Effect of Sodium Benzoate on Cognitive Function Among Patients With Behavioral and Psychological Symptoms of Dementia: Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Female gender is a major risk factor for dementia; however, gender has not yet been adequately addressed by clinical trials. A recent study demonstrated that sodium benzoate, a D-amino acid oxidase inhibitor, improved cognitive function in early-phase Alzheimer disease.

OBJECTIVE

To examine the potential gender difference in the effects of benzoate treatment on the behavioral and psychological symptoms of dementia (BPSD).

DESIGN, SETTING, AND PARTICIPANTS

This post hoc secondary analysis used data from a randomized, double-masked, placebo-controlled trial conducted in 3 major medical centers in Taiwan and enrolled 97 patients with BPSD. Data were analyzed between February 2014 and November 2017.

INTERVENTIONS

Six weeks of treatment of 250 to 1500 mg/d of sodium benzoate or placebo.

MAIN OUTCOMES AND MEASURES

The primary outcome measures were Alzheimer disease assessment scale-cognitive subscale (ADAS-cog) and Behavioral Pathology in Alzheimer Disease Rating Scale (BEHAVE-AD) scores.

RESULTS

Among 97 total participants (62 [64%] women; mean [SD] age, 75.4 [7.7] years), 49 patients (30 women and 19 men) were randomized to sodium benzoate, and 48 (32 women and 16 men) were randomized to placebo. Among 62 women, 6-week benzoate treatment significantly surpassed placebo in the effects on ADAS-cog performance (mean [SD] difference in score between baseline and end point, -3.1 [6.4] points vs 0 [4.5] points; Cohen d = 0.56; P = .04) but not BEHAVE-AD performance. In contrast, among 35 men, the 2 treatment groups did not differ significantly in both ADAS-cog and BEHAVE-AD scores. Compared with placebo, benzoate treatment also increased estradiol to follicle-stimulating hormone ratios among women (mean [SD] difference between baseline and end point, 0 [0.2] vs -0.1 [0.3]; P = .03).

CONCLUSIONS AND RELEVANCE

These findings suggest that benzoate treatment may improve cognitive function in women with later-phase dementia. In the future, longer dose-finding trials are warranted to further clarify the efficacy of benzoate for later-phase dementia and investigate the role of sex hormones and other factors in the pathogenesis of dementia.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02103673.

[Role and related mechanism of Mst-1 on regulating hypoxic reoxygenation induced autophagy and apoptosis in cardiomyocytes of mouse]

Objective: To explore the role and related mechanism of mammalian sterile 20-like kinase 1(Mst-1)in regulating hypoxia reoxygenation (HR) induced myocardial cell autophagy and apoptosis. Methods: Enzyme digestion method combined with differential adherent method was used to culture neonatal mouse myocardial cells. HR model was established by hypoxia for 24 hours and reoxygenation for 6 hours. The experimental groups including control group (normal cultured cardiomyocytes), Mst-1 empty virus group (cardiomyocytes transfected with recombinant lentiviral empty vector for 48 hours), Mst-1 knockdown group (recombinant lentivirus carrying Mst-1small interfering RNA (siRNA) was transfected into cardiomyocytes for 48 hours), Mst-1 overexpression group (cardiomyocytes were transfected with recombinant lentivirus carrying Mst-1 gene for 48 hours), HR group (cardiomyocytes exposed to HR), Mst-1 knockdown+HR group (HR model of cardiomyocyte was established 48 hours after transfection with recombinant lentivirus carrying Mst-1siRNA) and Mst-1 overexpression+HR group (HR model of cardiomyocyte was established 48 hours after transfection with recombinant lentivirus carrying Mst-1 gene). Real-time fluorescence quantitative RCR (qPCR) and Western blot were used to detect the relative expression of Mst-1 mRNA and protein in the cells, immunofluorescence staining was used to detect cardiomyocyte troponin T (cTnT), and autophagosomes and autophagy enzyme changes. TUNEL method was used to detect myocardial cell apoptosis, Western blot was adopted to detect autophagy-related protein microtubule-related protein 1 light chain 3 (LC3) Ⅱ/LC3 Ⅰ, P62 and apoptosis-related protein cleaved-caspase 9, pro-caspase 9, cleaved-caspase-3, pro-caspase-3, and myeloid leukemia 1 (MCL-1) expression. MCL-1 inhibitor A1210477 was used to validate the signaling pathway of Mst-1 on regulating cardiomyocyte apoptosis and autophagy. Results: Immunofluorescence detection revealed that the cultured cells expressed cardiomyocyte-specific marker cTnT. The expression of Mst-1 in cardiomyocytes increased in HR model. Lentiviral transfection could effectively inhibit or overexpress Mst-1 in treated cells. The levels of autophagosomes and autophagolysosomes in cardiomyocytes undergoing HR and in Mst-1 overexpression+HR group were lower than those of control group, while autophagosomes and autophagolysosomes in cardiomyocytes of Mst-1 knockdown+HR group was significantly higher than in the HR group (all P<0.05). The TUNEL results showed that the proportion of TUNEL positive cells was significantly increased in the HR group and Mst-1 overexpression+HR group than in the control group, while the proportion of TUNEL positive cells was significantly decreased in the Mst-1 knockdown group+HR group as compared to the HR group (all P<0.05). Western blot results showed that the LC3 Ⅱ/LC3 Ⅰ levels were significantly lower, while the expression levels of P62, cleaved-caspase-9 and cleaved-caspase-3 were significantly higher in the HR group and Mst-1 overexpression+HR group than in control group (all P<0.05). The LC3 Ⅱ/LC3 Ⅰ value was significantly higher, and the expression levels of P62, cleaved-caspase-9 and cleaved-caspase-3 were significantly lower in the Mst-1 knockdown+HR group than in the HR group (P both<0.05). The expression level of P-MCL-1 protein was significantly lower in cardiomyocytes of HR and Mst-1 overexpression+HR group than in control group, and the expression level of P-MCL-1 protein was higher in Mst-1 knockdown+HR group than in HR group (P both<0.05). The recovery experiment showed that inhibiting MCL-1 in cells can block the regulatory effect of Mst-1 siRNA on cell autophagy and apoptosis. Conclusion: Inhibiting Mst-1 expression in cardiomyocytes can promote the autophagy of cardiomyocytes induced by hypoxic reoxygenation and reduce the apoptosis of cardiomyocytes via activating McL-1.

Precision Medicine of Sodium Benzoate for the Treatment of Behavioral and Psychological Symptoms of Dementia (BPSD)

OBJECTIVE

Behavioral and psychological symptoms of dementia (BPSD) are associated with poorer prognosis of dementia. A 24-week study demonstrated that sodium benzoate, a D-amino acid oxidase (DAAO) inhibitor, surpassed placebo in improving cognitive function in early-phase Alzheimer's disease; however, benzoate did not excel placebo in another 6-week study on BPSD. The current study examined whether the precision medicine approach was able to identify specific individuals with BPSD who could benefit from benzoate treatment.

METHODS

In the randomized, double-blind, placebo-controlled, 6-week trial, 97 patients with BPSD were allocated to receive 250-1500 mg/day of sodium benzoate or placebo. Cognitive function was measured by the Alzheimer's disease assessment scale-cognitive subscale (ADAS-cog) and behavioral and psychological symptoms were mainly measured by Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). DAAO level, amino acids (L-serine, D-serine, L-alanine, and D-alanine, glycine), and two antioxidants (catalase, superoxide dismutase) were assayed in peripheral blood.

