Neuro-ophthalmic features of patients with spontaneous cerebrospinal fluid leaks

Background

Increased intracranial pressure is a potential cause of spontaneous cerebrospinal fluid (sCSF) leak. Associated neuro-ophthalmic features have not been well studied, particularly relationships with idiopathic intracranial hypertension (IIH). We hypothesized that neuro-ophthalmic features routinely used in evaluations for IIH can be useful in the investigation of a causal relationship between IIH and sCSF leak. We reviewed the neuro-ophthalmic examination and office-based ophthalmic imaging data of all consecutive patients with sCSF leaks and at least one repair to investigate the clinical and neuro-ophthalmic features of increased intracranial pressure.

Methods

We conducted a retrospective longitudinal study at a single institution by querying the electronic medical record system for CSF leak Current Procedural Terminology (CPT) codes (G96.00 and G96.01) from June 1, 2019, to July 31, 2022. For patients with a confirmed diagnosis of sCSF leak, demographic information, eye examination results, and ophthalmic imaging details for both eyes were collected.

Results

A total of 189 patients with CSF leaks were identified through CPT coding; 159 had iatrogenic or traumatic CSF leaks, and 30 individuals (3 male, 27 female) had confirmed sCSF leaks. The mean age of patients with sCSF leaks was 46 years (range: 29 - 81), with a mean body mass index of 35.2 kg/m2 (range: 18.2 - 54.1). Only 11 of 30 underwent eye examinations (8 before surgical repair and 10 after). The mean pre-repair and post-repair best-corrected visual acuity were 20/30 (range: 20/20 - 20/55) and 20/25 (range: 20/20 - 20/40), respectively (P = 0.188). The mean retinal nerve fiber layer thickness was 99 µm (range: 96 - 104) pre-repair and 97 µm (range: 84 - 103) post-repair (P = 0.195). The mean ganglion cell complex thickness was 84 µm (range: 72 - 94) pre-repair and 82 µm (range: 71 - 94) post-repair (P = 0.500). Humphrey visual field average mean deviation was -5.1 (range: -12.4 - -1.8) pre-repair and -1.0 (range: -10.1 - 2.1) post-repair (P = 0.063).

Conclusions

Serial neuro-ophthalmic examinations are recommended for patients with sCSF leaks to screen for signs of current or prior increased intracranial pressure. Larger studies are required to clarify the longitudinal changes in neuro-ophthalmic features, to investigate the incidence of IIH in cases of sCSF leak development or recurrence after surgical repair, and to explore potential causal relationships to guide post-repair management and prevent recurrent leaks. A multicenter consortium is also suggested to develop a standard clinical protocol for comprehensive management of sCSF leaks.

Alkaloid content in microsporidia-infected Adalia bipunctata (Coleoptera: Coccinellidae) life stages, and pathogen spore load in adults after exposure to physical stress

The two-spotted lady beetle, Adalia bipunctata L., displays warning colouration that is reinforced by the production of adaline and adalinine. These alkaloids are thought to provide defense against predation throughout all life stages of A. bipunctata and may play a role in the insect immune system. Vairimorpha (Nosema) adaliae, a microsporidium described from A. bipunctata, has minimal effects on its host (delayed larval development) when reared under optimum conditions but stress factors are shown to affect the development of microsporidiosis. The objectives of this study were to determine the effects of V. adaliae on relative alkaloid content (adaline) during A. bipunctata development, and to evaluate the combined effects of physical stress and infection on adult beetles (relative alkaloid content and infection load). First-instar larvae were isolated from uninfected and V. adaliae-infected colonies. Eggs and first-instar larvae were immediately prepared for alkaloid analysis, whereas late-instar larvae, pupae and adults were systematically processed when each reached their designated developmental stage. Upon eclosion, a subsample of beetles was exposed to varying amounts of physical agitation: control (no shaking), alternate shaking (every other day), and daily shaking. Immediately following these stress trials, alkaloid samples were collected for analysis and spore loads were assessed. Overall, relative adaline proportions increased from egg to adult. Uninfected individuals had significantly higher relative proportions of adaline than did infected individuals during early development; however, adaline content was higher in infected A. bipunctata from the third-instar onwards, when compared to their uninfected counterparts. Following exposure to physical agitation on alternate days, uninfected adults had a significantly higher relative proportion of adaline than did infected adults. Interestingly, exposure to different levels of agitation had no significant effect on alkaloid production for either uninfected or infected beetles. Mean spore counts were significantly higher for adults that were exposed to daily shaking when compared to individuals from the control and alternate shaking groups. From a biological perspective, one would expect to observe differences in alkaloid production through coccinellid development, as each successive life stage faces different external pressures and risks. When infected with the microsporidium V. adaliae, however, adaline production was reduced during early development but increased significantly in late life stages.

