Phase I and II study of high-dose ifosfamide, carboplatin, and etoposide with autologous bone marrow rescue in lymphomas and solid tumors.

High-dose chemotherapy produces durable disease-free remissions in a minority of patients with resistant lymphomas and solid tumors. In an attempt to improve on the available regimens, ifosfamide, carboplatin, and etoposide (ICE) were selected for a new high-dose regimen because of their favorable spectrum of nonhematopoietic toxicity and evidence of synergy in in vitro systems. Forty-one patients with drug-resistant Hodgkin's and non-Hodgkin's lymphomas, and breast and testicular cancers were entered onto a phase I and II trial of a single course of ICE with autologous bone marrow rescue. Before transplantation, all patients received combination chemotherapy until maximal tumor response was achieved. Patients received total doses of ifosfamide from 10 to 18 g/m2, carboplatin from 0.9 to 1.98 g/m2, and etoposide from 0.6 to 1.5 g/m2 administered during a 4-day period, with a maximum-tolerated dose (MTD) of ifosfamide 16 g/m2, carboplatin 1.8 g/m2, and etoposide 1.5 g/m2. The dose-limiting toxicities included irreversible renal, cardiac, and CNS dysfunction. There were three toxic deaths (7%), and all occurred above the MTD. Thirteen patients who were treated at the MTD tolerated the regimen well; reversible renal dysfunction and grade 2 mucositis commonly were observed. Of 23 heavily pretreated patients with persistent disease at the time of transplant, 10 (43%) achieved complete remissions (CRs) and 11 (48%) achieved partial remissions (PRs). Hodgkin's and non-Hodgkin's lymphoma patients who were treated at or below the MTD had a median potential follow-up of 11.9 months, and 12-month progression-free survivals of 62% and 48%, respectively. High-dose ICE with bone marrow rescue was well tolerated with a high response rate, and should be considered for further testing.


Allogeneic marrow transplantation during untreated first relapse of acute myeloid leukemia.

The purpose of this report was to review the Seattle experience in bone marrow transplantation (BMT) for acute myeloid leukemia (AML) during untreated first relapse. Through 1990, 126 patients were transplanted during untreated first relapse of AML. Several preparative regimens were used, two of which involved more than 20 patients. Regimen 1 (29 patients) consisted of cyclophosphamide (CY) 120 mg/kg and 15.75 Gy of fractionated total-body irradiation (TBI) with methotrexate (MTX) given intermittently during a 102-day period to prevent graft-versus-host disease (GVHD). Regimen 2 (22 patients) consisted of the same CY and TBI treatment and a combination of MTX and cyclosporine (CSP) for GVHD prophylaxis. The remaining 75 patients were treated with 17 other transplant regimens. Outcome was compared for patients who were treated with regimen 1, regimen 2, and any other regimen. The 5-year probabilities of relapse-free survival (RFS), relapse, and nonrelapse mortality for 126 patients were .23, .57, and .44, respectively. With regimen 1, relapse (.26) was significantly less than for regimen 2 (.70; P = .004) or any other regimen (.76; P = .004). Regimen 1 patients developed more acute GVHD (.67) than regimen 2 patients (.26; P = .02) or patients on other regimens (.41; P = .02), and had increased nonrelapse mortality. Nevertheless, regimen 1 patients had a significantly higher 3-year RFS (.38) than those treated with regimen 2 (.18; P = .04) or any other regimen (.20; P = .05). For patients who received 120 mg/kg CY and 15.75 Gy TBI, relapse incidence was less and survival was better after GVHD prophylaxis with MTX alone than after a combination of MTX and CSP, despite a significantly higher incidence of acute GVHD. The results of treatment with regimen 1 justify future studies of the optimal timing of allogeneic BMT in the treatment of patients with AML.


Ifosfamide plus etoposide in newly diagnosed Ewing's sarcoma of bone.

We assessed the activity of ifosfamide plus etoposide against newly diagnosed Ewing's sarcoma of bone by administering this drug pair before standard induction therapy (the upfront window approach). Twenty-six children and adolescents with newly diagnosed, previously untreated Ewing's sarcoma of bone were enrolled onto this pilot study (EW-87). Eighteen were at a higher risk of treatment failure, with a primary tumor size of more than 8 cm or metastases at diagnosis. Window therapy with ifosfamide (1.6 g/m2/d with mesna uroprotection) and etoposide (100 mg/m2/d) was given in three 5-day cycles at 21-day intervals. Responses were evaluated clinically and radiologically. Subsequent induction therapy comprised three cycles of cyclophosphamide and doxorubicin. Radiation therapy was the primary local control modality; surgery was limited to biopsy or resection of expendable bones. After the local control phase, alternating courses of vincristine plus dactinomycin, ifosfamide plus etoposide, and cyclophosphamide plus doxorubicin were given as maintenance therapy. There were four complete responses and 21 partial responses to ifosfamide/etoposide window therapy (overall response rate 96%; 95% confidence interval [CI], 80% to 99%). Disease progression was observed in four patients during the cyclophosphamide/doxorubicin phase. Chemotherapy was well tolerated; only 16% (20 of 125) of all ifosfamide/etoposide window and maintenance cycles resulted in hospitalization for fever and neutropenia. Two patients developed chemotherapy-induced cystitis. The combination of ifosfamide and etoposide is highly active against previously untreated Ewing's sarcoma and generally is well tolerated. The ultimate impact of these two agents on outcome will be determined in randomized multicenter studies.


