Respiratory benefit in preterm lambs is progressively lost when the concentration of fetal plasma betamethasone is titrated below two nanograms per milliliter

Antenatal steroid therapy is the standard of care for women at imminent risk of preterm delivery. Current dosing regimens use suprapharmacological doses to achieve extended fetal steroid exposures. We aimed to determine the lowest fetal plasma betamethasone concentration sufficient to achieve functional preterm lung maturation. Ewes with single fetuses underwent surgery to install a fetal jugular catheter. Adopting a stepwise design, ewes were randomized to either a saline-only group (negative control group; n = 9) or one of four betamethasone treatment groups. Each betamethasone group fetus received a fetal intravenous infusion to target a constant plasma betamethasone level of either 1) 2 ng/mL (2 ng/mL positive control group, n = 9); 2) 1 ng/mL, (1 ng/mL group, n = 10); 3) 0.5 ng/mL (0.5 ng/mL group, n = 10); or 4) 0.25 ng/mL (0.25 ng/mL group, n = 10). Fetuses were infused for 48 h, delivered, and ventilated. The positive control group, negative control group, and mid-point 0.5 ng/mL group animals were tested first. An interim analysis informed the final betamethasone group tested. Positive control group animals had large, statistically significant improvements in respiratory function. Based on an interim analysis, the 1.0 ng/mL group was studied in favor of the 0.25 ng/mL group. Treatment efficacy was progressively lost at plasma betamethasone concentrations lower than 2 ng/mL. We demonstrated that the acute respiratory benefit conveyed by antenatal steroid exposure in the fetal sheep is progressively lost when constant fetal plasma betamethasone concentrations are reduced below a targeted value of 2 ng/mL.NEW & NOTEWORTHY Lung maturation benefits in preterm lambs were progressively lost when fetal plasma betamethasone concentrations fell below 2 ng/mL. The effective floor threshold for a robust, lung-maturing exposure likely lies between 1 and 2 ng betamethasone per milliliter of plasma. Hypothalamic pituitary adrenal axis signaling and immunocyte populations remained materially disrupted at subtherapeutic steroid concentrations. These data demonstrate the potential to improve antenatal steroid therapy using reduced dose regimens informed by glucocorticoid pharmacokinetics and pharmacodynamics.

Preclinical evaluation of drugs to block inflammation-driven preterm birth

Intrauterine inflammation, the major cause of early preterm birth, can have microbial and sterile aetiologies. We assessed in a Transwell model the anti-inflammatory efficacies of five drugs on human extraplacental membranes delivered after preterm spontaneous labour (30-34 wk). Drugs [TPCA1 (IKKβ inhibitor), 5 z-7-oxozeaenol (OxZ, TAK1 inhibitor), inhibitor of NF-κB essential modulator binding domain (iNBD), SB239063 (p38 MAPK inhibitor) and N-acetyl cysteine (free radical scavenger free radicals)] were added after 12 h equilibration to the amniotic compartment. Concentrations of IL-6, TNF-α, MCP-1, IL-1β and PGE₂ in the media, and IL6, TNFA and PTGS2 mRNA expression levels in membranes, were determined after 12 h. Data were analysed using mixed models analyses. Thirteen of the 28 membranes had histological chorioamnionitis (HCA⁺); five were positive for bacterial culture and six for fetal inflammatory reaction. Baseline PGE₂ and cytokine production was similar between HCA^- and HCA⁺ membranes. Anti-inflammatory effects were also similar between HCA^- and HCA⁺ membranes. TPCA1 and OxZ were the most effective drugs; each inhibited amniotic secretion of 4/5 pro-inflammatory mediators and mRNA levels of 2/3, regardless of stimulus. We conclude that treatment with TPCA1 or OxZ, in combination with antibiotics, may minimise the adverse effects of intrauterine inflammation in pregnancy.

Ureaplasma parvum genotype, combined vaginal colonisation with Candida albicans, and spontaneous preterm birth in an Australian cohort of pregnant women

BACKGROUND

Detection of Ureaplasma, Mycoplasma and Candida spp. in the vagina during pregnancy has previously been associated with preterm birth (PTB). However, the prevalence of these microorganisms and the associated obstetric risks (likely to be population-specific) have not been determined in Australian women; furthermore, in the case of Ureaplasma spp., very few studies have attempted characterisation at the species level and none have examined genotype/serovar status to further refine risk assessment.

METHODS

In order to address these issues we sampled the vaginal fluid of 191 pregnant Australian women at three time points in pregnancy. Culture methods were used for detection of Ureaplasma spp. and Candida spp., and real-time PCR was used for speciation of U. parvum and U. urealyticum, non-albicans Candida spp., Mycoplasma hominis and Mycoplasma genitalium. High-resolution melt PCR was used to genotype U. parvum. Data on various lifestyle factors (including sex during pregnancy and smoking), antimicrobial use and pregnancy outcome were collected on all participants. Chi-square tests were used to assess the association of vaginal microorganisms with PTB.

RESULTS

Detection of Ureaplasma spp. was higher among spontaneous PTB cases, specifically in the presence of U. parvum [77 % preterm (95 % confidence interval (CI) 50-100 %) vs. 36 % term (CI: 29-43 %), p = 0.004], but not U. urealyticum. The association with PTB strengthened when U. parvum genotype SV6 was detected (54 % preterm (CI: 22-85 %) vs. 15 % term (CI: 10-20 %), p = 0.002); this genotype was also present in 80 % (4/5) of cases of PTB <34 weeks gestation. When present with Candida albicans in the same sample, the association with PTB remained strong for both U. parvum [46 % preterm (CI: 15-78 %) vs. 13 % term (CI: 8-18 %), p = 0.005] and U. parvum genotype SV6 [39 % preterm (CI: 8-69 %) vs. 7 % term (CI: 3-11 %), p = 0.003]. With the exception of Candida glabrata, vaginal colonisation status for all organisms was stable throughout pregnancy. Smoking significantly increased the likelihood of detection of all target organisms.