RESULTS

After benzoate treatment, DAAO inhibition was correlated with ADAS-cog decrease (p = 0.034), while baseline DAAO level was correlated with baseline BEHAVE-AD score. Multiple linear regression analyses showed that cognitive improvement after benzoate treatment was correlated with DAAO decrease, female gender, younger age, BMI, baseline BPSD severity, and antipsychotic use.

CONCLUSION

The finding suggests that sodium benzoate may have potential to benefit cognitive function in a fraction of BPSD patients after 6 weeks of treatment. Of note, the precision medicine approach may be helpful for identifying individuals who could respond to benzoate. More studies are warranted to confirm the preliminary findings.

TRIAL REGISTRATION

The trial was registered online (https://clinicaltrials.gov/ct2/show/NCT02103673).

[Impact and related mechanism on the improvement of hyperglycemia-induced pyroptosis in H9c2 cells by mircoRNA-214]

Objective: To investigate whether microRNA(miR)-214 can improve hyperglycemia induced pyroptosis in H9c2 cells through targeting caspase-1. Methods: H9c2 cells of rats those in good growth condition were selected and incubated into the T25 culture bottle after digestion and passage. Cells were cultured in an incubator at 37 ℃ with 5%CO(2), repeat passage was made after cell density reached about 80%, The 5(th) to 8(th) generations of cells were selected for the subsequent experiments. To observe the effect of overexpression of miR-214 on pyroptosis and caspase-1 expression in H9c2 cells induced by hyperglycemia, the cells were divided into 4 groups: Control group(H9c2 cells cultured normally), Hyperglycemia group (HG group, 50 mmol/L glucose was used to intervene H9c2 cells for 24 hours), miR-214 mimics+hyperglycosis group (mimics+HG group, H9c2 cells were transfected with miR-214 mimics for 24 hours and then treated with 50 mmol/L hyperglycosis for 24 hours), miR-214 mimic-negative control+hyperglycaemic group(MNC+HG group, H9c2 cells were transfected with miR-214 mimic-negative control for 24 hours and then treated with 50 mmol/L hyperglycaemic for 24 hours). In order to further verify the anti-pyroptosis effect of miR-214 was mediated by targeted inhibition on caspase-1, cells overexpressing caspase-1 were used in the rescue experiment. The cells overexpressing caspase-1 were divided into 4 groups: Hyperglycemia group (HG group, 50 mmol/L glucose was used to intervene H9c2 cells for 24 hours), miR-214 mimics+hyperglycosis group (mimics+HG group, H9c2 cells were transfected with miR-214 mimics for 24 hours and then treated with 50 mmol/L hyperglycosis for 24 hours), miR-214 mimics+hyperglycosis+recombinant adenovirus (Ad-caspase-1-EGFP) group with caspase-1 gene and EGFP green fluorescent protein expression (mimics+HG+Ad-caspase-1-EGFP group, H9c2 cells were transfected with caspase-1-green fluorescent protein-carrying adenovirus for 48 hours, followed by transfection of miR-214 mimics for 24 hours, and then treated with 50 mmol/L hyperglycaemia for 24 hours), miR-214 mimics+HG+Ad-EGFP empty virus group (mimics+HG+Ad-EGFP group, H9c2 cells were transfected with empty adenovirus containing green fluorescent protein for 48 hours, followed by transfection with miR-214 mimics for 24 hours, and then treated with 50 mmol/L hyperglycosis for 24 hours). The mRNA expression levels of miRNA-214 and caspase-1 in cells were detected by real-time quantitative PCR. The expression and localization of caspase-1 protein were detected by immunofluorescence assay. Western blot was used to detect protein expression levels of procaspase-1, cleaved caspase-1, NLRP3 and ACS with β-actin as internal reference. The secretion of IL-1β and IL-18 in cell culture medium was detected by ELISA. The correlation between miR-214 and caspase-1 was detected by double luciferase reporter gene. Results: (1) The mRNA expression levels of miR-214 and caspase-1 in each group: the mRNA expressions of miR-214 in HG group and MNC+HG group were significantly lower than that in control group(P<0.05). The mRNA expression of miR-214 in mimics+HG group was significantly higher than that in control group (P<0.05). The mRNA expression levels of caspase-1 in HG group and MNC+HG group were significantly higher than that in control group(P<0.05). The mRNA expression level of caspase-1 in mimics+HG group was lower than that in control group(P<0.05). (2) The expression of caspase-1 in each group: the green fluorescence intensity in the control group was weak, which was strong in the HG group and MNC+HG group. The green fluorescence expression was weaker in mimics+HG group than in HG group. (3) ASC and NLRP3 protein expression levels in each group: ASC and NLRP3 protein expression levels in HG group and MNC+HG group were higher than those in control group(P<0.05). ASC and NLRP3 protein expression levels were significantly lower in mimics+HG group than in mimics+HG group (P<0.05). (4) The secretion of IL-1β and IL-18 in the cell culture medium of each group: the content of IL-1β and IL-18 in the cell culture medium of HG group and MNC+HG group was significantly higher than that of control group (P<0.05). The content of IL-1β and IL-18 in the cell culture medium of mimics+HG group was significantly lower than that of the HG group (P<0.05). (5) Correlation between miR-214 and caspase-1: miR-214 specifically binds to caspase-1 3 'UTR. Meanwhile, Western blot results showed that cleaved caspase-1 protein expression levels were significantly higher in both HG group and MNC+HG group than in control group (P<0.05). The levels of cleaved caspase-1 were significantly lower in mimics+HG group than in HG group (P<0.05). There was no significant difference in procaspase-1 expression among groups (P>0.05). (6) The expression levels of procaspase-1, cleaved caspase-1, ASC and NLRP3 in each group in rescue experiment: there was no significant difference in the expression of procaspase-1 in each group (P>0.05). Cleaved caspase-1, ASC and NLRP3 protein expressions were significantly lower in mimics+HG group than in HG group (P<0.05). However, cleaved caspase-1, ASC and NLRP3 protein expressions were significantly higher in mimics+HG+ Ad-caspase-1-EGFP group than in mimics+HG group (P<0.05). (7) The expression of IL-1β and IL-18 in rescue experiment: the secretions of IL-1β and IL-18 in the cell culture medium of the mimics+HG group were significantly lower than that of HG group (P<0.05), which were significantly higher in mimics+HG+Ad-caspase-1-EGFP group than in mimics+HG group (P<0.05). Conclusion: miR-214 can improve the hyperglycemia induced pyroptosis in H9c2 cells by targeted inhibition of the caspase-1.

Non-headache symptoms in migraine patients

Migraine is one of the most common neurological disorders. In addition to severe headaches, non-headache symptoms associated with migraine attacks as well as co-morbid disorders frequently aggravate the disabling of migraine patients. Some of these symptoms are related to poor outcomes. In this review, we update the advances of studies on certain non-headache symptoms, including visual disturbance, gastrointestinal symptoms, allodynia, vestibular symptoms, and symptoms of co-morbid restless legs syndrome and psychiatric disorders.

