[Dyspnea «sine materia»]

Dyspnea is a symptom of respiratory discomfort commonly encountered in clinical practice which, in most of the cases, relates to a cardiopulmonary or a metabolic disorder. Its genesis is complex and results from numerous interactions within cortical and limbic brain areas following intero- and nociceptive stimuli. The term dyspnea «sine materia» points to a state where no clear underlying cardiopulmonary or metabolic pathology has been identified and we include here the hyperventilation syndrome and the physical deconditioning. Treatment of dyspnea «sine materia» is based on behavioural psychotherapy and on reathtletisation programme in case of physical deconditioning.

Preterm neonate delivered to COVID-19 positive mother on ECMO support

Despite ongoing research and recent discoveries, there remains a paucity of data regarding COVID-19 and its implications for pregnant women, particularly its effects on the developing fetus. To date, there are a limited number of articles available regarding the utility of Extra Corporeal Membrane Oxygenation (ECMO) for cardio-respiratory support of pregnant women during the perinatal period. Additionally, there are only a few case reports detailing the delivery management of a baby born to a mother on ECMO support. Here, we report a case of a premature, low birth weight neonate delivered by a 32-year-old woman while on ECMO due to severe acute respiratory distress syndrome resulting from COVID-19 infection.

Hippocampal Sclerosis Detection with NeuroQuant Compared with Neuroradiologists

BACKGROUND AND PURPOSE

NeuroQuant is an FDA-approved software that performs automated MR imaging quantitative volumetric analysis. This study aimed to compare the accuracy of NeuroQuant analysis with visual MR imaging analysis by neuroradiologists with expertise in epilepsy in identifying hippocampal sclerosis.

MATERIALS AND METHODS

We reviewed 144 adult patients who underwent presurgical evaluation for temporal lobe epilepsy. The reference standard for hippocampal sclerosis was defined by having hippocampal sclerosis on pathology (n = 61) or not having hippocampal sclerosis on pathology (n = 83). Sensitivities, specificities, positive predictive values, and negative predictive values were compared between NeuroQuant analysis and visual MR imaging analysis by using a McNemar paired test of proportions and the Bayes theorem.

RESULTS

NeuroQuant analysis had a similar specificity to neuroradiologist visual MR imaging analysis (90.4% versus 91.6%; P = .99) but a lower sensitivity (69.0% versus 93.0%, P < .001). The positive predictive value of NeuroQuant analysis was comparable with visual MR imaging analysis (84.0% versus 89.1%), whereas the negative predictive value was not comparable (79.8% versus 95.0%).

CONCLUSIONS

Visual MR imaging analysis by a neuroradiologist with expertise in epilepsy had a higher sensitivity than did NeuroQuant analysis, likely due to the inability of NeuroQuant to evaluate changes in hippocampal T2 signal or architecture. Given that there was no significant difference in specificity between NeuroQuant analysis and visual MR imaging analysis, NeuroQuant can be a valuable tool when the results are positive, particularly in centers that lack neuroradiologists with expertise in epilepsy, to help identify and refer candidates for temporal lobe epilepsy resection. In contrast, a negative test could justify a case referral for further evaluation to ensure that false-negatives are detected.

Antineoplastic agents exacerbating Charcot Marie Tooth disease: red flags to avoid permanent disability

BACKGROUND

Charcot Marie Tooth (CMT) disease is the most common form of hereditary neuropathy. Due to the high prevalence of mild and undiagnosed forms, patients with CMT disease may be exposed to severe neurotoxicity following the administration of neurotoxic chemotherapies. The aim of this report is to alert oncologists to the potential to precipitate severe irreversible peripheral neuropathies when administering neurotoxic compounds to undiagnosed CMT patients.

MATERIAL AND METHODS

A retrospective research in the OncoNeuroTox database was performed (2010-2016), searching for patients with the diagnosis of chemotherapy-induced peripheral neuropathy (CIPN) and CMT disease. A comprehensive literature review for previously published cases was performed using the Pubmed and Cochrane databases (1972-2017).

RESULTS

Among 428 patients with CIPN, we identified eight patients with concomitant CMT disease. Seven patients out of the eight had no previous diagnosis of CMT disease, although accurate familial history disclosed mild signs of peripheral neuropathy in five cases. Patients themselves had minor stigmata of long-standing peripheral damage. Patients received chemotherapy regimens based on vinca alkaloids, taxanes or a combination of vinca alkaloids and platinum compounds. In two cases, cumulative doses were below or equal to the expected neurotoxic threshold. Following chemotherapy administration, patients developed severe length-dependent sensory-motor deficits. Despite early drug discontinuation, most patients remained severely disabled.

