A Pilot Study Evaluating Novel Urinary Biomarkers for Crohn's Disease

Introduction

Although collecting faeces and blood samples are considered non-invasive methods of monitoring Crohn's disease (CD), these methods are less preferred by some patients. This study utilized urine as an alternative to evaluate four disease biomarkers in young adults with active CD before and after exclusive enteral nutrition (EEN) therapy.

Methods

Urine samples collected at baseline (W0) and after 8 weeks (W8) of EEN therapy were assayed by ELISA for levels of intestinal fatty acid-binding protein (I-FABP), liver fatty acid-binding protein (L-FABP), claudin-3, and calprotectin. Levels of each biomarker were also compared with standard clinical parameters, including disease indexes, nutrient, and inflammatory markers.

Results

Of the paired urine samples from 14 patients, 10 were female and 12 were newly diagnosed with CD. Urinary I-FABP: Cr (standardized to urine Cr) levels were significantly reduced, while urinary L-FABP: Cr levels increased following EEN therapy. Urinary L-FABP: Cr correlated positively with serum insulin-like growth factor 1 (IGF-1) (r = 0.60, p = 0.02). Urinary CLND3: Cr and calprotectin: Cr levels were not significantly different after treatment.

Conclusion

I-FABP is a potential urinary biomarker of disease activity in adults with CD, while urinary L-FABP may be an indirect marker of nutritional status in adults with CD. CLND3 and calprotectin do not appear to have roles as urinary biomarkers in CD. These findings warrant further investigations using a larger sample size.

1190 Engaging Patients And Family Members To Understand What Matters Most Living With Obstructive Sleep Apnea

Introduction

As a common but modifiable chronic condition, obstructive sleep apnea (OSA) has been identified as the top secondary cause of many other diseases including cardiovascular diseases and type 2 diabetes. Diagnosing and managing OSA provides neurological, cardiovascular and metabolic benefits, however real-world studies indicate disconnections between evidence and outcomes. Using an engagement approach and qualitative design, this project aims to better understand care and research gaps in OSA in a community healthcare setting.

Methods: Methods

Patient and family representatives were identified and recruited through OSA support meetings hosted by MultiCare Sleep Medicine Centers, to form a board of 12, with three key patient advocates. Six meetings, each facilitated by one or two members of the board, were held to encourage focus group discussion and accommodate interactive conversations on the topic. Discussions were audio recorded and edited to exclude patients’ identifiable information, then transcribed. Manual open coding was completed by two coders for each transcription to develop a codebook, followed by auto-coding and inductive content analysis using Nvivo 11.

Results

All enrolled patients had diagnosed moderate-to-severe OSA and were prescribed with continuous positive airway pressure (CPAP) therapy. Two participants were African American and one was multiethnic. Patients’ age ranged from early 30s to 80s. Seven main themes were identified: OSA diagnostic issues; treatment experiences and options; comorbidities; patient community and support needs; long-term management challenges beyond “compliance”; knowledge of OSA, CPAP and care; and patient-driven research. The first few weeks after CPAP initiation appeared to be a critical time window that impacted patients’ adaptation and use.

Conclusion

Our study revealed barriers and facilitators in OSA diagnosis and treatment. Results showed highly prevalent chronic co-morbidities and the needs to care for patients in the comorbid scenario. It was highlighted that a paradigm of patient-centered care and research is lacking and warranted. Participants also called for better coordination between sleep medicine, primary care, other specialists, durable device suppliers and insurance. Key research efforts are expected to focus on the first 30-day post CPAP dispense to improve compliance.

Support

Patient Centered Outcomes Research Institute (PCORI) (Contract #: 7717241)

Relationships Between Pharmacovigilance, Molecular, Structural, and Pathway Data: Revealing Mechanisms for Immune-Mediated Drug-Induced Liver Injury

Immune-mediated drug-induced liver injury (IMDILI) can be devastating, irreversible, and fatal in the absence of successful transplantation surgery. We present a novel approach that combines the methods of pharmacoepidemiology with in silico molecular modeling to identify specific features in toxic ligands that are associated with clinical features of IMDILI. Specifically, from pharmacovigilance data multivariate logistic regression identified 18 drugs associated with IMDILI (P < 0.00015). Eleven of these drugs, along with their known and proposed metabolites, constituted a training set used to develop a four-point pharmacophore model (sensitivity 75%; specificity 85%). Subsequently, this information was combined with information from immune-pathway reviews and genetic-association studies and complemented with ligand-protein docking simulations to support a hypothesis implicating two putative targets within separate, possibly interacting, immune-system pathways: the major histocompatibility complex within the adaptive immune system and Toll-like receptors (TLRs), in particular TLR-7, which represent pattern recognition receptors of the innate immune system.

Childhood social inequalities influences neural processes in young adult caregiving

Childhood poverty is associated with harsh parenting with a risk of transmission to the next generation. This prospective study examined the relations between childhood poverty and non-parent adults' neural responses to infant cry sounds. While no main effects of poverty were revealed in contrasts of infant cry versus acoustically matched white noise, a gender by childhood poverty interaction emerged. In females, childhood poverty was associated with increased neural activations in the posterior insula, striatum, calcarine sulcus, hippocampus, and fusiform gyrus, while, in males, childhood poverty was associated with reduced levels of neural responses to infant cry in the same regions. Irrespective of gender, neural activation in these regions was associated with higher levels of annoyance with the cry sound and reduced desire to approach the crying infant. The findings suggest gender differences in neural and emotional responses to infant cry sounds among young adults growing up in poverty.

Approaching the biology of human parental attachment: brain imaging, oxytocin and coordinated assessments of mothers and fathers

Brain networks that govern parental response to infant signals have been studied with imaging techniques over the last 15 years. The complex interaction of thoughts and behaviors required for sensitive parenting enables the formation of each individual's first social bonds and critically shapes development. This review concentrates on magnetic resonance imaging experiments which directly examine the brain systems involved in parental responses to infant cues. First, we introduce themes in the literature on parental brain circuits studied to date. Next, we present a thorough chronological review of state-of-the-art fMRI studies that probe the parental brain with a range of baby audio and visual stimuli. We also highlight the putative role of oxytocin and effects of psychopathology, as well as the most recent work on the paternal brain. Taken together, a new model emerges in which we propose that cortico-limbic networks interact to support parental brain responses to infants. These include circuitry for arousal/salience/motivation/reward, reflexive/instrumental caring, emotion response/regulation and integrative/complex cognitive processing. Maternal sensitivity and the quality of caregiving behavior are likely determined by the responsiveness of these circuits during early parent-infant experiences. The function of these circuits is modifiable by current and early-life experiences, hormonal and other factors. Severe deviation from the range of normal function in these systems is particularly associated with (maternal) mental illnesses - commonly, depression and anxiety, but also schizophrenia and bipolar disorder. Finally, we discuss the limits and extent to which brain imaging may broaden our understanding of the parental brain given our current model. Developments in the understanding of the parental brain may have profound implications for long-term outcomes in families across risk, resilience and possible interventions. This article is part of a Special Issue entitled Oxytocin and Social Behav.

