33% of normal breast tissues. PSA positivity in breast tumors was highest in stage I disease (34%) and decreased with disease stage (24% in stage II and 18% in stage III-IV). Using polymerase chain reaction amplification we have shown PSA mRNA presence in patients with PSA protein-positive tissues (benign and malignant) but not in patients with PSA protein-negative tissues. Our data suggest that PSA is expressed frequently by normal breast tissue, by tissue of benign breast diseases, and by breast cancer tissue. Highest expression is seen in benign breast disease and lowest expression in advanced stage cancerous tissue. As PSA production is mediated by steroid hormones and their receptors, we propose that PSA may be a new marker of steroid hormone action in the normal or diseased female breast. The role of this enzyme in the development of breast diseases including breast cancer is currently unknown.

Corticostriatal projections from layer V cells in rat are collaterals of long-range corticofugal axons

Corticostriatal projections arising from the infragranular layers of the motor and second somatosensory cortices were studied in rats after labeling small pools of neurons with biocytin. Camera lucida reconstruction of 263 fibers arising from laminae V and VI revealed that all corticostriatal projections derive from collaterals of lamina V cells whose main axons descend into the cerebral peduncle. In contrast, lamina VI cells do not branch upon the striatum, but upon the thalamus. Together with the results obtained in previous tracing studies, the present data raise the possibility that no neuron is exclusively corticostriatal. We therefore propose that all corticostriatal projections are collaterals given off by the axons of two types of neurons: layer V cells whose main axon project to the brainstem and/or spinal cord, and layer III cells that project to the contralateral hemisphere.

Expression of the prostate-specific antigen gene by a primary ovarian carcinoma

We describe a patient with primary ovarian carcinoma that developed after liver transplantation whose tumor was highly positive for prostate-specific antigen (PSA). PSA in tumor tissue was characterized by two immunoassays, HPLC, immunohistochemistry, reverse transcription-PCR, Southern blotting, and DNA sequencing. PSA in the ovarian tumor was present as free, M(r) 33,000 protein (> 90%) and as PSA bound to alpha 1-antichymotrypsin (M(r) 100,000; < 10%). Immunohistochemistry localized PSA in the cytoplasm of epithelial cells of the tumor. Two separate reverse transcription-PCRs for PSA amplified the expected products which hybridized specifically to a PSA cDNA probe on Southern blots. Sequencing of the PCR products, representing the whole coding sequence of the PSA gene, revealed identity with the sequence of PSA cDNA from prostate tissue. These data suggest that the PSA produced by the ovarian tumor was identical in molecular weight and sequence to prostatic PSA. Based on data of tissue culture experiments with breast carcinoma cell lines, we speculate that the PSA gene in the tumor of this patient was up-regulated by the therapeutically administered glucocorticoids after liver transplantation.

Haemoperitoneum due to spontaneous rupture of hepatic haemangiomatosis: treatment by superselective arterial embolization and partial hepatectomy

A case is reported of a 36-year-old woman with haemoperitoneum due to spontaneous rupture of hepatic haemangiomatosis. Computed tomography showed a subcapsular hepatic mass in the posterior segment of the right hemiliver (subsegment 7) containing a fluid-fluid level. Magnetic resonance imaging depicted a subcapsular hepatic mass displaying an internal fluid-fluid level suggestive of haematoma. Hepatic angiography showed an intense arterial blush in the area of the subsegment 7 and permitted a subsequent and temporarily effective superselective transcatheter embolization of the subsegmental arterial branch for subsegment 7. Because of a recurrence of intraperitoneal haemorrhage 15 days after the first embolization, a new selective hepatic artery embolization was performed. However, intraperitoneal haemorrhage recurred 10 days after the second embolization, and the patient underwent resection of the posterior segments of the right hemiliver (subsegments 6 and 7). This case suggests that superselective arterial embolization, when used alone, does not provide a permanent treatment of haemoperitoneum due to spontaneous rupture of hepatic haemangiomatosis. However, this technique seems to be useful in avoiding an emergency surgery, allowing a planned hepatic resection.

Prostate-specific antigen expression by various tumors

There is a growing body of evidence indicating that prostate-specific antigen (PSA) may be present in many steroid hormone-stimulated epithelial tissues other than that of the prostate. In particular, breast tumor cell lines treated with steroid hormone receptor agonists, breast tumors, and normal human breast have recently been found by our group to contain PSA. To investigate whether PSA may also be present in other human tumors, we employed a highly sensitive immunofluorometric assay technique to quantify PSA immunoreactivity in tumor extracts. Using a PSA-positivity cutoff value of 0.005 ng per mg of protein, 23 of 43 diverse tumors tested positive for PSA protein. Confirmatory analyses for PSA by a commercially available method (IMx) on six samples demonstrated a high degree of concordance between the two methods. To establish the molecular weight of the immunoreactive species, the most highly positive tumor extracts of each tumor type were fractionated by high performance liquid chromatography. Whereas the majority of tumors had immunoreactivity eluting at both 100 KDa and 33 KDa, corresponding to PSA bound to alpha 1-antichymotrypsin and free PSA, respectively, the colon and parotid tumors displayed immunoreactivity only at the 33 KDa fraction. We conclude that in addition to breast tumors and normal breast, colon, ovarian, liver, kidney, adrenal, and parotid tumors can also produce PSA. The physiological role of PSA in these tumors is currently under investigation.

