P11.55.B Postoperative MRI is able to detect an unexpected residual tumor after surgery of brain metastases: experience from 5 specialized centers

Background

Brain metastases (BM) constitute the most common central nervous system tumors. The treatment options of BM consist of surgery, radiotherapy, radiosurgery, chemotherapy, and immunotherapy. Regarding surgery in BM, the extent of resection (EOR) represents a crucial factor for patient prognosis. However, first studies using postoperative MRI demonstrated that an unexpected residual tumor after surgery of BM is not uncommon despite these tumors were considered to be well-demarcated. The aim of this study was thus to investigate in a large cohort including multiple neurosurgical centers the EOR following BM resection, potential risk factors for incomplete resection and postsurgical follow-up data.

Material and Methods

In the current retrospective study conducted at 5 specialized neurosurgical centers in Austria, we included patients with BM resection and available postoperative MRI. The EOR following BM resection was determined by postoperative MRI (complete vs incomplete resection). Additionally, the data on the intraoperative judgement of the EOR of the performing neurosurgeon were collected. Moreover, potential factors for incomplete resection including tumor localization, tumor volume, primary tumor, pattern of contrast media enhancement on imaging and tumor eloquence were investigated. Finally, the rate of local progression of BM after initial surgery was analyzed in the follow-up period and overall survival data were collected.

Results

Altogether, 548 patients with 649 surgically treated BM were included. According to postoperative MRI, complete resection was achieved in 407 (66%) of 649 BM and incomplete resection in 176 (29%) of 649 BM. Misjudgment of the EOR by the neurosurgeon was found in 25% of cases and resulted in an unexpected residual tumor which was evident on postoperative MRI in 122 (22%) BM. Preoperative tumor volume was significantly larger in incompletely resected BM. Moreover, local progression was significantly more common in cases with incompletely resected BM and was also associated with shorter overall survival.

Conclusion

Our data of this study including multiple centers indicate that postoperative MRI is capable to detect a relatively high rate of unexpected residual tumors following resection of BM. Since local progression was more common in BM with residual tumors and this was associated with shorter survival, special attention should be paid to achieve a complete tumor resection.

Architecture of Anoteropora latirostris (Bryozoa, Cheilostomata) and implications for their biomineralization

Cheilostome Bryozoa Anoteropora latirostris, a colonial marine invertebrate, constructs its skeleton from calcite and aragonite. This study presents firstly correlated multi-scale electron microscopy, micro-computed tomography, electron backscatter diffraction and NanoSIMS mapping. We show that all primary, coarse-grained platy calcitic lateral walls are covered by fine-grained fibrous aragonite. Vertical lateral walls separating autozooid chambers have aragonite only on their distal side. This type of asymmetric mineralization of lateral walls results from the vertical arrangement of the zooids at the growth margins of the colony and represents a type of biomineralization previously unknown in cheilostome bryozoans. NanoSIMS mapping across the aragonite-calcite interface indicates an organic layer between both mineral phases, likely representing an organic template for biomineralization of aragonite on the calcite layer. Analysis of crystallographic orientations show a moderately strong crystallographic preferred orientation (CPO) for calcite (7.4 times random orientation) and an overall weaker CPO for aragonite (2.4 times random orientation) with a high degree of twinning (45%) of the aragonite grains. The calculated Young's modulus for the CPO map shows a weak mechanical direction perpendicular to the colony's upper surface facilitating this organism's strategy of clonal reproduction by fragmentation along the vertical zooid walls.

A comprehensive and quantitative analysis of the major specificities in rabbit antithymocyte globulin preparations

Antithymocyte globulin (ATG) preparations are used for treatment and prevention of graft rejection episodes, graft versus host disease and aplastic anemia. The immunomodulatory and immuosuppressive properties of ATGs are mediated by their interaction with a large variety of antigens expressed on immune and nonimmune cell populations. We have conducted a comprehensive analysis on antibody specificities contained in rabbit ATGs in clinical use, ATG-Fresenius (ATG-F) and Thymoglobulin (THG). We have used retroviral expression cloning to identify novel ATG antigens and demonstrate that together with ATG antigens described earlier, these molecules account for the majority of ATG antibodies directed to human cells. Moreover, we have employed cell lines engineered to express antigens at high levels to quantify the antibodies directed to each ATG antigen. We have used cell lines expressing the T cell receptor complex, CD2 and CD28 to remove antibodies to these antigens from ATG preparations and demonstrate that this treatment abrogated the ability of ATGs to induce activation and forkhead box P3 expression in T cells. Comprehensive information and differences on the antigens targeted by ATG-F and THG as well as novel approaches to assess their functional properties are the basis for a better understanding of their immunomodulatory capacities and might eventually translate into improved ATG-based regimen.

