Intraoperative neurophysiological monitoring and spinal cord stimulator implantation

INTRODUCTION

Spinal cord injury (SCI) is one of the most dreaded complications after spinal cord stimulation (SCS) implantation surgery. As a result, intraoperative neurophysiological monitoring (IONM) has been proposed to avoid accidental damage to nervous structures under anesthesia and confirm positioning for optimal stimulation. Our study uses a large administrative claims database to determine the 30-day risk of SCI after SCS implantation.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial and Medicare Supplemental Databases from 2016 to 2019. Adult patients undergoing SCS surgical procedures with at least 90 days of follow-up, IONM use, the type of sedation used during the procedure, and subsequent SCI were identified using administrative codes. In addition, logistic regression was used to examine the relationship between various risk factors and subsequent SCI.

RESULTS

A total of 9676 patients underwent SCS surgery (64.7% percutaneous implants) during the study period. Nine hundred and forty-four (9.75%) patients underwent SCS implantation with IONM. Conscious sedation, Monitored Anesthesia Care anesthesia, and general anesthesia were used in patients with 0.9%, 60.2%, and 28.6%, respectively. Eighty-one (0.8%) patients developed SCI within 30 days after SCS implant surgery. The SCI rate was higher in the group that underwent IONM (2% vs 0.7%, p value <0.001) during the implantation procedure, reflecting the underlying risk. After adjustment for other factors, the OR of SCI is 2.39 (95% CI: 1.33 to 4.14, p value=0.002) times higher for those with IONM than those without IONM.

CONCLUSIONS

Increased SCI risk among patients with IONM likely reflects higher baseline risk, and further research is needed for risk mitigation.

REPORT-SCS: minimum reporting standards for spinal cord stimulation studies in spinal cord injury

Objective.Electrical spinal cord stimulation (SCS) has emerged as a promising therapy for recovery of motor and autonomic dysfunctions following spinal cord injury (SCI). Despite the rise in studies using SCS for SCI complications, there are no standard guidelines for reporting SCS parameters in research publications, making it challenging to compare, interpret or reproduce reported effects across experimental studies.Approach.To develop guidelines for minimum reporting standards for SCS parameters in pre-clinical and clinical SCI research, we gathered an international panel of expert clinicians and scientists. Using a Delphi approach, we developed guideline items and surveyed the panel on their level of agreement for each item.Main results.There was strong agreement on 26 of the 29 items identified for establishing minimum reporting standards for SCS studies. The guidelines encompass three major SCS categories: hardware, configuration and current parameters, and the intervention.Significance.Standardized reporting of stimulation parameters will ensure that SCS studies can be easily analyzed, replicated, and interpreted by the scientific community, thereby expanding the SCS knowledge base and fostering transparency in reporting.

Neural signal data collection and analysis of Percept™ PC BrainSense recordings for thalamic stimulation in epilepsy

Deep brain stimulation (DBS) using Medtronic's Percept™ PC implantable pulse generator is FDA-approved for treating Parkinson's disease (PD), essential tremor, dystonia, obsessive compulsive disorder, and epilepsy. Percept™ PC enables simultaneous recording of neural signals from the same lead used for stimulation. Many Percept™ PC sensing features were built with PD patients in mind, but these features are potentially useful to refine therapies for many different disease processes. When starting our ongoing epilepsy research study, we found it difficult to find detailed descriptions about these features and have compiled information from multiple sources to understand it as a tool, particularly for use in patients other than those with PD. Here we provide a tutorial for scientists and physicians interested in using Percept™ PC's features and provide examples of how neural time series data is often represented and saved. We address characteristics of the recorded signals and discuss Percept™ PC hardware and software capabilities in data pre-processing, signal filtering, and DBS lead performance. We explain the power spectrum of the data and how it is shaped by the filter response of Percept™ PC as well as the aliasing of the stimulation due to digitally sampling the data. We present Percept™ PC's ability to extract biomarkers that may be used to optimize stimulation therapy. We show how differences in lead type affects noise characteristics of the implanted leads from seven epilepsy patients enrolled in our clinical trial. Percept™ PC has sufficient signal-to-noise ratio, sampling capabilities, and stimulus artifact rejection for neural activity recording. Limitations in sampling rate, potential artifacts during stimulation, and shortening of battery life when monitoring neural activity at home were observed. Despite these limitations, Percept™ PC demonstrates potential as a useful tool for recording neural activity in order to optimize stimulation therapies to personalize treatment.

Low-frequency deep brain stimulation reveals resonant beta-band evoked oscillations in the pallidum of Parkinson's Disease patients

Introduction

Evidence suggests that spontaneous beta band (11-35 Hz) oscillations in the basal ganglia thalamocortical (BGTC) circuit are linked to Parkinson's disease (PD) pathophysiology. Previous studies on neural responses in the motor cortex evoked by electrical stimulation in the subthalamic nucleus have suggested that circuit resonance may underlie the generation of spontaneous and stimulation-evoked beta oscillations in PD. Whether these stimulation-evoked, resonant oscillations are present across PD patients in the internal segment of the globus pallidus (GPi), a primary output nucleus in the BGTC circuit, is yet to be determined.

