Oral immunotherapy with omalizumab reverses the Th2 cell-like programme of regulatory T cells and restores their function

BACKGROUND

Oral immunotherapy (OIT) successfully desensitizes patients with food allergies, but the immune mechanisms mediating its efficacy remain obscure.

OBJECTIVES

We tested the hypothesis that allergen-specific regulatory T (Treg) cell function is impaired in food allergy and is restored by anti-IgE antibody (omalizumab)-supplemented OIT.

METHODS

Peanut-specific T effector (Teff) and Treg cell proliferative responses, activation markers and cytokine expression were analysed by flow cytometry in 13 peanut-allergic subjects before the start of omalizumab-supplemented OIT and periodically in some subjects thereafter for up to 2 years. Peripheral blood regulatory T cells (Treg cells) were analysed for their peanut-specific suppressor function before and at 1 year following OIT. This study was registered on ClinicalTrials.gov (NCT01290913).

RESULTS

Proliferation of allergen-specific Teff and Treg cells precipitously declined following the initiation of omalizumab therapy prior to OIT, followed by partial recovery after the initiation of OIT. At baseline, peanut-specific Treg cells exhibited a Th2 cell-like phenotype, characterized by increased IL-4 expression, which progressively reversed upon OIT. Peanut-specific Treg cell suppressor activity was absent at the start of omalizumab/OIT therapy but became robust following OIT. Absent peanut-specific Treg cell function could also be recovered by the acute blockade of IL-4/IL-4R receptor signalling in Treg cells, which inhibited their IL-4 production.

CONCLUSIONS AND CLINICAL RELEVANCE

OIT supplemented by omalizumab promotes allergen desensitization through an initial omalizumab-dependent step that acutely depletes allergen-reactive T cells, followed by an increase in allergen-specific Treg cell activity due to the reversal of their Th2 cell-like programme. Improved Treg cell function may be a key mechanism by which OIT ameliorates food allergy.

Early Magnesium Treatment After Aneurysmal Subarachnoid Hemorrhage: Individual Patient Data Meta-Analysis

BACKGROUND AND PURPOSE

Delayed cerebral ischemia (DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Trials of magnesium treatment starting <4 days after symptom onset found no effect on poor outcome or DCI in SAH. Earlier installment of treatment might be more effective, but individual trials had not enough power for such a subanalysis. We performed an individual patient data meta-analysis to study whether magnesium is effective when given within different time frames within 24 hours after the SAH.

METHODS

Patients were divided into categories according to the delay between symptom onset and start of the study medication: <6, 6 to 12, 12 to 24, and >24 hours. We calculated adjusted risk ratios with corresponding 95% confidence intervals for magnesium versus placebo treatment for poor outcome and DCI.

RESULTS

We included 5 trials totaling 1981 patients; 83 patients started treatment<6 hours. For poor outcome, the adjusted risk ratios of magnesium treatment for start <6 hours were 1.44 (95% confidence interval, 0.83-2.51); for 6 to 12 hours 1.03 (0.65-1.63), for 12 to 24 hours 0.84 (0.65-1.09), and for >24 hours 1.06 (0.87-1.31), and for DCI, <6 hours 1.76 (0.68-4.58), for 6 to 12 hours 2.09 (0.99-4.39), for 12 to 24 hours 0.80 (0.56-1.16), and for >24 hours 1.08 (0.88-1.32).

CONCLUSIONS

This meta-analysis suggests no beneficial effect of magnesium treatment on poor outcome or DCI when started early after SAH onset. Although the number of patients was small and a beneficial effect cannot be definitively excluded, we found no justification for a new trial with early magnesium treatment after SAH.

Catastrophic antiphospholipid syndrome with concurrent thrombotic and hemorrhagic manifestations

Antiphospholipid syndrome (APS) is a distinct autoimmune prothrombotic disorder due to pathogenic autoantibodies directed against proteins that bind to phospholipids. APS is characterized by arterial and venous thrombosis and their clinical sequelae. Catastrophic antiphospholipid syndrome (CAPS) is a rare and often fatal form of APS characterized by disseminated intravascular thrombosis and ischemic injury resulting in multiorgan failure. Rarely, intravascular thrombosis in CAPS is accompanied by hemorrhagic manifestations such as diffuse alveolar hemorrhage. Here, we report a 43-year-old woman who presented with anemia, acute gastroenteritis, abnormal liver function tests, bilateral pulmonary infiltrates, and a systemic inflammatory response syndrome. The patient developed respiratory failure as a result of diffuse alveolar hemorrhage followed by acute renal failure. Laboratory tests disclosed hematuria, proteinuria, and reduced platelet count. Microbiologic tests were negative. A renal biopsy demonstrated acute thrombotic microangiopathy and extensive interstitial hemorrhage. Serologic tests disclosed antinuclear antibodies and reduced serum complement C4 concentration. Coagulation studies revealed the lupus anticoagulant and autoantibodies against cardiolipin, beta 2-glycoprotein I, and prothrombin. High-dose glucocorticoids and plasma exchange resulted in rapid resolution of pulmonary, renal, and hematological manifestations. This rare case emphasizes that CAPS can present with concurrent thrombotic and hemorrhagic manifestations. Rapid diagnosis and treatment may result in complete recovery.