Evaluation of manuka honey on the microsporidian pathogen Vairimorpha (Nosema) adaliae and its host, the two-spotted lady beetle, Adalia bipunctata L. (Coleoptera: Coccinellidae)

Honey is known for its antibacterial and antifungal properties. Manuka honey was examined for its potential to manage the microsporidium Vairimorpha (Nosema) adaliae infecting Adalia bipunctata larvae. Development time for uninfected larvae fed aphids and water was 13.0 ± 0.2 days, which did not differ significantly from larvae fed aphids and manuka honey. Development of V. adaliae-infected larvae fed aphids and water was 16.3 ± 0.5 days, compared to 15.0 ± 0.2, 15.2 ± 0.3, and 15.6 ± 0.2 days for larvae fed aphids and 5 %, 10 %, or 15 % manuka honey, respectively. Development time was shorter for all honey treatments, but only those fed 5 % manuka differed significantly from the control. Control adults had 19.4 ± 3.0 spores/120 µm², compared to 19.0 ± 2.0, 19.1 ± 2.1, and 14.3 ± 2.2, for adults provided with 5 %, 10 %, and 15 % honey, respectively. Although spore loads did not differ significantly (p > 0.05), lighter infections were observed in the group fed 15 % manuka.

Improving Patient Education of Facial Fractures Using 3-Dimensional Computed Tomography

OBJECTIVE

Advances in 3-dimensional modeling have revolutionized presurgical planning for maxillofacial reconstruction, yet little is known about how this technology may affect patient education. This study was designed to evaluate the efficacy of 2-dimensional computed tomography versus 3-dimensional computed tomography for patient education in maxillofacial reconstruction.

STUDY DESIGN

Crossover study.

SETTING

General otolaryngology outpatients from a tertiary referral center were recruited.

METHODS

A single computed tomography data set of a zygomaticomaxillary complex fracture was used to generate 2 educational video tutorials: one in a 2-dimensional format and one in a 3-dimensional format. The tutorials were embedded into the Qualtrics^XM platform. Participants were randomly assigned into 2 groups. Group 1 viewed the 2-dimensional tutorial, took a self-assessment survey, took an information recall survey, viewed the 3-dimensional tutorial, and finally took a tutorial comparison survey. Group 2 followed the same sequence but viewed the 3-dimensional tutorial followed by the 2-dimensional tutorial.

RESULTS

Group 2 participants (viewing the 3-dimensional tutorial first) scored better on the self-assessment survey than their counterparts in group 1 did (P = .023). Group 2 also scored better on the recall survey (P = .042). Of all participants, 61% preferred the 3-dimensional tutorial, and 31% preferred the use of both tutorials together in the comparison survey.

CONCLUSIONS

Three-dimensional patient educational tutorial regarding a zygomaticomaxillary complex fracture resulted in better knowledge retention and was preferred over the 2-dimensional format.

Effects of food availability on microsporidiosis and alkaloid production in the two-spotted lady beetle, Adalia bipunctata L

The effects of food availability and infection with the microsporidium Nosema adaliae on alkaloid production in the two-spotted lady beetle, Adalia bipunctata L., was examined. Alkaloid production (relative percent adaline in reflex-fluid) and pathogen load (spore counts) were quantified for both uninfected and N. adaliae-infected A. bipunctata. Alkaloid content was significantly higher for beetles fed irregularly than for those fed daily. For beetles infected with N. adaliae, spore counts were significantly higher for those fed irregularly compared to those fed daily. These results suggest that adaline content in reflex-fluid is influenced by infection and that irregular food supply increases pathogen load.