Methods

We characterized spontaneous and stimulation-evoked local field potentials (LFPs) in the GPi of four PD patients (five hemispheres) using deep brain stimulation (DBS) leads externalized after DBS implantation surgery.

Results

Our analyses show that low-frequency (2-4 Hz) stimulation in the GPi evoked long-latency (>50 ms) beta-band neural responses in the GPi in 4/5 hemispheres. We demonstrated that neural sources generating both stimulation-evoked and spontaneous beta oscillations were correlated in their frequency content and spatial localization.

Discussion

Our results support the hypothesis that the same neuronal population and resonance phenomenon in the BGTC circuit generates both spontaneous and evoked pallidal beta oscillations. These data also support the development of closed-loop control systems that modulate the GPi spontaneous oscillations across PD patients using beta band stimulation-evoked responses.

Cardiovascular Effects of Spinal Cord Stimulation: The Highs, the Lows, and the Don't Knows

BACKGROUND AND OBJECTIVES

There are many potential etiologies of impaired cardiovascular control, from chronic stress to neurodegenerative conditions or central nervous system lesions. Since 1959, spinal cord stimulation (SCS) has been reported to modulate blood pressure (BP), heart rate (HR), and HR variability (HRV), yet the specific stimulation sites and parameters to induce a targeted cardiovascular (CV) change for mitigating abnormal hemodynamics remain unclear. To investigate the ability and parameters of SCS to modulate the CV, we reviewed clinical studies using SCS with reported HR, BP, or HRV findings.

MATERIALS AND METHODS

A keyword-based electronic search was conducted through MEDLINE, Embase, and PubMed data bases, last searched on February 3, 2023. Inclusion criteria were studies with human participants receiving SCS with comparison with SCS turned off, with reporting of either HR, HRV, or BP findings. Non-English studies, conference abstracts, and studies not reporting standalone effects of SCS when comparing SCS with non-SCS interventions were excluded. Results were plotted for visual analysis. When available, participant-specific stimulation parameters and effects were extracted and quantitatively analyzed using ordinary least squares regression.

RESULTS

A total of 59 studies were included in this review; 51 studies delivered SCS invasively through implanted/percutaneous leads. Eight studies used noninvasive, transcutaneous electrodes. We found numerous reports of cervical, high thoracic, and mid-to-low thoracolumbar SCS increasing resting BP, and cervical/mid-to-low thoracolumbar SCS decreasing BP. The effect of SCS location on HR and HRV was equivocal. We were unable to analyze stimulation parameters owing to inadequate parameter reporting in many publications.

CONCLUSIONS

Our findings suggest CV neuromodulation, particularly BP modulation, with SCS to be a promising frontier. Further research with larger randomized controlled trials and detailed reporting of SCS parameters will be necessary for appropriate evaluation of SCS as a CV therapy.

Effect of epidural spinal cord stimulation on female sexual function after spinal cord injury

Sexual dysfunction is a common consequence for women with spinal cord injury (SCI); however, current treatments are ineffective, especially in the under-prioritized population of women with SCI. This case-series, a secondary analysis of the Epidural Stimulation After Neurologic Damage (E-STAND) clinical trial aimed to investigate the effect of epidural spinal cord stimulation (ESCS) on sexual function and distress in women with SCI. Three females, with chronic, thoracic, sensorimotor complete SCI received daily (24 h/day) tonic ESCS for 13 months. Questionnaires, including the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS) were collected monthly. There was a 3.2-point (13.2%) mean increase in total FSFI from baseline (24.5 ± 4.1) to post-intervention (27.8 ± 6.6), with a 4.8-50% improvement in the sub-domains of desire, arousal, orgasm and satisfaction. Sexual distress was reduced by 55%, with a mean decrease of 12 points (55.4%) from baseline (21.7 ± 17.2) to post-intervention (9.7 ± 10.8). There was a clinically meaningful change of 14 points in the International Standards for Neurological Classification of Spinal Cord Injury total sensory score from baseline (102 ± 10.5) to post-intervention (116 ± 17.4), without aggravating dyspareunia. ESCS is a promising treatment for sexual dysfunction and distress in women with severe SCI. Developing therapeutic interventions for sexual function is one of the most meaningful recovery targets for people with SCI. Additional large-scale investigations are needed to understand the long-term safety and feasibility of ESCS as a viable therapy for sexual dysfunction. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03026816, NCT03026816.