Ecology of zoonoses: natural and unnatural histories

More than 60% of human infectious diseases are caused by pathogens shared with wild or domestic animals. Zoonotic disease organisms include those that are endemic in human populations or enzootic in animal populations with frequent cross-species transmission to people. Some of these diseases have only emerged recently. Together, these organisms are responsible for a substantial burden of disease, with endemic and enzootic zoonoses causing about a billion cases of illness in people and millions of deaths every year. Emerging zoonoses are a growing threat to global health and have caused hundreds of billions of US dollars of economic damage in the past 20 years. We aimed to review how zoonotic diseases result from natural pathogen ecology, and how other circumstances, such as animal production, extraction of natural resources, and antimicrobial application change the dynamics of disease exposure to human beings. In view of present anthropogenic trends, a more effective approach to zoonotic disease prevention and control will require a broad view of medicine that emphasises evidence-based decision making and integrates ecological and evolutionary principles of animal, human, and environmental factors. This broad view is essential for the successful development of policies and practices that reduce probability of future zoonotic emergence, targeted surveillance and strategic prevention, and engagement of partners outside the medical community to help improve health outcomes and reduce disease threats.

First Report of the Oak Wilt Fungus, Ceratocystis fagacearum, in New York State

Ceratocystis fagacearum (T.W. Bretz) J. Hunt is considered to be the most destructive vascular pathogen of oaks (Fagaceae: Quercus spp.) in the eastern, north-central, and south-central United States. (1,2,4). All red oak species (subgenus Quercus: section Lobatae) are highly susceptible to C. fagacearum, and infected trees typically die within 3 months of first symptom expression. However, members of the white oak group (subgenus Quercus: section Quercus) are moderately to highly resistant to C. fagacearum and rarely die from oak wilt (1,3). In early August of 2008, we received branch samples taken from wilting red oaks (Q. rubra L.) growing in a residential neighborhood in Scotia, NY (Schenectady County). The endoconidial state of the oak wilt fungus, Thielaviopsis quercina (B.W. Henry) A.E. Paulin, T.C. Harr. & McNew, was consistently isolated from the xylem in the branches. The cultures were identified based on hyphal and conidial morphology on acidified potato dextrose agar (aPDA) as well as sequences of the internal transcribed spacer (ITS) (GenBank Accession No. FJ347031) and large subunit (LSU) (GenBank Accession No. FJ347030) regions of nuclear ribosomal DNA (rDNA). The nucleotide identities for the ITS and LSU sequences were a precise match, 99 and 100%, to rDNA sequences (GenBank Accession Nos. AF043598 and AF222483, respectively) of other isolates of C. fagacearum. According to the homeowners at the site, 12 red oaks have died during the last 3 years, and each tree died within one growing season after oak wilt-like symptoms were noted. In a brief survey of nearby properties in late August of 2008, we found 12 additional trees that were either expressing crown symptoms of oak wilt (e.g., premature leaf casting, bronzing of leaf margins, and water-soaked leaves) or were standing dead and within close proximity (5 to 10 m) to symptomatic trees. Branch samples from four of the symptomatic trees revealed limited (spotted) or no vascular discoloration; however, C. fagacearum was isolated from each suspect tree on aPDA. Remnants of gray mycelial mats and associated pressure cushions were observed beneath the bark of one standing dead oak. The sweet fruit-like odor characteristic of the oak wilt fungus was immediately evident once the bark overlying the mats was removed. Prior to this discovery, the Susquehanna River in north-central Pennsylvania was considered to be the northeastern limit for oak wilt occurrence in the United States (2,4). To our knowledge, this is the first report of the fungus from New York and expands the known range of C. fagacearum to the northeast by at least 300 km, supporting the hypothesis that the range of this fungus continues to expand via animal vectors and/or human activities (2). An isolate of C. fagacearum from New York has been deposited at the Centraalbureau voor Schimmelcultures (CBS 123913). References: (1) D. N. Appel. Ann. Rev. Phytopathol. 33:103, 1995. (2) J. Juzwik et al. Ann. Rev. Phytopathol. 46:13, 2008. (3) W. L. MacDonald et al. European oaks-susceptible to oak wilt? Page 131 in: Shade Tree Wilt Diseases. C. L. Ash, ed. The American Phytopathological Society, St. Paul, MN, 2001. (4) USDA Forest Service. Oak Wilt Distribution. Northeast Area, State and Private Forestry, St. Paul, MN. Online publication, 2005.

A proposed approach to recognise "near-remission" quantitatively without formal joint counts or laboratory tests: a patient self-report questionnaire routine assessment of patient index data (RAPID) score as a guide to a "continuous quality improvement" s

A proposed approach is presented to recognise a status of "near-remission" in a patient with rheumatoid arthritis (RA) on the basis of patient self-report questionnaire data without formal joint counts or laboratory tests. Indices of patient-reported outcome (PRO) measures distinguish active from control treatments in RA clinical trials at levels similar to American College of Rheumatology (ACR) or disease activity score (DAS) 28 improvement levels. PRO measures on a multidimensional health assessment questionnaire (MDHAQ) can be compiled into a routine assessment of patient index data (RAPID) score. RAPID 3 includes the three PRO measures from the ACR Core Data Set - physical function, pain, and global estimate. RAPID 4 adds a self-report joint count from a rheumatoid arthritis disease activity index (RADAI). RAPID 5 adds a physician estimate of global status. RAPID cores may be classified into four preliminary proposed categories, as "near-remission" (0-1), "low severity" (1.01-2), "moderate severity" (2.01-4), and "high severity" (> 4), analogous to the four categories of the DAS28 of "remission" (< 2.6), as well as "low" (2.6-3.19), "moderate" (3.2-5.1), and "high" (> 5.1) disease activity. RAPID scores are correlated significantly with DAS28 (rho = 0.64-0.67, p < 0.001), and about 75% of patients with DAS < 2.6 have RAPID scores < 2, while about 75% of patients with DAS > 5.1 have RAPID scores > 4. RAPID data are available on one side of one page, and are feasible to collect in standard clinical care. RAPID 3 scores may be calculated in about 10 seconds, and RAPID 4 and RAPID 5 scores in 20 to 30 seconds. RAPID scores every 3 months or more on simple flowsheets can be a basis for a "continuous quality improvement" strategy in standard clinical care to recognise a need for aggressive therapy, an inadequate response to a therapy, and "near- remission" status.