Low cholesterol level associated with severity and outcome of spontaneous intracerebral hemorrhage: Results from Taiwan Stroke Registry

The relationship between cholesterol level and hemorrhagic stroke is inconclusive. We hypothesized that low cholesterol levels may have association with intracerebral hemorrhage (ICH) severity at admission and 3-month outcomes. This study used data obtained from a multi-center stroke registry program in Taiwan. We categorized acute spontaneous ICH patients, based on their baseline levels of total cholesterol (TC) measured at admission, into 3 groups with <160, 160–200 and >200 mg/dL of TC. We evaluated risk of having initial stroke severity, with National Institutes of Health Stroke Scale (NIHSS) >15 and unfavorable outcomes (modified Rankin Scale [mRS] score >2, 3-month mortality) after ICH by the TC group. A total of 2444 ICH patients (mean age 62.5±14.2 years; 64.2% men) were included in this study and 854 (34.9%) of them had baseline TC <160 mg/dL. Patients with TC <160 mg/dL presented more often severe neurological deficit (NIHSS >15), with an adjusted odds ratio [aOR] of 1.80; 95% confidence interval [CI], 1.41–2.30), and 3-month mRS >2 (aOR, 1.41; 95% CI, 1.11–1.78) using patients with TC >200 mg/dL as reference. Those with TC >160 mg/dL and body mass index (BMI) <22 kg/m² had higher risk of 3-month mortality (aOR 3.94, 95% CI 1.76–8.80). Prior use of lipid-lowering drugs (2.8% of the ICH population) was not associated with initial severity and 3-month outcomes. A total cholesterol level lower than 160 mg/dL was common in patients with acute ICH and was associated with greater neurological severity on presentation and poor 3-month outcomes, especially with lower BMI.

Genome-wide association study identifies novel susceptibility loci for migraine in Han Chinese resided in Taiwan

Background Susceptibility genes for migraine, despite it being a highly prevalent and disabling neurological disorder, have not been analyzed in Asians by genome-wide association study (GWAS). Methods We conducted a two-stage case-control GWAS to identify susceptibility genes for migraine without aura in Han Chinese residing in Taiwan. In the discovery stage, we genotyped 1005 clinic-based Taiwanese migraine patients and 1053 population-based sex-matched controls using Axiom Genome-Wide CHB Array. In the replication stage, we genotyped 27 single-nucleotide polymorphisms with p < 10^-4 in 1120 clinic-based migraine patients and 604 sex-matched normal controls by using Sequenom. Variants at LRP1, TRPM8, and PRDM, which have been replicated in Caucasians, were also genotyped. Results We identified a novel susceptibility locus (rs655484 in DLG2) that reached GWAS significance level for migraine risk in Han Chinese ( p = 1.45 × 10^-12, odds ratio [OR] = 2.42), and also another locus (rs3781545in GFRA1) with suggestive significance ( p = 1.27 × 10^-7, OR = 1.38). In addition, we observed positive association signals with a similar trend to the associations identified in Caucasian GWASs for rs10166942 in TRPM8 (OR = 1.33, 95% confidence interval [CI] = 1.14-1.54, P_permutation = 9.99 × 10^-5; risk allele: T) and rs1172113 in LRP1 (OR = 1.23, 95% CI = 1.04-1.45, P_permutation = 2.9 × 10^-2; risk allele: T). Conclusion The present study is the first migraine GWAS conducted in Han-Chinese and Asians. The newly identified susceptibility genes have potential implications in migraine pathogenesis. DLG2 is involved in glutamatergic neurotransmission, and GFRA1 encodes GDNF receptors that are abundant in CGRP-containing trigeminal neurons. Furthermore, positive association signals for TRPM8 and LRP1 suggest the possibility for common genetic contributions across ethnicities.

Susceptible genes of restless legs syndrome in migraine

Objective Several genetic variants have been found to increase the risk of restless legs syndrome (RLS). The aim of the present study was to determine if these genetic variants were also associated with the comorbidity of RLS and migraine in patients. Methods Thirteen single-nucleotide polymorphisms (SNPs) at six RLS risk loci ( MEIS1, BTBD9, MAP2K5, PTPRD, TOX3, and an intergenic region on chromosome 2p14) were genotyped in 211 migraine patients with RLS and 781 migraine patients without RLS. Association analyses were performed for the overall cohort, as well as for the subgroups of patients who experienced migraines with and without aura and episodic migraines (EMs) vs. chronic migraines (CMs). In order to verify which genetic markers were potentially related to the incidence of RLS in migraine patients, multivariate regression analyses were also performed. Results Among the six tested loci, only MEIS1 was significantly associated with RLS. The most significant SNP of MEIS1, rs2300478, increased the risk of RLS by 1.42-fold in the overall cohort ( p = 0.0047). In the subgroup analyses, MEIS1 augmented the risk of RLS only in the patients who experienced EMs (odds ratio (OR) = 1.99, p = 0.0004) and not those experiencing CMs. Multivariate regression analyses further showed that rs2300478 in MEIS1 (OR = 1.39, p = 0.018), a CM diagnosis (OR = 1.52, p = 0.022), and depression (OR = 1.86, p = 0.005) were independent predictors of RLS in migraine. Conclusions MEIS1 variants were associated with an increased risk of RLS in migraine patients. It is possible that an imbalance in iron homeostasis and the dopaminergic system may represent a link between RLS incidence and migraines.

RISK OF NEW ONSET TYPE II DM IN MDD PATIENTS RECEIVING SECOND-GENERATION ANTIPSYCHOTICS TREATMENT: A NATIONWIDE COHORT STUDY

BACKGROUND

Second-generation antipsychotics (SGA) augmentation treatment has showed better efficacy in patients with major depressive disorder (MDD). However, the association between SGA and diabetes mellitus (DM) in MDD patients deserves further investigation. The study aimed to examine the risk of new onset type II DM in MDD patients receiving SGA treatment.

METHODS

From the Psychiatric Inpatient Medical Claim Dataset, MDD patients treated with SGA continuously for more than 8 weeks were analyzed in a 1:1 propensity score matched pair sample to 1,049 patients that had never been treated with SGA. Patients were followed up to 5 years based on ICD-9 CM codes indicating incident type II DM. Cumulative incidences of type II DM were calculated and the Cox proportional hazards model with competing risk was applied to determine the risk factors for type II DM onset.

RESULTS

Cumulative incidences of new-onset type II DM between the two groups were similar. Use of SGA showed no significant increase in risk for new-onset type II DM (hazard ratio [HR] = 0.898; 95% confidence interval [CI], 0.605-1.334; P-value = 0.596). Increased risk for type II DM was shown to be associated with aging (per year) (HR = 1.039; 95% CI, 1.026-1.053; P-value < 0.001) and history of hyperlipidemia (HR = 2.323; 95% CI, 1.469-3.675; P-value < 0.001).

CONCLUSIONS

This study indicated that there is no significant difference in the risk of developing type II DM between MDD patients with and without SGA exposure. More studies focused on the benefit-risk assessment of SGA treatment in patients with MDD are warranted.

Neuropsychiatric Symptoms in Parkinson's Disease Dementia Are More Similar to Alzheimer's Disease than Dementia with Lewy Bodies: A Case-Control Study

Background and purpose

Previous studies on the clinical and pathological manifestations of Parkinson’s disease dementia (PDD) have reported findings more similar to dementia with Lewy bodies (DLB) than to Alzheimer’s disease (AD). The aim of this study was to investigate the neuropsychiatric symptoms of PDD compared to DLB and AD.