Immunoreactive prostate-specific antigen in lung tumors

Prostate-specific antigen (PSA) is a glycoprotein produced by the epithelial cells of the prostate. PSA is currently used clinically to diagnose and monitor prostate carcinoma. In previous work we have demonstrated that 30% of breast tumors and, more rarely other tumors, contain significant amounts of PSA. PSA appears to be a favorable prognostic indicator in breast cancer. Here, using a sensitive assay, we demonstrated for the first time that lung adenocarcinomas and squamous cell carcinomas also contain PSA. PSA in lung tumor extracts was present mainly in its 33 KDa form (free PSA), at levels measurable by commercial methods. The presence of PSA was associated more closely with male patients and adenocarcinomas. The physiological role of PSA in lung tissue and the prognostic significance of PSA in lung cancer remain to be determined. These and our previous data as well as reports by other groups support the view that PSA is a ubiquitous biochemical marker of steroid hormone action.

Involvement of superior mesenteric vessels and portal vein in pancreatic adenocarcinoma: detection with CT during arterial portography

A prospective study was designed to determine the utility of computed tomography (CT) during arterial portography (CTAP) in the detection of superior mesenteric vessels and portal vein involvement in patients with pancreatic adenocarcinoma. Eighteen patients with adenocarcinoma of the head of the pancreas and eight patients with benign pancreatic disease were investigated with CTAP, dynamic contrast-enhanced CT, and angiography. Appropriate review was made to determine presence or absence of superior mesenteric vessels and portal vein involvement. Final diagnosis was obtained in all cases by surgical explorations. The overall accuracy rate for detecting or excluding superior mesenteric vessels and portal vein involvement was 96% (25 of 26 patients) with CTAP, 88% (23 of 26 patients) with dynamic contrast-enhanced CT, and 85% (22 of 26 patients) with angiography. No statistically significant difference in accuracy was found among the three techniques. Our results suggest that the use of CTAP is not indicated in the preoperative detection of superior mesenteric vessels and portal vein involvement in patients with pancreatic adenocarcinoma.

MRI of Budd-Chiari syndrome

A retrospective study was undertaken to reassess the various magnetic resonance imaging (MRI) features of Budd-Chiari syndrome (BCS). MRI examinations of 22 patients with pathologically confirmed BCS were studied. Spin-echo (SE) T1- (TR = 300-450 ms/TE = 12-15 ms), and SE T2-weighted (TR = 1600-2000 ms/TE = 30-60/90-120 ms) MRI images were obtained in all patients. Gradient-recalled-echo (GRE) images (TR = 7-60 ms/TE = 3-19 ms, flip angle = 10-40 degrees) were obtained in 14 patients. MRI showed thrombosis of three or two hepatic veins in 19 (86%) and 3 (14%) patients, respectively. Spontaneous intrahepatic anastomoses was depicted in five (23%) patients. Ascites appeared in 15 patients (68%). Thrombosis or external compression of the inferior vena cava (IVC) by an enlarged caudate lobe was depicted in six (27%) and five (23%) patients, respectively. Prominent azygos and hemiazygos veins were demonstrated in seven (32%) patients (six of whom had thrombosis of the IVC). MRI showed hepatomegaly in all patients and enlarged caudate lobe in 18 (82%) patients. SE T1- and SE T2-weighted MRI images revealed inhomogeneous signal intensity of hepatic parenchyma in 14 (64%) patients. SE T1- and SE T2-weighted MRI images showed homogeneous signal intensity of hepatic parenchyma in eight (36%) patients. Our results demonstrate that BCS displays various features on MRI images, and such information is important for diagnosis.

Detection of recurrent hepatic metastases after partial hepatectomy: value of CT combined with arterial portography

OBJECTIVE

We did a retrospective study to evaluate the sensitivity of CT combined with arterial portography in detecting recurrent hepatic metastases after partial hepatectomy.

MATERIALS AND METHODS

CT scans combined with arterial portography in 18 patients who had partial hepatectomy and suspected intrahepatic recurrence of metastases were retrospectively reviewed. Eleven of the patients had further surgery, and recurrent hepatic metastases were proved; seven patients were inoperable. The sensitivity of CT with arterial portography for detecting recurrent intrahepatic metastases was determined and correlated with intraoperative findings and findings on follow-up imaging studies in the 11 patients (with a total of 23 hepatic metastases) who had further surgery.