CONCLUSIONS

These data suggest that the presence of different species and serovars of Ureaplasma spp. in the vagina confers an increased risk of spontaneous PTB, findings which may be useful in risk assessment for identifying women who would benefit from antimicrobial treatment.

A New, Potent, and Placenta-Permeable Macrolide Antibiotic, Solithromycin, for the Prevention and Treatment of Bacterial Infections in Pregnancy

Intrauterine infection–inflammation is a major cause of early preterm birth and subsequent neonatal mortality and acute or long-term morbidity. Antibiotics can be administered in pregnancy to prevent preterm birth either prophylactically to women at high risk for preterm delivery, or to women with diagnosed intrauterine infection, prelabor rupture of membranes, or in suspected preterm labor. The therapeutic goals of each of these scenarios are different, with different pharmacological considerations, although effective antimicrobial therapy is an essential requirement. An ideal antibiotic for these clinical indications would be (a) one that is easily administered and orally bioactive, (b) has a favorable adverse effect profile (devoid of reproductive toxicity or teratogenicity), (c) is effective against the wide range of microorganisms known to be commonly associated with intra-amniotic infection, (d) provides effective antimicrobial protection within both the fetal and amniotic compartments after maternal delivery, (e) has anti-inflammatory properties, and (f) is effective against antibiotic-resistant microorganisms. Here, we review the evidence from clinical, animal, and ex vivo/in vitro studies that demonstrate that a new macrolide-derived antibiotic – solithromycin – has all of these properties and, hence, may be an ideal antibiotic for the treatment and prevention of intrauterine infection-­related pregnancy complications. While this evidence is extremely encouraging, it is still preliminary. A number of key studies need to be completed before solithromycin’s true potential for use in pregnancy can be ascertained.

Outside-in? Acute fetal systemic inflammation in very preterm chronically catheterized sheep fetuses is not driven by cells in the fetal blood

BACKGROUND

The preterm birth syndrome (delivery before 37 weeks gestation) is a major contributor to the global burden of perinatal morbidity and death. The cause of preterm birth is complex, multifactorial, and likely dependent, at least in part, on the gestational age of the fetus. Intrauterine infection is frequent in preterm deliveries that occur at <32 weeks gestation; understanding how the fetus responds to proinflammatory insult will be an important step towards early preterm birth prevention. However, animal studies of infection and inflammation in prematurity commonly use older fetuses that possess comparatively mature immune systems.

OBJECTIVE

Aiming to characterize acute fetal responses to microbial agonist at a clinically relevant gestation, we used 92-day-old fetuses (62% of term) to develop a chronically catheterized sheep model of very preterm pregnancy. We hypothesized that any acute fetal systemic inflammatory responses would be driven by signaling from the tissues exposed to Escherichia coli lipopolysaccharide that is introduced into the amniotic fluid.

STUDY DESIGN

Eighteen ewes that were carrying a single fetus at 92 days of gestation had recovery surgery to place fetal tracheal, jugular, and intraamniotic catheters. Animals were recovered for 24 hours before being administered either intraamniotic E coli lipopolysaccharide (n = 9) or sterile saline solution (n = 9). Samples were collected for 48 hours before euthanasia and necroscopy. Fetal inflammatory responses were characterized by microarray analysis, quantitative polymerase chain reaction, and enzyme-linked immunosorbent assay.

RESULTS

Intraamniotic lipopolysaccharide reached the distal trachea within 2 hours. Lipopolysaccharide increased tracheal fluid interleukin-8 within 2 hours and generated a robust inflammatory response that was characterized by interleukin-6 signaling pathway activation and up-regulation of cell proliferation but no increases in inflammatory mediator expression in cord blood RNA.

CONCLUSIONS

In very preterm sheep fetuses, lipopolysaccharide stimulates inflammation in the fetal lung and fetal skin and stimulates a systemic inflammatory response that is not generated by fetal blood cells. These data argue for amniotic fluid-exposed tissues that play a key role in driving acute fetal and intrauterine inflammatory responses.

Drugs to block cytokine signaling for the prevention and treatment of inflammation-induced preterm birth

Preterm birth (PTB) at less than 37 weeks of gestation is the leading cause of neonatal morbidity and mortality. Intrauterine infection (IUI) due to microbial invasion of the amniotic cavity is the leading cause of early PTB (<32 weeks). Commensal genital tract Ureaplasma and Mycoplasma species, as well as Gram-positive and Gram-negative bacteria, have been associated with IUI-induced PTB. Bacterial activation of Toll-like receptors and other pattern recognition receptors initiates a cascade of inflammatory signaling via the NF-κB and p38 mitogen-activated protein kinase (MAPK) signaling pathways, prematurely activating parturition. Antenatal antibiotic treatment has had limited success in preventing PTB or fetal inflammation. Administration of anti-inflammatory drugs with antibiotics could be a viable therapeutic option to prevent PTB and fetal complications in women at risk of IUI and inflammation. In this mini-review, we will discuss the potential for anti-inflammatory drugs in obstetric care, focusing on the class of drugs termed “cytokine suppressive anti-inflammatory drugs” or CSAIDs. These inhibitors work by specifically targeting the NF-κB and p38 MAPK inflammatory signaling pathways. Several CSAIDs are discussed, together with clinical and toxicological considerations associated with the administration of anti-inflammatory agents in pregnancy.