Learning signatures of decision making from many individuals playing the same game

Human behavior is incredibly complex and the factors that drive decision making-from instinct, to strategy, to biases between individuals-often vary over multiple timescales. In this paper, we design a predictive framework that learns representations to encode an individual's 'behavioral style', i.e. long-term behavioral trends, while simultaneously predicting future actions and choices. The model explicitly separates representations into three latent spaces: the recent past space, the short-term space, and the long-term space where we hope to capture individual differences. To simultaneously extract both global and local variables from complex human behavior, our method combines a multi-scale temporal convolutional network with latent prediction tasks, where we encourage embeddings across the entire sequence, as well as subsets of the sequence, to be mapped to similar points in the latent space. We develop and apply our method to a large-scale behavioral dataset from 1,000 humans playing a 3-armed bandit task, and analyze what our model's resulting embeddings reveal about the human decision making process. In addition to predicting future choices, we show that our model can learn rich representations of human behavior over multiple timescales and provide signatures of differences in individuals.

Learning signatures of decision making from many individuals playing the same game

Human behavior is incredibly complex and the factors that drive decision making--from instinct, to strategy, to biases between individuals--often vary over multiple timescales. In this paper, we design a predictive framework that learns representations to encode an individual's 'behavioral style', i.e. long-term behavioral trends, while simultaneously predicting future actions and choices. The model explicitly separates representations into three latent spaces: the recent past space, the short-term space, and the long-term space where we hope to capture individual differences. To simultaneously extract both global and local variables from complex human behavior, our method combines a multi-scale temporal convolutional network with latent prediction tasks, where we encourage embeddings across the entire sequence, as well as subsets of the sequence, to be mapped to similar points in the latent space. We develop and apply our method to a large-scale behavioral dataset from 1,000 humans playing a 3-armed bandit task, and analyze what our model's resulting embeddings reveal about the human decision making process. In addition to predicting future choices, we show that our model can learn rich representations of human behavior over multiple timescales and provide signatures of differences in individuals.

Image-Guided Measurement of Radiation Force Induced by Focused Ultrasound Beams

The radiation force balance (RFB) is a widely used method for measuring acoustic power output of ultrasonic transducers. The reflecting cone target is attractive due to its simplicity and long-term stability, at a reasonable cost. However, accurate measurements using this method depend on the alignment between the ultrasound beam and cone axes, especially for highly focused beams utilized in therapeutic applications. With the advent of dual-mode ultrasound arrays (DMUAs) for imaging and therapy, image-guided measurements of acoustic output using the RFB method can be used to improve measurement accuracy. In this article, we describe an image-guided RFB measurement of focused DMUA beams using a widely used commercial instrument. DMUA imaging is used to optimize the alignment between the acoustic beam and reflecting cone axes. In addition to image-guided alignment, DMUA echo data is used to track the displacement of the cone, which provides an auxiliary measurement of acoustic power. Experimental results using a DMUA prototype with [Formula: see text] shows that 1-2 mm of misalignment can result in 5%-14% error in the measured acoustic power. In addition to the use of B-mode image guidance for improving measurement accuracy, we present preliminary results demonstrating the benefit of displacement tracking using real-time DMUA imaging during the application of (sub)therapeutic focused beams. Displacement tracking provides a direct measurement of the radiation force with high sensitivity and follows the expected dependence on changes in amplitude and duty cycle (DC) of the focused ultrasound (FUS) beam. This could lead to simpler, more reliable methods for measuring acoustic power based on the radiation force principle. Combined with appropriate computational modeling, the direct measurement of acoustic radiation force could lead to reliable dosimetry in situ in emerging applications such as transcranial FUS (tFUS) therapies.

Advances in Epidural Spinal Cord Stimulation to Restore Function after Spinal Cord Injury: History and Systematic Review

Epidural spinal cord stimulation (eSCS) has been recently recognized as a potential therapy for chronic spinal cord injury (SCI). eSCS has been shown to uncover residual pathways within the damaged spinal cord. The purpose of this review is to summarize the key findings to date regarding the use of eSCS in SCI. Searches were carried out using MEDLINE, EMBASE, and Web of Science database and reference lists of the included articles. A combination of medical subject heading terms and keywords was used to find studies investigating the use of eSCS in SCI patients to facilitate volitional movement and to restore autonomic function. The risk of bias was assessed using Risk Of Bias In Non-Randomized Studies of Interventions tool for nonrandomized studies. We were able to include 40 articles that met our eligibility criteria. The studies included a total of 184 patient experiences with incomplete or complete SCI. The majority of the studies used the Medtronic 16 paddle lead. Around half of the studies reported lead placement between T11- L1. We included studies that assessed motor (n = 28), autonomic (n = 13), and other outcomes (n = 10). The majority of the studies reported improvement in outcomes assessed. The wide range of included outcomes demonstrates the effectiveness of eSCS in treating a diverse SCI population. However, the current studies cannot definitively conclude which patients benefit the most from this intervention. Further study in this area is needed to allow improvement of the eSCS technology and allow it to be more widely available for chronic SCI patients.