Methods

We conducted a retrospective case-control study on 125 newly diagnosed consecutive PDD patients and age- and dementia stage-matched controls with either DLB (N = 250) or AD (N = 500) who visited the same hospital over the same period. For each case and control, neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory (NPI).

Results

Overall, 513 (58.6%) patients were female and 362 (41.4%) were male. Comparisons of clinical data revealed that the PDD group, similar to the AD group, had a lower NPI total score, NPI caregiver burden score, and rate of antipsychotic use (all p < 0.001) than the DLB group. One or more psychiatric symptoms were reported in 95.2% of the PDD, 99.2% of the DLB, and 96.8% of the AD patients. The PDD group had lower subscores in the items of delusions, hallucinations, agitation, anxiety, irritation, aberrant motor behavior compared to the DLB group. Severe neuropsychiatric symptoms among all dementia patients were associated with younger age, more advanced stage, and a diagnosis of DLB.

Conclusion

Neuropsychiatric symptoms in PDD were more like those in AD than in DLB. Severe neuropsychiatric symptoms in degenerative dementia were associated with younger age, more advanced stage of dementia, and a diagnosis of DLB.

Bidirectional triggering association between migraine and restless legs syndrome: A diary study

OBJECTIVE

Migraine is comorbid with restless legs syndrome (RLS). However, the temporal association between these two episodic disorders remains elusive. The current study investigated the temporal relationship between migraine and RLS attacks.

METHODS

Migraine patients with RLS were recruited from a headache clinic. Patients with symptomatic RLS, RLS mimics, daily headaches, or daily RLS attacks were excluded. The patients recorded their headaches and RLS attacks for two weeks in a diary. The severity of each headache or RLS attack was rated on a four-point (0-3) Likert scale. Logit-normal, random-effects models were employed to estimate the odds ratios (ORs) for the temporal association between migraine and RLS attacks.

RESULTS

Thirty migraine patients with RLS (28 F/2 M, mean age 35.5 ± 9.0 years) completed the study. On the basis of 420 daily diary records, migraine attacks were associated with subsequent RLS attacks occurring on the same and next nights (OR = 6.94, 95% confidence interval (CI) = 4.39-11.0 and OR = 3.00, CI = 1.92-4.68; both ITALIC! p < 0.001). RLS attacks were associated with subsequent migraine attacks only on Day 1 (OR = 1.97 (CI = 1.3-2.98; ITALIC! p = 0.01). Overall, the frequencies of migraine and RLS attacks in two weeks were correlated (Spearman's correlation = 0.56, ITALIC! p = 0.001).

CONCLUSIONS

Our study results showed a bidirectional triggering association between migraine and RLS attacks. The association was stronger and lasted longer for migraine triggering subsequent RLS than that for vice versa.

Effects of two sesquiterpene lactones isolated fromArtemisia annua on physiology ofLemna minor

The effects of artemisinin and arteannuic acid extracted fromArtemisia annua on the physiology ofLemna minor were evaluated. Changes in frond production, growth, dry weight, and chlorophyll content ofL. minor were determined. Photosynthesis and respiration were evaluated with a differential respirometer. Artemisinin (5 µM) inhibitedL. minor frond production and dry weight 82 and 83%, relative to methanol controls. Chlorophyll content was reduced 44% by artemisinin (2.5 µM). Arteannuic acid (10 µM) was less active, inhibiting frond production 61% and reducing chlorophyll content 66% at 5 µM. Artemisinin (1 µM) reducedL. minor photosynthesis 30% and 2.5 µM reduced respiration 39%. Arteannuic acid had no significant effect on photosynthesis or respiration at the levels tested.

Onset Headache Predicts Good Outcome in Patients With First-Ever Ischemic Stroke

Background and Purpose—

The study aimed to assess whether onset headache is an ominous sign in patients with first-ever ischemic stroke.

Methods—

A large population of ischemic stroke patients was obtained from the Taiwan Stroke Registry. Stroke subtypes were classified by the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. On the basis of the International Classification of Headache Disorders, second version, onset headache was defined as a new headache that developed at the onset of ischemic stroke. Clinical features and impact on stroke outcomes, including in-hospital stroke in evolution, changes in National Institutes of Health Stroke Scale on discharge, and Barthel index and modified Rankin scale ≤6 months after stroke were compared between those with and without onset headache.

Results—

Among 11 523 patients with first-ever ischemic stroke, 848 had onset headache (7.4%). Patients with specific cause, large-artery atherosclerosis, or cardioembolism were more likely to have onset headache. Patients with onset headache were younger, predominantly female, and more likely to have posterior circulation ischemic lesions. Compared with patients without onset headache, those with onset headache had a lower frequency of stroke in evolution (4.5% versus 6.7%; adjusted relative risk, 0.64; 95% confidence interval, 0.52–0.79), greater improvement in National Institutes of Health Stroke Scale score on discharge (0.08 versus −0.20; P =0.02), higher mean Barthel index scores (86.5±20.0 versus 83.9±23.3; adjusted difference, 1.43; 95% confidence interval, 0.28–2.89), and a lower frequency of modified Rankin scale higher than 2 (27.6% versus 31.5%; adjusted relative risk, 0.85; 95% confidence interval, 0.72–0.95) at 1-month follow-up. There was also a trend for better functional outcome in 3- and 6-month follow-ups.

Conclusions—

By adopting standard classification criteria, this large-scale study demonstrated that onset headache was associated with modest but significantly better outcomes after ischemic stroke.

Chinese medicine patterns in patients with post-stroke dementia

A stroke often results in post-stroke dementia, a rapid decline in memory and intelligence causing dysfunctions in daily life. The Chinese medicine doctor uses 4 examinations of inspection, listening, smelling, and feeling to determine the Chinese medicine pattern (CMP). Therefore, the purpose of the present study was to investigate the CMP in patients with post-stroke dementia. A total of 101 stroke patients were examined, consistent with the DSM IV diagnostic criteria of the American Psychiatric Association, as well as the National Institute of Neurological Disorders and Stroke-Association International pour Ia Recherche et I’Enseignement en Neurosciences vascular dementia diagnostic criteria of post-stroke dementia. Results: 100 patients (99.0%) were KEDP (kidney essence deficiency pattern, shèn jīng kuī xū zhèng, 腎精虧虛證), 83 patients were AHLYP (ascendant hyperactivity of liver yang pattern, gān yáng shàng kàng zhèng, 肝陽上亢證), 83 patients were QBDP (qi-blood deficiency pattern, qì xuè kuī xū zhèng, 氣血虧虛證), 81 patients were SBOCP (static blood obstructing the collaterals pattern, yū xuè zǔ luò zhèng, 瘀血阻絡證), 72 patients were BSTRP (bowels stagnation turbidity retention pattern, fǔ zhì zhuó liú zhèng, 腑滯濁留證), 50 patients were FHIEP (fire heat interior excess pattern, huǒ rè nèi sheng zhèng, 火熱內盛證), and 39 participants (38.6%) were PTOOP (phlegm turbidity obstructing the orifices pattern, tán zhuó zǔ qiào zhèng, 痰濁阻竅證); one to 31 patients have at least 2 CMPs simultaneously. In conclusion, the most CMP is KEDP CMP in the post-stroke dementia patients, and one patient may have one or at least 2 CMPs simultaneously.