Whole blood flow cytometric analysis of Ureaplasma-stimulated monocytes from pregnant women

We hypothesised that circulating monocytes of women with vaginal colonisation with Ureaplasma spp., genital microorganisms known to cause inflammation-driven preterm birth, would elicit a tolerised cytokine response to subsequent in vitro Ureaplasma parvum serovar 3 (UpSV3) stimulation. Using multi-parameter flow cytometry, we found no differences with regard to maternal colonisation status in the frequency of TNF-α-, IL-6-, IL-8- and IL-1β-expressing monocytes in response to subsequent UpSV3 stimulation (P > 0.10 for all cytokines). We conclude that vaginal Ureaplasma spp. colonisation does not specifically tolerise monocytes of pregnant women towards decreased responses to subsequent stimulation.

The Maternal Serological Response to Intrauterine Ureaplasma sp. Infection and Prediction of Risk of Pre-Term Birth

Pre-term birth (PTB) associated with intrauterine infection and inflammation (IUI) is the major cause of early PTB less than 32 weeks of gestation. Ureaplasma spp. are common commensals of the urogenital tract in pregnancy and are the most commonly identified microorganisms in amniotic fluid of pre-term pregnancies. While we have an understanding of the causal relationship between intra-amniotic infection, inflammation and PTB, we are still unable to explain why vaginal Ureaplasma sp. colonization is tolerated in some women but causes PTB in others. It is now known that placental tissues are frequently colonized by bacteria even in apparently healthy pregnancies delivered at term; usually this occurs in the absence of a significant local inflammatory response. It appears, therefore, that the site, nature, and magnitude of the immune response to infiltrating microorganisms are key in determining pregnancy outcome. Some evidence exists that the maternal serological response to Ureaplasma sp. colonization may be predictive of adverse pregnancy outcome, although issues such as the importance of virulence factors (serovars) and the timing, magnitude, and functional consequences of the immune response await clarification. This mini-review discusses the evidence linking the maternal immune response to risk of PTB and the potential applications of maternal serological analysis for predicting obstetric outcome.

Successful combined intratumoral immunotherapy of established murine mesotheliomas requires B-cell involvement

Combination immunotherapy has resulted in a number of impressive outcomes in mouse models and clinical settings. In this study, we report that a timed triple immunotherapy (TTI) protocol using 3 agonist antibodies (anti-CD25mAb, anti-TGF-βmAb, and anti-CTLA-4mAb) produced complete clearance of established AB1 murine mesothelioma tumors. Combining all 3 agonist antibodies into a single cocktail for intratumoral injection was as effective as the TTI in tumor eradication. Cured mice showed elevated levels of tumor-specific IgG antibodies at 95 days posttreatment. Time-course studies of tumor clearance showed (1) that IgG levels were not elevated during tumor clearance and (2) that B-cell numbers were increased in the tumor-draining lymph nodes and spleens during tumor clearance. Finally, employment of B-cell knockout mice indicated a significant role for B cells in the successful eradication of the established tumors by the triple immunotherapy cocktail.

Intrauterine Candida albicans infection elicits severe inflammation in fetal sheep

BACKGROUND

Preventing preterm birth and subsequent adverse neonatal sequelae is among the greatest clinical challenges of our time. Recent studies suggest a role for Candida spp. in preterm birth and fetal injury, as a result of their colonization of either the vagina and/or the amniotic cavity. We hypothesized that intraamniotic Candida albicans would cause a vigorous, acute fetal inflammatory response.

METHODS

Sheep carrying singleton pregnancies received single intraamniotic injections of either saline (control) or 10(7) colony-forming units C. albicans 1 or 2 d prior to surgical delivery and euthanasia at 124 ± 2 d gestation.

RESULTS

Colonization of the amniotic cavity by C. albicans resulted in a modest inflammatory response at 1 d and florid inflammation at 2 d, characterized by fetal thrombocytopenia, lymphopenia, and significant increases of inflammatory cytokines/chemokines in the fetal membranes skin, lung, and the amniotic fluid.

CONCLUSION

Acute colonization of the amniotic cavity by C. albicans causes severe intrauterine inflammation and fetal injury. C. albicans is a potent fetal pathogen that can contribute to adverse pregnancy outcomes.

Effects of cytokine-suppressive anti-inflammatory drugs on inflammatory activation in ex vivo human and ovine fetal membranes

Intrauterine infection and inflammation are responsible for the majority of early (<32 weeks) spontaneous preterm births (PTBs). Anti-inflammatory agents, delivered intra-amniotically together with antibiotics, may be an effective strategy for preventing PTB. In this study, the effects of four cytokine-suppressive anti-inflammatory drugs (CSAIDs:N-acetyl cysteine (NAC), SB239063, TPCA-1 and NEMO binding domain inhibitor (NBDI)) were assessed on human and ovine gestational membrane inflammation. Full-thickness membranes were collected from healthy, term, human placentas delivered by Caesarean section (n=5). Using a Transwell model, they were stimulatedex vivowith γ-irradiation-killedEscherichia coliapplied to the amniotic face. Membranes from near-term, ovine placentas were stimulatedin uterowith lipopolysaccharide,Ureaplasma parvumor saline control and subjected to explant culture. The effects of treatment with CSAIDs or vehicle (1% DMSO) on accumulation of PGE2and cytokines (human interleukin 6 (IL6), IL10 and TNFα; ovine IL8 (oIL8)) were assessed in conditioned media at various time points (3–20 h). In human membranes, the IKKβ inhibitor TPCA-1 (7 μM) and p38 MAPK inhibitor SB239063 (20 μM) administered to the amniotic compartment were the most effective in inhibiting accumulation of cytokines and PGE2in the fetal compartment. NAC (10 mM) inhibited accumulation of PGE2and IL10 only; NBDI (10 μM) had no significant effect. In addition to the fetal compartment, SB239063 also exerted consistent and significant inhibitory effects in the maternal compartment. TPCA-1 and SB239063 suppressed oIL8 production, while all CSAIDs tested suppressed ovine PGE2production. These results support the further investigation of intra-amniotically delivered CSAIDs for the prevention of inflammation-mediated PTB.