0817 Abnormal REM Sleep Atonia Control In Patients With Chronic Post-traumatic Stress Disorder

Introduction

Post-traumatic stress disorder (PTSD) is characterized by persistent mental and emotional stress following one or more significant physical or psychological traumatic incidents earlier in life. Vivid recall of the events, including traumatic nightmares, and prominent sleep disturbance are usual in PTSD. Previous studies have suggested that PTSD may share some clinical features with idiopathic REM sleep behavior disorder (iRBD) including altered REM sleep without atonia (RSWA) levels. Our group has previously found evidence for altered RSWA control in patients with psychiatric disease, including a pilot sample of PTSD patients with iRBD. We aimed to comparatively analyze RSWA levels between patients with PTSD, PTSD and RBD (PTSD+RBD), iRBD, and controls.

Methods

We selected 18 PTSD, 18 PTSD+RBD, 15 iRBD, and 51 healthy control patients matched for age and sex from the Mayo Clinic Center for Sleep Medicine’s polysomnography database for RSWA quantification. RSWA amounts in the submentalis (SM) and anterior tibialis (AT) were quantitatively analyzed as a percentage of REM sleep duration, in accordance with previously published methods. Non-parametric analyses were performed to compare RSWA, patient demographics, and PSG data across groups. Significance was set at p < 0.016.

Results

Patients with PTSD had significantly higher RSWA than controls in all RSWA density measures (p < 0.016 for all). All measures of RSWA, excluding average SM duration, were significantly greater in PTSD+RBD patients compared with controls (p < 0.016 for all). Within the PTSD group, patients on antidepressants did not have significantly higher RSWA in any of the measures. PTSD+RBD patients had significantly higher SM Phasic, AT Any, SM+AT Any, and Tonic RSWA measures than PTSD patients (p < 0.016 for all).

Conclusion

PTSD patients have significantly higher RSWA than controls, with PTSD+RBD patients having higher RSWA levels than PTSD patients. These data provide the first evidence for abnormal RSWA control in patients with chronic PTSD. This provides evidence of a unique biology in PTSD that could imply a future risk for neurodegenerative disease in PTSD similar to RBD patients. Further prospective studying will need to be performed on patients with PTSD to understand the unique biology.

Support

 

0003 LGI1 and CASPR2 Autoimmunity: Sleep Symptoms, Polysomnography, and Quantitative REM Sleep without Atonia

Introduction

Sleep disturbances, including rapid eye movement (REM) behavior disorder (RBD), are known manifestations of voltage-gated-potassium-channel-complex VGKC-IgG seropositivity (VGKC+). Discovery of leucine-rich, glioma inactivated protein 1 (LGI1) and contactin-associated protein 2 (CASPR2) have refined our understanding of VGKC+. VGKC+ without LGI1/CASPR2-IgG (“double-negative”) has lost its clinical significance. Previous detailed sleep analysis of these subtypes has been limited.

Methods

We performed a retrospective study to characterize clinical and polysomnographic features of LGI1/CASPR2 seropositive (LGI1+/CASPR2+) and VGKC double-negative patients, including quantitative REM sleep without atonia (RSWA). Quantified RSWA was compared to matched controls and normative RSWA percentiles.

Results

Eleven LGI1+/CASPR2+ (LGI1+, 9) and twelve VGKC double-negative patients were analyzed. Insomnia was seen in 55% of LGI1+/CASPR2+ and 8% of VGKC double-negative patients (p=0.05). The LGI1+/CASPR2+ group had reduced slow wave sleep compared to the VGKC double-negative group. Five LGI1+ patients had clinical dream enactment behavior (DEB). Eight LGI1+ patients met quantitative diagnostic levels of RSWA. Higher RSWA levels were seen in the LGI1+/CASPR2+ group. Ten LGI1+/CASPR2+ patients received immunotherapy; all ten neurologically benefited with sleep benefits in 6/10.

Conclusion

Sleep disorders such as insomnia and RBD are part of the LGI1/CASPR2 autoimmune phenotype. Objective sleep manifestations can be seen on polysomnogram in the form of reduced N3 and elevated RSWA as compared to controls. Quantitative RSWA analysis identified RBD in more LGI1+ patients than clinical report or qualitative RSWA. In this study, RBD was only seen with LGI1+, not CASPR2+. The intermediate RSWA levels of the VGKC double-negative patients may suggest a spectrum of abnormal motor activity in these related antibodies. Additional studies are needed to further explore the biomarker potential of quantitative RSWA in autoimmune neurological conditions.

Support

This project was supported by the National Center forResearch Resources, National Institutes of Health, through Grant Number 1 UL1 RR024150- 01.