Neuroendocrinology of parental response to baby-cry

This overview attempts to synthesise current understandings of the neuroendocrine basis of parenting. The parent-infant bond is central to the human condition, contributes to risks for mood and anxiety disorders, and provides the potential for resiliency and protection against the development of psychopathology. Animal models of parenting provide compelling evidence that biological mechanisms may be studied in humans. This has led to brain imaging and endocrine system studies of human parents using baby stimuli and concerted psychological and behavioural measures. Certain brain circuits and related hormonal systems, including subcortical regions for motivation (striatum, amygdala, hypothalamus and hippocampus) and cortical regions for social cognition (anterior cingulate, insula, medial frontal and orbitofrontal cortices), appear to be involved. These brain circuits work with a range of endocrine systems to manage stress and motivate appropriate parental caring behaviour with a flexibility appropriate to the environment. Work in this field promises to link evolving models of parental brain performance with resilience, risk and treatment toward mother-infant mental health.

Prevalence and effectiveness of treatment of hypertension on cardiovascular morbidity and mortality in an elderly population aged 70 years and over

The prevalence of hypertension, effectiveness of blood pressure control and compliance, and the effectiveness of treatment on 18-month overall mortality and development of cardiovascular disease in an elderly Chinese population were studied. The study group examined were aged 70 years and over, and consisted of a random sample of subjects on the Old Age and Disability Allowance register. They were stratified by sex and 5-year age groups from 70-74 to 90+ years. Information obtained at baseline included medical history, use of drugs, and measurement of blood pressure. Subjects with a blood pressure > 160/90 were classified as hypertensive. The overall prevalence of hypertension was 48%, 19% being undiagnosed. Among subjects with a known history of hypertension and taking drugs, only approximately half had adequate control (BP < or = 160/90). One fifth of those with a known diagnosis of hypertension were not taking drugs. Subjects who developed stroke had a higher mean systolic and pulse pressure at baseline; no difference in mean pressures was observed for overall mortality or development of heart disease. No difference in mortality or development of cardiovascular disease was observed between the following groups: known history of hypertension and taking medication with controlled blood pressure, known history and taking medication and blood pressure poorly controlled or not taking drugs, and normal blood pressure with no history of hypertension.

Comfort evaluation of maternity support garments in a wear trial

This study aims to evaluate the wear comfort of eight commercially available maternity support garments. The thermophysiological, sensory/tactile and movement comfort were assessed in a wear trial using a 19-item questionnaire. Fourteen pregnant Chinese women aged 32.3 +/- 4.2 years were recruited from a local obstetric clinic. The results show that the tested garments generally provided greater sensory comfort than thermophysiological comfort. The thermophysiological comfort was mainly influenced by the fibre contents and breathability. Significant linear relationships were found between material appearance and hand feel (r = 0.86, p < 0.001), and between non-itchiness and no red mark (r = 0.78, p < 0.001). Movement comfort was influenced by the garment type and style features. Overall, the soft, good-fit, cotton/elastane maternity brief was perceived as the best product. The findings of comfort needs in pregnant women and the effects of various garment attributes would be helpful for the development of maternity support garment design criteria that are required to satisfy critical ergonomic needs. Low back pain during pregnancy is a common and significant health problem. A maternity support garment is regarded as a convenient and safe device to stabilise the lumbar spine so as to relieve pain. However, patient compliance is likely to be affected by discomfort and inconvenience. The results of this study provide guidance for the optimal design of maternity support clothing.

Fetal cells in maternal blood: state of the art for non-invasive prenatal diagnosis

In Singapore, 1 in 5 pregnancies occur in mothers > 35 years old and genetic diseases, such as thalassaemia, are common. Current methods for the diagnosis of aneuploidy and monogenic disorders require invasive testing by amniocentesis, chorion villus biopsy or fetal blood sampling. These tests carry a procedure-related risk of miscarriage that is unacceptable to many couples. Development of non-invasive methods for obtaining intact fetal cells would allow accurate prenatal diagnosis for aneuploidy and single gene disorders, without the attendant risks associated with invasive testing, and would increase the uptake of prenatal diagnosis by women at risk. Isolation of fetal erythroblasts from maternal blood should allow accurate non-invasive prenatal diagnosis of both aneuploidies and monogenic disorders. Expression of gamma-globin in maternal erythroblasts and the inability to locate fetal erythroblasts reliably in all pregnancies have prevented its clinical application. In the absence of a highly specific fetal cell marker, enrichment, identification and diagnosis--the 3 components of non-invasive prenatal diagnosis--have clearly defined objectives. Since fetal cells are rare in maternal blood, the sole purpose of enrichment is yield--to recover as many fetal cells as possible--even if purity is compromised at this stage. In contrast, the primary goal of identification is specificity; absolute certainty of fetal origin is required at this stage if the ultimate objective of diagnosis, accuracy, is to be achieved. This review summarises the current state of the art of non-invasive prenatal diagnosis using fetal erythroblasts enriched from maternal blood.

Economic analysis of four triple regimens for the treatment of Helicobacter pylori-related peptic ulcer disease in in-patient and out-patient settings in Hong Kong

BACKGROUND

One-week triple regimens have been shown to be effective for the treatment of Helicobacter pylori-related peptic ulcer disease.

AIM

To conduct an economic analysis of four triple regimens for the treatment of H. pylori-related peptic ulcer disease from the perspective of a public health organization in Hong Kong.

METHODS

Records of 200 patients with H. pylori-related peptic ulcer disease, who had previously participated in a randomized comparison of ranitidine bismuth citrate (RBC) with amoxicillin and clarithromycin (RAC), omeprazole with amoxicillin and clarithromycin (OAC), RBC with metronidazole and tetracycline (RMT), or, colloidal bismuth subcitrate with metronidazole and tetracycline (BMT) in either in-patient or out-patient setting were reviewed.

RESULTS

Fifty patients were excluded because of incomplete documentation or lack of peptic ulcer. In the out-patient group (n=72), the median direct costs of the RAC group (HK $ 5094) were lower those of the BMT (HK $ 5400), RMT (HK $ 5394), or OAC (HK $ 5440) groups, but the difference was significant only between the RAC and BMT groups (P < 0.05). In the in-patient group (n=78), the median direct costs of the RMT group (HK $ 8524) were significantly lower than those of the OAC (HK $ 13 871) and RAC (HK $ 12 092) groups (P < 0.05), but were similar to those of the BMT group (HK $ 8758).

CONCLUSIONS

RAC and RMT are the least costly regimens for out-patient and in-patient treatment, respectively, of H. pylori-related peptic ulcer disease in Hong Kong.

Distribution of intranodal vessels in differentiating benign from metastatic neck nodes

AIM

Recent studies report high accuracy of power Doppler sonography in the differentiation of benign from malignant cervical lymphadenopathy. This study was undertaken to identify which of the parameters used in Doppler sonography of cervical lymph nodes is accurate and readily applicable in routine clinical practice.

MATERIALS AND METHODS

We reviewed the power Doppler ultrasound examinations of 50 patients with cytologically proven metastatic nodes from nasopharyngeal carcinoma and 50 patients with proven reactive lymphadenopathy. All the examinations had been performed by an experienced sonologist, and intranodal vascular distribution and resistance were evaluated during real-time ultrasound. Twenty metastatic nodes and 40 reactive nodes were less than 10 mm in maximum transverse diameter. The vascular patterns of lymph nodes were classified into three categories: (1) hilar; (2) capsular; (3) hilar and capsular. The resistive index (RI) and pulsatility index (PI) were measured by spectral Doppler.

RESULTS

Although metastatic nodes (RI, 0.81 +/- 0.11; PI, 1.89 +/- 0.89) tended to have higher intranodal vascular resistance than reactive nodes (RI, 0.65 +/- 0.08; PI, 1.07 +/- 0.26), there was considerable overlap of the resistance parameters between benign and malignant nodes. Most of the metastatic nodes showed the presence of capsular vascularity (capsular, 16%; capsular and hilar, 78%), whereas the majority of the reactive nodes showed hilar vascularity (98%), and the difference was significant.