Intra-arterial thrombolysis in acute ischaemic stroke

Several thrombolytic agents for the treatment of acute ischaemic stroke have been examined; however, to date, only the i.v. administration of recombinant tissue plasminogen activator is licensed in Australia. Although no trials directly comparing intra-arterial and i.v. delivery of thrombolytics exist, intra-arterial thrombolysis has several potential advantages, including angiographic assessment of the thrombus and the site of occlusion and collateral circulation, improved recanalization, and delivery of higher local concentrations of thrombolytic agents and extending the therapeutic time window for treatment. We conducted a retrospective audit of our experience with the use of intra-arterial urokinase to treat acute ischaemic stroke at an Australian tertiary-care hospital between June 1993 and June 2003. We examined time from stroke onset to assessment, computerized tomography scan, cerebral angiography and thrombolysis, anatomical classification of intra-arterial thrombus, rates of symptomatic intracerebral haemorrhage, and clinical outcome at 3 months. We believe that in carefully selected individuals in appropriate centres of expertise, intra-arterial thrombolytic therapy holds great promise.

Fatal brain stem event complicating acute pancreatitis

Acute pancreatitis, developing in a patient with chronic renal failure, was complicated by a fatal neurological illness during which MRI showed pontine and extrapontine changes consistent with pontine and extrapontine myelinolysis. At post mortem, acute pancreatitis was confirmed but the neuropathological findings were more in keeping with an unusual presentation of acute haemorrhagic leucoencephalitis, perhaps even representing a form of 'pancreatic encephalopathy'. Although the development of CT and MRI scanning has greatly increased the resolution of neuroimaging and facilitated diagnosis during life, the value of autopsy examination is confirmed in cases such as this. Sometimes the findings may raise more questions than may have been answered - this too is an important function!

Changing role for preoperative embolisation in the management of arteriovenous malformations of the brain

BACKGROUND

The aim of this study was to analyse the results of the use of preoperative embolisation in the management of arteriovenous malformations of the brain at one institution between 1989 and 1999.

METHODS

Two hundred and fifty consecutive cases of angiographically confirmed arteriovenous malformations underwent surgery by one surgeon. Cases of dural or spinal arteriovenous malformations have been excluded. Forty-five cases underwent preoperative embolisation. Embolisation was mostly by particulate embolic material delivered 4 to 6 days before the intended surgery. The incidence of embolisation declined from 21 cases of the first 50 arteriovenous malformation cases surgically treated to five in the last 50 cases. For arteriovenous malformations of less than 3 cm, only the first two temporal quintiles had embolised cases; six in the first and three in the second. Outcome was measured by the Modified Rankin Scale.

RESULTS

By 12 months (or last follow up, if less than this time has elapsed) following surgery, 1.6% of patients had died, 2.4% had a Modified Rankin scale score of 4 or 5, 6.4% had a Modified Rankin scale score of 3, 8.4% had a Modified Rankin scale score of 2, 14.4% had a Modified Rankin scale score of 1, and 66.8% were without neurological deficit. There was no difference in outcomes in each of the temporal quintiles. The four deaths were related to intraoperative haemorrhage, ruptured aneurysm, acute myocardial infarction or unrelated infection. Angiographic cure was achieved in 244 of 246 surviving cases. The two cases with residual arteriovenous malformations underwent focussed irradiation. Permanent morbidity could be attributable to embolisation, intraoperative events (resection functional brain, arteriovenous malformation rupture, aneurysm rupture or myocardial infarction) or postoperative events (arterio-capillary-venous hypertensive syndrome or infection). Of these 29 patients 14 had undergone embolisation. Mortality and major morbidity (Modified Rankin scale score greater than 2 due to treatment) occurred in 8.8% undergoing embolisation compared with 1.9% not embolised. The cause for major morbidity in these four embolised cases was intraoperative or postoperative haemorrhage.

CONCLUSIONS

These results reflect that cases selected for embolisation were those at most risk from intraoperative haemorrhage. Arteriovenous malformations that are less than 3 cm in maximal diameter should only rarely be considered for preoperative embolisation because of their low surgical morbidity. In the presence of a significant deep perforating artery contribution that cannot be effectively embolised the risks of operative haemorrhage is high irrespective of the effectiveness of embolising ancillary non-perforating arteries.