Effects of temperature on larval development, alkaloid production and microsporidiosis in the two-spotted lady beetle, Adalia bipunctata L. (Coleoptera: Coccinellidae)

Nosema adaliae, a microsporidian pathogen described from the two-spotted lady beetle, Adalia bipunctata L., delays larval development when A. bipunctata is reared under laboratory conditions at 25 °C. In nature, lady beetles often experience a wide range of environmental temperatures, but little is known regarding the effects of microsporidian pathogens on lady beetles when they are reared at higher and lower temperatures. In this study, the effects of elevated rearing temperatures and microsporidiosis were observed on larval development time and mortality, sex ratios, alkaloid content (adaline and adalinine), and adult morphometrics. Uninfected larvae (24 h-old) were provided either an uninfected or N. adaliae-infected conspecific egg and subsequently reared at three temperatures (25 °C, 27.5 °C or 30 °C). After the egg was eaten, larvae were provided a diet of green peach aphids and their development was recorded daily. Following eclosion, a subsample of adults were photographed for microscopic measurements and reflex-fluid was collected for alkaloid analysis using gas chromatography-mass spectrometry. Afterwards, all individuals were examined to determine the number that had become infected, and the same subsample was used to assess the severity of infection. Development time was delayed significantly for larvae that consumed a N. adaliae-infected egg, and infected larvae took significantly longer to develop at 25 °C than at 27.5 °C or 30 °C. No differences were observed for larval mortality or sex ratios. The relative proportion of adaline increased when larvae were reared at 30 °C, but adaline concentration was not affected by the pathogen, N. adaliae. Adults reared at 25 °C had larger body measurements when compared to those reared at 27.5 °C and 30 °C. Overall, adults that had eaten a N. adaliae-infected A. bipunctata egg as larvae had similar body measurements to those that ate an uninfected egg. When comparing male and female measurements, a significant interaction between infection status, temperature and sex was observed for elytra length and head capsule width only. These measurements were similar for uninfected and N. adaliae-infected females across all temperatures. However, when reared at 25 °C, uninfected males had significantly smaller elytra and head capsules than did infected males; but when reared at 30 °C, no significant difference was observed for these measurements. Both percent infection and average spore count decreased at 27.5 °C and 30 °C. These results suggest that temperatures above 25 °C have a mitigating effect against N. adaliae in A. bipunctata.

Assessment of a Patient-Specific, 3-Dimensionally Printed Endoscopic Sinus and Skull Base Surgical Model

Importance

Three-dimensional (3D) printing is an emerging tool in the creation of anatomical models for simulation and preoperative planning. Its use in sinus and skull base surgery has been limited because of difficulty in replicating the details of sinus anatomy.

Objective

To describe the development of 3D-printed sinus and skull base models for use in endoscopic skull base surgery.

Design, Setting, and Participants

In this single-center study performed from April 1, 2017, through June 1, 2017, a total of 7 otolaryngology residents and 2 attending physicians at a tertiary academic center were recruited to evaluate the procedural anatomical accuracy and haptic feedback of the printed model.

Interventions

A 3D model of sinus and skull base anatomy with high-resolution, 3D printed material (VeroWhite) was printed using a 3D printer. Anatomical accuracy was assessed by comparing a computed tomogram of the original patient with that of the 3D model across set anatomical landmarks (eg, depth of cribriform plate). Image-guided navigation was also used to evaluate accuracy of 13 surgical landmarks. Likert scale questionnaires (1 indicating strongly disagree; 2, disagree; 3, neutral; 4, agree; and 5, strongly agree) were administered to 9 study participants who each performed sinus and skull base dissections on the 3D-printed model to evaluate anatomical accuracy and haptic feedback.

Main Outcomes and Measures

Main outcomes of the study include objective anatomical accuracy through imaging and navigation and haptic evaluation by the study participants.

Results

Seven otolaryngology residents (3 postgraduate year [PGY]-5 residents, 2 PGY-4 residents, 1 PGY-3 resident, and 1 PGY-2 resident) and 2 attending physicians evaluated the haptic feedback of the 3D model. Computed tomographic comparison demonstrated a less than 5% difference between patient and 3D model measurements. Image-guided navigation confirmed accuracy of 13 landmarks to within 1 mm. Likert scores were a mean (SD) of 4.00 (0.71) for overall procedural anatomical accuracy and 4.67 (0.5) for haptic feedback.