Impaired excitatory drive to spinal GABAergic neurons of neuropathic mice

Adequate pain sensitivity requires a delicate balance between excitation and inhibition in the dorsal horn of the spinal cord. This balance is severely impaired in neuropathy leading to enhanced pain sensations (hyperalgesia). The underlying mechanisms remain elusive. Here we explored the hypothesis that the excitatory drive to spinal GABAergic neurons might be impaired in neuropathic animals. Transgenic adult mice expressing EGFP under the promoter for GAD67 underwent either chronic constriction injury of the sciatic nerve or sham surgery. In transverse slices from lumbar spinal cord we performed whole-cell patch-clamp recordings from identified GABAergic neurons in lamina II. In neuropathic animals rates of mEPSC were reduced indicating diminished global excitatory input. This downregulation of excitatory drive required a rise in postsynaptic Ca(2+). Neither the density and morphology of dendritic spines on GABAergic neurons nor the number of excitatory synapses contacting GABAergic neurons were affected by neuropathy. In contrast, paired-pulse ratio of Aδ- or C-fiber-evoked monosynaptic EPSCs following dorsal root stimulation was increased in neuropathic animals suggesting reduced neurotransmitter release from primary afferents. Our data indicate that peripheral neuropathy triggers Ca(2+)-dependent signaling pathways in spinal GABAergic neurons. This leads to a global downregulation of the excitatory drive to GABAergic neurons. The downregulation involves a presynaptic mechanism and also applies to the excitation of GABAergic neurons by presumably nociceptive Aδ- and C-fibers. This then leads to an inadequately low recruitment of inhibitory interneurons during nociception. We suggest that this previously unrecognized mechanism of impaired spinal inhibition contributes to hyperalgesia in neuropathy.

Properties of spinal lamina III GABAergic neurons in naïve and in neuropathic mice

BACKGROUND

Nerve injury leads to Aβ-fibre-mediated mechanical allodynia that is in part due to an impaired GABAergic inhibition in the spinal cord dorsal horn. The properties and function of GABAergic neurons in spinal cord lamina III, an area where low-threshold mechanosensitive Aβ-fibres terminate are, however, largely unknown.

METHODS

We used transgenic mice, which express enhanced green fluorescent protein (EGFP) under control of the promoter GAD67. The morphology and neurochemical characteristics of GABAergic, EGFP-expressing neurons were characterized. We assessed active and passive membrane properties of spinal lamina III GABAergic neurons in naïve animals and animals with a chronic constriction injury (CCI) of the sciatic nerve.

RESULTS

EGFP-expressing neurons in lamina III were predominantly islet cells (47%), whereas non-EGFP-expressing neurons were largely inverted stalked cells (40%). EGFP-expressing neurons accounted for about 25% of GABAergic neurons in lamina III. Forty-four percent co-expressed glycine, 10% neuronal nitric oxide synthase and 3% co-expressed parvalbumin. We found costaining with protein kinase CβII in 42% of EGFP-expressing neurons but no expression of protein kinase Cγ. Membrane properties and excitability of EGFP-and non-EGFP-expressing neurons from naïve and neuropathic animals were indistinguishable. The most frequent firing pattern was tonic firing (naïve: 35%, neuropathic: 37%) followed by gap firing (naïve: 33%, neuropathic: 25%). Delayed, initial burst and single-spike firing patterns made up the remainder in both groups.

CONCLUSION

A change in membrane excitability or discharge pattern of this group of lamina III GABAergic neurons is unlikely the cause for mechanical allodynia in animals with CCI.

Interaction of antithymocyte globulins with dendritic cell antigens

The polyclonal rabbit antithymocyte globulins (ATGs), Thymoglobulin and ATG-Fresenius S, are widely used for prevention and therapy of allograft rejection and graft versus host disease. Dendritic cells (DC) govern immune responses and thus the interaction of ATGs with these cells could potentially contribute to the clinical effects of ATG therapy. Currently there is little information on the DC-antigens targeted by ATGs. In this study we have used a new methodology to identify DC surface antigens recognized by ATGs. By screening an eukaryotic expression library generated from DC with ATGs we could identify several novel ATG antigens including CD81, CD82, CD98, CD99 and CD147. Furthermore, we engineered cells to express previously described ATG antigens and probed them with Thymoglobulin and ATG-Fresenius S. Our results demonstrated strong binding to some but not all of these molecules. We show that previously described antigens and antigens identified in this study account for around 80% of the DC reactivity of ATGs. Analysis of molecules induced by ATG-DC interaction are more in support for an activation of these cells by ATGs than for a specific induction of a tolerogenic DC phenotype.