Topically applied Melaleuca alternifolia (tea tree) oil causes direct anti-cancer cytotoxicity in subcutaneous tumour bearing mice

BACKGROUND

Melaleuca alternifolia (tea tree) oil (TTO) applied topically in a dilute (10%) dimethyl sulphoxide (DMSO) formulation exerts a rapid anti-cancer effect after a short treatment protocol. Tumour clearance is associated with skin irritation mediated by neutrophils which quickly and completely resolves upon treatment cessation.

OBJECTIVE

To examine the mechanism of action underlying the anti-cancer activity of TTO.

METHODS

Immune cell changes in subcutaneous tumour bearing mice in response to topically applied TTO treatments were assessed by flow cytometry and immunohistochemistry. Direct cytotoxicity of TTO on tumour cells in vivo was assessed by transmission electron microscopy.

RESULTS

Neutrophils accumulate in the skin following topical 10% TTO/DMSO treatment but are not required for tumour clearance as neutrophil depletion did not abrogate the anti-cancer effect. Topically applied 10% TTO/DMSO, but not neat TTO, induces an accumulation and activation of dendritic cells and an accumulation of T cells. Although topical application of 10% TTO/DMSO appears to activate an immune response, anti-tumour efficacy is mediated by a direct effect on tumour cells in vivo. The direct cytotoxicity of TTO in vivo appears to be associated with TTO penetration.

CONCLUSION

Future studies should focus on enhancing the direct cytotoxicity of TTO by increasing penetration through skin to achieve a higher in situ terpene concentration. This coupled with boosting a more specific anti-tumour immune response will likely result in long term clearance of tumours.

The Role of Regulatory T Cells in Mesothelioma

Malignant mesothelioma (MM) appears to be responsive to immunotherapy. The lack of complete tumour cure as a result of many immunotherapies tested to date suggests that the immune response to MM is complex and multi-parametric. Regulatory T (Treg) cells are prevalent within murine and human mesotheliomas with their removal shown to result in tumour growth inhibition and the release of anti-tumour effector T cells from immunosuppression. The targeting of immune checkpoints as treatments for various solid tumours has recently shown promise in clinical settings. In addition, synergy between chemotherapy and immunotherapy has been demonstrated for many cancers, including mesothelioma. Here we demonstrate Treg cells as critical mediators of the anti-tumour immune response to MM and potential targets for anti-tumour immunotherapy; though the timing and dosage of Treg cell manipulating immunotherapies need to be optimised.

Induction of necrosis and cell cycle arrest in murine cancer cell lines by Melaleuca alternifolia (tea tree) oil and terpinen-4-ol

PURPOSE

To examine the in vitro anticancer activity of Melaleuca alternifolia (tea tree) oil (TTO), and its major active terpene component, terpinen-4-ol, against two aggressive murine tumour cell lines, AE17 mesothelioma and B16 melanoma.

METHODS

Effects of TTO and terpinen-4-ol on the cellular viability of two tumour cell lines and fibroblast cells were assessed by MTT assay. Induction of apoptotic and necrotic cell death was visualised by fluorescent microscopy and quantified by flow cytometry. Tumour cell ultrastructural changes were examined by transmission electron microscopy and changes in cell cycle distribution were assessed by flow cytometry, with changes in cellular morphology monitored by video time lapse microscopy.

RESULTS

TTO and terpinen-4-ol significantly inhibited the growth of two murine tumour cell lines in a dose- and time-dependent manner. Interestingly, cytotoxic doses of TTO and terpinen-4-ol were significantly less efficacious against non-tumour fibroblast cells. TTO and terpinen-4-ol induced necrotic cell death coupled with low level apoptotic cell death in both tumour cell lines. This primary necrosis was clarified by video time lapse microscopy and also by transmission electron microscopy which revealed ultrastructural features including cell and organelle swelling following treatment with TTO. In addition, both TTO and terpinen-4-ol induced their inhibitory effect by eliciting G1 cell cycle arrest.

CONCLUSION

TTO and terpinen-4-ol had significant anti-proliferative activity against two tumour cell lines. Moreover, the identification of primary necrotic cell death and cell cycle arrest of the aggressive tumour cells highlights the potential anticancer activity of TTO and terpinen-4-ol.

Alpha-Tocopheryl succinate: toxicity and lack of anti-tumour activity in immuno-competent mice

Alpha-tocopheryl succinate (alpha-TOS), an analogue of vitamin E (VitE), inhibits peritoneal human malignant mesoethelioma xenograft development in immuno-compromised mice via the induction of apoptosis of tumour cells [Tomasetti, M., Gellert, N., Procopio, A., Neuzil, J., 2004. A vitamin E analogue suppresses malignant mesothelioma in a preclinical model: a future drug against a fatal neoplastic disease? Int. J. Cancer 109, 641-642]. We tested the effect of systemic alpha-TOS treatment in our immuno-competent and syngeneic murine mesothelioma model. VitE analogues such as alpha-TOS have been developed for clinical use as supplements mainly for the treatment of VitE deficiency and are considered safe and non-toxic when taken orally. In our murine model of mesothelioma alpha-TOS was not only ineffective at inhibiting established tumour development at the published doses, but resulted in severe side effects characterized by both behavioural changes, intra-peritoneal abnormalities and the destruction of T cells. Toxicity of alpha-TOS has not been reported to date perhaps due to a lack of studies conducted in fully immuno-competent hosts. Our results suggest that the translation of animal studies to clinical treatment with alpha-TOS requires careful consideration.