CONCLUSION

A brief checklist to disclose long-standing signs of peripheral neuropathy could be helpful to detect patients with undiagnosed hereditary neuropathies who could be at risk of developing severe irreversible neurotoxicity following the administration of neurotoxic agents.

Profound and persistent decrease of circulating dendritic cells is associated with ICU-acquired infection in patients with septic shock

PURPOSE

Septic shock induces a decrease in dendritic cells (DCs) that may contribute to sepsis-induced immunosuppression. We analyzed the time course of circulating DCs in patients with septic shock and its relation to susceptibility to intensive care unit (ICU)-acquired infections.

METHODS

We enrolled adult patients with septic shock (n = 43), non-septic shock (n = 29), and with sepsis without organ dysfunction (n = 16). Healthy controls (n = 16) served as reference. Blood samples were drawn on the day of shock (day 1), then after 3 and 7 days. Myeloid (mDC) and plasmacytoid (pDC) DCs were counted by flow cytometry. Cell surface HLA-DR expression was analyzed in both DC subsets.

RESULTS

At day 1, median mDC and pDC counts were dramatically lower in septic shock patients as compared to healthy controls (respectively, 835 mDCs and 178 pDCs/ml vs. 19,342 mDCs and 6,169 pDCs/ml; P < 0.0001) but also to non-septic shock and sepsis patients (P < 0.0001). HLA-DR expression was decreased in both mDCs and pDCS within the septic shock group as compared to healthy controls. DC depletion was sustained for at least 7 days in septic shock patients. Among them, 10/43 developed ICU-acquired infections after a median of 9 [7.5-11] days. At day 7, mDC counts increased in patients devoid of secondary infections, whereas they remained low in those who subsequently developed ICU-acquired infections.

CONCLUSION

Septic shock is associated with profound and sustained depletion of circulating DCs. The persistence of low mDC counts is associated with the development of ICU-acquired infections, suggesting that DC depletion is a functional feature of sepsis-induced immunosuppression.

How effective is endovascular intracranial revascularization in stroke prevention? Results from Borgess Medical Center Intracranial Revascularization Registry

BACKGROUND AND PURPOSE

The WASID study established the risk of subsequent ischemic stroke at 1 year in subjects with symptomatic intracranial atherosclerotic stenosis (70%-99%) at 18%. The efficacy of different methods of endovascular revascularization in stroke prevention still has not been established. We compared the stroke rate in our registry at 1 year following intervention with the WASID results to identify which method, if any, provides the most benefit in stroke prevention. This result from the BMC-IRR follows a previously published article comparing stent placement and angioplasty outcomes.

MATERIALS AND METHODS

We maintained a nonrandomized single-center single-operator registry of consecutive symptomatic patients who underwent endovascular intracranial revascularization. Data were collected prospectively and retrospectively and analyzed retrospectively. Patients were treated with angioplasty, BMS, or self-expanding WS. To make our data comparable with that in the WASID study, we selected patients with a single lesion of 50%-99% stenosis undergoing a single intervention. Data was collected on patients until symptom recurrence, repeat intervention, or 1 year postintervention, whichever occurred first.

RESULTS

We found that 115 patients fit the inclusion criteria, with 38 angioplasty, 28 BMS, and 49 WS cases. For patients with 70%-99% stenosis, the overall probability of stroke at 1 year postintervention was 19.3%. The overall stroke probability per device, independent of clinical presentation, was 12.5% for angioplasty, 20.2% for BMS, and 24.1% for WS.

CONCLUSIONS

Compared with the WASID data, angioplasty appears to have a lower stroke rate after 1 year than medical therapy alone. However, neither stent-placement arm compared favorably with the WASID results.

Predictors of unfavorable outcome in intracranial angioplasty and stenting in a single-center comparison: results from the Borgess Medical Center-Intracranial Revascularization Registry

BACKGROUND AND PURPOSE

Intracranial angioplasty and stent placement are used to treat intracranial atherosclerotic disease. The 2 interventions have not been directly compared.

MATERIALS AND METHODS

This was a single-center, single-operator registry of consecutive, symptomatic subjects receiving treatment (angioplasty, BMS, or WS, chosen based on safety as judged by the operator). After November 2005, angioplasty alone was abandoned following the introduction of the WS. The primary end point was stroke rate per intervention at 30 days. The secondary end point was stroke rate per patient beyond 30 days. Success, dissection, restenosis, and occlusion rates were tracked.