Controlling pallidal oscillations in real-time in Parkinson's disease using evoked interference deep brain stimulation (eiDBS): Proof of concept in the human

Approaches to control basal ganglia neural activity in real-time are needed to clarify the causal role of 13-35 Hz ("beta band") oscillatory dynamics in the manifestation of Parkinson's disease (PD) motor signs. Here, we show that resonant beta oscillations evoked by electrical pulses with precise amplitude and timing can be used to predictably suppress or amplify spontaneous beta band activity in the internal segment of the globus pallidus (GPi) in the human. Using this approach, referred to as closed-loop evoked interference deep brain stimulation (eiDBS), we could suppress or amplify frequency-specific (16-22 Hz) neural activity in a PD patient. Our results highlight the utility of eiDBS to characterize the role of oscillatory dynamics in PD and other brain conditions, and to develop personalized neuromodulation systems.

Procedure-Related Outcomes Including Readmission Following Spinal Cord Stimulator Implant Procedures: A Retrospective Cohort Study

BACKGROUND

Spinal cord stimulation (SCS) has been shown to reduce opioid consumption, reduce pain, improve quality of life compared to conventional therapy, and be more effective than spine reoperation in carefully selected patients. In this study, we evaluate readmissions after SCS implantation procedures, costs, predictors, and etiologies for readmission following implantation procedures.

METHODS

The study was a retrospective cohort using the National Readmissions Database from 2013 to 2017. Administrative billing codes were used to identify patients undergoing SCS implantation procedures. The primary outcome of our study was 30-day readmission following the SCS implantation procedure. Continuous outcomes were compared between groups using the Student t test or Wilcoxon rank sum test. In addition, multivariable predictors of 30-day readmission were assessed by hierarchical logistic regression analysis.

RESULTS

A total of 3737 (26.7% open surgical SCS implants [OS-SCS]) individuals admitted to the hospital for SCS implantation were included in the final cohort analysis. The cohort consisted of predominantly female patients (58.71%) and in the 50- to 64-year age group (35.46%). Patients who underwent open surgical SCS implantation had a longer length of stay during the initial admission and a higher 30-day readmission rate (9.4% vs 7% P = .01). OS-SCS, older age, lower socioeconomic status, patients with specific comorbidities (ie, hypertension or chronic obstructive pulmonary disease [COPD]), and home discharge are associated with readmission.

CONCLUSIONS

Readmission rates after SCS implantation are around 7.7% in the United States. Infection and postoperative complications remain the top etiologies for readmission. Open surgical SCS implantation is associated with more extended initial hospitalization and a higher rate of readmission when compared to percutaneous SCS implantation procedures.

Optimization of Spinal Cord Stimulation Using Bayesian Preference Learning and Its Validation

Epidural spinal cord stimulation has been reported to partially restore volitional movement and autonomic functions after motor and sensory-complete spinal cord injury (SCI). Modern spinal cord stimulation platforms offer significant flexibility in spatial and temporal parameters of stimulation delivered. Heterogeneity in SCI and injury-related symptoms necessitate stimulation personalization to maximally restore functions. However, the large multi-dimensional stimulation space makes exhaustive tests impossible. In this paper, we present a Bayesian optimization strategy for identifying personalized optimal stimulation patterns based on the participant's expressed preference for stimulation settings. We present companion validation protocols for investigating the credibility of learned preference models. The results obtained for five participants in the E-STAND spinal cord stimulation clinical trial are reported. Personalized preference models produced by the proposed learning and optimization algorithm show that there is more similarity in optimal frequency than in pulse width across participants. Across five participants, the average model prediction accuracy is 71.5% in internal cross-validation and 65.6% in prospective validation. Statistical tests of both validation studies show that the ability of the preference models to correctly predict unseen preference data is significantly greater than chance. The personalized preference models are also shown to be significantly correlated with motor task performance across participants. We show that several aspects in participants' quality of life has been improved over the course of the trial. Overall, the results indicate that the Bayesian preference optimization algorithm could assist clinicians in the systematic programming of individualized therapeutic stimulation settings and improve the therapeutic outcomes.

Long-Term Spinal Cord Stimulation After Chronic Complete Spinal Cord Injury Enables Volitional Movement in the Absence of Stimulation

Background: Chronic spinal cord injury (SCI) portends a low probability of recovery, especially in the most severe subset of motor-complete injuries. Active spinal cord stimulation with or without intensive locomotor training has been reported to restore movement after traumatic SCI. Only three cases have been reported where participants developed restored volitional movement with active stimulation turned off after a period of chronic stimulation and only after intensive rehabilitation with locomotor training. It is unknown whether restoration of movement without stimulation is possible after stimulation alone.