RESULTS

Not one of the 18 CT examinations combined with arterial portography was compromised by inhomogeneous perfusion of contrast material in the portal vein. Of the 23 metastases that were found in the 11 patients who had further surgery, 21 (91%) were shown on CT with arterial portography. In two patients, CT with arterial portography showed two subcapsular hypoattenuating pseudolesions that were correctly identified as nontumorous perfusion defects, as confirmed by intraoperative findings and follow-up imaging studies.

CONCLUSION

This study shows that postoperative CT with arterial portography is efficacious in the detection of intrahepatic recurrent metastases in patients who have had a partial hepatectomy. Furthermore, prior partial hepatectomy does not compromise the quality of this examination.

Cystic tumors of the pancreas: dynamic CT studies

OBJECTIVE

Our retrospective study was performed to reassess the common dynamic CT manifestations of cystic tumors of the pancreas and to determine whether they might allow the differentiation between benign and malignant tumors.

MATERIALS AND METHODS

Dynamic CT examinations of 19 patients with 20 cystic tumors of the pancreas, including 7 serous cystadenomas, 3 benign mucinous cystadenomas, 5 mucinous cystadenocarcinomas, 3 mucin-producing duct ectasias, and 2 papillary cystic epithelial neoplasms, were retrospectively reviewed. The examinations were obtained with 4 to 5 mm collimation with intravenous injection of 120-130 ml of contrast agent.

RESULTS

Calcifications were found only in benign tumors (seven serous cyst-adenomas). Internal septations were found in benign and malignant tumors (seven serous cystadenomas, three benign mucinous cystadenomas, three mucinous cystadenocarcinomas). Solid excrescences within cystic cavities were found only in malignant tumors (two mucinous cystadenocarcinomas, two mucin-producing duct ectasias). Dynamic CT features allowed the distinguishing of serous cystadenomas from other cystic tumors and mucin-producing duct ectasias from other mucinous tumors. Dynamic CT features did not permit differentiation between benign mucinous cystadenomas, mucinous cystadenocarcinomas, and papillary cystic epithelial neoplasms.

CONCLUSION

The review suggests that dynamic CT findings are useful to differentiate (a) serous cystadenomas and mucin-producing duct ectasias from other cystic tumors of the pancreas and (b) benign from malignant tumors. Such differentiation has impact on patient management.

CT of hepatic tumors: prevalence and specificity of retraction of the adjacent liver capsule

OBJECTIVE

The purpose of this study was to describe the CT features of capsular retraction of the liver adjacent to hepatic tumors and to test the hypothesis that this finding is specific for malignant hepatic tumors.

MATERIALS AND METHODS

We first retrospectively reviewed the CT scans of eight patients with pathologically proved malignant hepatic tumors (five secondary and three primary) who had CT scans that showed retraction of the overlying liver capsule. Then, using criteria developed from the first eight cases, we prospectively studied 253 patients with pathologically proved hepatic tumors (75 benign, 178 malignant) to determine the prevalence of retraction of the liver capsule shown by CT and the specificity of this finding for malignant hepatic tumors.

RESULTS

CT scans in the first eight patients showed two types of capsular retraction. In seven patients, the retracted liver capsule was smooth and regular. In one patient, capsular retraction was associated with central ulceration extending to and eroding the liver capsule. Four of 253 patients studied prospectively had hepatic tumors with associated capsular retraction (prevalence, 2%). In those four cases, the retracted liver capsule was smooth and regular. All four tumors were malignant (one fibrolamellar hepatocellular carcinoma, two carcinoid tumors, one colorectal metastasis).

CONCLUSION

Capsular retraction of the liver adjacent to hepatic tumors is an uncommon CT finding that appears to be specific for malignant hepatic tumors.

Focal hepatic masses: comparison of detection during arterial portography with MR imaging and CT

PURPOSE

A prospective study was performed to compare the sensitivity and specificity of magnetic resonance (MR) imaging and computed tomography (CT) both performed during arterial portography in depicting focal hepatic masses.

MATERIALS AND METHODS

Eleven patients with 31 pathologically proved focal hepatic masses were prospectively evaluated. MR arterial portography was performed with 4 mL of a 0.5 mmol/kg solution of gadolinium tetraazacyclododecanetetraacetic acid (DOTA) injected through a catheter into the superior mesenteric artery during multisection gradient-echo imaging.

RESULTS

MR arterial portography depicted 29 of the 31 masses (sensitivity, 94%). CT arterial portography depicted 27 of the 31 masses (sensitivity, 87%). Two masses not depicted with either CT or MR had a diameter of 3 and 7 mm, respectively. Neither MR nor CT demonstrated a false-positive finding (specificity, 100%). The difference in sensitivity and specificity between the two techniques was not statistically significant.

CONCLUSION

MR arterial portography does not enable detection of significantly more focal hepatic masses than does CT arterial portography.