Conclusions and Relevance

This study shows that high-resolution, 3D-printed sinus and skull base models can be generated with anatomical and haptic accuracy. This technology has the potential to be useful in surgical training and preoperative planning and as a supplemental or alternative simulation or training platform to cadaveric dissection.

Effects of microsporidiosis and food availability on the two-spotted lady beetle, Adalia bipunctata L., and convergent lady beetle, Hippodamia convergens Guérin-Méneville

Two species of microsporidia have been described from lady beetles that are commercially available for biological control: Nosema adaliae from the two-spotted lady beetle, Adalia bipunctata L., and Tubulinosema hippodamiae from the convergent lady beetle, Hippodamia convergens Guérin-Méneville. These pathogens delay larval development under controlled conditions, but little is known regarding the effects that microsporidia cause when their hosts are subjected to stressful conditions that are often experienced in nature. In this study, the combined effects of microsporidiosis (N. adaliae on A. bipunctata and T. hippodamiae on H. convergens) and irregular food availability were observed on host fitness (larval development and mortality, sex ratios, and adult morphometrics). For each beetle species, 24 h-old larvae were provided either an uninfected or microsporidia-infected conspecific egg. After the egg was eaten, some larvae were provided an abundance of aphids daily, whereas others were provided aphids on an irregular basis. Development was delayed significantly for larvae that consumed a microsporidia-infected egg, and for those fed irregularly. For A. bipunctata, a significant interaction was observed between infection status and food availability. This suggests that N. adaliae-infected A. bipunctata larvae that have an irregular supply of aphids undergo further developmental delays than those with a generous food supply. This interaction was not observed for T. hippodamiae-infected H. convergens. For both species, larval mortality and sex ratios did not differ significantly, regardless of infection status or food availability. Adults that were fed daily as larvae were significantly larger than those fed irregularly. However, the elytra of N. adaliae-infected A. bipunctata were significantly larger than the elytra of their uninfected cohorts, and T. hippodamiae-infected H. convergens had wider pronota and head capsules than uninfected H. convergens. Because N. adaliae and T. hippodamiae prolong larval development of their respective hosts under controlled conditions, one would expect these pathogens to cause more profound effects when their hosts experience stressful conditions. The results from this study indicate that this was the case for A. bipunctata, but not for H. convergens.

Optimization of 3D Print Material for the Recreation of Patient-Specific Temporal Bone Models

Objective:

Identify the 3D printed material that most accurately recreates the visual, tactile, and kinesthetic properties of human temporal bone

Subjects and Methods:

Fifteen study participants with an average of 3.6 years of postgraduate training and 56.5 temporal bone (TB) procedures participated. Each participant performed a mastoidectomy on human cadaveric TB and five 3D printed TBs of different materials. After drilling each unique material, participants completed surveys to assess each model’s appearance and physical likeness on a Likert scale from 0 to 10 (0 = poorly representative, 10 = completely life-like). The 3D models were acquired by computed tomography (CT) imaging and segmented using 3D Slicer software.

Results:

Polyethylene terephthalate (PETG) had the highest average survey response for haptic feedback (HF) and appearance, scoring 8.3 (SD = 1.7) and 7.6 (SD = 1.5), respectively. The remaining plastics scored as follows for HF and appearance: polylactic acid (PLA) averaged 7.4 and 7.6, acrylonitrile butadiene styrene (ABS) 7.1 and 7.2, polycarbonate (PC) 7.4 and 3.9, and nylon 5.6 and 6.7.

Conclusion:

A PETG 3D printed temporal bone models performed the best for realistic appearance and HF as compared with PLA, ABS, PC, and nylon. The PLA and ABS were reliable alternatives that also performed well with both measures.

Evaluation of Aintree LOSS, a community-based, multidisciplinary weight management service: outcomes and predictors of engagement