Objective: We describe the development of spontaneous volitional movement (SVM) without active stimulation in a subset of participants in the Epidural Stimulation After Neurologic Damage (ESTAND) trial, in which locomotor training is not prescribed as part of the study protocol, and subject’s rehabilitation therapies are not modified.

Methods: Volitional movement was evaluated with the Brain Motor Control Assessment using sEMG recordings and visual examination at baseline and at follow-up visits with and without stimulation. Additional functional assessment with a motor-assisted bicycle exercise at follow-up with and without stimulation identified generated work with and without effort.

Results: The first seven participants had ASIA Impairment Scale (AIS) A or B thoracic SCI, a mean age of 42 years, and 7.7 years post-injury on average. Four patients developed evidence of sustained volitional movement, even in the absence of active stimulation after undergoing chronic epidural spinal cord stimulation (eSCS). Significant increases in volitional power were found between those observed to spontaneously move without stimulation and those unable (p < 0.0005). The likelihood of recovery of spontaneous volitional control was correlated with spasticity scores prior to the start of eSCS therapy (p = 0.048). Volitional power progressively improved over time (p = 0.016). Additionally, cycling was possible without stimulation (p < 0.005).

Conclusion: While some SVM after eSCS has been reported in the literature, this study demonstrates sustained restoration without active stimulation after long-term eSCS stimulation in chronic and complete SCI in a subset of participants. This finding supports previous studies suggesting that “complete” SCI is likely not as common as previously believed, if it exists at all in the absence of transection and that preserved pathways are substrates for eSCS-mediated recovery in clinically motor-complete SCI.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03026816.

Factors Influencing Electrode Position and Bending of the Proximal Lead in Deep Brain Stimulation for Movement Disorders

BACKGROUND

The introduction of intracranial air (ICA) during deep brain stimulation (DBS) surgery is thought to have a negative influence on targeting and clinical outcomes.

OBJECTIVE

To investigate ICA volumes following surgery and other patient-specific factors as potential variables influencing translocation of the DBS electrode and proximal lead bowing.

METHODS

High-resolution postoperative computed tomography scans (≤1.0 mm resolution in all directions) within 24 h following DBS surgery and 4-6 weeks of follow-up were acquired. A total of 50 DBS leads in 33 patients were available for analysis. DBS leads included Abbott/St. Jude Medical InfinityTM, Boston Scientific VerciseTM, and Medtronic 3389TM.

RESULTS

Both ICA volume and anatomical target were significantly associated with measures of DBS electrode translocation. ICA volume and DBS lead model were found to be significant predictors of proximal lead bowing. Measures of proximal lead bowing and translocation along the electrode trajectory for the Medtronic 3389TM DBS lead were significantly larger than measures for the Abbott/St. Jude Medical InfinityTM and Boston Scientific VerciseTM DBS leads.

CONCLUSION

The association between ICA volume and translocation of the DBS electrode is small in magnitude and not clinically relevant for DBS cases within a normal range of postoperative subdural air volumes. Differences in proximal lead bowing observed between DBS leads may reflect hardware engineering subtleties in the construction of DBS lead models.

Epidural Spinal Cord Stimulation Facilitates Immediate Restoration of Dormant Motor and Autonomic Supraspinal Pathways after Chronic Neurologically Complete Spinal Cord Injury

Epidural Spinal Cord Stimulation (eSCS) in combination with extensive rehabilitation has been reported to restore volitional movement in a select group of subjects after motor-complete spinal cord injury (SCI). Numerous questions about the generalizability of these findings to patients with longer term SCI have arisen, especially regarding the possibility of restoring autonomic function. To better understand the effect of eSCS on volitional movement and autonomic function, two female participants five and 10 years after injury at ages 48 and 52, respectively, with minimal spinal cord preservation on magnetic resonance imaging were implanted with an eSCS system at the vertebral T12 level. We demonstrated that eSCS can restore volitional movement immediately in two female participants in their fifth and sixth decade of life with motor and sensory-complete SCI, five and 10 years after sustaining severe radiographic injuries, and without prescribed or significant pre-habilitation. Both patients experienced significant improvements in surface electromyography power during a volitional control task with eSCS on. Cardiovascular function was also restored with eSCS in one participant with cardiovascular dysautonomia using specific eSCS settings during tilt challenge while not affecting function in a participant with normal cardiovascular function. Orgasm was achieved for the first time since injury in one participant with and immediately after eSCS. Bowel-bladder synergy improved in both participants while restoring volitional urination in one with eSCS. While numerous questions remain, the ability to restore some supraspinal control over motor function below the level of injury, cardiovascular function, sexual function, and bowel and bladder function should promote intense efforts to investigate and develop optimization strategies to maximize recovery in all participants with chronic SCI.