Subjective visual vertical in patients with benign paroxysmal positional vertigo

The ocular tilt reaction leads to an alteration in the subjective visual vertical (SVV). Nonsurgical peripheral vestibular dysfunction only rarely leads to changes in the SVV. To our knowledge, no studies have examined the effects on the SVV in patients with benign positional paroxysmal vertigo (BPPV) post Hallpike and Semont maneuvers. Sixteen patients with posterior canal BPPV were assessed in the vestibular clinic in Winnipeg, Manitoba. These patients had assessment of their SVV at baseline, post Hallpike and Semont maneuvers, and at follow-up 2 weeks later. These patients were also compared to a control group (n = 9). Ten of 16 patients showed a statistically significant change in SVV post Hallpike maneuver. An even larger number of patients, 14 of 16, showed a significant difference when compared to the control group post Hallpike. These findings suggest that the inferior vestibular nerve may to some degree influence the ocular tilt reaction.

Decision matrix analysis for tonic ocular torsional abnormalities with posturography abnormalities

Tonic ocular torsions can arise from a variety of central or peripheral, vestibular, and nonvestibular lesions. However, the role of tonic ocular torsions in neurotology has been limited to surgical patients after unilateral vestibular deafferentation. By using 12 patients with a spectrum of well-defined unilateral peripheral vestibular lesions confirmed by electronystagmography (ENG), we identified a link between ipsiversive tonic ocular torsion compensation and vestibulospinal compensation, as measured by computerized dynamic posturography. In the context of ENG findings and posturography, the differential diagnosis of ocular torsions may be localized to the otoliths by using a decision matrix. Specifically, conditions of absent vision and sway-referenced support on computerized dynamic posturography associated with concurrent static ocular torsional abnormalities may suggest an otolith disorder. Furthermore, static ocular torsion assessment provides another important window on central vestibular compensation.

Ocular torsion monitoring in chemical labyrinthectomy

OBJECTIVE

To study the usefulness of ocular torsion analysis as an adjunct to examining central vestibular compensation.

DESIGN

Prospective evaluation.

SETTING

The Vestibular Disorders Clinic, University of Manitoba Health Sciences Centre.

METHODS

Seven patients with intractable Meniere's disease underwent elective transtympanic gentamycin labyrinthectomy. Serial examination of patient progress was performed using fundus photography, subjective visual vertical estimations, electronystagmography, and audiometry.

RESULTS

Ocular torsion analysis reveals unexpected initial and early contraversive torsion behaviour in some patients, which may represent an early irritative phenomenon stemming from either the gentamicin or the Meniere's disease itself.

CONCLUSION

Despite the sensitivity of the ocular torsion measures, there appears to be no useful predictive correlation between ocular torsion and audiometric functioning that might predict impending hearing loss. Nevertheless, ocular torsion analysis reveals subtle changes in vestibular system functioning and may provide useful adjunctive information in the assessment of vestibular ototoxicity.

Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the commonest peripheral vestibular disorder seen in dizziness clinics. It was long believed that the condition was caused by inorganic particles in the cupula of the posterior semicircular canal (PSC). More recently it has been suggested that BPPV may result from free-floating densities in the endolymph of the long arm of the PSC. Among the various treatment modalities used, two maneuvers, each based on a different theory of pathogenesis, have reported equally high success in the control of this disorder. These maneuvers are customarily followed by strict post-treatment instructions. We studied patients with BPPV prospectively by comparing the therapeutic effectiveness of these two modalities and studying the importance of post-treatment instructions in affecting the final outcome in each modality. We showed that both maneuvers were equally successful in controlling the symptoms and that post-treatment instructions were not necessary.

Dizziness Handicap Inventory correlates of computerized dynamic posturography

To assess the handicapping effect of dizziness related to posture and balance, the Dizziness Handicap Inventory (DHI) and Computerized Dynamic Posturography (CDP) were used to assess 101 consecutive patients referred for neurotologic evaluation of dizziness. Most patients, regardless of diagnosis, related some level of preexisting handicap, most often in the DHI Physical subscale. Generally, females and patients with bilateral lesions scored higher in all DHI subscales. No clinically useful correlations emerged between DHI and CDP testing, although DHI scores were marginally higher for patients failing CDP conditions. Functional balance ability could not be correlated with patient handicap, but a literature review suggests that the desynchrony between dizziness signs and symptoms may be related to underlying patient anxiety and differences in coping strategies.

Vestibular evoked myogenic potentials

A pilot study was undertaken in our Vestibular Disorders Clinic to re-evaluate the clinical benefits of vestibular evoked myogenic potentials (VEMP). In seven normal subjects and 20 documented unilateral peripheral vestibular disorder patients, electromyograms were recorded from surface electrodes over the sternomastoid muscles and averaged in response to 0.1-millisecond clicks played through headphones. Control patients demonstrated EMG positive-negative potentials (p14-n21) of equivalent latencies and amplitudes both ipsilateral and contralateral to the stimuli. In patients with documented unilateral peripheral vestibular disorders, the p14-n21 potentials were preserved in the presence of sensorineural hearing loss and absent in those patients with partial or total vestibular loss. A high directional correlation is noted between the p14-n21 potential and gold-standard caloric testing. We suspect the origin of the response may be in the saccule and suggest that VEMP testing may be useful in assessing intact vestibulocollic pathways in humans.