Medical Research Council prospective study of surveillance for stage I testicular teratoma. Medical Research Council Testicular Tumors Working Party.

A prospective study of surveillance after orchidectomy alone in patients with stage I nonseminomatous germ cell testicular tumor (NSGCT) was performed to determine the relapse-free rate and to identify the histologic criteria that predict for relapse. Three hundred ninety-six patients from 16 United Kingdom and one Norwegian centers were entered onto the study between January 1, 1984 and October 1, 1987 of whom 373 were eligible for analysis. In a previous retrospective study, we defined a prognostic index based on histologic criteria that identified a group of patients with a high risk of relapse. This index was based on the presence of venous and lymphatic invasion, undifferentiated cells, and the absence of yolk sac elements in the primary tumor. The 2-year actuarial relapse-free rate after orchidectomy was 75% (95% confidence interval, 71% to 79%), and the rate at 5 years was 73%. Five patients died of tumor or treatment-related complications, which resulted in a 5-year survival of 98%. The relapse-free rate in patients with three or four risk factors was 54%. This study confirms the safety of surveillance as a method of management and identifies a group of patients with a high risk of relapse. A prospective phase II study has been initiated to determine whether two courses of platinum-based adjuvant chemotherapy will prevent relapse in these high-risk patients.


Consolidation hemibody radiotherapy following induction combination chemotherapy in high-tumor-burden multiple myeloma.

Curative therapy for multiple myeloma continues to be an elusive goal. This report discusses the Northern California Oncology Group (NCOG) phase I and II trial in high-tumor-burden disease that used a strategy that consisted of induction chemotherapy (vincristine, melphalan, cyclophosphamide, and prednisone [VMCP]) for eight cycles followed by sequential hemibody radiation therapy (RT) and subsequent chemotherapy for an additional eight cycles. Seventy-two previously untreated stage III myeloma patients were entered onto the study. Sixty-nine received induction chemotherapy, 40 received induction chemotherapy and hemibody RT, and 23 received induction chemotherapy, hemibody RT, and consolidative chemotherapy. Twenty-two complete responses (CRs) were obtained by induction chemotherapy, with four additional CRs after RT and consolidative chemotherapy. Nineteen patients developed grade 4 hematologic toxicity primarily after upper hemibody RT. Eight of these developed long-standing neutropenia or thrombocytopenia. Median survival of the group was 134 weeks, which was not significantly different from other approaches. Hemibody RT can be combined with chemotherapy as induction therapy and can be safely administered in a community setting. However, as administered here no survival advantage was demonstrated.


Suramin: rapid loading and weekly maintenance regimens for cancer patients.

Suramin is an anticancer agent with a narrow therapeutic window and a terminal half-life of 45 to 55 days. These characteristics make it necessary to control accurately the serum concentrations of the drug. Therefore, the aim of the present study was to develop a rapid loading regimen, followed by weekly administration of suramin to maintain serum concentrations of between 150 and 300 micrograms/mL for 8 weeks. Eligible patients were treated with five different loading regimens. Initially, weekly maintenance doses were estimated manually by the treating physician. Subsequently, computer-assisted dosing that used Bayesian pharmacokinetic modeling was used. Thirty-eight courses of suramin that were administered to 35 patients were studied. The optimal loading regimen consisted of a continuous infusion of 600 mg/m2 during a 24-hour period, which resulted in a mean serum concentration of 319 micrograms/mL. Potentially toxic concentrations that were observed with shorter infusions were avoided. Maintenance treatment, which used the weekly administration of suramin during a 6-hour period, seemed to be able to maintain mean suramin serum trough concentrations of 150 micrograms/mL, while preventing mean peak concentrations of more than 300 micrograms/mL. The use of Bayesian pharmacokinetics was superior to manual estimation in tailoring the optimal dose to the therapeutic window. Continuous infusion is the optimal way of delivering suramin during the loading phase. To maintain trough levels and peak levels within a narrower therapeutic window, suramin will have to be administered more frequently than once a week. Bayesian modeling based on individual serum levels and population pharmacokinetics allows accurate dosing to maintain suramin levels within the therapeutic window.