New developments in the diagnostics for the fusion products on JET in preparation for ITER (invited)

Notwithstanding the advances of the past decades, significant developments are still needed to satisfactorily diagnose “burning plasmas.” D–T plasmas indeed require a series of additional measurements for the optimization and control of the configuration: the 14 MeV neutrons, the isotopic composition of the main plasma, the helium ash, and the redistribution and losses of the alpha particles. Moreover a burning plasma environment is in general much more hostile for diagnostics than purely deuterium plasmas. Therefore, in addition to the development and refinement of new measuring techniques, technological advances are also indispensable for the proper characterization of the next generation of devices. On JET an integrated program of diagnostic developments, for JET future and in preparation for ITER, has been pursued and many new results are now available. In the field of neutron detection, the neutron spectra are now routinely measured in the energy range of 1–18 MeV by a time of flight spectrometer and they have allowed studying the effects of rf heating on the fast ions. A new analysis method for the interpretation of the neutron cameras measurements has been refined and applied to the data of the last trace tritium campaign (TTE). With regard to technological upgrades, chemical vapor deposition diamond detectors have been qualified both as neutron counters and as neutron spectrometers, with a potential energy resolution of about one percent. The in situ calibration of the neutron diagnostics, in preparation for the operation with the ITER-like wall, is also promoting important technological developments. With regard to the fast particles, for the first time the temperature of the fast particle tails has been obtained with a new high purity Germanium detector measuring the gamma emission spectrum from the plasma. The effects of toroidal Alfven eigenmodes modes and various MHD instabilities on the confinement of the fast particles have been determined with a combination of gamma ray cameras, neutral particle analyzers, scintillator probe, and Faraday cups. From a more technological perspective, various neutron filters have been tested to allow measurement of the gamma ray emission also at high level of neutron yield.

The anomalous currents in the front foils of the JET lost alpha diagnostic KA-2

We have examined the observed currents in the front foils of the JET Faraday cup lost alpha particle diagnostic KA-2. In particular, we have sought to understand the currents during Ohmic plasmas for which the ion flux at the detectors was initially assumed to be negligible. We have considered two sources of this current: plasma ions (both deuterium and impurity) in the vicinity of the detector (including charge exchange neutrals) and photoemission from scattered UV radiation. Based upon modeling and empirical observation, the latter source appears most likely and, moreover, seems to be applicable to the currents in the front foil during ELMy H-mode plasmas. A very thin gold or nickel foil attached to the present detector aperture is proposed as a solution to this problem, and realistic calculations of expected fluxes of lost energetic neutral beam ions during TF ripple experiments are presented as justification of this proposed solution.

Neonatal Upper Airway Obstruction in Osteogenesis Imperfecta: Series of Three Cases and Review of the Literature

Objectives:

Osteogenesis imperfecta (OI) is a genetic disorder characterized by variable degrees of dysfunction in type I collagen formation. We sought to explore an association between OI and upper airway obstruction (UAO) in light of our recent experience.

Methods:

We performed a retrospective chart audit and a review of the literature.

Results:

Three consecutive cases of OI at our institution required otolaryngological evaluation for UAO. The first patient had the mildest mutation type and did well until he developed severe reflux-triggered laryngospasm that improved with Nissen fundoplication and gastrostomy tube placement. He had mild hypotonia on endoscopy. The second patient had severe OI and the greatest acute fracture burden at birth. He required tracheotomy after early respiratory failure, and some mild bronchomalacia was noted. The third patient had severe OI and underwent cesarean section delivery. She developed respiratory failure after 1 month, requiring tracheotomy; mild tracheomalacia and glottic narrowing were noted on endoscopy.

Conclusions:

The UAO consisted of mild hypotonia or malacia in 3 consecutive cases of OI, and may have contributed to pulmonary and mechanical causes of tracheotomy requirement. The greatest predictors of tracheotomy requirement appear to be the severity of the OI mutation and the fracture burden. Elective cesarean section should be considered in severe cases of OI.

Impact of Pneumococcal Polysaccharide Vaccine (Prevnar) on Middle Ear Fluid in Children Undergoing Tympanostomy Tube Insertion

OBJECTIVES

The purpose of this study was to describe the bacteriology of middle ear effusions in children who have received the pneumococcal polysaccharide vaccine (Prevnar) compared with unvaccinated children.

METHODS

A prospective review of medical records from July 2001 to July 2002 was conducted on children with middle ear effusion at time of tympanostomy tube insertion. Middle ear fluid was plated onto culture media immediately after acquisition, and antimicrobial resistance of cultured organisms along with serotyping of Streptococcus pneumoniae was examined. Vaccination status, demographics, and risk factors were determined from patients' medical records, parent interviews, or contact with their primary care physicians.