CONCLUSION

The distribution of intranodal vascularity appears to be more useful than RI or PI in differentiating benign from malignant cervical lymphadenopathy. It is also easier to evaluate the distribution and the results are therefore readily applicable in routine clinical practice.

Does anybody know how we should measure Doppler parameters in lymph nodes?

AIM

To show how currently described techniques confuse interpretation of Doppler indices in lymph node characterization.

MATERIALS AND METHODS

The Doppler indices [resistivity index (RI) and pulsatility index (PI)] were obtained in 35 malignant lymph nodes by colour duplex sonography. Each node was sampled at eight different sites. Data were analysed using our own method, and methods employed in six previous studies.

RESULTS

Restistivity index values varied between 0.69 and 0.88 and PI values ranged from 1.28 to 2.34. All but two methods produced different resistance indices (P < 0.05).

CONCLUSION

Conflicting results are obtained analysing the same data using different methods. Standardized techniques should be agreed and employed in future studies.

Differentiation of lymphadenopathy in different forms of carcinoma with Doppler sonography

AIM

The aim of the study was to show whether it may be possible to characterize malignant nodes of different aetiologies with Doppler imaging. Non-Hodgkin's lymphoma (NHL) and nasopharyneal carcinoma (NPC) were used as the models.

MATERIALS AND METHODS

A prospective study was undertaken using colour Doppler sonography in 60 enlarged peripheral lymph nodes of 34 patients with either lymphoma or NPC. The vascular distribution, peak systolic velocity (PSV), end diastolic velocity (EDV), resistivity index (RI) and the pulsatility index (PI) of the largest node on each side of the patient were investigated.

RESULTS

The vascular distribution was predominantly 'capsular and central' or 'capsular' in 57 nodes, consistent with previous descriptions, but there was no significant difference in the mean PSV (lymphoma: 20.0 cm/s; NPC: 21.86 cm/s;P > 0.05) and mean EDV (lymphoma: 5.95 cm/s; NPC: 5.07 cm/s;P > 0.05). However, significant differences were shown in the mean RI (lymphoma: 0.71; NPC: 0.81;P < 0.05) and mean PI (lymphoma: 1.43; NPC: 1.88;P < 0.05) of these two groups of lymph nodes.

CONCLUSIONS

There is significant difference in the Doppler waveform between malignant nodes affected by lymphoma or NPC, suggesting that further differentiation of malignant nodes may be possible.

Preferred technique for blood flow volume measurement in cerebrovascular disease

BACKGROUND AND PURPOSE

A noninvasive reliable technique that can reveal cerebral blood flow volume could be a valuable tool in screening programs for stroke prevention. In diagnostic ultrasonography, spectral Doppler imaging (SDI) is popular among sonologists and vascular technologists to estimate blood flow volume despite its documented inaccuracy and the availability of the more accurate technique of color velocity imaging (CVI). The aim of the present study was to demonstrate the discrepancy of blood flow volume estimation with CVI and SDI with use of an "internal" standard.

METHODS

The common, internal, and external carotid arteries of 50 healthy subjects (22 men, 28 women, age range 19 to 54 years) were examined with CVI and SDI. The total blood flow volume of the internal and external carotid arteries was then compared with the ipsilateral common carotid artery flow. An accurate technique would demonstrate no difference. The difference (expressed as a percent inconsistency) was therefore a measure of the accuracy of the method.

RESULTS

The mean+/-SD inconsistency was found to be 10.6+/-8.3% for CVI and 27.9+/-14.3% for SDI. The difference in inconsistency between CVI and SDI in measurement of carotid blood flow volume was statistically significant (P<0.01).

CONCLUSIONS

CVI is more accurate than SDI in the determination of blood flow volume in the carotid arteries. For noninvasive clinical estimation of cerebrovascular blood flow volume, CVI quantification should be the preferred technique.

Competitiveness and conflict behavior in simulation of a social dilemma

This experiment examined the competitive behavior in a seven-choice Prisoner's Dilemma game of 108 adult students (68 women, 40 men) classified as high, average, or low in competitiveness based on their scores on the Competitiveness Index. Participants were then presented one of three preprogrammed response conditions representing (1) Competitive, (2) De-escalating, or (3) Noncompetitive conflict behavior from a simulated opponent. Participants high in competitiveness engaged in more competitive behavior and reported higher satisfaction with the task than those low in competitiveness. As expected, the Competitive conditions elicited more competitive behavior than Noncompetitive conditions. The results suggest competitive individuals may be particularly susceptible to social cues that trigger competitive behavior.

Degree of ERK activation influences both positive and negative thymocyte selection

Considerable evidence suggests that the ERK pathway is required for positive but not negative thymocyte selection. Here, we report that ERK is highly activated in double-positive (DP) thymocytes expressing an MHC class I-restricted TCR (P14) in response to negatively selecting conditions, whereas ligands that trigger positive selection induced weaker ERK activation. Biochemical evidence also shows that death by neglect is associated with a further reduction in ERK activation. These findings are consistent with the affinity / avidity model of thymocyte selection. To further examine the role of ERK in negative selection we used the MEK-1 inhitibor, PD98059, a specific pharmacological inhibitor of the ERK pathway. Biochemical data demonstrated a reduction of ERK activity by PD98059 in the presence of the negatively selecting ligand. Analysis of P14 TCR-transgenic fetal thymic lobes cultured with PD98059 under negatively selecting conditions showed impaired clonal deletion of DP thymocytes and a concomitant increase in positive selection of functional mature, TCR(hi) transgenic T cells. This demonstrates that altering ERK activity switched negative to positive selection. Contrary to previous reports that show an exclusive role for ERK signaling in positive selection, our data demonstrate that negative selection is also sensitive to the degree of ERK activation.

Longitudinal colour doppler study of superficial lymph nodes in non-Hodgkin's lymphoma patients on chemotherapy

AIMS/METHODS

A longitudinal study of 22 malignant lymph nodes by colour Doppler (CD) and/or colour power (CP) ultrasonography was undertaken in 12 non-Hodgkin's lymphoma patients to delineate changes in vascularity, and correlate this response with clinical outcome.

RESULTS

Reduced vascularity in response to chemotherapy was shown to be a positive prognostic sign.

CONCLUSIONS

More persistent nodal vascularity may signify a less favourable prognosis.

Comparison of laparoscopic sonography with surgical pathology in the evaluation of pelvic lymph nodes in women with cervical cancer

OBJECTIVE

This study compared laparoscopic sonography with surgical pathology in the evaluation of pelvic lymph nodes in women with cervical cancer.

SUBJECTS AND METHODS

Intraoperative laparoscopic sonography of pelvic lymph nodes was performed in 31 women with biopsy-proven cervical cancer. A lymph node that was rounded (longitudinal-transverse axis ratio of <2) or showed absence of central hilum was defined as positive for metastasis. For comparison, lymph nodes from each hemipelvis were grouped anatomically into paraaortic, common, internal, and external iliac chains during evaluation on laparoscopic sonography and on surgical pathologic examination.