Aggressive management of aneurysmal subarachnoid haemorrhage based on a papaverine angioplasty protocol

The aim of this study was to analyse the results of intensive therapy unit management of aneurysmal subarachnoid haemorrhage incorporating angioplasty in the protocol. Two hundred consecutive patients were treated using a detailed protocol that included nimodipine, early aneurysm repair, and surveillance angiography. Angiography was performed on days 5 to 7 (or when the clinical state suggested the presence of vasospasm). If angiographic vasospasm was identified, irrespective of whether clinical vasospasm was present or absent, papaverine was selectively administered. In patients with vasospasm blood pressure was elevated to 160-180 mmHg and selective papaverine administration was repeated daily until vasospasm resolved. In cases requiring more frequent administration of papaverine, or in whom papaverine failed to adequately reverse spasm, balloon angioplasty was considered and for clinically refractory cases barbiturate coma was introduced. 43% of patients underwent papaverine administration and of these the average number of separate papaverine procedures was four (maximum 23). 26% of patients developed neurological deficits though to be due to vasospasm whilst 17% underwent papaverine angioplasty without clinical signs of vasospasm. Twelve patients (6%) were entered into barbiturate coma. There was a 5.5% mortality and no difference in outcome between patients who developed angiographic vasospasm and those who did not. For those developing clinical vasospasm, 71% were independent and 10% were dead at follow up compared with 84% reaching independent grades and 4% dead in those not developing clinical vasospasm. These differences failed to reach a significant difference. The average Intensive Therapy Unit stay for aneurysmal subarachnoid haemorrhage patients was 13.1 days with a mean cost to the hospital of $AUD 24,379. This protocol appears to be both a clinically and cost effective method of managing aneurysmal subarachnoid haemorrhage.

The need for delivery room intubation of thin meconium in the low-risk newborn: a clinical trial

The delivery room management of meconium-stained amniotic fluid remains controversial. We attempted to determine if intubation of the low-risk newborn with thin meconium affects the incidence of respiratory symptoms. Exclusion criterion included moderate or thick meconium, fetal distress, neonatal depression, or prematurity. Eligible infants were randomized to either an intubation (group I) or to a nonintubation group (group II). The outcome was the presence of respiratory symptoms. Patients were studied from May 1994 to June 1997. There were 8967 births during this period: 7.9% (708/8967) were delivered through meconium. Thin meconium was noted in 50.3% (356/708) of all births. 24/356 infants with thin meconium were excluded for medical criterion. One hundred sixty-three infants were medically eligible but could not be randomized due to lack of consent, late arrival of the team, or obstetrician request. These were placed into intubation (group I B) and nonintubation (group II B) groups. Seventy-seven infants were randomized into group I and 92 infants into group II. From the intubation groups I and I B, one required supplemental oxygen and was weaned to room air in 7 hr. From the nonintubation groups II and II B, two infants required oxygen, weaning to room air in 11 and 46 hr. Comparing birth weight, gestational age, sex, mode of delivery and 5-min Apgar, there were no significant differences. However, the intubation groups had significantly lower 1-min Apgar scores. There was no airway morbidity reported in the intubation groups. In the infant with thin meconium and an otherwise low-risk pregnancy, we were unable to demonstrate a difference in respiratory symptoms with intubation and intratracheal suctioning.

Temporal arteritis and sensorineural hearing loss

OBJECTIVES

The association of temporal arteritis and sensorineural hearing loss is a rare occurrence. We present four cases with both these disorders.

METHODS

A 10-year retrospective review of all cases seen at the Geisinger Medical Center showed 271 cases of temporal arteritis and four cases with concomitant sensorineural hearing loss. The four cases were identified, obtained, and extensively reviewed. Patients ranged in age from 59 to 76 years and presented with sensorineural hearing loss and signs, symptoms, and biopsy evidence of temporal arteritis. The response to therapy and clinical course of each case are discussed.

RESULTS

In three patients, the hearing loss preceded the diagnosis of giant cell arteritis by 2 days to 2 months. In one case, the hearing loss was noted concurrently with systemic features of giant cell arteritis. All cases were treated with corticosteroids and had full or partial return of hearing.

CONCLUSIONS

Sensorineural hearing loss can be a preceding or concurrent symptom of temporal arteritis. Recognition and treatment may lead to partial or full recovery. It is not certain whether the time from onset of hearing loss to diagnosis to institution of therapy influences recovery.

Polyarteritis nodosa presenting as acute myocardial infarction with coronary dissection

Coronary manifestations of polyarteritis nodosa (PAN) are rarely identified pre-mortem. We report a 51-year-old female with PAN causing a coronary dissection and new lesions developing over the next 5 days. PAN should be added to the list of differential diagnoses for spontaneous coronary dissections.

Multiple isoforms of eukaryotic protein synthesis initiation factor 4E in Caenorhabditis elegans can distinguish between mono- and trimethylated mRNA cap structures

The rate-limiting step for cap-dependent translation initiation in eukaryotes is recruitment of mRNA to the ribosome. An early event in this process is recognition of the m7GTP-containing cap structure at the 5'-end of the mRNA by initiation factor eIF4E. In the nematode Caenorhabditis elegans, mRNAs from 70% of the genes contain a different cap structure, m32,2,7GTP. This cap structure is poorly recognized by mammalian elF4E, suggesting that C. elegans may possess a specialized form of elF4E that can recognize m32,2,7GTP. Analysis of the C. elegans genomic sequence data base revealed the presence of three elF4E-like genes, here named ife-1, ife-2, and ife-3. cDNAs for these three eIF4E isoforms were cloned and sequenced. Isoform-specific antibodies were prepared from synthetic peptides based on nonhomologous regions of the three proteins. All three eIF4E isoforms were detected in extracts of C. elegans and were retained on m7GTP-Sepharose. One eIF4E isoform, IFE-1, was also retained on m32,2,7GTP-Sepharose. Furthermore, binding of IFE-1 and IFE-2 to m7GTP-Sepharose was inhibited by m32,2,7GTP. These results suggest that IFE-1 and IFE-2 bind both m7GTP- and m32,2, 7GTP-containing mRNA cap structures, although with different affinities. In conjunction with IFE-3, these eIF4E isoforms would permit cap-dependent recruitment of all C. elegans mRNAs to the ribosome.