RESULTS

After adjusting for age and number of previous infections, children vaccinated with Prevnar are two times less likely to have non-S. pneumoniae pathogenic bacteria isolated than children not vaccinated. Of those with growth, vaccinated children were almost three times more likely than nonvaccinated children to have the presence of H. influenzae. Vaccinated children with H. influenzae were 7.5 times less likely to have beta-lactamase producing H. influenzae than nonvaccinated children with H. influenzae.

CONCLUSION

Because the incidence of S. pneumoniae was low, no inference could be made whether Prevnar decreased otitis media with effusion or recurrent acute otitis caused by the S. pneumoniae serotypes covered by the vaccine. However, vaccinated children did appear to have the unexpected benefit of having a certain level of protection to growth of typical acute otitis media pathogens.

Observation of compressional Alfvén modes during neutral-beam heating on the national spherical torus experiment

Neutral-beam-driven compressional Alfvén eigenmodes at frequencies below the ion cyclotron frequency have been observed and identified for the first time in the National Spherical Torus Experiment. The modes are observed as a broad spectrum of nearly equally spaced peaks in the frequency range from approximately 0.2omega(ci) to approximately 1.2omega(ci). The frequency has a scaling with toroidal field and plasma density consistent with Alfvén waves. The modes have been observed with high bandwidth magnetic pickup coils and with a reflectometer.

Endobronchial tumors in children: an uncommon clinical entity

We performed a retrospective chart review of 10 children in whom endobronchial tumors were diagnosed in a tertiary-care children's medical center from 1988 to 1998. Of the 10 patients, 6 were male and 4 were female (8 white, 1 Hispanic, 1 African American). The mean age at presentation was 5.2 years. Eight tumors were benign, and 2 were malignant; 4 were on the right side, 3 were on the left side, and 3 were bilateral. Histologic findings included 3 bronchial papillomas, 3 inflammatory masses, 1 endobronchial hemangioma, 1 leiomyoma, 1 mucoepidermoid carcinoma, and 1 bronchial carcinoid. Endobronchial tumors in children are a rare disorder. The diagnosis requires a high index of suspicion in children with atypical or chronic respiratory complaints. Newer adjuvant medical therapies and surgical innovations offer improved disease control in these patients, and a multidisciplinary approach is often warranted.

Benzo(a)pyrene enhances atherosclerosis in White Carneau and Show Racer pigeons

Benzo(a)pyrene (BaP), a major environmental pollutant and component of cigarette smoke, is both carcinogenic and atherogenic in experimental models. We investigated the effect of long-term administration of BaP on atherogenesis in both atherosclerosis-susceptible White Carneau (WC) and atherosclerosis-resistant Show Racer (SR) pigeons. The number and size of arterial lesions in the brachiocephalic arteries in WC and SR females but not males were significantly enhanced after long-term dosing with BaP. Metabolic activation appears to be required for BaP atherogenicity, since benzo(e)pyrene (BeP), a noncarcinogenic analogue of BaP, did not enhance lesion development. Studies with 3H-BaP revealed no significant differences between male and female or between WC and SR pigeons in the arterial distribution of BaP and/or its metabolites. There were no consistent differences in blood pressure or plasma cholesterol levels between breeds or sexes. However, chronic administration of BaP did result in complete infertility in female birds, concomitant with grossly visible changes in ovarian appearance. These results clearly show that long-term dosing with BaP alters ovarian structure and function in treated birds, at the same time aggravating the development of arterial lesions. Thus, BaP-induced atherogenicity in female pigeons may be a consequence of an alteration in estrogen production or of antiestrogenic properties of BaP at the level of the arterial wall and may serve as a highly useful animal model to examine the well-known rapid development of atherosclerosis in postmenopausal women.

The dangers of dairy farming: the injury experience of 600 workers followed for two years

In order to better understand the work-related injuries sustained on central New York dairy farms, we undertook a two-year population-based study of 600 farmers and farm workers on 201 dairy farms. During the observation period, 1984-1986, 151 persons had 200 injuries, giving an injury rate of 16.6%/year (166 injuries/1,000 workers/year). Men were injured more often than women (p less than or equal to 0.01). Injured workers were older (p less than or equal to 0.01), worked more hours (p less than or equal to 0.001), and had heavier workloads than noninjured workers (p less than or equal to 0.001). The growing and harvest seasons had the most injuries; winter the fewest. More than 2/3 of the injuries occurred in the afternoon. Owners/operators, often the most experienced, knowledgeable people on the farms, were most often hurt. Those working more than 60 hours/week, with greater than 30 acres under tillage/worker, had a relative risk of 2.76 compared with all other workers. The attributable risk for this group was 51%. There were two fatalities, both involved owner/operators. Our findings suggest that previous studies may have underestimated the risks faced by farmers. Dairy farming in central New York is very dangerous work. Those who own and operate these dairy farms are most often hurt and killed. Analysis of events on individual farms will be reported separately.