RESULTS

Pelvic dissection in 31 women yielded 630 lymph nodes. There were 54 metastatic nodes in 12 women. Laparoscopic sonography revealed 32 (59%) of all pathologically metastatic lymph nodes. Sensitivity on laparoscopic sonography when comparing groups by hemipelves was 93.3% and by anatomic lymph node chains was 76.2%. Metastatic nodes were most commonly located in the common iliac region and were characteristically rounded, hypoechoic, showed absence of central hilum, and occasionally showed central necrosis. Nine (28%) of 32 metastatic lymph nodes revealed by laparoscopic sonography measured 1 cm or less. Six benign nodes in four patients were also visualized with laparoscopic sonography.

CONCLUSION

Laparoscopic sonography achieved a sensitivity exceeding 90% in the detection of metastatic lymph nodes in the hemipelves of women with cervical cancer. Laparoscopic sonography is a feasible and promising technique for the evaluation of pelvic lymph nodes in women with cervical cancer and merits further evaluation.

Temporal lobe developmental malformations and hippocampal sclerosis: epilepsy surgical outcome

BACKGROUND

Temporal lobe developmental malformations coexist with mesial temporal sclerosis in the form of dual pathology with a high frequency of bilateral amygdala or hippocampal abnormalities.

OBJECTIVE

The aim of this study was to correlate and compare the MRI findings and the surgical outcome in patients with temporal lobe developmental malformations (n = 20) and isolated mesial temporal sclerosis (n = 36).

METHODS

MRI-based normalized volumetry of the amygdala and hippocampal formation in patients with unilateral temporal lobe developmental malformations and isolated mesial temporal sclerosis who underwent temporal lobe resections was performed. Seizure outcome was compared between groups at follow-up.

RESULTS

The frequency of bilateral hippocampal or amygdala atrophy (p < 0.04) and combined hippocampal-amygdala atrophy (p < 0.02) was higher in patients with temporal lobe developmental malformations. Although no significant difference in postsurgical seizure-free status was found between the temporal lobe developmental malformations and isolated mesial temporal sclerosis groups (70% versus 91%), patients with temporal lobe developmental malformations and bilateral amygdala or hippocampal-amygdala atrophy had a significantly worse outcome (p < 0.02).

CONCLUSION

Bilateral hippocampal atrophy is frequent in patients with temporal lobe developmental malformations. However, it is the presence of bilateral amygdala or amygdalo-hippocampal atrophy that is associated with a higher risk of seizure recurrence.

Metastatic adenopathy from nasopharyngeal carcinoma: successful response to radiation therapy assessed by color duplex sonography

BACKGROUND AND PURPOSE

Although the role of gray-scale sonography for neck nodes is well documented, it plays a limited role in the evaluation of nodal response to treatment. This preliminary limited study sought to determine color duplex sonographic changes in successfully treated metastatic nodes from nasopharyngeal carcinoma.

METHODS

Fourteen patients with nodal metastases from nasopharyngeal carcinoma were studied. A pretreatment sonogram was obtained for all patients. Patients were divided into two groups of seven: in one group, repeat sonograms were obtained 8 weeks after completion of treatment; in the second group, sonograms were obtained 16 weeks after treatment. The features studied included distribution of intranodal vascularity, resistive and pulsatility indexes, and peak systolic velocity. In 11 patients, follow-up sonograms were obtained 1 year after treatment.

RESULTS

The majority (90%) of malignant nodes from nasopharyngeal carcinoma have an increased central and peripheral vascularity, a high resistive index (0.8), and a high pulsatility index (1.8). After radiation therapy to the nodes, a reduction in intranodal vascularity and a statistically significant reduction in the resistive index (0.58 to 0.59) and pulsatility index (0.91 to 0.93) are found. Although a similar reduction in the peak systolic velocity is observed, it is not statistically significant.

CONCLUSION

Our preliminary findings suggest that after radiation therapy for malignant nodes in nasopharyngeal carcinoma, a reduction in intranodal vascularity is found, and the resistive and pulsatility indexes may return to benign parameters as early as 8 weeks after completion of treatment.

Amygdala atrophy and seizure outcome after temporal lobe epilepsy surgery

Surgical outcome in hippocampal atrophy (n = 44) and amygdalohippocampal atrophy (n = 14) were compared. Hippocampal atrophy had better seizure-free outcome than amygdalohippocampal atrophy (80% versus 50%, p = 0.043). Severity of hippocampal atrophy correlated with duration of epilepsy in patients with hippocampal atrophy (r = 0.4, p = 0.007), but not in those with amygdalohippocampal atrophy, suggesting that these two groups may have a different pathogenesis.

Temporal lobe developmental malformations and epilepsy: dual pathology and bilateral hippocampal abnormalities

Temporal lobe developmental malformations (TLDM) with focal cortical dysplasia and balloon cells may coexist with mesial temporal sclerosis. The true incidence of this dual pathology is unknown. Our aim was to assess the frequency of amygdala (AM)-hippocampal abnormality in a homogeneous population with this specific developmental malformation. MRI-based volumetry of the AM and hippocampal formation (HF) in 30 patients with unilateral TLDM and intractable partial epilepsy was performed. A volume normalization process defined a normal range of HF and AM volumes in control subjects, and enabled the detection of bilateral volume loss. Normalized volumes detected HF atrophy in 26 patients (nine unilateral and 17 bilateral) and AM atrophy in 18 patients (three unilateral and 15 bilateral). Visual analysis detected unilateral HF abnormality in 21 patients and bilateral abnormality in two. When compared with a group of patients with temporal lobe epilepsy and pure hippocampal sclerosis (N = 92), where volumetry revealed bilateral HF atrophy in 18%, a significant difference in the frequency of bilateral HF atrophy was found (p < 0.0001). Dual pathology is frequent in patients with TLDM (87%), and the AM-HF abnormality is often bilateral (57%). Our data suggest that more widespread and potentially epileptogenic lesions coexist with visibly detectable unilateral TLDM. This has implications for the selection of patients for temporal lobe surgery and may influence surgical strategies.

Normal fetal thyroid volume

A prospective study of 289 normal fetal thyroids was undertaken between 20 and 36 weeks of gestation in 289 mothers without any history of thyroid disease or maternal disease that could cause intrauterine growth restriction. The fetal thyroid volume was calculated by the ellipsoid equation, with the assumption that each lobe was an ellipse. A nomogram relating fetal thyroid volume to gestational age was established. The mean fetal thyroid volume was found to be 0.23 +/- 0.18 cm3 (median 0.17 cm3; range 0.022-0.85 cm3). The ratio of fetal thyroid volume to estimated fetal weight (V/W ratio) (at 0.163 +/- 0.079 cm3/kg) was constant throughout gestation. The value was smaller than those of the child and the adult reported in other studies, indicating that fetal thyroid enlargement is likely to be underestimated if based on postnatal criteria. It was found that the mean fetal thyroid volume was significantly correlated with estimated fetal weight and gestational age, in which the former dominated the effect. The fetal thyroid increased in size much faster after 32 weeks, suggesting that evaluation of possible fetal goiter should take into account gestational age and the nomogram developed in this study.

Pleural fluid pseudouridine in malignant and benign pleural effusions

Pseudouridine in urine and plasma has been proved to be a useful tumour marker in many malignant conditions. We studied its usefulness in pleural fluid for distinguishing malignant from non-malignant pleural effusions. Pleural fluid pseudouridine concentrations in different groups of patients with pleural effusion (31 malignant, 29 benign, 16 unknown, 1 double pathology) was measured and compared. Its usefulness in distinguishing malignant from non-malignant pleural effusions was analysed by receiver-operating characteristic (ROC) curve analysis. Pseudouridine concentrations in the malignant group were significantly higher than the non-malignant group (P < 0.017, Bonferroni adjustment) with values overlapping extensively at the lower end. The area-under-the curve (AUC) value in the ROC curve analysis was 0.675 (P < 0.05). We conclude that the pleural fluid pseudouridine is of limited clinical value in distinguishing malignant from non-malignant pleural effusion due to its extensive overlap. However, it is useful when the concentration is higher than 65 mumol/L, which indicates malignancy.