Comet 81P/Wild 2 Under a Microscope

The Stardust spacecraft collected thousands of particles from comet 81P/Wild 2 and returned them to Earth for laboratory study. The preliminary examination of these samples shows that the nonvolatile portion of the comet is an unequilibrated assortment of materials that have both presolar and solar system origin. The comet contains an abundance of silicate grains that are much larger than predictions of interstellar grain models, and many of these are high-temperature minerals that appear to have formed in the inner regions of the solar nebula. Their presence in a comet proves that the formation of the solar system included mixing on the grandest scales.

The mechanism of corrosion of palladium–silver binary alloys in artificial saliva

Palladium dental casting alloys are alternatives to gold alloys. The aim of this study was to determine the electrochemical behaviour and the corrosion mechanism of binary silver-palladium alloys. Seven binary silver-palladium alloys and pure palladium and silver were tested in a model saliva solution. Electrochemical tests included corrosion potential, polarization resistance, and potentiodynamic polarization measurements. The corrosion products, which may be theoretically formed, were determined by thermodynamic calculation. The behaviour of silver and silver-rich alloys was dominated by the preferential formation of a thiocyanate surface layer, which controlled the free corrosion potential. Palladium dissolved in the form of a thiocyanate complex, but the surface became passivated by either palladium oxide or solid palladium thiocyanate layer, the thermodynamic calculations indicating preference for the oxide. Palladium-rich alloys showed evidence of silver depletion of the surface, resulting in behaviour similar to palladium. Examination of binary silver-palladium alloys has made possible determination of the role of the components of the alloys and model saliva in the corrosion behaviour. The findings are applicable to the more complex commercial dental alloys containing silver and palladium as major components.

[Poisoning with a podophyllin-containing wart-treating tincture]

HISTORY AND ADMISSION FINDINGS

A 57-year-old depressive and alcohol-dependent man was admitted because of frequent nausea and vomiting and abdominal complaints after he had ingested 40 ml of a tincture for treating warts. He was under the influence of alcohol, but normally oriented and without contributory findings other than his gastrointestinal complaints and tachypnea.

INVESTIGATIONS

Transaminases were raised (GOT 1197 U/l, GPT 170 U/l, gammaGT 150 U/l, LDH 2047 U/l), as were creatine phosphokinase (426 U/l) and ferritin (12 200 ng/ml). Platelet count was 36000 mm3, Leucocytes count 11 700/mm (3). Gastroscopy showed marked mucosal necrosis along the entire esophagus and the pulled-up small intestine (state after gastrectomy).

DIAGNOSIS, TREATMENT AND COURSE

The patient became comatose within 5 hours, acidotic, oliguric, required ventilation and went into severe shock. The symptoms and the fact that podophyllin (pod.) was the main agent in the wart preparation confirmed the suspicion of pod. poisoning. Symptomatic and intensive care measures stabilized his critically grave condition. He was extubated on the 7th day after ingestion and on the 10th day was discharged at his own request in a relatively good general state. When he was re-admitted after 4 weeks he was without psychiatric symptoms but deeply depressed, and he had signs of a polyneuropathy in all limbs, typical of pod. toxin poisoning.

CONCLUSION

Pod. toxin, a spindle poison, is the toxic agent of pod., the resin from the roots and rhizomes of various Berberis plants. While the potential toxicity of the resin, taken either orally or applied externally, has been long known, the poorly definied raw product is still being added to anti-wart tinctures.

Preparing future aging advocates: the Oklahoma Aging Advocacy Leadership Academy

PURPOSE

This article describes the organization, operation, and evaluation of the Oklahoma Aging Advocacy Leadership Academy (OAALA).

DESIGN AND METHODS

The Academy was designed to assure the continuation of future cohorts of advocates and volunteers for aging programs and services. It is a statewide training program consisting of 10 weekend sessions. The curriculum incorporates age-related content and advocacy/leadership/voluntary skills training. Evaluation consisted of: (a) a pre-post assessment of perceived familiarity with advocacy and volunteer leadership issues; (b) post-Academy participant assessments of the quality of various aspects of the Academy; (c) post-Academy written statements about areas that were valuable and in need of change; and (d) a compilation of student volunteer and advocacy activities.