Aintree LOSS is a community-based, multidisciplinary weight management programme for patients with severe and complex obesity, focusing on a flexible and individualized service with follow-up for up to 2 years. We evaluated all 2472 patients referred to the service between October 2009 and 2013. Demographic data were recorded at baseline, with the Index of Multiple Deprivation (IMD) used to measure socioeconomic deprivation. Weight was recorded at each visit. Mean body mass index at baseline was 45.6 (standard deviation 6.8), and 58.9% of patients lived in areas in the most deprived decile nationally. Of 2315 appropriate referrals, 1249 (55.1%) attended >2 visits; mean final weight loss was 3.50 ± 8.55 kg, and 24.1% achieved ≥5% weight loss. Of the patients, 754 (33.3%) attended for over 6 months; mean final weight loss was 4.94 ± 10 kg, and 34% achieved 5% weight loss. Multivariate logistic regression analysis showed increasing age, residence in a less deprived area and sleep apnoea to be independently associated with attendance for >6 months, and there was a linear relationship between 6-month attendance and deprivation quintile. Year-on-year analyses showed improvement in engagement over time, coinciding with efforts to improve access to the service. This work shows a multidisciplinary, community-based weight loss programme prioritizing a fully flexible and individualized approach functioning effectively in real-world practice. Maintaining engagement remains a challenge in weight loss programmes, and our results suggest younger patients living in areas with greater deprivation should be a target for efforts to improve engagement.

Pediatric laryngotracheal separation following a go-cart injury

Less than one percent of trauma admission cases are categorized as pediatric neck trauma [13]. Nevertheless, due to an increasingly mobile society, there has been an increasing frequency of pediatric neck trauma with motor vehicle accidents being the most common mechanism of injury [8]. We present a case of laryngotracheal separation from a blunt, clothesline injury to the neck in a pediatric patient. We also review the literature and discuss the benefit of balloon airway dilation and its assistance in the management of laryngeal trauma and its resultant effects.

Impact of bariatric surgery on physical functioning in obese adults

Obesity is associated with a profound impairment in the ability to perform the basic physical activities required for everyday function. This impacts on quality of life and contributes to disability. Bariatric surgery leads to weight loss and metabolic improvements in severe obesity; however, less is known about its effect on physical functioning. This narrative review summarizes current evidence on the effect of bariatric surgery on this outcome with a consideration of the mechanisms involved. Nine longitudinal observational studies reporting objective measures of physical functioning were identified. Inclusion criteria, follow-up time and outcomes reported varied considerably between studies and sample sizes were small. They all showed a significant improvement in performance following surgery despite variations in baseline patient characteristics. Additionally, six studies were found in which subjects were subjected to exercise testing protocols. Performance of the test protocol improved in all. Where reported, peak oxygen uptake related to body weight improved; however, absolute values were either unchanged or decreased. In conclusion, observational evidence suggests that patients' physical functioning improves following bariatric surgery. More evidence is required regarding mechanisms involved; however, it may be due to improved efficiency in performing activities as opposed to absolute improvements in cardiorespiratory or muscle function.

Nosema adaliae sp. nov., a new microsporidian pathogen from the two-spotted lady beetle, Adalia bipunctata L. (Coleoptera: Coccinellidae) and its relationship to microsporidia that infect other coccinellids

The two-spotted lady beetle, Adalia bipunctata L., is a tree-dwelling lady beetle endemic to parts of Europe, Central Asia and North America that is commercially available for aphid control in Europe and North America. Lady beetles host a wide variety of symbionts including parasitoids, viruses, eugregarines, fungi, bacteria, nematodes and microsporidia. Four species of microsporidia have been described from lady beetles, and an undescribed microsporidium was recently isolated from local populations of A. bipunctata in Nova Scotia, Canada. In a previous study, this pathogen prolonged the development of A. bipunctata larvae but had no effect on adult fecundity, longevity or sex ratios. The objective of this study was to formally describe the microsporidium by means of its ultrastructure, tissue pathology and molecular characterization. All stages of the microsporidium were diplokaryotic and developed in direct contact with the host cell cytoplasm. Mature spores measured 4.25±0.09×1.82±0.03μm (SE, n=49, from micrographs) and fresh spores measured 6.10±0.06×3.01±0.05μm (±SE, n=60; range: 5.0-6.9×2.18-3.86μm). The polar filament was isofilar with 10-18 coils that were frequently arranged in a single row. The lamellar polaroplast was not typically visible and spores contained a relatively small posterior vacuole. Both the flight muscles and fat body were heavily infected and a large number of spores were observed within and between the cells of these tissues. The ovaries, developing oocytes, spermatocytes and accessory glands within the testes, midgut epithelium, Malpighian tubules, ileum, colon, and ventral nerve cord were also infected but not as heavily. Connective tissue near the cuticle and surrounding the trachea were lightly infected. The presence of spores in both the alimentary canal and ovaries (particularly within developing oocytes) suggests that the microsporidium can be transmitted per os (horizontally) and transovarially (vertically). Molecular analysis of the genome of the microsporidium described in this study was 97% similar to Nosema bombi and 96% similar to Nosema thomsoni, Nosema vespula and Nosema oulemae. Based on information gained during this study, we propose that the microsporidium in A. bipunctata be given the name Nosema adaliae sp. nov.