Intraoperative laparoscopic sonography for improved preoperative sonographic pathologic characterization of adnexal masses

This study compares the diagnostic accuracy of laparoscopic sonography and transvaginal sonography in the evaluation of adnexal masses. Fifty-eight women underwent transvaginal sonography, which showed 69 adnexal masses, and laparoscopic ultrasonography, which showed 68 adnexal lesions. Conventional gray-scale ultrasonography (using transvaginal sonography and laparoscopic ultrasonography) was performed with morphologic characterization of internal architecture, followed by color Doppler imaging with spectral Doppler analysis where possible. A specific diagnosis was obtained with transvaginal sonography and laparoscopic ultrasonography based on a combination of imaging features. The specific diagnosis obtained with each imaging modality was compared with the final histologic diagnosis as the gold standard in 57 patients with 68 adnexal masses who underwent cystectomy or oophorectomy. The ability of laparoscopic sonography to detect the contralateral ovary and any residual ovarian tissue in the presence of a mass was also compared with transvaginal sonography. The accuracy of laparoscopic ultrasonography in the characterization of adnexal masses was 83.8% and that of transvaginal sonography was 73.5% (P < 0.05). Laparoscopic sonography showed greater morphologic detail than that obtained with transvaginal sonography, allowed more precise and specific characterization of adnexal masses, and detected additional adnexal lesions not evident on preoperative transvaginal sonography. Laparoscopic ultrasonography showed the contralateral ovary in 86.2% of patients, compared with 81.0% using transvaginal sonography (P = 0.51). In addition, laparoscopic ultrasonography was able to demonstrate the presence of residual ovarian tissue in the side affected pathologically in 76.5% of patients compared with 59.4% using transvaginal sonography (P < 0.005). Laparoscopic sonography allows more precise morphologic characterization of internal architecture and histologic diagnosis of adnexal lesions, but it is as yet unable to increase the diagnostic accuracy of borderline or malignant lesions, possibly due to the small sample size. Laparoscopic sonography is superior to transvaginal sonography in the evaluation of residual ovarian tissue in the side affected pathologically, which may help in surgical planning between cystectomy and oophorectomy, and also in the identification of the contralateral ovary, which may potentially increase the detection of bilateral pathologic conditions.

Congenital porencephaly: MR features and relationship to hippocampal sclerosis

PURPOSE

We determined the frequency of amygdalar-hippocampal atrophy in patients with congenital porencephaly-related seizure disorders to ascertain whether specific MR features of the porencephaly correlate with amygdalar-hippocampal atrophy and epilepsy.

METHODS

We studied brain MR images of 22 patients with congenital porencephaly and measured the volume of the amygdala, the hippocampal formation, and the porencephalic cyst. We then compared imaging features with seizure symptoms.

RESULTS

Porencephaly was unilateral in 20 patients and bilateral in two. Eighteen patients had cortical or subcortical cavitation and four had encephaloclastic changes (noncircumscribed parenchymal destruction associated with cystic components). The porencephaly was located in the middle cerebral artery territory in 12 patients, in the posterior cerebral artery in four, in the internal carotid artery in two, and in multiple vessels in four. The volume of the porencephalic cyst ranged from 1% to 32% of total intracranial volume (mean, 11%). Volumetry detected atrophy of the hippocampal formation in 21 cases (11 unilateral, 10 bilateral) and atrophy of the amygdala in 12 (nine unilateral, three bilateral). No correlation was found between size or location of the porencephaly and degree of hippocampal atrophy. Seizure symptoms correlated with mesial temporal origin but not with cyst location.

CONCLUSION

Amygdalar-hippocampal atrophy often coexists with congenital porencephaly (95%), and the atrophy may be bilateral despite unilateral cysts. Hippocampal structures should be carefully assessed in patients with porencephaly-related seizures.

Congenital porencephaly and hippocampal sclerosis. Clinical features and epileptic spectrum

We studied clinical features and seizure localization in 14 patients with porencephaly and intractable seizures. Perinatal complications were present in nine patients, childhood febrile convulsions in two, congenital hemiparesis in 12, and intellectual impairment in seven. Ten patients had psychoparetic complex partial seizures (CPS), three had sensorimotor simple partial seizures, and one had generalized tonic-clonic seizures. Surface EEG showed temporal onset in nine patients (one bitemporal) and extratemporal onset in four. MRI showed porencephaly in the distribution of the middle cerebral artery in eight patients, posterior cerebral in three, internal carotid in one, and multiple vessels in two. MR-based volumetry revealed hippocampal formation atrophy in 13 patients (eight unilateral and five bilateral) and amygdalar atrophy in 10 patients (nine unilateral and one bilateral). Hippocampal formation atrophy was concordant with CPS semiology in 10 patients (71%) and with EEG temporal localization in nine patients. Two patients had pathologic confirmation of mesial temporal sclerosis and were seizure free after temporal lobectomy. We conclude that mesial temporal sclerosis often coexists with porencephaly and is the likely seizure focus in the presence of concordant electroclinical data. This recognition implies that effective surgical intervention can be offered to certain patients with porencephaly-related seizure disorders. The dual pathology and association with perinatal cerebral vascular occlusion suggest a common ischemic pathogenesis.

Perfusion patterns during temporal lobe seizures: relationship to surgical outcome

We sought to determine whether patterns of ictal hyperfusion demonstrated using [99mTC]HMPAO (hexamethylpropylene amine oxime) single photon emission computed tomography (SPECT) predict outcome of temporal lobectomy; in particular, whether the more extensive patterns of ictal hyperperfusion are associated with poor outcome. We studied 63 patients who had ictal SPECT studies prior to temporal lobectomy. Hyperperfusion on ictal SPECT scans was lateralized, and classified into: (i) 'typical', (ii) 'typical with posterior extension', (iii) 'bilateral' and (iv) 'atypical' patterns. Outcome (minimum of 2 years follow-up) was classified as either seizure free, or not seizure free. Actuarial analysis was used to test the relationship of SPECT patterns with outcome. There were 35 cases with the typical ictal SPECT pattern, 13 posterior, nine bilateral and six atypical cases. The atypical pattern was associated with lack of pathology in the surgical specimen. Outcome was similar for the typical, posterior and bilateral with 60%, 69% and 67% seizure free, respectively. In contrast, the atypical group had a worse outcome with only 33% seizure free. Actuarial analysis showed a significant difference in outcome between patients with the typical pattern, and patients with the atypical pattern (P = 0.04). We conclude that extended patterns of ictal perfusion in temporal lobe epilepsy do not predict poor outcome, indicating that extended hyperperfusion probably represents seizure propagation pathways rather than intrinsically epileptogenic tissue. Atypical patterns of hyperperfusion are associated with poor outcome and may indicate diffuse or extra-temporal epileptogenicity.

Algorithm on the clinical evaluation of epilepsy

Epilepsy is an important public health problem because of its prevalence in the community and the economic disadvantage associated with its chronic morbidity. Uncontrolled seizures are potentially life-threatening and have adverse psychosocial consequences. Surgery is an effective but underutilized therapy for some patients with medically refractory seizures. However, this form of treatment demands precise localization of the epileptogenic zone. In recent years there have been major advances in the development of various imaging techniques for seizure localization. The best combination of diagnostic testing with regard to cost-benefit has been debated. A rational strategy for the deployment of these techniques is discussed.