Setting health priorities: community boards accurately reflect the preferences of the community's residents

Setting priorities remains an important part of healthcare planning and program management. Local community input is often sought in government or publicly sponsored programs. Community policy/advisory boards are a common vehicle to represent the community's interests in program decisions and direction. Questions remain whether community boards accurately represent their communities' views. As part of a planning effort within Chicago and Cook County, Illinois, local District Health Councils (DHCs) have been created to provide assistance and leadership in systemization and improvement of the healthcare in communities with the poorest health status in the region. We sought to discover how closely the perceptions of health priorities of DHC members agreed with those of community members. A structured five-point Likert scale questionnaire of 22 of the most common diseases and conditions known to impact health were used for a random digit dialing telephone interview with a sample of 286 households from three under-served communities. The same interview was repeated with all DHC members (n = 80) representing those communities. Sociodemographic profiles and health-related behaviors were also collected. The results of this interview indicate a close and substantial agreement in priorities between community members and DHC members. Psychosocial conditions such as violence and substance abuse were ranked as the highest priorities by both groups. In contrast, sociodemographics and healthcare behavior differed significantly between DHC members and community's residents. This study demonstrates that these community policy/advisory boards can closely reflect the views of the communities they represent. Attention to their differences in sociodemographics and healthcare experiences with the community may strengthen their role even more.

Effects of pegorgotein on neurologic outcome of patients with severe head injury. A multicenter, randomized controlled trial

OBJECTIVE

To evaluate outcome of patients with severe closed head injury treated with pegorgotein, a scavenger of oxygen-derived free radicals.

DESIGN

Randomized, parallel, placebo-controlled, third-party-blind, multicenter trial, with a blinded, multicenter follow-up protocol.

SETTING

Twenty-nine centers in the United States.

PATIENTS

A total of 463 patients with severe closed head injury and a Glasgow Coma Scale score of 8 or less after resuscitation and stabilization.

INTERVENTIONS

Patients received a single intravenous dose of placebo, 10 000 U/kg of pegorgotein, or 20 000 U/kg of pegorgotein within 8 hours after injury.

OUTCOME MEASURES

The primary endpoint was the Glasgow Outcome Scale (GOS) score at 3 months after brain injury with GOS data trichotomized into good, fair, or poor outcome. Secondary efficacy endpoints included the Disability Rating Scale (DRS) and mortality. A secondary analysis was performed using GOS scores dichotomized into favorable and unfavorable outcomes. In a follow-up protocol at 6 months, GOS and DRS scores were again determined.

RESULTS

Of 463 patients randomized, 162 received placebo; 149, pegorgotein 10 000 U/kg; and 152, pegorgotein 20 000 U/kg. Treatment groups were comparable with respect to demographic characteristics, mechanism of injury, and time to treatment. Pegorgotein was well tolerated at both dose levels. At month 3, the trichotomized analysis found no significant statistical difference in neurologic outcome between the pegorgotein and the placebo groups. Although differences were not statistically significant, there were more favorable outcomes and no increase in the number of deaths or vegetative states among the patients given pegorgotein, more subjects had good or favorable outcomes with the 10 000-U/kg dose than with the 20 000-U/kg dose or placebo, and less disability was observed with the 10 000-U/kg dose than with either the 20 000-U/kg dose or placebo. No differences in mortality rate or cause of death were found between the 10 000-U/kg and placebo groups at either month 3 or month 6. The only statistically significant difference between the groups was a decreased incidence of adult respiratory distress syndrome in the 10 000-U/kg group as compared with the placebo group (P<.015).

CONCLUSIONS

In this clinical trial of 463 patients with severe head injury, no statistically significant difference in neurologic outcome or mortality was observed between patients treated with pegorgotein and those receiving placebo.

The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain

STUDY DESIGN

A prospective cross-sectional analytic study.

OBJECTIVES

To assess in patients with chronic low back pain whether the presence or absence of pain originating from the lumbar zygapophysial joints correlates with changes seen on computed tomography.

SUMMARY OF BACKGROUND DATA

Results of studies have been divided as to whether or not radiologic imaging is able to predict those patients with pain originating from the zygapophysial joints.

METHODS

Sixty-three patients with low back pain lasting for longer than 3 months underwent computed tomography and blocks of the zygapophysial joints at L5-S1, L4-L5, and L3-L4. The zygapophysial joints of all images were scored by three independent, masked radiologists.

RESULTS

Interobserver agreement was poor with intraclass correlation coefficients of 0.34-0.66 using total joint scores for all three assessors. Using the results of a repeat assessment with two radiologists there was no statistically significant difference in joint scores between those with and those without pain originating from the zygapophysial joint.

CONCLUSIONS

Computed tomography has no place in the diagnosis of lumbar zygapophysial joint pain.

Mutational analysis of the PRP4 protein of Saccharomyces cerevisiae suggests domain structure and snRNP interactions

The PRP4 protein of Saccharomyces cerevisiae is an essential part of the U4/U6 snRNP, a component of the mRNA splicing apparatus. As an approach to the determination of structure-function relationships in the PRP4 protein, we have isolated more than fifty new alleles of the PRP4 gene through random and site-directed mutagenesis, and have analyzed the phenotypes of many of them. Twelve of the fourteen single-point mutations that give rise to temperature-sensitive (ts) or null phenotypes are located in the portion of the PRP4 gene that corresponds to the beta-transducin-like region of the protein; the remaining two are located in the central portion of the gene, one of them in an arginine-lysine-rich region. Nine additional deletion or deletion/insertion mutations were isolated at both the amino- and carboxy-termini. These data show that the amino-terminal region (108 amino acids) of PRP4 is non-essential, while the carboxy-terminal region is essential up to the penultimate amino acid. A deletion of one entire beta-transducin-like repeat (the third of five) resulted in a null phenotype. All ts mutants show a first-step defect in the splicing of U3 snRNA primary transcript in vivo at the non-permissive temperature. The effects on prp4 mutant growth of increased copy-number of mutant prp4 genes themselves, and of genes for other components of the U4/U6 snRNP (PRP3 and U6 snRNA) have also been studied. We suggest that the PRP4 protein has at least three domains: a non-essential amino-terminal segment of at least 108 amino acids, a central basic region of about 140 residues that is relatively refractile to mutation and might be involved in RNA interaction, and an essential carboxy-terminal region of about 210 residues with the five repeat-regions that are similar to beta-transducins, which might be involved in protein-protein interaction. A model of interactions of snRNP components suggested by these results is presented.