RESULTS

Evaluation results indicate that the OAALA led to significant increases in perceived familiarity with issues and very positive participant assessments of quality. In addition, many participants spontaneously initiated advocacy and volunteer activities while enrolled in the Academy.

IMPLICATIONS

Our experience with the Academy suggests that it is a feasible means of preparing individuals to become successful old-age advocates and volunteer leaders.

Pyogenic osteomyelitis of the spine in the elderly: three cases of a synchronous non-axial infection by a different pathogen

STUDY DESIGN

A retrospective chart review of patients over 65 years of age treated at the Spine Care Unit for pyogenic vertebral osteomyelitis.

OBJECTIVES

To assess the reliability of peripheral blood, urine and sputum cultures in the treatment of pyogenic vertebral osteomyelitis in the elderly.

SETTING

Study performed at the Spine Care Unit, Meir Hospital, Kfar-Saba, Israel.

METHODS

The Meir Hospital records were searched for patients over 65 years of age, treated at the Spine Care Unit for pyogenic vertebral osteomyelitis. Charts, culture results and imaging studies were reviewed. A medline literature search was performed to survey the literature regarding pyogenic vertebral osteomyelitis in the elderly with emphasis on diagnostic imaging modalities and surgical treatment.

RESULTS

Three patients were identified with concurrent peripheral infection by a different organism than the organism causing the vertebral osteomyelitis. Delay in correct diagnosis led to neurologic impairment in all patients and surgical treatment was performed in all three to drain the epidural abscess, decompress the spinal cord and obtain direct tissue culture. Following decompression and epidural abscess evacuation, one patient has functionally recovered and was ambulating with a cane, two patients did not recover and remained paraparetic and ambulate in a wheelchair.

CONCLUSIONS

Pyogenic vertebral osteomyelitis in the elderly can be caused by a different pathogen than that isolated from blood, sputum or urine cultures. In the elderly, a biopsy of the vertebral lesion should be obtained for susceptibility studies prior to conservative treatment with bracing and intravenous antibiotics.

Ventilatory-control abnormalities in familial sleep apnea

The role of ventilatory-control abnormalities in predisposing to familial sleep-disordered breathing (SDB) was assessed in 31 subjects 28 +/- 10 yr of age (mean +/- SD). Subjects with (n = 10) and without SDB (n = 12) were recruited from 13 families having two or more members with SDB. Nine age- and gender-matched controls were recruited from families having no member with SDB. Respiratory responses to eucapnic hypoxia, and ventilatory and occlusion pressure responses to hyperoxic hypercapnia with and without added resistive loads (6.5 cm H2O/L/s), were assessed through rebreathing. Age, FEV1, and FVC did not differ among the groups. Hypoxic responses (delta VE/delta SaO2) were significantly lower among the first-degree relatives of SDB families than among controls (-0.76 +/- 0.47 L/min/% SaO2, and -1.32 +/- 0.92 L/min/% SaO2, respectively, p < 0.05). Respiratory responses to hypercapnia during unloaded conditions were similar among the groups. With resistive loading, inspiratory impedance, as measured through the relationship of mouth occlusion pressure (P100) to inspiratory flow (VT/TI), increased with increasing hypercapnia to a greater extent in members of SDB families than in controls (0.169 +/- 0.054 cm H2O/L/min versus 0.122 +/- 0.051, respectively, p < 0.05). These data suggest that familial SDB may be based partly on a familial abnormality in ventilatory control associated with blunting of the hypoxic ventilatory response. The greater increase in impedance during inspiratory loading in members of affected families also suggests a propensity for dynamic airway narrowing.

Brucellosis of the spine with a synchronous Staphylococcus aureus pyogenic elbow infection

Staphylococcus aureus osteomyelitis and pyogenic arthritis has a different pattern in the elderly than in the young. The axial skeleton is the most frequent site of infection and treatment is usually by intravenous antibiotics. We report a case of Staph. aureus septic arthritis of the elbow with concomitant osteomyelitis of the spine that was thought to be due to Staph. aureus, but culture of debrided material from the lesion grew Brucella in culture. We suggest that in the elderly it is advisable to obtain a tissue culture diagnosis and not to instigate therapy based on positive blood cultures or a concomitant infection.