Disappearing suprarenal masses in fetuses and infants

This paper presents 12 infants (9 boys, 3 girls) in whom the diagnosis of a suprarenal mass (10 left, 2 bilateral) was made on antenatal sonography. All were otherwise healthy neonates who were born at term after a normal pregnancy, labor and delivery. The masses ranged from 1 to 3.5 cm in diameter on initial scans at gestational ages of 19-35 weeks. Eleven masses were hyperechoic and 4 of these contained small, well-defined cysts. The 12th was hypoechoic. Follow-up sonography showed complete disappearance of the mass antenatally in 1 case and postnatally by 4-6 months in 5 cases; there was marked diminution in the size of the mass by 2 months of age in 4 infants, by 4 months in 1 case and by 15 months in 1 case. Eleven were managed nonoperatively. Laparotomy (after disappearance of the mass) in the 12th case revealed only some fibrous tissue. The 11 echogenic masses resemble previously reported imaging findings in infants with histologically proven intra-abdominal sequestrated lung. Conservative management with careful sonographic follow-up should, therefore, be considered in otherwise healthy fetuses or neonates with these imaging findings. We are less certain what the hypoechoic mass represented.

Mathematical evaluation of the influence of adverse effect on therapeutic efficacy in a direct response system: a case of pharmacodynamic variability of adverse effect

Two major concerns in therapeutics are the efficacy (E) and adverse effects (Ae) exhibited by a pharmacological agent. Although these elements are studied routinely in both animals and humans during the drug development processes, the data are usually considered independently and in different contexts. Since E and Ae are different yet inseparable components in drug therapy, E should not be used as the sole descriptor for drug responses. To accommodate the influence of Ae on E, the present approach requires the observed Ae data to be transformed to the equivalencies of E data (Ae'). Using appropriate pharmacokinetic modeling techniques, this approach permits the prediction of the adjusted therapeutic effect (ATE) (i.e. , E minus Ae') as a function of time. Effects of pharmacodynamic variability of Ae due to variations in Hill's parameters (i.e., Ae (max), AeC (50), and n (Ae) ) on ATE were studied by computer simulations for a hypothetical one-compartment model drug that displays simple first-order absorption and elimination with central sites for E and Ae. An increase in Ae' (max) and a decrease in AeC (50) and n (Ae) cause a downward shift and peak inversion on the ATE versus time curves coupling with a longer duration of influence of Ae on E. Results also showed that the downward shift of these curves was more apparent with decreasing n (Ae) values and that peak inversion became less noticeable for n (Ae) values <1.5. Subsequent analyses established the optimal dose for the hypothetical drug studied. This approach allows a more comprehensive description of the time course of the overall drug responses and is potentially useful for therapeutic drug monitoring and dose selection during the drug development process.

Temporal lobe epilepsy subtypes: differential patterns of cerebral perfusion on ictal SPECT

PURPOSE

We studied cerebral perfusion patterns in the various subtypes of TLE, as determined by pathology and good outcome after temporal lobectomy (as confirmation of temporal origin).

METHODS

We studied clinical features and ictal technetium 99m hexamethyl-propyleneamineoxime (99mTc-HM-PAO) single-photon emission-computed tomography (SPECT) in four subgroups of patients with intractable temporal lobe epilepsy (TLE) treated with surgery: hippocampal sclerosis (group 1, n = 10), foreign-tissue lesion in mesial temporal lobe (group 2, n = 8), foreign-tissue lesion in lateral temporal lobe (group 3, n = 7), and normal temporal lobe tissue with good surgical outcome (group 4, n = 5).

RESULTS

No major clinical differences in auras, complex partial seizures or postictal states were identified among the groups. Ictal SPECT showed distinct patterns of cerebral perfusion in these subtypes of TLE. In groups 1 and 2, hyperperfusion was seen in the ipsilateral mesial and lateral temporal regions. In group 3, hyperperfusion was seen bilaterally in the temporal lobes with predominant changes in the region of the lesion. Hyperperfusion was restricted to the ipsilateral anteromesial temporal region in group 4. Ipsilateral temporal hyperperfusion in mesial onset seizures can be explained by known anatomic projections between mesial structures and ipsilateral temporal neocortex. Bilateral temporal hyperperfusion in lateral onset seizures can be explained by the presence of anterior commissural connections between lateral temporal neocortex and the contralateral amygdala.

CONCLUSIONS

We conclude that the perfusion patterns seen on ictal SPECT are helpful for subclassification of temporal lobe seizures, whereas clinical features are relatively unhelpful. These perfusion patterns provide an insight into preferential pathways of seizure propagation in the subtypes of TLE.

Comparison of oral ciprofloxacin and amoxycillin in treating infective exacerbations of bronchiectasis in Hong Kong

A randomised double-blind controlled clinical trial was conducted to compare oral ciprofloxacin (500 mg b.d.) and amoxycillin (1 g t.d.s.) in the treatment of infective exacerbations of bronchiectasis. The commonest organism isolated from sputum was Pseudomonas aeruginosa, which accounted for 34% of all positive sputum cultures. Other Pseudomonas species and Haemophilus influenzae, accounted for 19%, respectively. Ciprofloxacin produced better clinical response, a higher sputum to serum antibiotic level (mean of 0.65 in the ciprofloxacin group vs. 0.18 in amoxycillin group, p = 0.0001), broader spectrum of antibacterial activity and less side-effect. It was also better tolerated by patients. The findings suggest that ciprofloxacin is an effective treatment of infective exacerbations of bronchiectasis.

Gene expression of interleukin-3 and granulocyte macrophage colony-stimulating factor in circulating CD4+ T cells in acute severe asthma

BACKGROUND

Interleukin (IL)-3 and granulocyte macrophage colony-stimulating factor (GM-CSF) may influence the inflammatory process in asthma through their regulatory role on eosinophil survival, differentiation and effector function.

OBJECTIVE

To examine the relationships between IL-3 and GM-CSF messenger (m) ribonucleic acid (RNA) expression in peripheral blood CD4+ cells and serum levels of eosinophil cationic protein (ECP), a marker of eosinophil activation, and disease activity in asthma.

METHODS

Venous blood was drawn from patients with acute severe asthma prior to the commencement of systemic steroid therapy (day 1) and 7 days afterwards (day 7), patients with stable disease and normal healthy volunteers. The capacity for expression of IL-3 and GM-CSF in ex vivo stimulated circulating CD4+ cells was assessed semi-quantitatively by reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

We found that the capacity for expression of IL-3 and GM-CSF was significantly higher in acute asthmatics prior to steroid treatment (n = 24) than those in stable disease (n = 38) and healthy subjects (n = 32, P < 0.001 for IL-3 and < 0.05 for GM-CSF), but no difference was observed between the latter two groups. Further assessment made in 15 of the 24 acute asthmatics 7 days after systemic steroid treatment revealed a significant reduction in GM-CSF expression (P < 0.05) but not for IL-3. At the same time, PEF also improved significantly from 30.4 +/- 3.5% of predicted value to 72.9 +/- 7.2% (P < 0.0001) and serum ECP concentration also fell from 19.9 +/- 5.9 micrograms/L to 4.3 +/- 2.0 micrograms/L (n = 10, P < 0.01).