RESULTS

From April 2002 to January 2009, 140 subjects with 159 lesions (50%-100% stenosis) underwent 209 interventions: 89 angioplasty, 47 BMS, and 73 WS cases. Overall stroke rate at 30 days was 12.9%. The angioplasty arm had the lowest stroke rate (4.5%), whereas the WS arm had the highest (24.7%; P = .0002), leaving the BMS with 10.7%. Stroke rate beyond 30 days was 9%. The success rate was 58.4% for angioplasty, 81.3% for BMS, and 94.4% for WS, whereas the restenosis rates were 28.2%, 5.8%, and 13.3%, respectively. Dissection increased the risk of stroke in the first 30 days (P = .0439) and restenosis (P = .0051). Perforator vessels were more likely than nonperforators to have stroke within 30 days (P = .008). Eccentric lesions were more likely to have stroke than concentric lesions (P = .0726).

CONCLUSIONS

In this comparison, angioplasty had a significantly lower stroke rate than WS. Certain lesion locations, morphologic characteristics, and the presence of dissection after treatment were other predictors of unfavorable outcome.

Poplar volatiles - biosynthesis, regulation and (eco)physiology of isoprene and stress-induced isoprenoids

Plants interact with their environment through a wide variety of biogenic volatile organic compounds (BVOCs), with isoprenoids ( identical with terpenes), i.e. isoprene, mono- and sesquiterpenes, playing an important role. Isoprene, a hemiterpene, is the simplest isoprenoid compound mainly emitted by tree species like poplars, oaks and willows. Woody plants alone comprise 75% of the global isoprene emitted to the atmosphere. Due to its significant influence on atmospheric chemistry, research has been focused on this C5 compound, with poplar being the most prominent model system. Recent studies indicate that isoprene can enhance thermotolerance or quench oxidative stress, while also interfering with the attraction of herbivores and parasitoids to plants. In this paper, we report on biosynthesis, regulation and function of isoprene and other stress-induced volatile isoprenoids in poplar, and discuss the future scientific challenges in this genus with respect to the importance of plant volatiles in high-density poplar biomass plantations.

Natural history of multiple sclerosis in a population-based cohort

BACKGROUND AND PURPOSE

We sought to identify predictive clinical factors of disability during initial course in multiple sclerosis (MS) patients.

METHODS

A total of 2871 MS patients from the LORSEP (Lorraine Multiple Sclerosis) population-based cohort were analyzed. The relationships between baseline demographic, clinical predictors and time to assignment of Expanded Disability Status Scale (EDSS) scores of 3, 4 and 6 were assessed using a Cox regression model.

RESULTS

Multivariate analysis showed that, for relapsing-remitting patients, a shorter time to assignment of an EDSS score of 4 was associated with an older age of onset of MS and incomplete recovery from the first relapse. Median times were not influenced by gender or the time between the first two relapses. The results also demonstrated that MS progression is independent of the initial clinical data once an EDSS score of 4 is reached rather than a score of 3 because the time from EDSS 3 to assignment of EDSS 4 were correlated with predicting variables. The data were very different for the time between assignment of scores of 4 and 6 because the median times were not influenced by any of the predicting variables.

Increasing incidence of multiple sclerosis among women in Lorraine, Eastern France

This study aims to describe the prevalence and incidence rates of multiple sclerosis (MS) in Lorraine, France, and its secular trend from 1990 to 2002. Cases were sourced from the regional network of MS healthcare workers in the Lorraine region and include all cases with definite or probable MS according to Poser's criteria. We identified 2718 patients with MS on 31 December 2004. The prevalence rate was 120/100,000 (95% confidence interval [CI]: 119-121). Between 1990 and 2002, the average age- and sex-adjusted annual incidence rate was 5.5/100,000 (95% CI: 4.4-6.6). During this same period, there was a significant increase in overall incidence in women but not in men. The mean age at MS onset, disability score five years after onset, number of relapses during the first five years, and proportion of first attack with sequelae or polysymptomatic symptoms were not significantly different between each annual cohort during the study period. The prevalence and incidence rates of MS we found in our study were higher than in previous studies in France. The increase in incidence of MS between 1990 and 2002, mostly in women, was not related to better ascertainment of patients with mild disability.

Validity of a French version of the fatigue impact scale in multiple sclerosis

Purpose Fatigue is a frequent and common symptom of multiple sclerosis (MS) that can interfere with patients' everyday activities. There is no objective scale for assessing fatigue in French MS patients. The objective of this study was to adapt an English language scale for use with French patients.

Methods The Fatigue Impact Scale was translated and culturally adapted into French by a committee of medical and linguistic specialists. The psychometric properties of this new instrument, called EMIF-SEP were assessed.