Synthesis and neurotoxicological evaluation of putative metabolites of the serotonergic neurotoxin 2-(methylamino)-1-[3,4-(methylenedioxy)phenyl]propane [(methylenedioxy)methamphetamine]

Theoretical considerations and recent experimental data have prompted an investigation of the neurotoxicological properties of the 6-hydroxydopamine analogue 2-(methylamino)-1-(2,4,5-trihydroxyphenyl)propane (5) and its possible precursor 1-[2-hydroxy-4,5-(methylenedioxy)phenyl]-2- (methylamino)propane (4), potential metabolites of the serotonergic neurotoxin MDMA. Systemic, intracerebroventricular, and intraparenchymal (intrastriatal and intracortical) administration of 4 led to no detectable alterations of hippocampal or cortical serotonin or striatal dopamine levels in the rat under conditions that caused significant biogenic amine depletions by established neurotoxins. By contrast, intraparenchymal administration of 5 caused profound depletions of dopamine and serotonin, with the former being more severely depleted than the latter. Although not conclusive, these data suggest a possible role for 5 in the mediation of MDMA's neurotoxic actions.

Phase I clinical and pharmacokinetic trial of irofulven

PURPOSE

To evaluate the clinical tolerability of a new schedule of 6-hydroxymethylacylfulvene (irofulven, MGI 114, HMAF, NSC 683863), a semisynthetic sesquiterpene derived from the cytotoxic mushroom metabolite illudin S. Irofulven has been shown to induce DNA damage and apoptosis in vitro and has shown activity in a number of human tumor xenograft models. A number of drug-resistant cell lines including those that express the mdr phenotype, retain sensitivity to irofulven.

METHODS

We conducted a phase I trial of irofulven given as an intravenous infusion (30 min) on a daily x5 schedule every 28 days. A total of ten patients were enrolled and treated at three dose levels, 6, 8, and 11 mg/m2 per day.

RESULTS

Irofulven reached steady-state concentrations during the 30-min infusions with biexponential kinetics. Irofulven disappeared rapidly from plasma and was detectable for only 15-30 min after the end of the infusion. The mean half-life was 4.91 min and the mean clearance was 4.57 l/mm per m2. Peak plasma concentrations of irofulven of approximately 300 ng/ml were achieved. Pharmacokinetic parameters did not differ significantly from day 1 to day 5. Irofulven was highly emetogenic. Other prominent toxicities included anorexia and fatigue. One case of delayed-onset metabolic acidosis possibly secondary to irofulven was observed. No other renal or metabolic toxicity was encountered. One patient experienced a late-onset grade 3 extravasation skin injury thought to be secondary to extravasation of irofulven. Minimal marrow suppression was observed. No objective tumor responses were observed.

CONCLUSIONS

The recommended phase II dose on this schedule is 6 mg/m2.

The effect of N-methylation on fenfluramine's neurotoxic and pharmacologic actions

N-Methylation separates methamphetamine's neurotoxic and pharmacologic effects. In particular, N-methylation eliminates methamphetamine's neurotoxic activity while preserving its behavioral pharmacologic activity. The purpose of the present studies was to determine whether N-methylation could also be used to separate fenfluramine's neurotoxic and pharmacologic effects. Fenfluramine-induced serotonin neurotoxicity was assessed by measuring serotonin axonal markers 2 weeks after fenfluramine administration. Pharmacologic effects of fenfluramine were assessed by measuring fenfluramine-induced anorexia and fenfluramine discrimination. Both fenfluramine and its N-methylated analog, N-methylfenfluramine, produced dose-related effects in food intake, drug-discrimination and neurotoxicity studies. Although N-methylation reduced the neurotoxic potency of fenfluramine, it also reduced its pharmacologic activity. Neurotoxic potency was reduced 4- to 8-fold (depending on brain region), while pharmacologic potency was reduced 4- to 10-fold (depending on paradigm). Notably, N-methylation did not change the efficacy of fenfluramine as a serotonin neurotoxin, anorectic agent or discrimination stimulus. These results indicate that fenfluramine's behavioral and neurotoxic effects, unlike those of methamphetamine, are not dissociated by N-methylation. Further, the present results suggest that the effectiveness of side-chain nitrogen substitution in separating the behavioral and neurotoxic effects of amphetamine derivatives is strongly influenced by ring substitutions.