Behavioral changes correlated with brain-stem auditory evoked responses in term infants with moderate hyperbilirubinemia

The purpose of this study was to test the hypotheses that newborn infants with moderate serum bilirubin concentrations have depressed Brazelton scores and increased brain-stem conduction time and that serum bilirubin levels correlate with Brazelton behavior scores and brain-stem auditory evoked response changes. Fifty term infants who were enrolled into either a low serum bilirubin group (less than 8 mg/dl) or a moderate serum bilirubin group (10 to 20 mg/dl) were tested with the Brazelton Neonatal Behavioral Assessment Scale and a brain-stem auditory evoked response test. Partial correlation analysis controlling for phototherapy revealed that increased bilirubin concentration correlated negatively with the Brazelton orientation and with state range clusters and individual Brazelton test items that involve auditory processing. Increased bilirubin concentration correlated with an increased latency of brain-stem auditory evoked response wave 4, 5. An increased interpeak 1-5 (brain-stem conduction time) correlated with the decreased animate visual and auditory item. We conclude that moderate hyperbilirubinemia in term infants affects both infant behavior, as measured by specific components of the Brazelton test, and brain-stem conduction time, as measured by the brain-stem auditory evoked response test.

Organic dust toxicity (pulmonary mycotoxicosis) associated with silo unloading

An acute febrile illness associated with unloading silos occurs more frequently than any other farm associated respiratory illness in mid state New York. This report describes 29 cases of organic dust toxic syndrome (also known as pulmonary mycotoxicosis) occurring in 24 men and one woman with a mean age of 29 years. In 16 instances more than one worker was exposed to the dust, and in 12 of these shared exposures more than one worker became ill. Patients presented 5.3 (SD 3.3) hours after inhalation of organic dust and mould with fever (79%), myalgia (76%), chest tightness (72%), cough (66%), and headache (59%). The mean temperature was 38.7 degrees C and the mean white blood cell count 13.2 X 10(9)/l. In contrast to patients with allergic alveolitis, nearly all these patients had normal breath sounds, chest radiographs, and arterial oxygen saturation. Tests for precipitating antibodies to farmer's lung disease antigens gave negative results in all 26 episodes in which they were done; of these, 10 had no evidence of precipitating antibodies to an aqueous extract of the silage associated with their own illness. Organic dust toxic syndrome appears to be a common and substantial respiratory hazard to young farm workers. Despite being frequently mis-diagnosed as farmer's lung, organic dust toxic syndrome is clearly a distinctly different disease process.

Analysis of the catalytic domain of phosphotransferase activity of two avian sarcoma virus-transforming proteins

Proteolytic digestion of the transforming protein of Rous sarcoma virus (pp60src) with trypsin, chymotrypsin, or thermolysin generated a 29,000-dalton fragment representing the carboxyl half of this molecule. This proteolytic fragment was able to phosphorylate pp60src-specific immunoglobulin as well as exogenous substrates such as angiotensin, casein, and tubulin. When quantitated on a molar basis, the protease-resistant fragment of pp60src had a greater specific activity than the intact enzyme. Digestion of pp90yes, the transforming protein of Y73 sarcoma virus with these proteases yielded a peptide of similar molecular weight which was capable of autophosphorylation as well as the phosphorylation of exogenous substrates. The proteolytic fragments of both pp60src and pp90yes displayed the same strict specificity for phosphorylation of tyrosine as the intact enzymes. These results indicate that the 29,000-dalton carboxyl end of pp60src and pp90yes can function independently as phosphotransferases and indicate that the catalytic domains of these molecules have a conformation which confers protection against limited conditions of proteolysis.

Interaction between the Rous sarcoma virus transforming protein and two cellular phosphoproteins: analysis of the turnover and distribution of this complex

The transforming protein of Rous sarcoma virus (RSV), pp60src, was previously shown to associate with two cellular proteins of Mr 90,000 and 50,000 in RSV-transformed chicken cells. In this report, we demonstrate that this interaction is specific for a discrete population of pp60src molecules. Newly synthesized pp60src was found to preferentially associate with pp90 and pp50 to form a short-lived complex. The half-life of this complex varied from 9 to 15 min in cells transformed by nondefective strains of RSV. This interaction between pp60src, pp50, and pp90 took place in a soluble fraction of the cell, and the complex-bound pp60src molecules were not phosphorylated on tyrosine. These results suggest that pp90 and pp50 may be involved in the processing of pp60src molecules before the association of pp60src with the plasma membrane. The kinetics of dissociation of this complex were shown to be altered in cells infected with viruses containing a temperature-sensitive defect in the src gene. When cells infected with these viruses were grown at the nonpermissive temperature, more than 90% of the pp60src molecules were associated with pp90 and pp50, and little or no dissociation was observed in a 3-h chase period. These results suggest that mutations in the src gene which affect the transforming activity of pp60src also affect the stability of the interaction of pp60src with pp90 and pp50.