Results EMIF-SEP is composed of 40 items. Four dimensions of this scale (cognitive, physical, social role and psychological) were identified by factor analysis. Each dimension had a high internal consistency (Cronbach's alpha >0.80). The test-retest reproducibility was very satisfactory; intra-class correlation coefficients were all above 0.70.

Conclusion EMIF-SEP is the first scale for assessing MS-related fatigue which has been adapted to French-speaking patients. It is useful for clinical practice and MS-related research. Multiple Sclerosis 2007; 13: 1026—1032. http://msj.sagepub.com

Multiple sclerosis with a progressive course from onset in Lorraine-Eastern France

To investigate the patient characteristics, disease progression, and associated risk factors in patients with multiple sclerosis (MS) with a progressive onset, we conducted a longitudinal population-based study of 359 patients (252 with primary progressive MS (PPMS) and 107 with progressive relapsing MS (PRMS)) in Lorraine, France. As outcome measures, we assessed the time from MS onset to reaching disability status scale (DSS) scores of 4, 6 and 7 and the time from assignment of DSS score of 6 to assignment of DSS score of 7. We studied the influence on these outcomes of sex, age of onset and symptoms of onset. We also studied the influence of the time from MS onset to assignment of DSS 6 on the time from MS onset to assignment of DSS 7. There were no significant differences in the demographic data (gender and age at onset of MS) and clinical data (median time to DSS scores of 4, 6 and 7) between the patients with PPMS and PRMS suggesting such a distinction may be unnecessary. The male/female ratio in all 359 patients with MS with a progressive onset was 1/1.36. The median age at onset was 42.7 years (25% Q1 = 34.7; 75% Q3 = 50.0), was lower for male (40.5 years) than for female patients (44.2 years; p = 0.002). The median time to DSS scores of 4, 6 and 7 were (in years) 3.0 (95% CI = 2.8 to 3.7), 9.9 (95% CI = 9.0 to 10.6), and 17.0 (95% CI = 14.9 to 19.0). A cane was required in 25% of patients 5 years after onset and in 75% 15 years after onset. We did not find any significant unfluence of sex, age at onset, or symptoms at onset on the time from MS onset to assignment of scores 6 or 7 or on the time from the assignment of a score of 6 to the assignment of a score of 7.

A new estrogen receptor on ER-negative breast cancer?

10604

Background: Premenopausal women and BRCA-1 mutation carriers have estrogen receptor-negative (ER-) breast cancers that paradoxically seem responsive to hormonal deprivation such as oophorectomy. GPR30 is a G protein-coupled receptor that is activated not only by estradiol but also tamoxifen and fulvestrant. The prevalence and significance of GPR30 in breast cancer are unknown. We hypothesized that GPR30 may be present in ER-negative tumors and may promote growth of ER-negative breast cancer in premenopausal patients. Methods: An immunohistochemical staining protocol for rabbit polyclonal GPR30 antibody (Novus Biological) was developed initially on the known GPR30-positive breast cancer cell line MCF-7 and the GPR30-negative breast cancer cell line MDA-MB-231 and later on a panel of human breast tumors from archived paraffin blocks. After an automated protocol was optimized, under an IRB-approved protocol all incoming breast cancer specimens were stained for GPR30 and reviewed by a pathologist blinded to the ER/PR status. Significance of associations was tested by chi square analysis. Results: Twenty-seven breast cancer tumors were studied. The mean age of the patients was 53 (range 20–87). All of 10 triple negative (ER-,PR-, HER2 neu-) and 2 ER-/Her2 neu+ tumors stained positive for GPR30. Only 4 of 11 ER+/Her2neu - tumors stained positive for GPR30 (p=0.004). The mean age of triple negative patients was 43.7 yr, while the mean age of ER+/Her2 neu- was 63.2 (p=0.02). Three out of 4 ER+/HER2 neu+ tumors stained positive for GPR30. Four patients were African Americans, 2 had triple negative tumors and 2 ER+/Her2+, all 4 were positive for GPR30. Conclusions: GPR30 appears to be frequently expressed in ER-negative breast cancer and may represent an adverse factor. ER+ tumors with good prognostic features (PR+, HER2 neu-) were mostly negative for GPR30, while high-risk tumors were positive for GRP30. Premenopausal status and African-American race are known risk factors for lower survival. In this study, the African-American patients had high-risk tumors that were also positive for GPR30. A longer- range study is needed to test the association of GPR30 expression with recurrence and death. Future studies to assess the function of GPR30 in breast cancer cells may yield prognostic and therapeutic applications.