Morning headache in habitual snorers: frequency, characteristics, predictors and impacts

OBJECTIVES

Morning headache has been considered as an accompanying symptom of obstructive sleep apnoea syndrome (OSAS). However the frequency, characteristics, predictors and impacts of morning headache in habitual snorers are not well defined.

METHODS

We studied consecutive patients with habitual snoring in a sleep laboratory using polysomnography. All patients were interviewed by a physician regarding the presence or absence of morning headache, migraine and insomnia. Each patient completed the Short Form-36 health survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Morning headache was defined as headache on awakening ≥1 day/week for ≥6 months.

RESULTS

Of the 268 participants with habitual snoring, 63 (23.5%) had morning headache and 184 (69%) had OSAS. Patients with morning headache reported lower scores in all eight domains of the SF-36 than those without (difference: 10.6 to 29.7 points, all p ≤ 0.005). The independent predictors of morning headache were migraine (adjusted odds ratio (AOR) 6.3), insomnia (AOR 4.2), psychological distress (HADS ≥ 8) (AOR 3.9) and OSAS (AOR 2.6). Morning headache in 12 patients (19%) fulfilled the criteria for migraine attacks.

CONCLUSIONS

Morning headache was common in habitual snorers and associated with a pervasive impairment of health-related quality of life. Migrainous features were not uncommon. Not only OSAS, but migraine, insomnia and psychological distress were also important predictors for morning headache, even in snoring patients.

[Treatment guidelines for acute and preventive treatment of cluster headache]

The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated both the acute and the preventive treatments for cluster headache now being used in Taiwan, based on the principles of evidence- based medicine. We assessed the quality of clinical trials and levels of evidence, and referred to other treatment guidelines proposed by other countries. Throughout several panel discussions, we merged opinions from the subcommittee members and proposed a consensus on the major roles, recommended levels, clinical efficacy, adverse events and cautions of clinical practice regarding acute and preventive treatments of cluster headache. The majority of Taiwanese patients have episodic cluster headaches, because chronic clusters are very rare. Cluster headache is characterized by severe and excruciating pain which develops within a short time and is associated with ipsilateral autonomic symptoms. Therefore, emergency treatment for a cluster headache attack is extremely important. Within the group of acute medications currently available in Taiwan, the subcommittee determined that high-flow oxygen inhalation has the best evidence of effectiveness, followed by intranasal triptans. Both are recommended as first-line medical treatments for acute attacks. Oral triptans were determined to be second-line medications. For transitional prophylaxis, oral corticosteroids are recommended as the first-line medication, and ergotamine as the second-line choice. As for maintenance prophylaxis, verapamil has the best evidence and is recommended as the first-line medication. Lithium, melatonin, valproic acid, topiramate and gabapentin are suggested as the second-line preventive medications. Surgical interventions, including occipital nerve stimulation, deep brain stimulation, radiofrequency block of the sphenopalatine ganglion, percutaneous radiofrequency rhizotomy and trigeminal nerve section, are invasive and their long-term efficacy and adverse events are still not clear in Taiwanese patients; therefore, they are not recommended currently by the subcommittee. The transitional and maintenance prophylactic medications can be used together to attain treatment efficacy. Once the maintenance prophylaxis achieves efficacy, the transitional prophylactic medications can be tapered gradually. We suggest the corticosteroids be used within two weeks, if possible. The duration of maintenance treatment depends on the individual patient's clinical condition, and the medications can be tapered off when the cluster period is over.

Comorbidities of migraine

Migraine is a common neurological disorder and can be severely disabling during attacks. The highest prevalence occurs between the ages of 25 and 55 years, potentially the most productive period of life. Migraine leads to a burden not only for the individual, but also for the family and society in general. Prior studies have found that migraine occurs together with other illnesses at a greater coincidental rate than is seen in the general population. These occurrences are called “comorbidities,” which means that these disorders are interrelated with migraine. To delineate the comorbidities of migraine is important, because it can help improve treatment strategies and the understanding of the possible pathophysiology of migraine. The comorbid illnesses in patients with migraine include stroke, sub-clinical vascular brain lesions, coronary heart disease, hypertension, patent foramen ovale, psychiatric diseases (depression, anxiety, bipolar disorder, panic disorder, and suicide), restless legs syndrome, epilepsy and asthma. In this paper, we review the existing epidemiological and hospital-based studies, and illustrate the connections between these illnesses and migraine.

Association between restless legs syndrome and migraine

BACKGROUND

An association between restless legs syndrome and migraine has been reported recently. The clinical correlates and impact of comorbidity of restless legs syndrome (RLS) are not fully described in patients with migraine.

OBJECTIVES

To investigate the frequency of RLS among different primary headache disorders, and its impact and clinical correlates in migraine patients.

METHODS

Consecutive patients with migraine, tension-type headache (TTH) and cluster headache (CH) were recruited in a headache clinic. Each patient completed the Migraine Disability Assessment (MIDAS) questionnaire, Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index (PSQI) and International RLS Study Group (IRLSSG) Rating Scale. RLS was diagnosed using the IRLSSG criteria.

RESULTS

A total of 1041 patients (migraine 772, TTH 218, CH 51) completed the study. The frequencies of RLS in patients with migraine (11.4%) was higher than in those with TTH (4.6%) or CH (2.0%) (p=0.002). In migraine patients, comorbidity with RLS was associated with higher frequencies of photophobia, phonophobia, exacerbation due to physical activities, vertigo, dizziness, tinnitus and neck pain, and higher mean scores of MIDAS and HADS. Migraine patients with RLS had a poorer sleep quality (Pittsburgh Sleep Quality Index score 11.1+/-4.1 vs 8.9+/-4.0, p<0.001) than those without.

CONCLUSION

An association between migraine and RLS among different primary headache disorders is demonstrated. Comorbid RLS in migraine patients worsened sleep quality. A shared underlying mechanism may account for the correlates between migraine features and comorbid RLS.

Confusion or delirium in patients with posterior cerebral arterial infarction

OBJECTIVE

To identify the possible anatomic sites and risk factors for the development of confusion or delirium in patients with posterior cerebral arterial (PCA) infarction.

MATERIALS AND METHODS

Twenty-nine patients aged 34-86 years with PCA infarction were divided into two groups: one with and the other without perturbed mentation. The clinical and laboratory data, including neuroimages, were retrospectively reviewed. Student-t, chi-square and Fisher's exact tests were performed for data analysis.

RESULTS

Confusion or delirium tended to develop in the left (10/13) or bilateral (5/5) PCA infarction as compared to the right PCA infarction (3/15) (P< 0.05) and medial occipital-temporal gyri involvement was crucial for its development (P< 0.05). The results were also noted in the patients with first-ever stroke. Diabetes mellitus was the sole biochemical factor to be associated with confusion or delirium (P< 0.01).

CONCLUSIONS

The involvement of the medial occipito-temporal gyri, especially on the left side was the pivotal factor for the development of confusion or delirium in patients with PCA infarction. Higher prevalence of diabetes mellitus was also observed in the group with mental perturbation.