CONCLUSION

Our data suggest both IL-3 and GM-CSF may be important in the pathogenesis of acute severe asthma.

Respiratory symptoms in elderly Chinese living in Hong Kong

Respiratory diseases can cause considerable disability in the elderly because of their limited respiratory reserve as a result of ageing. We have investigated the prevalence of respiratory symptoms and diseases in elderly Chinese in Hong Kong and compared these data with those in elderly Caucasian populations. Two thousand and thirty two (999 male and 1,033 female) subjects, selected by age-stratified random sampling from a register of Hong Kong residents aged 70 yrs and over were interviewed to complete a respiratory questionnaire. Total serum immunoglobulin E (IgE) was measured in 195 subjects. At least one respiratory symptom was reported by 56% of subjects. The most frequently reported symptoms were morning phlegm (26%), chronic cough with phlegm (10%) and wheeze in the past 12 months (8%). Of the self-reported diseases, the commonest was chronic bronchitis (7%), followed by asthma (5%), pulmonary tuberculosis (3%) and emphysema (2%). Of the 218 subjects with obstructive airway diseases, 128 (59%) had sought medical advice in the past 12 months. The most important determinants for respiratory symptoms and diseases were smoking and social class. Total serum IgE was significantly higher in current smokers than nonsmokers and also in those with chronic cough and phlegm than those without these complaints. Our study shows that respiratory ailments in Hong Kong elderly are as common as those reported in Sweden and the USA but less than those in England.

Inhaled salmeterol and albuterol in asthmatic patients receiving high-dose inhaled corticosteroids

Salmeterol may be useful in the treatment of asthmatic patients requiring high-dose inhaled steroids, and there have been debates about its anti-inflammatory action. We have compared the efficacy and effects on serum inflammatory markers, including soluble interleukin 2R (sIL-2R), eosinophil cationic protein (ECP), and tryptase of salmeterol and albuterol in 20 patients with moderate to severe asthma who were all receiving high-dose inhaled corticosteroids and inhaled beta 2-agonist on demand. After a 2-week run-in period, they received, in a randomized, crossover, double-blind and placebo-controlled manner, either salmeterol, 50 micrograms twice a day, or albuterol 400 micrograms, four times a day, from a powder inhaler during two 2-week treatment periods, separated by a 2-week washout. Compared with albuterol, salmeterol treatment was associated with better morning and mean peak expiratory flow (p = 0.013 and 0.016, respectively), less daytime and nocturnal symptoms (p = 0.008 and 0.01, respectively), reduced requirement of rescue albuterol (p = 0.04), and better efficacy rating by patients (p = 0.04). However, serum concentration of sIL-2R was significantly higher during regular albuterol treatment (p = 0.014) but no differences were seen in the concentrations of ECP and tryptase between the two treatment periods. We conclude that inhaled salmeterol, 50 micrograms twice daily, confers a better control of asthma than albuterol, 400 micrograms four times daily, in patients with moderate to severe disease, and the latter treatment may be associated with increased T-lymphocyte activation.

Comparison of ictal SPECT and interictal PET in the presurgical evaluation of temporal lobe epilepsy

We retrospectively compared ictal technetium 99m hexamethylpropyleneamineoxime single-photon emission computed tomography (SPECT) and interictal 18F-fluorodeoxyglucose positron emission tomography (PET) in 35 patients with well-lateralized temporal lobe epilepsy (TLE). Based on SPECT scans the two observers correctly lateralized seizure foci with certainty in 89% of patients; interobserver agreement was excellent. Both observers incorrectly lateralized the seizure focus on two SPECT scans; one error was explained by rapid electroencephalographic spread to the contralateral side and for the other patient, isotope was injected during a brief aura. Based on PET scans, observers correctly lateralized the foci with certainty in 63% and with lesser confidence in 83%; four incorrect lateralizations were made by one observer and none by the other. PET interobserver disagreement was explained by differences between observers in weighting the relative hypometabolism in medial and lateral temporal regions. The detection rate for PET was lower in the absence of structural imaging abnormalities (60 vs 87%). PET yielded correct lateralizations in the 2 patients for whom SPECT interpretation was difficult. We conclude that both ictal SPECT and interictal PET are sensitive methods for the lateralization of TLE, but SPECT can be interpreted with greater certainty and is more sensitive when magnetic resonance imaging findings are negative. False lateralization is rare with ictal SPECT and can be explained when interpreted in conjunction with electroclinical data. Both investigations have complementary roles when localization is difficult.

The Use of Corticosteroid/Beta-Blocker Combinations in the Management of Regression After PRK for High Myopia

After nearly 8 years of clinical experience, and with conflicting evidence from trials with and without corticosteroids, there is still no single, universally agreed postoperative management regimen for photorefractive keratectomy (PRK). All agree that corticosteroids will reverse sudden regressions, and so most still use varying corticosteroid regimens. In Hong Kong we are faced with many patients whose myopia is greater than -6 diopters (D), and we agree with the general observation that the regression/haze rate is much greater for these higher errors, and that increased intraocular pressure (IOP) seems to be associated with increased haze. We placed our high myopia group (greater than -6.00D) on corticosteroid/beta-blocker combinations and observed a much lower incidence of haze and regression from this group. We use this regimen now on all our patients and are achieving more accurate endpoint refraction and less haze. Our hypothesis is that lowering the IOP to less than 16 mm Hg reduces keratocyte migration by "tightening" the corneal lamellae, thus dampening the healing response. Case studies are presented to illustrate this relationship.

Comparison of various icing times in decreasing bone metabolism and blood flow in the knee

In a previous study we used technetium-99m bone scans to show that cooling a knee for 20 minutes with a standard ice wrap will decrease soft tissue blood flow by a mean of 26%, and skeletal blood flow and metabolism by 19%. The present study examined the effects of shorter and longer icing periods to determine minimum cooling time for a measurable and consistent decrease, and time to produce maximal decrease within a safe period of icing (< 30 minutes). Thirty-eight subjects were studied. An ice wrap was applied to one knee for an assigned time (5, 10, 15, 20, or 25 minutes). Triple-phase bone scans of knees were obtained; mean percentages of decrease in the iced knee for each of the five time groups at each of the three phases of the bone scan were calculated and compared. Mean decreases of 11.1% in soft tissue blood flow, and 5.1% in skeletal metabolism and blood flow were measured at 5 minutes; maximums of 29.5% and 20.9%, respectively, were obtained at 25 minutes. A small but consistent decrease in soft tissue blood flow and skeletal blood flow and metabolism in a knee appear to be obtained with as little as 5 minutes of ice application. This effect is time-dependent and can be enhanced three- to four-fold by increasing the ice application time to 25 minutes.

Parietal lobe epilepsy: clinical features and seizure localization by ictal SPECT

We studied clinical and ictal single-photon emission computed tomography (SPECT) features in 14 patients with parietal lobe epilepsy, nine of whom had structural parietal lobe lesions. Thirteen patients had simple partial seizures of somatosensory (eight), psychic (four), and motor (nine) types. Complex partial seizures (CPS) occurred in seven patients; six were psychoparetic (prominent staring, relative immobility) and one had hyperkinetic activity. Seizures lasted 7 to 110 seconds; 99mTc-HMPAO (hexamethylpropylene amine oxime) was injected ictally, 7 to 89 seconds from seizure onset and 0 to 74 seconds (mean, 21.0 +/- 24.4 seconds) before seizure termination. Ictal SPECT demonstrated focal areas of parietal hyperperfusion in all 14 cases and corresponded with sites of the structural lesions. Parietal hyperperfusion was anterior in eight, posterior in four, and diffuse in two. Quantitative analysis revealed increases in parietal side-to-side perfusion ratios on ictal compared with interictal scans of 11 to 51% (mean, 25.5 +/- 14.4%). Ictal SPECT localization correlated with two main clinical seizure patterns: an anterior syndrome characterized by sensorimotor manifestations and a posterior syndrome characterized by CPS of the psychoparetic type. Ictal SPECT is helpful for localization of parietal seizures. Parietal hyperperfusion is discrete and short-lived, demanding true ictal injections for diagnostic studies.