No significant financial relationships to disclose.

Clinical follow-up of 304 patients with multiple sclerosis three years after mitoxantrone treatment

The objectives of this study were to assess the benefits of 1) mitoxantrone after three years of follow-up and 2) disease-modifying treatment (DMT) after stopping mitoxantrone. A retrospective analysis was performed on 304 patients with active relapsing-remitting (RR) or progressive multiple sclerosis (PMS) who were treated with mitoxantrone. After mitoxantrone therapy, some patients received DMT (interferon-beta or glatiramer acetate) while others did not. The disease course of the two groups was evaluated by the Expanded Disability Status Scale (EDSS) before and after mitoxantrone and then every year for three years. The mean EDSS score at starting mitoxantrone and three years after stopping mitoxantrone respectively, were: 3.3 (1.3) and 3.2 (1.7) for the RRMS patients and 5.9 (1.2) and 6.4 (1.4) for the PMS patients. Before starting mitoxantrone, demographic and clinical parameters of predictive disability were not significantly different between patients who received DMT or not. The variation of EDSS between time of stopping mitoxantrone and three years later was significantly different (+0.9 versus +0.3; P=0.03) for patients with RRMS. We found that mitoxantrone treatment induces stable disease up to two years after discontinuation of mitoxantrone therapy. In the third year, patients without DMT deteriorated.

Humoral and cellular responses to influenza vaccination in human recipients naturally tolerant to a kidney allograft

Rare kidney allograft recipients enjoy unaltered graft function years after interruption of their immunosuppressive treatment. To assess the extent to which this state of 'operational tolerance' (TOL) is specific to the graft and not the result of a global immunodeficiency, we analyzed the response of such patients following influenza vaccination. Hemagglutination inhibition titers and frequency of IFNgamma-secreting T cells were measured before 1 and 3 months after vaccination. The proportion of healthy volunteers (HV) responding to vaccine was significantly higher than that of immunosuppressed (IS) patients. Three 'TOL' patients presented a humoral response similar to that of HV, whereas the two others had a poor response, like the IS recipients. Although the small number of patients does not allow for definitive conclusions to be made, these data suggest that the status of tolerance may be heterogeneous, with some patients with a global immunodeficiency and others with an adapted response to vaccination.

Structural organization and expression of human MTUS1, a candidate 8p22 tumor suppressor gene encoding a family of angiotensin II AT2 receptor-interacting proteins, ATIP

The Mitochondrial Tumor suppressor 1 (MTUS1) gene is a newly identified candidate tumor suppressor gene at chromosomal position 8p22. We report here that MTUS1 encodes a family of proteins whose leader member (ATIP1) was previously isolated in our laboratory as a novel interacting partner of the angiotensin II AT2 receptor involved in growth inhibition (Nouet, JBC 279: 28989-97, 2004). The MTUS1 gene contains 17 coding exons distributed over 112 kb of genomic DNA. Alternative exon usage generates three major transcripts (ATIP1, ATIP3 and ATIP4), each showing different tissue distribution. ATIP polypeptides are identical in their carboxy-terminal region carrying four coiled-coil domains. In their amino-terminal portion, ATIP polypeptides exhibit distinct motifs for localisation in the cytosol, nucleus or cell membrane, suggesting that MTUS1 gene products may be involved in a variety of intracellular functions in an AT2-dependent and independent manner. ATIP1 is ubiquitous and highly expressed in the brain. ATIP3 is the major transcript in tissues (prostate, bladder, breast, ovary, colon) corresponding to cancer types with frequent loss of heterozygosity at 8p22. Interestingly, ATIP4 is a brain-specific transcript highly abundant in the cerebellum and fetal brain. High evolutionary conservation of ATIP amino-acid sequences suggests important biological roles for this new family of proteins in tumor suppression and/or brain function.

Mutation analysis of the 8p22 candidate tumor suppressor gene ATIP/MTUS1 in hepatocellular carcinoma

A high frequency of allelic loss affecting chromosome 8p and a minimal region of deletion at p21-22 have been previously reported in hepatocellular carcinoma (HCC), suggesting that at least one tumor suppressor gene is present in this region. In this study, we assessed whether the angiotensin II AT2 receptor interacting protein (ATIP)/mitochondrial tumor suppressor gene (MTUS1), a gene newly identified at position 8p22, may be a candidate tumor suppressor gene mutated in HCC. We searched for alterations in the 17 coding exons of ATIP/MTUS1 by means of denaturating high-performance liquid chromatography and sequencing, in 51 HCC tumors and 58 cell lines for which loss of heterozygosity status was known. Five major nucleotide substitutions were identified, all located in exons used by the ATIP3 transcript which is the only ATIP transcript variant expressed in liver. These nucleotide variations result in amino-acid substitution or deletion of conserved structural motifs (nuclear localisation signal, polyproline motif, leucine zipper) and also affect exonic splicing enhancer motifs and physiological splice sites, suggesting potential deleterious effects on ATIP3 function and/or expression.