Analysis of candidate genes on chromosome 2 in oral cleft case-parent trios from three populations

Isolated oral clefts, including cleft lip with/without cleft palate (CL/P) and cleft palate (CP), have a complex and heterogeneous etiology. Case-parent trios from three populations were used to study genes spanning chromosome 2, where single nucleotide polymorphic (SNP) markers were analyzed individually and as haplotypes. Case-parent trios from three populations (74 from Maryland, 64 from Singapore and 95 from Taiwan) were genotyped for 962 SNPs in 104 genes on chromosome 2, including two well-recognized candidate genes: TGFA and SATB2. Individual SNPs and haplotypes (in sliding windows of 2-5 SNPs) were used to test for linkage and disequilibrium separately in CL/P and CP trios. A novel candidate gene (ZNF533) showed consistent evidence of linkage and disequilibrium in all three populations for both CL/P and CP. SNPs in key regions of ZNF533 showed considerable variability in estimated genotypic odds ratios and their significance, suggesting allelic heterogeneity. Haplotype frequencies for regions of ZNF533 were estimated and used to partition genetic variance into among-and within-population components. Wright's fixation index, a measure of genetic diversity, showed little difference between Singapore and Taiwan compared with Maryland. The tensin-1 gene (TNS1) also showed evidence of linkage and disequilibrium among both CL/P and CP trios in all three populations, albeit at a lower level of significance. Additional genes (VAX2, GLI2, ZHFX1B on 2p; WNT6-WNT10A and COL4A3-COL4A4 on 2q) showed consistent evidence of linkage and disequilibrium only among CL/P trios in all three populations, and TGFA showed significant evidence in two of three populations.

Comparison of speech results after Furlow palatoplasty and von Langenbeck palatoplasty in incomplete cleft of the secondary palate

BACKGROUND

Due to many confounding factors, it is not easy to answer which method of cleft repair is superior to others. The purpose of this study is to try to compare the treatment result of different types of palatoplasty in patients who had the same cleft type and same treatment protocol besides the method of cleft repair. We selected nonsyndromic patients with incomplete cleft of the secondary palate. The speech results after the two palatoplasties were compared.

METHODS

Ninety-six children with nonsyndromic incomplete clefts of the secondary palate who received palatoplasty at the Craniofacial Center of Chang Gung Memorial Hospital from 1989 to 1997 were studied. Forty-six patients received Furlow palatoplasty and 50 patients received von Langenbeck palatoplasty. Velopharyngeal function was evaluated by speech pathologists periodically after the patient was two and half years old. Adequacy of velopharyngeal function was used as a measurement of speech outcome.

RESULTS

The Furlow palatoplasty group showed excellent results with 98% (45/46) adequacy in velopharyngeal function. In the von Langenbeck palatoplasty group, only 70% (35/50) of the patients had adequate velopharyngeal function. Statistical analysis with Fisher's exact test showed a significant difference (p < 0.0001, p < 0.05). Only one patient had an oronasal fistula after Furlow palatoplasty. After von Langenbeck palatoplasty, one patient had an oronasal fistula and one had wound dehiscence.

CONCLUSION

In this study, there was a better speech outcome after Furlow palatoplasty than von Langenbeck palatoplasty for repair of incomplete cleft of the secondary palate. Also, the number of complications after a Furlow palatoplasty was low. It should be a recommended treatment.

A retrospective study of dental implants in diabetic patients

The efficacious placement of dental implants in diabetic patients remains controversial. Definitive guidelines with objective criteria, including the type of diabetes, age of onset, and level of long-term control, have not been determined. In addition, few relevant literature citations assess the survival rate of implants in diabetic patients. Therefore, it is the purpose of this study to assess the success and survival rates of dental implants in diabetic patients. In this retrospective analysis, 215 implants placed in 40 patients at 2 clinical centers were evaluated. Chart reviews and interviews provided medical and implant data. From the analysis, 31 failures occurred, for an overall success rate of 85.6%. Of these failures, 24 occurred within the first year of functional loading. The mean time of functional load was 4.05 +/- 2.6 years. When the success rate was analyzed by implant location, success rates for the maxilla and mandible were 85.5% and 85.7%, respectively. For the anterior and posterior regions, success rates were 83.5% and 85.6%, respectively. The lifetable analysis revealed a cumulative success rate of 85.7% after 6.5 years of function. Based on the data, the survival rate of dental implants in controlled diabetic patients is lower than that documented for the general population, but there is still a reasonable success rate. The increase in failure rate occurs during the first year following prosthetic loading.

Interdental distraction osteogenesis and rapid orthodontic tooth movement: a novel approach to approximate a wide alveolar cleft or bony defect

The closure of a wide alveolar cleft and fistula in cleft patients and the reconstruction of a maxillary dentoalveolar defect in traumatic patients are challenging for both orthodontists and surgeons. This is due to the difficulty in achieving complete closure by using local attached gingiva and the great volume of bone required for the graft. In this article, the authors propose using interdental distraction osteogenesis to create a segment of new alveolar bone and attached gingiva for the complete approximation of a wide alveolar cleft/fistula and the reconstruction of a maxillary dentoalveolar defect. They performed this procedure on one patient with a traumatic maxillary dentoalveolar defect and 10 patients with unilateral or bilateral cleft lips and palates who had varied dentoalveolar clefts/fistulas. Interdental and maxillary osteotomies were performed on one side of the dental arch by the cleft or defect. After a latency period of 3 days, the osteotomized distal segment of the dental arch was then distracted and transported toward the cleft or defect by using a toothborne intraoral distraction device. The alveoli and gingivae on both ends of the cleft or defect were approximated after distraction osteogenesis. The need for extensive alveolar bone grafting was eliminated. A segment of new edentulous alveolus and attached gingiva was created interdentally at a site distant to the cleft or defect. In the cleft patients, teeth were moved orthodontically into the regenerate (newly formed alveolar bone) dental crowding 1 week after distraction. The orthodontic tooth movement was rapidly completed in 3 months, and the edentulous space was eliminated. Interdental distraction osteogenesis minimizes an alveolar cleft/fistula and helps reconstruct a maxillary dentoalveolar defect by approximating the native alveoli and gingivae; it also creates new alveolar bone and gingiva for rapid orthodontic tooth movement.

Midface distraction osteogenesis in cleft patients: a case report

We present a case of midface distraction in a bilateral cleft lip and palate patient. The patient was a 10-year-old who underwent a high LeFort I osteotomy followed by placement of the Rigid External Distraction halo. Distraction was commenced on the fifth postoperative day at a rate of 1 to 1.5 mm per day until a total of 17 mm of maxillary advancement had been achieved. There were no complications and follow up was at 9 months post distraction. Results show that the patient had improved facial aesthetics and dental occlusion which was overcorrected to a Class III relationship. Velopharyngeal function was unaffected. Distraction osteogenesis of the midfacial skeleton in cleft patients offers the possibility to remodel not only the underlying bony skeleton but also all the soft tissues of the face and palate.