Comparison of different exercise programs in the rehabilitation of patients with chronic peripheral vestibular dysfunction

The purpose of this study was to evaluate the effects of two exercise programs on balance performance in patients with chronic peripheral vestibular dysfunction and to assess whether these exercise programs induce adaptive modifications of the vestibulo-ocular reflex (VOR). Patients were randomly assigned to one of two groups. (1) Those in the Rehab (Reh) group (n = 11) received a comprehensive exercise program that consisted of balance retraining and goal-directed eye-head exercises under combinations of varied visual and somatosensory sensory conditions. Patients received 45-minute training sessions, three times per week for 12 weeks, and were instructed on a custom home exercise program. (2) Those in the Home group (n = 12) were instructed to perform the Cooksey-Cawthorne eye-head exercises at home, on a daily basis, for 12 weeks. In addition, after completion of the exercise program and a follow-up period, 7 of the participants in the Home group (here defined as the A group) chose to enter the Reh program (here defined as the B group). Balance performance was assessed by measuring the peak-to-peak magnitude and total amount of anterior-posterior body sway, and of horizontal (shear) ground reaction force during six test conditions, in which visual and somatosensory orientation cues were reduced or altered by rotation of the visual surround or support surface in proportion to the subject's sway, and in which vision was eliminated (eyes closed). The VOR response to step chair rotations of 60 degrees/s and 120 degrees/s, and the optokinetic reflex (OKN) response to 60 degrees/s constant velocity optokinetic stimuli were recorded. Left-right difference in VOR gain, VOR time constant, and OKN gain were determined. These tests were performed 1 day prior to start of treatment (TD 1), 6 weeks after start of treatment (TD 2), at the end of the 12-week treatment period (TD 3), and 5 months after end of treatment (TD 4). The findings revealed a significant improvement in standing balance performance under dynamic conditions for patients in the Reh program (Reh and B groups) but not for patients performing the eye-head exercise (Home or A groups). Thus, even in patients with chronic vestibular dysfunction, compensation for the loss or disruption of peripheral vestibular inputs can be effectively induced by exercises that provide sensory feedback appropriate for behavioral changes involving sensory substitution or sensory-motor reorganization.(ABSTRACT TRUNCATED AT 400 WORDS)

Unilateral vestibular deafferentation: a model of adaptation

After acute loss of peripheral vestibular function, a centrally adaptive process takes place. Clinical measurements of vestibular adaptation are useful, both diagnostically and as a means of following patients after acute vestibular deficits. Ocular torsion is one measurement that can be used to follow these acutely disabled patients. The measurement is made from fundus photographs and is technically easy to perform and interpret. We present a pilot study from our Vestibular Disorders Clinic using fundus photography to measure the optic nerve head-foveal angle in six patients undergoing unilateral vestibular neurectomy, with subsequent analysis resulting in a speculative mathematical model of vestibular compensation in the roll plane. While the identification or selection of patients with significant ocular torsions from the vestibular population remains ill-defined, fundus photography remains an easy and useful method of following compensation in postoperative patients.

Effect of active head movements about the pitch, roll, and yaw axes on human optokinetic afternystagmus

Effects of active head movements about the pitch, roll, or yaw axes on horizontal optokinetic afternystagmas (OKAN) were examined in 16 subjects to test the hypothesis that otolith organ mediated activity induced by a change in head position can couple to the horizontal velocity storage in humans. Active head movements about the pitch axis, forwards or backwards, produced significant OKAN suppression. Pitch forward head movements exerted the strongest effect. Active head movements about the roll axis towards the right also produced OKAN suppression but only if the tilted position was sustained. No suppression was observed following sustained yaw. However, an unsustained yaw left movement after rightward drum rotation significantly enhanced OKAN. Sustained head movement trials did not significantly alter subsequent control trials. In contrast, unsustained movements about the pitch axis, which involve more complex interactions, exerted long-term effects on subsequent control trials. We conclude that otolith organ mediated activity arising from pitch or roll head movements couples to the horizontal velocity storage in humans, thereby suppressing ongoing OKAN. Activity arising from the horizontal canals during an unsustained yaw movement (observed mainly with yaw left), following drum rotation in a direction contralateral to the movement, may also couple to the velocity storage, resulting in increased activity instead of suppression.

Convergent effects from vestibulospinal tract and primary cutaneous afferent fibers on motoneurons to proximal lower limb flexor and extensor muscles in humans

In human subjects, the latency and magnitude of cutaneomuscular test reflexes, evoked by stimulation of the sural nerve in the contralateral and ipsilateral quadricep and hamstring muscles, were investigated during static tilts in the pitch axis. The ANOVA demonstrated a highly significant, tilt-dependent modulation of the magnitude of the test reflex for the initial phase of both ipsilateral quadriceps and ipsilateral hamstrings. These results are consistent with results from a similar study on human ankle muscles and provide further evidence that the tilt-dependence of these cutaneomuscular reflexes originates from activity in the otolith receptors.

Convergent effects from vestibulospinal tract and primary cutaneous afferent fibers on motoneurons to ankle extensor and flexor muscles in humans

The latency and magnitude of cutaneomuscular reflexes, evoked by stimulation of the sural nerve in the contralateral and ipsilateral tibialis anterior and soleus, were investigated in normal human subjects during static tilts in the pitch axis. For all subjects the test reflex consisted of oscillating sequences of excitation and inhibition, each muscle exhibiting a characteristic pattern defined by its latency and sign of the initial phase. The latency of the various components and the sign of the initial phase did not vary with angle of tilt. However, the results of an ANOVA demonstrate a highly significant tilt-dependent modulation of the amplitude of the test reflex for the initial inhibitory phase of the contralateral tibialis anterior. We propose that this tilt-dependent effect on the crossed cutaneomuscular reflex originates from activity in the otolith organ receptors.