Expression of E-cadherin in human colorectal cancer

AIM

To investigate the expression of E-cadherin, a calcium-dependent cell-cell adhesion molecule in colorectal carcinoma. Antibodies to E-Cadherin were used to establish the association of their expression with the clinicopathological characteristics of this disease using immunohistochemical methods.

METHODS

Immunohistochemical analysis for E-cadherin was carried out in formalin-fixed, paraffin-embedded sections of neoplastic colorectal tissues and non-neoplastic ones adjacent to the lesion from 49 patients who underwent surgery, by the standard peroxidase-antiperoxidase method. Expression of this antigen in normal and malignant epithelium and stromal cells was compared.

RESULTS

Both neoplastic and normal tissues showed expression of E-cadherin. There was, however, higher expression of E-cadherin in epithelial cells in both tumour and normal tissues than stromal cells. The percentage of expression in epithelial cells of well-differentiated tumours was significantly higher than moderately differentiated tumours. Loss of normal membranous expression and the presence of cytoplasmic and mixed staining were found frequently in tumour tissues (p = 0.004). This loss of membranous expression, however, did not correlate with Duke's staging, tumour grade, sex, size or site of the tumour.

CONCLUSION

This study suggests that the lower expression of E-cadherin in less differentiated tumours may explain their aggressive nature, although loss of membranous expression was not significantly correlated to Duke's staging, tumour grade, sex, size and site of tumour.

Atypical Sinusitis in Adults Must Lead to Looking for Cystic Fibrosis and Primary Ciliary Dyskinesia

HYPOTHESES/OBJECTIVES:: In adults, purulent pansinusitis or nasal polyposis starting early in life or that is permanently infected or associated either with chronic bronchial infection, infertility, or situs inversus are uncommon. In these atypical cases of chronic sinusitis (ACS), a primary dysfunction of the mucociliary clearance can be suspected. Adult patients with ACS were therefore investigated to detect primary ciliary dyskinesia (PCD) or cystic fibrosis (CF).

STUDY DESIGN

Open, prospective study.

PATIENTS AND METHODS

Forty-two patients with ACS were investigated with ciliary beat frequency and ultrastructure analysis in nasal cells and cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation analysis in blood leukocytes.

RESULTS

The diagnosis of PCD was confirmed in seven (17%) patients. At least one CFTR gene mutation was detected in 16 (38%) patients. The diagnosis of CF was suggested in three (7%) compound heterozygous patients. Another 13 (31%) patients were heterozygous for a CFTR gene mutation or a complex allele. Comparison of clinical features of ACS showed that only a family history of chronic sinusitis (P <.01) or chronic bronchitis (P <.02) and the presence of diffuse bronchiectasis (P <.0001) or serous otitis media (P <.0001) were significantly more frequent in PCD patients than in patients carrying CFTR gene mutations or those without PCD or CFTR gene mutations.

CONCLUSIONS

ACS should be considered a remarkable entity in which congenital abnormalities of epithelial cells are frequently detected (55% of patients). The higher frequency of mutations in ACS patients compared with the general population suggests that heterozygoty for CFTR gene mutation could be a sinusitis-causing status.

Spectroscopic determination of dynamic plasma gradients in implosion cores

The time-dependent gradient structure of a laser-compressed, high-energy-density plasma has been determined using a method based on the simultaneous analysis of time-resolved x-ray monochromatic images and x-ray line spectra from Ar-doped D2 implosion cores. The analysis self-consistently determines the temperature and density gradients that yield the best fits to the spatial-emissivity profiles and spectral line shapes. This measurement is important for understanding the spectra formation and plasma dynamics associated with the implosion process. In addition, since the results are independent of hydrodynamic simulations, they are also important for comparison with fluid-dynamic models.

Intrapelvic dislocation of the left hemipelvis as a complication of the pelvic "C" clamp: a case report and review

High-energy pelvic trauma, with posterior pelvic disruption, produces high morbidity and mortality rates. Part of the initial resuscitation has included an anterior external fixator to close the pelvic ring, thereby decreasing blood loss and reducing mortality. However, this technique has been found to be less efficacious in certain situations. This has stimulated an interest in alternative methods of stabilization, which has led to the recent development of the emergency pelvic "C" clamp. We present one of the potential pitfalls of this new device, discuss pertinent clinical and biomechanical studies, and offer suggestions regarding its use.