The use of nasal splints in the primary management of unilateral cleft nasal deformity

Primary surgical correction of the cleft lip nasal deformity is routinely performed at the Craniofacial Center at Chang Gung Memorial Hospital. Over time, however, there is a tendency for the lower lateral cartilage to retain its memory and, subsequently, recreate the preoperative nasal deformity. Therefore, it is current practice to use a nostril retainer for a period of at least 6 months to maintain the corrected position of the nose. The aim of this study was to qualitatively assess the benefit of postoperative nasal splinting in the primary management of unilateral cleft nasal deformity. Data from two groups of 30 patients with complete unilateral cleft lips each were retrospectively collected and analyzed. The first group served as a control (no nasal splints), and the second group used the nasal retainer compliantly for at least 6 months postoperatively. All patients had their primary lip repair at 3 months of age. A photographic evaluation of the results when the patients were between 5 and 8 years of age was conducted. The parameters used to assess the nasal outcome were nostril symmetry, alar cartilage slump, alar base level, and columella tilt. The first scores were based on residual nasal deformity, and the second set were based on overall appearance. It was found that the mean scores of residual nasal deformity for all four parameters in patients who used the nasal stent were statistically better than the scores of patients who did not (p values ranged from 0.0001 to 0.005). The overall appearance scores for the four parameters in the patients who used the nasal stent after surgery were also statistically better than the scores for those who did not (p values ranged from 0.0001 to 0.01). The results show that postoperative nasal splinting in the primary management of the unilateral cleft nasal deformity serves to preserve and maintain the corrected position of the nose after primary lip and nasal correction, resulting in a significantly improved aesthetic result. Therefore, it is recommended that all patients undergoing primary correction of complete unilateral cleft deformity use the nasal retainer postoperatively for a period of at least 6 months.

Branchio-oculo-facial syndrome: case report

Branchio-oculo-facial (BOF) syndrome is a rare dominant autosomal disorder. Less than 50 cases have been reported up to now. We present a Chinese boy with BOF syndrome who has characteristic features of bilateral postauricular cervical branchial cysts, bilateral complete cleft of primary palate, bilateral lacrimal duct obstruction and bilateral low set ears with posterior rotation. His intelligence and growth were normal at the age of 7 years. This is the first case reported in Taiwan. The overlap between BOR syndrome and BOF syndrome include external ear abnormalities with hearing loss, lacrimal duct obstruction, branchial cleft remnants, and renal or ureteral defects. The relationship between these two syndromes is still unclear. Contiguous gene deletion phenomenon, different mutations in the same gene, or distinct entities all have been proposed. The literature was reviewed and discussed, especially the reports about the gene EYA1 (eyes absent-like 1), which is responsible for branchio-oto-renal syndrome. If we can detect mutations of EYA1 gene in BOF patients, this could be the key for solving the above debate.

Augmentation of the nasal floor with Surgicel in primary lip repair: a prospective study showing no efficacy

The symmetry of the alar base and the nasal floor is very important in achieving a satisfactory result in primary lip and nasal reconstruction during cleft lip repair. The skeletal base of the nasal pyramid is usually hypoplastic even in incomplete clefts. A periosteal pocket filled with Surgicel can facilitate blood clot formation and can theoretically stimulate bone formation, thereby improving the asymmetry of the bone base. To test this hypothesis, a prospective study was performed in 64 primary lip repairs by comparing the effect of subperiosteal nasal floor augmentation with Surgicel. From February 1989 to June 1993, 64 patients with incomplete cleft lips (excluding occult cleft lip and complete clefts with Simonart's band) were operated by the same surgeon. The patients were divided randomly into two groups. One group had subperiosteal nasal floor augmentation with Surgicel and the other group did not. The lip repair was a rotation-advancement cheiloplasty with primary closed rhinoplasty of the tip and ala. In the first group, a subperiosteal pocket was created under the cleft alar base and the nasal floor. The pocket was filled with Surgicel up the point where the level of the alar base and the nasal floor was symmetrical with the noncleft side. The control group underwent a similar procedure, less the creation of the subperiosteal pocket and the use of Surgicel. All patients were followed for at least 3 years and their photographs were used to compare and analyze the results of their nasal correction. Critical attention was paid to the symmetry of their nasal floor and alar base. The results were evaluated by at least two plastic surgeons for consistency. The data indicate that the control group showed a higher number of subjects with asymmetry (10 of 32) compared with the study group (8 of 32). However, there was no statistical significance to the findings. Two patients in the study group who received Surgicel developed hypertrophic lip scars. This study, although unable to determine statistically the contributory affect of Surgicel in primary nasal reconstruction, does show a possible benefit from the use of osteogenic materials in the primary management of the deficient nasal floor. Hypertrophic scars developed by 2 patients in the study group may point to a possible soft-tissue reaction to the use of Surgicel in primary lip and nasal repair.

Transzygomatic coronoidectomy through an extended coronal incision for treatment of trismus due to an osteochondroma of the coronoid process of the mandible

Osteochondroma is the most common benign tumor of the skeletal system. In the craniofacial skeleton, however, osteochondroma is uncommon. Even more rare is osteochondroma of the coronoid process. A review of the literature reveals only 31 reported cases of osteochondroma of the coronoid process of the mandible. The preponderance of patients were young men (67.7%) and most presented with a facial deformity. As a benign tumor, the problems with surgical treatment have dealt with the inaccessibility of the lesion and hence the surgical approach of choice. The previous surgical approaches have either been intraoral, external, or a combination of both. We present a transzygomatic approach via a coronal incision that gives excellent access and a good cosmetic result, and protects the facial nerve from damage.

Primitive neuroectodermal tumor of the lingual nerve: a case report

This is a report of a primitive neuroectodermal tumor (PNET) arising from the lingual nerve of a 5-year-old girl. Twelve months after surgical excision and postoperative chemotherapy, the patient remained alive without any evidence of recurrence or metastasis. The occurrence of PNETs in the head and neck region in children is rare. This is the first case report in the literature of a PNET originating from a cranial nerve in a child. Because of its aggressive nature and poor prognosis, aggressive surgical and medical treatment regimens are needed. Surgeons should be mindful to include PNET in the differential diagnosis of head and neck tumors.

Treatment of frontal sinus osteoma using a craniofacial approach

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

Surgical correction of submucous cleft palate with Furlow palatoplasty

Many surgeons have favored using the pharyngeal flap as the primary treatment for the velopharyngeal insufficiency associated with submucous cleft palate. However, the increasing number of reports of sleep apnea and airway compromise as a result pharyngeal flap surgery support the need to eliminate any unnecessary pharyngeal flap surgery. From 1988 to 1993, 35 Chinese submucous cleft palate patients with velopharyngeal insufficiency received surgery. A Furlow palatoplasty was used in 30 patients (3 to 26 years old). The follow-up duration was 9 months to 5 1/2 years. These patients were selected after a thorough study for velopharyngeal insufficiency including intraoral examination, perceptual speech assessment, videonasopharyngoscopy, and/or multiview videofluoroscopy. The criteria for selection included age, intraoral finding of an obviously anterior inserted levator palatine muscle, size of velopharyngeal gap, pattern of velopharyngeal closure, degree of lateral pharyngeal wall movement, and response to biofeedback speech therapy. In general, younger patients with circular or sagittal pattern closure, a velopharyngeal gap less than 5 mm, or good response to biofeedback speech therapy were considered to be the best candidates for a Furlow palatoplasty. The 5 patients who did not fulfill these criteria and whose velopharyngeal function failed to improve on preoperative biofeedback therapy were treated by pharyngeal flap operation. Twenty-nine patients (96.7 percent) achieved competent velopharyngeal function after the Furlow palatoplasty. The procedure corrected the velopharyngeal insufficiency in 3 patients older than 20 years with a velopharyngeal gap of less than 2 mm. The only patient with an unsatisfactory result was a 26-year old woman who had very prominent action of the musculus uvulae before the surgery. The results show that a Furlow palatoplasty can satisfactorily correct velopharyngeal insufficiency in carefully selected submucous cleft palate patients and thus avoid the serious complications of pharyngeal flap surgery.