Human optokinetic afternystagmus. Is the fast component of OKAN decay due to smooth pursuit?

Eye movement after-effects subsequent to pursuit of a single LED target were studied in human subjects to test the hypothesis that constant velocity pursuit activates a velocity storage system in the neuronal pathway. The temporal characteristics of observed after-effects fall within those predicted from the Robinson model of eyeball mechanics, indicating that neuronal integration was not a factor.

The polyclonal antibody responses of Lewis rats to the synthetic encephalitogenic neuropeptide S55S (residues 72-84 of guinea pig myelin basic protein) and its analogs

Immunochemical analysis of polyclonal antisera from Lewis rats immunized with peptide analogs and subpeptides of residues 72-84 of guinea pig myelin basic protein (MBP) indicated that there were four main epitopic specificities involved: one represented by residues 76-80, one by residues 72-74, one by 81-84-Gly, and one involving 74-76 in a heteroclitic way even when the immunogen contained a tetraleucine spacer between residues 74 and 75. The affinities were all relatively low, ranging from 3 x 10(4) M-1 to 7.2 x 10(6) M-1, and each affinity population was very restricted with respect to heterogeneity. The results were commensurate with our hypothesis that autoimmune responses to homologous encephalitogenic neuropeptide determinants reflect an evolutionarily imposed degeneration of the overall response, and were also in agreement with our hypothesis that the affinities of autoantibodies against epitopes in the molecular neighborhood of an encephalitogen would be necessarily low. It was also found that peptide 69-81-Gly (S67) in solution would not interact in liquid phase radioimmunoassays with any of the above antibody populations, thus indicating that its preferred conformation did not allow the expression of autoreactive epitopes. There was no evidence that S67 in solution. even in the presence of S53, would express any epitopes reactive with autoantibodies. How this finding for a B cell product correlates with T cell-mediated immunologic responses is not totally understood, but it will be recalled that S67 by itself does not induce T cell-mediated experimental allergic encephalomyelitis (EAE), that S53 (residues 75-84-Gly) induces only clinical symptoms of EAE without attendant pathological disease, but that the two together induce classical EAE.(ABSTRACT TRUNCATED AT 250 WORDS)

Polyclonal antibodies to the encephalitogenic neighborhoods of myelin basic protein: singular affinity populations neutralized by specific synthetic peptide probes

Specific ligand neutralization was used to probe the extent to which singular antibody affinity populations signified specific determinants in the neighborhood myelin basic protein (MBP) encephalitogens. The probes were individual members of a panel of synthetic peptide analogs subsuming encephalitogenic regions. Comparative Scatchard analyses of neutralized and unneutralized antisera helped to identify the particular peptide determinants involved in the original polyclonal antibody responses to the multiple antigenic determinants of encephalitogenic peptides. The range of affinities for an antibody population against a singular MBP peptide determinant was found to be relatively restricted while the range of affinities overall for all populations within a given antipeptide antiserum was found to be relatively wide and invariably discontinuous. Consequently, the individual discontinuous affinity populations could readily be dissected by application of the Rosenthal method of Scatchard curve analysis. It was found that the singular high affinity antibody population (5.6 x 10(7) M-1) of a Lewis rat antiserum to rat encephalitogenic GSLPQKAQRPQDENG (S49) was against a determinant near the N-terminal non-encephalitogenic end of the peptide. Only the low affinity antibody populations were found that had reactivity for determinants within the encephalitogenic region itself. The singular high affinity antibody population (5.97 x 10(7) M-1) of a rabbit antiserum to rabbit encephalitogenic TTHYGSLPQKAQGHRPQDEG (S82) was against a determinant centered about the tyrosyl residue, within the encephalitogenic region for the rabbit, but was completely cross-reactive with a specific circulating endogenous inhibitor. The results obtained with the rat and rabbit EAE sera were consistent with a previously advanced hypothesis that antibodies to determinants within encephalitogenic neighborhoods would effectively block the onset of EAE if high enough in affinity and not neutralized by an endogenous inhibitor.

Heteroclitic antibodies in Fischer 344 rats to a synthetic encephalitogenic myelin basic protein peptide

Fischer 344 rats, immunized with the synthetic encephalitogenic myelin basic protein peptide YS49 (YGSLPQKAQRPQDENG), produced heteroclitic antibodies that reacted much more extensively and with a much higher affinity with the cross-reacting encephalitogenic guinea pig sequence S49S (GSLPQKSQRSQDENG) than they did with the immunogenic YS49. On the other hand, antisera against S49S reacted in a normal manner with homologous S49S and cross-reacted only poorly with YS49. The phenomenon of heteroclisis in Fischer 344 rats correlated with the greater encephalitogenic potency of the cross-reacting entity. Kibler et al. (J. Exp. Med., 146 (1977) 1323-1331), by comparing the encephalitogenic guinea pig sequence to a less potent analog, had also previously observed what now would be termed a heteroclitic phenomenon at the T cell level in Lewis rats. In their hands, however, as well as in ours Lewis rat antisera against the encephalitogenic peptide region were much too complex to be analyzed with respect to heteroclisis. It was shown in the present experiments that by utilizing the Fischer 344 system one may also readily obtain heteroclisis at the B cell level against encephalitogenic peptides. Neither YS49 nor S49S as immunogen produced detectable antibody in Brown Norway (BN) rats with exception of two immunized with YS49. In those two cases heteroclitic antibodies were obtained that had a very low significant (greater than 3 SD above baseline) antigen binding capacity for S49S and no detectable reactivity for the homologous YS49 ligand.