Somatosensory evoked potentials fail to diagnose thoracic outlet syndrome

Somatosensory evoked potentials (SEPs) are used in the diagnosis of thoracic outlet syndrome (TOS), even as an indication for surgery. The purpose of this study was to evaluate the use of SEPs in the diagnosis of TOS. Twenty-one patients (mean age, 37 years) with TOS and 23 control subjects (mean age, 34 years) were included. Somatosensory evoked potentials of median and ulnar nerves were measured bilaterally in patients in both a relaxed and arms-elevated provocative position. A three-way analysis of variance showed no significant difference between the interpeak latencies of the TOS and control groups (p = .352). Significant differences were found in testing positions (p = .0014) and nerve tested (p = .001) in both groups. Therefore, this study suggests that SEPs are not helpful in the diagnosis of TOS.

A randomized, blinded, placebo-controlled trial of divalproex sodium prophylaxis in adults with newly diagnosed brain tumors

BACKGROUND

Seizures occur after the diagnosis of brain tumors in up to 40% of patients. Prophylactic anticonvulsants are widely advocated despite a lack of convincing evidence of their efficacy in preventing first seizures. We conducted a randomized, double-blind, placebo-controlled study comparing the incidence of first seizures in divalproex sodium- and placebo-treated patients with newly diagnosed brain tumors.

PATIENTS AND METHODS

Patients who had not previously had a seizure were randomized within 14 days of diagnosis of their brain tumor to receive either divalproex sodium or placebo. All patients had at least one supratentorial brain lesion, a Karnofsky Performance Score (KPS) > or = 50%, and no previous anticonvulsant use or other brain disease. Compliance and adequacy of dosing were assessed by pill counts and monthly blood levels.

RESULTS

Seventy-four of 75 consecutive eligible patients were entered in this study. Median follow-up was 7 months. The drug and placebo groups did not differ significantly in age, sex, KPS, primary tumor type, number or location of brain lesions, frequency of brain surgery, or pretreatment EEG. Thirteen of 37 patients (35%) receiving divalproex sodium and 9 of 37 patients (24%) on placebo had seizures. The odds ratio for a seizure in the divalproex sodium arm relative to the placebo arm was 1.7 (95% CI 0.6 to 4.6; p = 0.3). The hypothesis that anticonvulsant prophylaxis provides a reduction in the frequency of first seizure as small as 30% was rejected (p = 0.05).

CONCLUSIONS

Anticonvulsant prophylaxis with divalproex sodium is not indicated for patients with brain tumors who have not had seizures.

Transient ictal cortical blindness during middle age. A case report and review of the literature

We report a case of transient ictal cortical blindness in a 63-year-old woman. We reviewed the literature of all seizure-induced bilateral blindness. After careful evaluation of 44 cases, it was evident that the cases could be categorized into three groups with different etiologies, duration of blindness, and probable visual prognosis. Transient cortical blindness may occur with unilateral focal seizure or with bilateral seizure activity of the primary generalized type. Seizure-induced blindness may be ictal or postictal (Todd's) phenomenon or a permanent consequence following status epilepticus. Its duration varies between less than 1 minute to 4 months, or can be permanent. Our case of cortical blindness is related to new onset occipital epilepsy from a left occipital focus, and adds to the evidence that cortical blindness occasionally occurs as an uncommon manifestation of seizure.

Sample survey of leprosy after three years of MDT in Bhavani taluk of Periyar District, Tamilnadu

A sample survey of Bhavani taluk was undertaken in March 1992 three years after the introduction of MDT. Ten percent of the population was taken for the sample. A population of 45,781 was enumerated and 41,554 was examined. The three sectors were stratified according to the prevalence rate and classifying the villages by the size of the population. Villages were selected by random sampling. The sample survey detected 288 new cases of leprosy of which 16 (5.55%) were bacteriologically positive for acid-fast bacilli. The child rate was 13.54% among new cases. According to the sample survey the current prevalence rate per 1000 population was 9.07 (with a new case detection rate of 6.93/1000 population), much higher than that derived from programme data (prevalence rate 3.45) and the expected ten fold reduction of prevalence under MDT. Independent sample surveys of NLEP units after three to five years of implementation of MDT will help to assess deficiencies in the programme and enable us to take remedial measures.