The dense basilar artery as a sign of basilar territory infarction

Three cases of basilar artery territory infarction, in which a dense basilar artery was noted, are described. The dense basilar artery was recognized on computed tomography (CT) by comparing its density with that of other unaffected intracranial vessels. This sign is thought to represent basilar thrombosis or embolism and has similarities to the dense middle cerebral artery sign. The dense basilar artery is an early sign suggesting basilar territory infarction and its use improves the CT detection of basilar territory infarction.

Overuse ballet injury of the base of the second metatarsal. A diagnostic problem

Performing classical ballet may cause major stress to the feet of the dancer. A variety of foot injuries have been described, with one such injury being an overuse syndrome involving the base of the second metatarsal and adjacent Lisfranc's joint. The diagnosis for this syndrome usually requires differentiating synovitis of Lisfranc's joint from a stress reaction of the base of the second metatarsal. Prompt diagnosis is important since the treatment for these two conditions differs significantly and, in the case of bone stress reaction, delay can cause progression of the lesion. We report good clinical results in a group of eight ballerinas for whom we obtained early diagnosis and treatment of their injuries. This is in contrast to poor results reported in the literature if the diagnosis and management of these types of injuries are delayed. We developed a simple diagnostic protocol to enable diagnosis at presentation. When a bone stress reaction had progressed to a fracture line, a characteristic appearance was found on magnetic resonance imaging, suggesting a specific mechanism of injury. A possible mechanism for this injury is discussed.

Is the metabolic response to injury different with or without severe head injury? Significance of plasma glutamine levels

Acute brain injury is the single largest cause of trauma center deaths. Injury that does not involve the brain directly can lead to a cascade of changes in neuroendocrine system function. In order to evaluate the effect of head injury in severely traumatized patients on the response of body fuel mobilization and utilization, 42 adult patients were studied in the early "flow" phase of injury in the fasting state. They were divided into two groups: (1) multiple trauma patients without head injury (MI group, n = 21); and (2) multiple trauma patients with severe head injury (HMI group, n = 21). This enabled evaluation of the influence of injured brain on the general response to body injury. Kinetic measurements of protein (primed-constant infusion of 15N glycine), glucose (14C and 3H isotopic glucoses), fat (two-stage glycerol infusion), and energy metabolism (indirect calorimetry) were made along with hormone and substrate determinations. The results of this integrated approach demonstrated similar hormonal and metabolic changes between these two groups of patients. However, hepatic glucose production and whole body lipolysis rates were significantly decreased in HMI patients. In addition, hyperglycemia and hypoglutaminemia were more pronounced in injured patients with associated head injury. Glutamine release, which forms a significant net release of brain amino acids in normal subjects may be impaired in HMI patients. Associated brain injury appears to moderate the systemic effect of trauma.

A deletion unit on chromosome 17q in epithelial ovarian tumors distal to the familial breast/ovarian cancer locus

Linkage analysis in familial breast and ovarian cancer and studies of allelic deletion in sporadic ovarian tumors have suggested that chromosome 17q may be the location of a gene of importance in ovarian carcinogenesis. We have examined tumor and normal DNA samples from 120 patients with ovarian tumors for allelic deletion at 12 loci on chromosome 17q. Allelic deletion was observed in 64 cases (53%) of which 56 showed loss of heterozygosity at all loci analyzed on 17q. The pattern of allele loss at metastatic sites was consistent with loss of heterozygosity having occurred prior to metastasis. A common region of deletion, defined by 6 cases of invasive epithelial ovarian cancer and a benign serous cystadenoma, spanned 16 cM and was delimited by nm23 and GH. This region is distal to the region on chromosome 17q to which the familial breast/ovarian cancer susceptibility gene has been mapped. The results suggest that a tumor suppressor gene involved in sporadic ovarian carcinogenesis is located on the distal portion of chromosome 17q and is distinct from the gene linked to familial cases.

Developing a collaborative culture in a hospital setting. Interview by Donald E.L. Johnson

Moving an organization from "me"to "we" can be a frightening proposition for any organization. Tim Harrington, chief executive officer of Victory Hospital, Waukegan, IL, offers his perspectives to Health Care Strategic Management publisher, Donald E. L. Johnson. Harrington found that a collaborative environment within Victory hospital and Baxter enabled the introduction of total quality management and continuous quality improvement concepts to be freely introduced into the system. He also provides guidance for establishing and fostering collaboration among hospital departments, especially amid middle-management personnel.