Differential expression of activation markers during tolerance induction by superantigens in T-cell receptor (beta-chain) transgenic mice

To investigate the process of tolerance induction we have developed an in vivo model using TCR beta-chain transgenic mice tolerized with the superantigen staphylococcal enterotoxin B. We have previously demonstrated that tolerized peripheral T cells were anergic when stimulated in vitro with immunogenic peptides, superantigens, mitogens, and immobilized anti-TCR mAb. However, the development of anergy is preceded by an induction phase which produces expansion followed by contraction of the peripheral T cell population presumably due to proliferation and programmed cell death, respectively. The current experiments focus on the induction phase of tolerance. A kinetic functional analysis showed that the inhibition of proliferation was apparent 2-3 days post-tolerization. Interestingly, the inhibition of proliferation correlated with the loss of IL-2R alpha expression, which occurred 2 days post-tolerization following an initial increase in IL-2R alpha expression. In addition, the expression of multiple activation markers including CD44, Ly-6A/E, and very early activation marker H1.2F3 is induced, whereas the expression of CD45RB is decreased during tolerance induction. Elevated expression of Ly-6A/E persists up to 28 days post-tolerization; however, altered expression of the other markers does not persist and near baseline levels of the other markers are noted 7 to 28 days post-tolerization. These results show that tolerance induction is an active process which has functional and phenotypic similarities to antigen-specific immunity. However, tolerance induction in our system differs from immunity in terms of the early loss of IL-2R alpha expression, the persistent increased expression of Ly-6A/E, and the lack of development of CD45RBlo memory-type T cells.

The effects of ice on blood flow and bone metabolism in knees

The effects of an ice wrap, applied to a knee for 20 minutes, on blood flow and bone metabolism were measured using triple-phase technetium bone scans. Twenty-one subjects between 29 and 63 years of age were studied. A commercially available ice wrap was applied to one knee 20 minutes before scanning, while an identical wrap left at room temperature was applied to the opposite knee to act as a control. Scans of the knees were obtained at the completion of cooling, and the images were quantified by computer image analysis for each knee at each phase of the scan. Percentage of decrease in blood flow and subsequent bone uptake of technetium for the iced knee as compared with the opposite knee were calculated. All iced knees demonstrated decreased arterial and soft tissue blood flow as well as decreased bone uptake, which is a reflection of changes in both bone blood flow and metabolism. The average decrease was 38.4% +/- 4.97 in arterial blood flow, 25.8% +/- 2.04 in soft tissue blood flow, and 19.3% +/- 2.0 (standard error of the mean in each) in bone uptake. This "ice effect" was not related to age, sex, knee circumference, or skin temperature after cooling. By decreasing blood flow and cell metabolism, ice theoretically can limit hemorrhage and cell death in the setting of acute traumatic injury. This study thus provides a scientific rationale for the use of ice as tested for such injuries to a large joint, whether in the soft tissues or bones.

Circulating adhesion molecules in tuberculosis

Leucocyte-endothelial adhesion molecules have been implicated in the pathogenesis of inflammatory diseases. To evaluate their role as markers of disease activity in tuberculosis, we have used an antigen capture ELISA to measure the serum concentrations of circulating intercellular adhesion molecule-1 (cICAM-1), E-selectin (cE-selectin) and vascular cell adhesion molecule-1 (cVCAM-1) in 34 patients with active tuberculosis (27 with pulmonary disease and seven with lymph node disease) before the commencement of standard chemotherapy, 15 subjects who had previously completed treatment for pulmonary tuberculosis, and 27 healthy volunteers. Circulating ICAM-1 and E-selectin levels were significantly elevated in patients with active tuberculosis when compared to those with treated disease (P < or = 0.01), and healthy controls (P < 0.02). Circulating VCAM-1 was raised in patients with active or old pulmonary tuberculosis (P < 0.02 versus healthy controls) but not in those with tuberculous lymphadenitis. Significant correlations were observed between the levels of cICAM-1 and cE-selectin (p = 0.63, P = 0.0001), and between cICAM-1 and cVCAM-1 (p = 0.28, P = 0.016). Taking the mean +2 s.d. of the serum level in healthy controls as the upper limit of normal range, circulating ICAM-1 had the best discriminative power in identifying active tuberculosis, being elevated in about 80% of patients but was raised in only 6.7% of subjects with treated disease and in 3.7% of normal subjects. Our data support the possibility that three adhesion molecules may be involved in the pathogenesis of tuberculosis and cICAM-1 may be a useful marker of disease activity.

Superantigen-induced peripheral tolerance inhibits T cell responses to immunogenic peptides in TCR (beta-chain) transgenic mice

TCR (beta-chain) transgenic mice were tolerized with the superantigen staphylococcal enterotoxin B (SEB). Three to 28 days after tolerization with SEB, flow cytometry of peripheral T cells showed the persistence of SEB-unresponsive T cells that did not express reduced levels of the TCR (beta-chain) transgene. Stimulation of the tolerized T cells with a panel of superantigens (SEC1), mitogens (Con A, PHA, and pertussis toxin) and mAb (anti-CD3 epsilon) did not induce T cell proliferation. In contrast to other models, exogenous rIL-2 did not reverse unresponsiveness and induce proliferation. In addition, lymphokines rIL-4 and rIL-6 also did not induce proliferation. However, the unresponsive T cells did respond to the combination of PMA plus ionomycin, but not to PMA or ionomycin alone. Thus, the block in signal transduction in the anergic state occurs between the stimulation of cell surface receptors and the activation of protein kinase C and the increase in intracellular calcium. In addition, these results show that mature T cells tolerized with the superantigen SEB are unresponsive to a wide array of T cell stimuli, indicating a block in a common signal transduction pathway.

Superantigen-induced peripheral tolerance inhibits T cell responses to immunogenic peptides in TCR (beta-chain) transgenic mice

TCR (beta-chain) transgenic mice were tolerized with the superantigen staphylococcal enterotoxin B (SEB). Three to 28 days after tolerization with SEB, flow cytometry of peripheral T cells showed the persistence of SEB-unresponsive T cells that did not express reduced levels of the TCR (beta-chain) transgene. Stimulation of the tolerized T cells with a panel of superantigens (SEC1), mitogens (Con A, PHA, and pertussis toxin) and mAb (anti-CD3 epsilon) did not induce T cell proliferation. In contrast to other models, exogenous rIL-2 did not reverse unresponsiveness and induce proliferation. In addition, lymphokines rIL-4 and rIL-6 also did not induce proliferation. However, the unresponsive T cells did respond to the combination of PMA plus ionomycin, but not to PMA or ionomycin alone. Thus, the block in signal transduction in the anergic state occurs between the stimulation of cell surface receptors and the activation of protein kinase C and the increase in intracellular calcium. In addition, these results show that mature T cells tolerized with the superantigen SEB are unresponsive to a wide array of T cell stimuli, indicating a block in a common signal transduction pathway.