Partial agonist activity of celiprolol

Celiprolol given intravenously (i.v.) to pithed rats in the dose range of 0.1-10,000 micrograms/g produced a dose-dependent increase in heart rate (HR) which was greatest (123 beats/min) at 1,000-3,000 micrograms/kg. This partial agonist effect was blocked by the selective beta 1-adrenoceptor antagonist CGP 20712A. Celiprolol also produced a vasodepressor effect in this dose range which was abolished by the relatively selective beta 2-adrenoceptor antagonist ICI 118551 but not CGP 20712A. The magnitude of this intrinsic sympathomimetic activity (ISA) response was not significantly altered by reserpine pretreatment. Celiprolol also antagonised the effects of isoprenaline 0.05 microgram/kg on HR and blood pressure (BP). The beta 1 selectivity of celiprolol as an antagonist in pithed rats (beta 1/beta 2 = 340:1) was similar to that observed in studies with isolated guinea pig atria and trachea (beta 1/beta 2 = 63:1), both being considerably greater than that observed with atenolol. Celiprolol, however, like atenolol, potentiated the bronchoconstrictor responses to histamine (3 micrograms/kg). Metabolic studies of rats and human urine failed to show significant amounts of potentially vasoactive metabolites. These data are consistent with celiprolol acting as both a beta 1- and beta 2- adrenoceptor partial agonist.

Reflex seizures in Down syndrome

A unique patient with Down syndrome who developed reflex seizures is described. The patient has had recurrent intermittent seizures for the past 3.5 years. These seizures were usually precipitated by auditory stimuli such as sudden loud noises. While having seizures the patient experienced severe discomfort in the posterior neck area. The seizures usually lasted 10-20 s, and there was no aura, nor was there a postictal phase. Of the numerous investigations performed, closed-circuit electroencephalogram video telemetry was most helpful in arriving at an accurate diagnosis. Carbamazepine administration resulted in total seizure control and reflex stimuli no longer provoke seizure activity. Although it has been suggested that reflex seizures may be due to genetic factors or structural central nervous system defects, we were unable to uncover the cause of the reflex seizures in our patient.

Seizure disorders in Down syndrome

The prevalence, onset, and type of seizure disorders, as well as seizure control, were studied in a large cohort of 405 individuals with Down syndrome (age range, 6 months to 45 years). The evaluation of a questionnaire completed by the subjects' parents and of the patients' medical records indicated that 33 (8.1%) of 405 persons with Down syndrome had seizure disorder. With regard to the onset of seizures, a bimodal distribution was noted: 40% of patients began having seizures before the age of 1 year, and another 40% started with seizure activity in the third decade of life. In the younger age group, primarily infantile spasms and tonic-clonic seizures with myoclonus were observed, and the older patients often had partial simplex or partial complex seizures as well as tonic-clonic seizures.

Pyruvate kinase: diagnostic value in neuromuscular disease

Pyruvate kinase activity was examined in the sera of a group of patients with neuromuscular disease and in carriers, and compared with that of creatine kinase. The following observations were made: 1. Pyruvate kinase activity was elevated in all 14 patients with Duchenne muscular dystrophy, with very high values generally correlating inversely with age or disease duration. Elevated values of pyruvate kinase were usually, but not invariably, associated with elevated values of creatine kinase. 2. Almost all patients with other muscle diseases and those with neural atrophy had modest elevations in pyruvate kinase activity. 3. ten of 17 individuals were identified as carriers of muscle disease by using both pyruvate kinase and creatine kinase while eight and nine, respectively, were detected using either assay alone. 4. When frozen stored EDTA-plasma was used for pyruvate kinase estimation, higher levels, as compared with the corresponding sera or fresh plasma, were found in controls and carriers but not in Duchenne muscular dystrophy patients. Frozen stored EDTA-plasma should, therefore, not be used for diagnostic purposes.

Pharmacological prophylaxis against the development of kindled amygdaloid seizures

The kindling of amygldaloid and cortical seizures in cats was used to study the prophylactic effects of phenobarbital, phenytoin, ethosuximide, acetazolamide, and dexamethason. Phenobarbital prevented the evolution of such seizures beyond stage 4 in all amygdaloid-kindling animals during 160 days of study. The prophylactic effect persisted on periodic challenge after the drug had been discontinued. Phenytoin, ethosuximide, acetazolamide, and dexamethasone appeared to have no prophylactic effect against the development of kindled amygdaloid seizures. With cortical kindling, both phenobarbital and phenytoin retarded the evolution of seizures without achieving true prophylaxis. The drugs appeared to act as suppressants. Prophylaxis was not an "all-or-none" phenomenon but rather a limitation of the stage of seizure evolution.