Outcome analysis in 654 surgically treated lumbar disc herniations

This article reports the outcomes of 654 consecutive patients treated during a 4.5-year period. Patients had a microdiscectomy, a laminectomy plus microdiscectomy, or a decompressive laminectomy with a microdiscectomy. The causes of ruptured discs were lifting (31.4%), falls (10.2%), and sports (10.0%). Almost all patients had complained of leg pain (99%), and 79% had radicular pain in a dermatomal distribution. Thirty-three percent of the patients had been involved in industrial accidents, and 6% had legal claims pending during the surgical period. Almost 11% of the patients had complications, and there was one death caused by abdominal arterial bleeding. Patients were also rated according to the Prolo Functional-Economic Outcome Rating Scale to improve the ability to compare series in the future. Almost 80% of the patients had good outcomes as defined by scores on this scale of 8 (16.2%), 9 (33.2%), and 10 (26.9%). Several conclusions can be drawn from the results of this series: 1) most patients had good outcomes; 2) patients with nonindustrial injuries had better outcomes than did patients with industrial injuries; 3) professionals with legal concerns and laborers with industrial insurance had good outcomes; and 4) the Functional-Economic Outcome Rating Scale appears to be a useful tool for comparing different procedures more objectively and for comparing the outcomes across series.

Radiographic, high detail radiographic, microangiographic and histological findings of the distal portion of the tarsus in weanling, young and adult horses

Clinical radiographic (LM and D35L-P1MO views), high detail radiographic, microangiographic and histological findings of the distal portion of the tarsus of 16 horses (five weanling, four young and six adult), without known clinical histories, were evaluated to determine the sensitivity of clinical radiographs for the detection of abnormalities in the distal tarsus and the prevalence of abnormalities in this population. Clinical radiographic and high detail radiographic abnormalities were observed in at least 30 per cent of the tarsi examined. Statistical agreement between observations from clinical radiographs and corresponding post mortem high detail radiographs was not good for subchondral bone plate irregularities and joint margin changes. Three patterns of sclerosis of the medullary spongiosa were visualised on high detail radiographs: thickening of the subchondral bone plate was seen commonly in the weanling group, whereas arching and bridging patterns were more prevalent in the young and adult groups. Bone production on the dorsal cortex of the central and third tarsal bones did not increase with age. Abnormalities in vascular perfusion and articular cartilage histology were observed in association with subchondral bone plate irregularities and focal regions of osteopenia observed on high detail radiographs.

Acute Barmah Forest polyarthritis

More than 60 arboviruses have been isolated in Australia with the human pathogenicity of the majority yet to be determined. Recent reports outline extensive clinical and sub-clinical infection occurring in Eastern Australia by such agents as Ross River and Barmah Forest viruses. We describe the clinical features of two patients with an acute polyarthritis associated with serological evidence of acute Barmah Forest virus infection to alert physicians to this form of viral polyarthritis and highlight the need to consider this agent when confronted with patients with an acute 'viral-type' polyarthritis in whom serology for Ross River virus is negative.

Continuous regional cerebral blood flow monitoring in acute craniocerebral trauma

Regional cortical cerebral blood flow (rCBF) and intracranial pressure (ICP) were monitored continuously with a combined thermal diffusion probe/ICP monitor in 12 patients (8 men and 4 women; mean age, 31 years; range, 7-65 years) with acute head injuries. The mean Glasgow Coma Scale score at admission was 6 (range, 4-12). The rCBF/ICP probes were placed during surgical procedures (n = 11) or in an intensive care unit (n = 1) for subdural hematomas (n = 7), cerebral contusions (n = 4), and an epidural hematoma (n = 1). No probe-related complications occurred. Reduced CBF often occurred and was often inversely proportional to elevations in ICP. Posttraumatic cerebral arterial vasospasm in one patient was detected by rCBF monitoring and confirmed by angiography. In 6 patients who progressed to brain death, rCBF patterns disappeared, which correlated with their clinical and electroencephalographic examinations. Several patients with severe, diffuse brain injuries and high ICP had hyperemic rCBF patterns. In 2 of these patients, increases in rCBF preceded rises in ICP, which implied loss of autoregulation as a mechanism in the development of malignant cerebral edema. This method of CBF monitoring has not yet been established for clinical decision making. The early detection of ischemic or hyperemic responses by continuous CBF monitoring could hasten intervention aimed at restoring adequate tissue perfusion. The technique could also serve as an index of the efficacy of therapeutic interventions and is suitable to gain more insight into the pathophysiology of head injury, especially the relationship of CBF to ICP.

Civilian gunshot wounds to the head: a prospective study

Previous retrospective studies of cranial gunshot wounds have failed to determine whether aggressive field resuscitation, triage to a neurosurgical center, and early surgical intervention can improve the assumed poor outcome of these severely injured patients. Therefore, we studied 100 consecutive patients prospectively to establish a systematic approach to treatment. If the patient retained two or more neurological signs after aggressive field resuscitation/intubation, a computed tomographic scan was performed. Rapid surgical debridement was done unless the patient deteriorated to clinical brain death. The Glasgow Coma Scale (GCS) score after resuscitation was 3 to 5 in 58 patients, 6 to 8 in 8 patients, 9 to 12 in 12 patients, and 13 to 15 in 22 patients. Seventy-six computed tomographic scans and 43 craniotomies were performed. The Glasgow Outcome Scale scores showed that 60 patients died, 2 were vegetative, 6 were severely disabled, 20 were moderately disabled, and 13 had good outcomes. There were 10 postoperative deaths. No patient with a GCS score of 3 to 5 had a satisfactory outcome; however, outcome progressively improved as the GCS score increased. We conclude that all cranial gunshot patients should initially receive aggressive resuscitation. Patients with stable vital signs should be examined by computed tomographic scan. If the patient's GCS score after resuscitation is 3 to 5 and no operable hematomas are present, then no further therapy should be offered. All patients with a GCS score greater than 5 should receive aggressive surgical therapy.