Human optokinetic afternystagmus. Charging characteristics and stimulus exposure time dependence in the two-component model

The dependence of human optokinetic afternystagmus (OKAN) velocity storage (charging) and optokinetic nystagmus (OKN) characteristics on optokinetic (OK) stimulus exposure time was investigated, using the two-component double exponential model for OKAN decay. Results are compatible with our previously proposed concept of two velocity storage integrators, one responsible for the short time constant decay (pursuit-mediated) and the other for the long time constant decay (OK system-mediated). The dependence of the long time constant integrator of OKAN on stimulus exposure time was clearly demonstrated. The short time constant integrator appeared to be independent of stimulus exposure time within the range studied. We conclude that the charging time-course of each component is distinct from that of the other. The time constants of each component decay were found to be invariant. A left-right asymmetry observed in both OKN and OKAN responses suggests that the integrators are direction sensitive.

Human optokinetic afternystagmus. Stimulus velocity dependence of the two-component decay model and involvement of pursuit

The dependence of human OKAN characteristics on optokinetic (OK) stimulus velocity was examined using the two-component double exponential model for OKAN decay. Drum velocities studied were between 10 degrees and 70 degrees deg/sec over a constant exposure period of 60 sec. Results reveal two distinct types of response: a 'low'-level response at lower drum velocities (10 degrees, 20 degrees, 30 degrees/sec) and a 'high'-level response at higher drum velocities (40 degrees, 60 degrees, 70 degrees /sec). These findings support our previous proposal that OKAN decay is a two-component process, and extend it by demonstrating that these two components have differing stimulus velocity sensitivities, as would be predicted if it were assumed that they represented direct (pursuit) and indirect (non-pursuit) pathways respectively.

Human optokinetic afternystagmus. Effects of repeated stimulation

Normal human subjects were exposed to repeated optokinetic afternystagmus (OKAN) testing in either one direction or alternating directions of stripe movement. Sessions were conducted at intervals of either one week or several weeks. Repeated exposure to OKAN stimulation in one direction produced significant response decrements in cumulative displacement, short time constant, long time constant, and the coefficient of the long time constant component (C). The data suggest that the decrease in C and cumulative displacement occurred most noticeably between trials 3 and 4 of the first session. Retesting after 1 week, and up to 8 weeks later revealed no recovery. Repeated exposure to alternating leftward and rightward stimuli resulted in response decrement in both cumulative displacement and C. Responses to leftward stimuli were indistinguishable from responses to rightward stimuli.

Human optokinetic afternystagmus. Slow-phase characteristics and analysis of the decay of slow-phase velocity

Events following the extinction of lights after 1-minute exposures of naive, normal subjects to an optokinetic stimulus at 40 deg/sec have been closely examined and quantified. Mean eye displacement in each slow phase decreased from 10.12 +/- 1.61 deg during optokinetic nystagmus (OKN) to 3.36 +/- 2.32 deg during optokinetic afternystagmus (OKAN). Slow-phase duration increased from 0.26 +/- 0.03 sec during OKN to 0.45 +/- 0.195 sec during OKAN. Eye displacement per slow phase remained fairly constant during OKAN, suggesting a spatial reference for the resetting of gaze. OKAN decay is a two-component process which can be closely approximated by a sum of two exponentials, one with a short time constant of 1.15 sec and the other with a long time constant of 48.8 sec. OKAN decay commenced at a time after lights out which depended upon the presence and timing of an intervening fast phase. When a fast phase intervened, OKAN decay commenced about 230 msec after it, and about 460 msec after lights out. When lights out occurred during the fast phase, OKAN decay commenced about 340 msec later.

Symmetrical optokinetic after-nystagmus loss in Wallenberg's syndrome and multiple sclerosis

We have demonstrated abolition of OKAN in either horizontal direction with retention of caloric responses in 3 patients with unilateral brain stem infarcts. In one further patient with diffuse brain stem disease, we have been able to show bilateral loss of horizontal OKAN in the acute phase, with recovery during remission. These findings support the conclusion that the velocity storage mechanism or connections to it, are permanently disabled by unilateral medullary infarcts and may be temporarily disabled by demyelinating disease. Retention of caloric responses in the absence of OKAN would appear to be of assistance in the differential diagnosis between peripheral and central vestibular pathway lesions.

Optokinetic after-nystagmus in man after loss or reduction of labyrinthine function - a preliminary report

Horizontal optokinetic after-nystagmus (OKAN) was studied in normal volunteers and in patients with either unilateral or bilateral loss of labyrinthine function. Optokinetic stimulation in normal volunteers produced OKAN in the same direction as preceding optokinetic nystagmus (OKN) with a duration of 45-90 seconds and a slowly decreasing slow phase eye velocity. Similar stimulation in the bilateral labyrinthine loss group produced markedly diminished or no OKAN. In the unilateral group when the optokinetic stimulus produced OKN with fast phase to the affected ear, OKAN was markedly diminished or absent and replaced by a nystagmus which was reversed in direction to the preceding OKN. The opposite stimulus produced OKAN similar to the volunteer group. The above results support the observation that in human beings, the production of normal OKAN depends on an intact bilateral peripheral vestibular input and further demonstrates that the technique has lateralizing value in unilateral vestibular disease. These results also suggest that separate storage mechanisms are responsible for producing OKAN in the two directions, and that these storage mechanisms are decoupled from each other.