Sensation of dyspnea during hypercapnia, exercise, and voluntary hyperventilation

To determine whether the intensity of dyspnea at a given level of respiratory motor output depends on the nature of the stimulus to ventilation, we compared the sensation of difficulty in breathing during progressive hypercapnia (HC) induced by rebreathing, during incremental exercise (E) on a cycle ergometer, and during isocapnic voluntary hyperventilation (IVH) in 16 normal subjects. The sensation of difficulty in breathing was rated at 30-s intervals by use of a visual analog scale. There were no differences in the level of ventilation or the base-line intensity of dyspnea before any of the interventions. The intensity of dyspnea grew linearly with increases in ventilation during HC [r = 0.98 +/- 0.02 (SD)], E (0.95 +/- 0.03), and IVH (0.95 +/- 0.06). The change in intensity of dyspnea produced by a given change in ventilation was significantly greater during HC [0.27 +/- 0.04 (SE)] than during E (0.12 +/- 0.02, P less than 0.01) and during HC (0.30 +/- 0.04) than during IVH (0.16 +/- 0.03, P less than 0.01). The difference in intensity of dyspnea between HC and E or HC and IVH increased as the difference in end-tidal PCO2 widened, even though the time course of the increase in ventilation was similar. No significant differences were measured in the intensity of dyspnea that occurred with changes in ventilation between E and IVH. These results indicate that under nearisocapnic conditions the sensation of dyspnea produced by a given level of ventilation seems not to depend on the method used to produce that level of ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous rupture of renal oncocytoma with acute abdomen. Case report

A unique case of spontaneous rupture of a renal oncocytoma presenting with hemorrhagic shock and acute abdomen is reported.

[Ultrasound biometry in childhood]

Within the last 18 months the authors have measured, in cases of juvenile cataract seen by them, the axial length of the eye and other parameters. As a control group, children from the authors' squint clinic, with various refractive errors, were examined. With the data thus gathered, correlation and regression analyses were performed, postoperative refraction values were calculated, and eye growth in phakic eyes was compared with that in aphakic eyes. Regression formulas were established which enabled the authors to calculate eye length at a given age, to determine the postoperative refraction of their juvenile cataract patients with great accuracy, and, so far, to prove that there is no significant difference between phakic and aphakic eyes as regards growth.

[Eye injuries in childhood]

The records of 500 eye injuries were analyzed according to age, causes, type of injury and place and time of accident. Children accounted for 16% of the cases, almost half of them between 11 and 15 years old. Forty percent of the injuries were the result of accidents while playing. An increase in the number of injuries in April, July, and on Saturdays was observed. On the basis of this investigation the authors have attempted to recommend a number of sensible preventive measures.

[Development of lens opacity in children's eyes following extracapsular cataract extraction]

In a group of 14 children who underwent extracapsular cataract extraction for cataract of the posterior pole, a reopacification of the posterior capsule was observed in all 18 eyes treated. Only in four eyes, in which rupture of the posterior capsule had occurred intraoperatively, was a reoperation unnecessary. In ten eyes satisfactory removal of the opacifications was accomplished using McIntyre's aspiration cannula; in four cases lensectomy was performed because of severe fibrosis. During a follow-up period of two to eight months after the posterior capsule had been rendered clear, transparency was found to be good in eight out of ten eyes.

Effects of age and respiratory efforts on the perception of resistive ventilatory loads

The present study examined the effects of age on the ability to quantitate changes in inspiratory resistive loads using signals related to the size of the load, per se. Magnitude scaling of inspiratory resistive loads was performed in different trials during breathing at small, large, and varied size tidal volumes. Subjects were specifically instructed to scale the magnitude of the airflow resistance. In both young and older adults, the perceived magnitude of a given resistance was the same in the small-, large-, and varied-sized breath trials despite substantial differences in inspiratory duration and peak inspiratory airway pressure. The change in sensation for a given change in resistance, however, was less in the older than in the younger adults. These results indicate that airflow resistance can be scaled independently of the effort used in breathing. The perception of airflow resistance is blunted in elderly adults probably as a result of an impairment in the central nervous system processing of separate signals of pressure and flow.

Fatal pulmonary reaction from low doses of bleomycin. An idiosyncratic tissue response

There were two cases of fatal interstitial pneumonia secondary to bleomycin sulfate administration. Although bleomycin pulmonary toxicity is generally thought to be dose-related and occurs infrequently with a total cummulative dose less than 300 to 400 units, the two reactions reported here occurred with doses of 105 and 165 units. Fatal bleomycin-induced pneumonia has been previously reported at these low dosages, and physicians should be aware that this toxic reaction may occur as an idiosyncratic response. Previous thoracic irradiation may be a predisposing factor. Patients receiving bleomycin should be meticulously monitored by interrogation for cough, dyspnea, and chest pain; by auscultation for rales; by serial chest roentgenograms; and by determinations of vital capacity and single-breath carbon monoxide diffusing capacity.