The benefits of early jejunal hyperalimentation in the head-injured patient

To determine the efficacy of early jejunal hyperalimentation as nutritional support in the head-injured patient, 32 head-injured patients with Glasgow Coma Scale scores less than 10 were studied for the first 7 days after injury. The experimental (E) group had nasojejunal feeding tubes placed fluoroscopically. Within 36 hours of injury, they received nutritional support equal to their measured resting energy expenditure. The control (C) group was fed gastrically when bowel sounds returned. There were no significant differences (P greater than 0.05) in age, Glasgow Coma Scale score, type of neurological injury, or associated injuries between the two groups. The mean resting energy expenditure, serum albumin, glucose, lymphocyte count, body weight, and total nitrogen loss were nearly identical for both groups. With the jejunal feedings, daily caloric (E = 2102 kcal versus C = 1100 kcal) and nitrogen intake (E = 11.1 g versus C = 5.6 g) and daily nitrogen balance (E = -4.3 g versus C = -11.8 g) improved. The incidence of bacterial infections (E = 3 versus C = 14) and days of intensive care unit hospitalization (E = 6 versus C = 10) were significantly reduced (P less than .05). Head-injured patients will tolerate early jejunal hyperalimentation despite the presence of a clinically silent abdomen, and the cost and complications of total parenteral nutrition are avoided. The increased caloric and nitrogen intake and improved nitrogen retention markedly reduced infections and days of stay in the intensive care unit.

Nutritional support and neurotrauma: a critical review of early nutrition in forty-five acute head injury patients

Forty-five acute head trauma patients were randomized into a neurotrauma nutritional study to compare the efficacy of two forms of standard nutritional supplementation; namely total parenteral nutrition (TPN) versus enteral nutrition (NG). Forty patients were male, 5 were female, with a median age of 28 years. The mean admitting Glasgow coma scale score was 5.8. Patients were given high calorie and nitrogen feedings for the 14 days of the study period in an attempt to achieve positive calorie and nitrogen balance. TPN patients had significantly higher mean daily nitrogen intakes (P less than 0.01) and mean daily nitrogen losses (P less than 0.001) than the NG fed patients; however, no significant differences were discovered with respect to maintenance of serum albumin levels, weight loss, the incidence of infection, nitrogen balance, and final outcome. The exaggerated nitrogen excretion experienced by patients fed large nitrogen loads illustrates a problem in achieving nitrogen equilibrium in acute head injured patients.

Multiple trauma associated with vertebral injury

Three hundred twenty-two vertebral fractures in multiply injured patients are reviewed. Associated general trauma was usually found to be regionalized to the same area of the body as the spinal injury. The exceptions were pelvic and sacral fractures, which were associated with more diffuse organ injury and multiple vertebral fractures.

Influence of the type of intracranial lesion on outcome from severe head injury

✓ Recent studies attempting to define the outcome from severe head injury have implied, directly or indirectly, that the severity of injury (as determined by the Glasgow Coma Scale (GSC)) is the sole determinant of outcome. Little attention has been focused on the type of lesion that causes the low GCS score, and there exists an unstated hypothesis that the lesion type is not an important determinant of outcome. No attempt has been made to determine whether patients who have the same GCS score caused by different lesions have the same or different outcomes. Since this is impossible to test without a large number of cases, data were obtained from seven head-injury centers on patients who fulfilled the Glasgow criteria for severe head injury (GCS ≤ 8 for at least 6 hours). Patients were categorized according to a simple classification system comprising seven lesion types, each of which was further subdivided into two GCS score ranges (3 to 5 and 6 to 8). Of 1107 patients, the overall mortality was 41%, but ranged from 9% to 74% among the different lesion categories. Conversely, 26% had good recovery (at 3 months), but among the different lesion groups the range was 6% to 68%. Acute subdural hematoma with GCS scores of 3 to 5 was uniformly the worst problem (74% mortality and 8% good recovery), whereas diffuse injury coma of 6 to 24 hours with GCS scores of 6 to 8 had 9% mortality and 68% incidence of good recovery. Results of this study demonstrate marked heterogeneity within this severe head-injury group and point out that patients with the same GCS score have markedly different outcomes, depending on the causative lesion. The type of lesion is thus as important a factor in determining outcome as is the GCS score, and both must be considered when describing severely head-injured patients.

Oxygen availability in ischemic brain following hypocarbia and hypercarbia. Polarographical depth electrode recordings in evolving and completed experimental stroke in the monkey

Acutely implanted oxygen-recording polarographical depth electrodes were used to appraise changes in oxygen availability (O 2 a) in the brain of the Rhesus monkey. Modifications of oxygen availability induced by hypocarbia and hypercarbia in the normal and the infarcted brain are described. The most consistent finding was a reversal of the expected effects of low and high Paco 2 values during the acutely ischemic period (evolving stroke) and an incomplete return to the normal response by five days (completed stroke).

Cerebral microangiography after hypocarbia and hypercarbia. Demonstration of deep vascular changes produced by Pa CO2 variations in the normal and ischemic brain of the rhesus monkey

Ischemic infarction was obtained in the basal ganglia and internal capsule of the Rhesus monkey by clipping the middle cerebral artery at its origin through a transorbital approach.

The postmortem microvasculature was demonstrated using microtized barium (Micropaque) and soft x-ray technology. The effects on this microvasculature induced by antemortem variations in Pa co co2 in tne normal and the acutely infarcted animal were studied. Microangiography was shown to be useful in the study of dynamic vascular changes in the deep structures of the ischemic brain.