Unusual complications of the Le Fort I osteotomy

In this report we describe three very different and interesting complications of the Le Fort I osteotomy. The first case is of a unilateral third nerve palsy developing as a result of a carotid-cavernous fistula and false aneurysm of the internal carotid artery. The second complication to be reported is total unilateral blindness. The third case is one of total avulsion of a lateral segment of the palate in a patient with a complete bilateral cleft of the primary and secondary palates. All complications were the result of a Le Fort I osteotomy performed for correction of midface hypoplasia secondary to congenital cleft lip and palate. The literature is reviewed, and the pathomechanics of each injury are hypothesized.

Augmentation of the free border of the lip in cleft lip patients using temporoparietal fascia

Deficiency of the free border of the lip is frequently encountered in secondary cleft lip deformities. The free border of the lip consists of the orbicularis oris marginalis muscle and its overlying subcutaneous tissue, vermilion, and mucosa. The pathology may involve any or all of these components. When there is an absolute shortage of subcutaneous tissue or orbicularis oris marginalis muscle, extra tissue from another source must be used for augmentation. A temporoparietal fascial graft is a simple and reliable method to increase the fullness of the free border of the lip. The tissue is soft in consistency and displays minimal resorption. Most important, more complicated procedures such as an Abbé flap or tongue flap may be avoided. From July of 1988 until June of 1992, the temporoparietal fascial graft was used successfully to correct deficiencies of the free border of the lip in 20 patients with cleft lip deformities. There were two graft exposures that healed with conservative treatment. The procedure is a useful method of augmenting both lateral lip and central lip deficiencies in secondary and tertiary cleft lip deformities.

Correction of secondary velopharyngeal insufficiency in cleft palate patients with the Furlow palatoplasty

To avoid the serious complications of pharyngeal flap surgery, a Furlow palatoplasty was used to correct velopharyngeal insufficiency after primary palatoplasty in 18 Chinese cleft palate patients (3 to 23 years old) from 1988 to 1992. The follow-up duration was 1 to 4 years. These patients were selected after a complete study for velopharyngeal insufficiency, including intraoral examination, perceptual speech assessment, videonasopharyngoscopy, and/or multiview videofluoroscopy. The criteria for selection included age, pattern of velopharyngeal closure, size of the velopharyngeal gap, extent of lateral pharyngeal wall movement, existence of a Passavant's ridge, and abnormal levator veli palatini muscle insertion. Complete velopharyngeal closure was achieved for 16 patients after surgery. The majority of these patients (15) had a velopharyngeal gap less than 5 mm. The 2 patients who still had velopharyngeal insufficiency after the surgery had a velopharyngeal gap larger than 10 mm before the surgery. The most important factor seemed to be the size of the velopharyngeal gap. Pattern of velopharyngeal closure or age of the patient also might play an important role. The results showed that a Furlow palatoplasty can satisfactorily correct velopharyngeal insufficiency in carefully selected patients. Although the criteria for the selection of this operation need further study, present results are encouraging.

Successful replantation of an amputated nasal tip by microvascular anastomosis

Successful microsurgical replantation of a completely avulsed nasal tip is presented. The result is excellent. The technical challenge involved no sizable veins for drainage. This problem was solved by an artery-to-vein shunting. For facial avulsions, there is nothing superior to the original tissue, and replantation should always be attempted first.

Corynebacterial kidney disease of salmonids: growth and serological studies on the causative bacterium

Comparative growth studies of 10 isolates of the Corynebacterium of salmonid kidney disease were quantified on four media. Greatest cell yield was obtained from Mueller-Hinton medium with 0.1% L-cysteine hydrochloride. Serological tests, in which rabbit antisera used against typical bacteria strains showed all to be antigenically homologous, provided a reliable method of identification.

DNA base composition of Cytophaga marinoflava n. sp. determined by buoyant density measurements in cesium chloride

A marine bacterium, NCMB 397, host strain for bacteriophages NCMB 384 and 385, has been subjected to taxonoinic analysis. Overall base composition of the highly purified deoxyribonucleic acid was determined and found to be 37 moles % guanine + cytosine. The phenetic and nucleic acid data suggest significant relationship of this strain and members of the genus Cytophaga. A description of Cytophaga marinoflava n. sp. is presented.

Acid phosphatase activity of normal and tumor tissue of tobacco grown in vitro and in vivo

Tissue cultures of Nicotiana labacum consisting of green, albino and habituated (normal origin) and teratoma (tomorous origin) were grown under asceptic conditions for 6 to 8 weeks and their extracts were analyzed for phosphatase activity. Comparative enzyme analyses were also made on crude stem extracts of greenhouse-grown normal and tumor tissues of Nicotiana tabacum (var. Wisconsin) and a hybrid (N. glauca x N. langsdorffii).All the crude extracts showed acid phosphatase activity with a pH optimum at 5.8 to 6.0. The total protein content and enzyme acivity of teratoma tissue (tumor) was higher than that of green, albino or habituated tissue (normal). Similar increased levels were seen in tumor tissue grown in greenhouse in comparison with greenhouse-grown normal tissues. The crude extracts of each of the tissues did not exhibit any qualitative difference in specificity with the 5 different substrates tested; however, differences in the level of activity was observed.The effect of 4 different culture media was tested on the growth, protein content and acid phosphatase activity of habituated tobacco in tissue culture. Tissues growing in medium containing high salt concentrations showed higher activities than tissues grown in a basal control medium. From the results, it is suggested that although many factors like auxin and other growth factors can influence growth of habituated tobacco tissue, they need not necessarily affect this specific enzyme activity.

Properties of two marine bacteriophages

Chen, Peter K. (Georgetown University, Washington, D.C.), Ronald V. Citarella, Omar Salazar, and Rita R. Colwell. Properties of two marine bacteriophages. J. Bacteriol. 91:1136-1139. 1966.-Various properties have been determined for two bacteriophages, NCMB 384 and 385, and their host, NCMB 397, a Cytophaga sp., isolated from the marine environment. The purified bacteriophages have been subjected to serological analysis, results of which indicate a high degree of relatedness. Purified, highly polymerized deoxyribonucleic acid (DNA) prepared from the host strain showed an overall base composition of 37 moles% guanine + cytosine (buoyant density of 1.696 g/cc). The bacteriophage DNA, in the native configuration, from NCMB 384 and 385 banded at 1.691 g/cc in a CsCl gradient and the denatured bacteriophage DNA demonstrated a bimodal peak. Stability tests of the bacteriophages in various buffers and diluents suggest a requirement for inorganic cations, most likely Na(+) and Mg(++), for retention of viability.

Structure of a marine bacteriophage as revealed by the negative-staining technique

Valentine, Artrice F. (Georgetown University, Washington, D.C.), Peter K. Chen, Rita R. Colwell, and George B. Chapman. Structure of a marine bacteriophage as revealed by the negative-staining technique. J. Bacteriol. 91:819-822. 1966.-The morphology of a marine bacteriophage has been determined by negative-staining techniques and electron microscopy. The virus possesses a head, 600 A in diameter, and a tail which may be from 860 to 1,000 A in lenght. No tail sheath is seen. The appearance of the terminal tail structure is discussed.