Characterizing cochlear mechano-electric transduction using a nonlinear systems identification procedure

A nonlinear systems identification technique [J. S. Bendat, Nonlinear System Analysis and Identification from Random Data (Wiley, New York, 1990)] provided the frequency-domain parameters of a third-order system polynomial equation describing cochlear mechano-electric transduction (MET) in Mongolian gerbils. The magnitude of the linear system term was the largest followed by the cubic and quadratic terms. The phase of the linear and cubic system terms differed by approximately 180 deg and the phase of the quadratic term lay between. Between-animal and within-animal variability was smallest for the linear and cubic terms, and largest for the quadratic term. Summing linear and nonlinear coherence functions revealed that the third-order system polynomial equation characterized approximately 83% of MET for low frequencies and 92% for high frequencies. Animals exposed to a 4-kHz pure tone at 100 dB SPL for 20 min showed changes in the magnitude and phase of the parameters of the third-order polynomial equation. An increase in linear coherence and a decrease in nonlinear coherence occurred at frequencies centered at the exposure frequency. Below the exposure frequency, linear coherence decreased and nonlinear coherence increased. Summation of the coherence functions showed that the third-order polynomial equation characterized MET better after exposure to the pure tone.

The Experience of Being a Male Student Nurse

Although schools of nursing market their programs to all segments of society, men are underrepresented in schools of nursing. The purpose of this study was to identify male students' perceptions of the motivational factors, barriers and frustrations encountered in becoming a nurse. Eighteen students attended one of four focus groups representing one associate program, two baccalaureate programs and one diploma program. The students' belief that society perceived nursing as a feminine profession was an underlying thread that related to many of their perceptions and feelings. The most influential support people noted were immediate family, especially wives. The participants also believed that high school counselors were of no assistance in choosing nursing as a career. Even though the schools of nursing were perceived as supportive, the participants had feelings of isolation and self-doubt.

Role of colposcopy in the diagnosis and outpatient treatment of cervical intraepithelial neoplasia

One hundred and seventy nine women with abnormal smears referred for colposcopy to the Samaritan Hospital were studied. After confirming CIN on repeat smear, colposcopy and histology, cone biopsy was carried out. One hundred and twenty one patients (68%) had treatment either with electrical loop diathermy under local anaesthesia (105 patients, 59%) or laser excision of transformation zone under general anaesthesia as a day case (16 patients, 9%). Cone biopsy was done in 121 patients (32%). We conclude that colposcopy is a valuable tool in combination with cytology and histology for diagnosis and delineating the extent of CIN, thus avoiding unnecessary cone biopsies particularly in women of child bearing age. The majority of patients were treated by an outpatient procedure, which is easy to learn, safe, effective and inexpensive.

Comparison of the efficacy and adverse effect profile of cefotaxime and ceftriaxone in ICU patients with susceptible infections

In a prospective randomized double-blind trial, the efficacy and safety of cefotaxime and ceftriaxone were compared in intensive care unit (ICU) patients with serious infections requiring systemic antimicrobial therapy. Patients were randomly assigned to receive either cefotaxime 1 g i.v. t.i.d. or ceftriaxone 2 g every 24 hr. Clinical and bacteriologic assessments were made before treatment, at 48 hr and 5 days during treatment, and 48 hr after treatment. At the time of reporting, a total of 34 patients had been entered into the trial, 27 of whom were evaluable; 23 patients (85%) completed a minimum of 5 days antibiotic treatment. At the end of treatment, using current statistics 67% of cefotaxime and ceftriaxone patients demonstrated clinical cure or improvement. Bacteriologic responses appeared greater in the cefotaxime group (55% vs 42%). The incidence of adverse effects, which were usually minor, was similar in each group. From these preliminary results, it would appear that at the doses used in this study, cefotaxime and ceftriaxone are equally effective in the treatment of infections in the ICU.

A case of coccidioidomycosis in Australia

We report what we believe to be the first case of coccidioidomycosis to be diagnosed within Australia, and emphasize the dangers of handling Coccidioides immitis in the laboratory.