Cardiotoxicity of high-dose continuous infusion fluorouracil: a prospective clinical study.

A prospective clinical study was performed to determine the incidence of high-dose continuous intravenous infusion fluorouracil (5FU-CIV) cardiotoxicity. Three hundred sixty-seven patients who were given first-cycle high-dose 5FU-CIV were monitored for cardiac function by clinical examination, ECG, and laboratory tests. 5FU-CIV was administered during a 96- or 120-hour period at doses that ranged from 600 to 1,000 mg/m2/d. Associated drugs included cisplatin (56%), mitomycin (12.5%), folinic acid (leucovorin) (7%), and others (14%). Thirty-nine patients (10.5%) received 5FU as a single agent. 5FU-induced cardiac events occurred in 28 patients (7.6%; 95% confidence interval, 4.9% to 10.3%). Nine of them had a history of cardiac disease. Primary tumors included head and neck (n = 13), gastrointestinal (n = 6), breast (n = 3), and others (n = 6). The mean onset time of cardiac symptoms was 3 days (range, 2 to 5). Inaugural symptoms included angina pectoris (n = 18), hypotension (n = 6), hypertension (n = 5), malaise (n = 4), dyspnea (n = 2), arrhythmia (n = 1), or sudden death (n = 1). At 5FU discontinuation, six patients' cardiac symptoms returned to baseline, but 21 patients experienced unstable angina (n = 8), hypotension/cardiovascular collapse (n = 11), pulmonary edema (n = 1), or sudden death (n = 4). The lethality rate was 2.2% (five sudden deaths plus three irreversible collapses). ECG showed repolarization changes (ST segment deviation; T-wave inversion) in 65% and/or diffuse microvoltage in 22% of the patients who presented with cardiac events. Echocardiography showed partial or global hypokinesia in nine of the 16 patients who were examined, and one case of prolonged akinesia. Cardiac enzymes rarely showed an increase (n = 2). In severe but reversible cases, clinical, ECG, and echographic parameters returned to baseline status within 48 hours after the drug discontinuation. A fluorine 19 nuclear magnetic resonance (19F NMR) analysis of urine was performed on 14 patients; six had cardiac symptoms and eight did not. Fluoroacetate (FAC), a known cardiotoxic compound, was detected in all cases. In our study, the incidence of high-dose 5FU-CVI cardiotoxicity was 7.6%. The hypothesis of a toxic cardiomyopathic process requires further confirmation.


Phase I evaluation of thrice-daily intravenous bolus interleukin-4 in patients with refractory malignancy.

A phase I dose-escalation trial of recombinant human interleukin-4 (IL-4) was performed to determine its toxicity, biologic activity, and potential antineoplastic effects. Ten patients with refractory malignancies received IL-4 by bolus intravenous injection every 8 hours on days 1 to 5 and 15 to 19 (maximum, 28 doses) of a 31-day study period. Three patients received 10 micrograms/kg per dose and seven received 15 micrograms/kg per dose of IL-4. Toxic symptoms noted at the second dose level included nasal congestion, diarrhea, nausea and vomiting, fatigue, anorexia, headache, dyspnea, and capillary leak syndrome (median weight gain, 6.1%; range, 3.4% to 11.7%). Fever or sustained hypotension sufficient to require pressors did not occur. Decreases in lymphocyte count and serum bicarbonate, sodium, albumin, fibrinogen and immunoglobulin (Ig) levels, and increases in hematocrit, prothrombin time/partial thromboplastin time (PT/PTT), soluble CD23, and, occasionally, serum creatinine and transaminases occurred. All side effects resolved by day 31. Phenotypic analysis of peripheral-blood mononuclear cells (PBMC) showed a decrease in the percentage of circulating CD16 and CD14(+) cells. Plasma tumor necrosis factor (TNF) and IL-1 beta levels were unaffected, whereas serum C-reactive protein (CRP) concentrations increased slightly and plasma IL-1 receptor antagonist (IL-1RA) levels increased markedly. No tumor responses were observed. We conclude that 10 micrograms/kg per dose of IL-4 is the maximum-tolerated dose for this schedule, although 15 micrograms/kg per dose can be tolerated if more intensive, but still non-intensive care unit level care is provided. The results of this study should aid in the design of future phase II trials that involve IL-4 alone or phase I studies that combine IL-4 with other cytokines such as IL-2.


Ethical issues in phase I oncology research: a comparison of investigators and institutional review board chairpersons.

Phase I research trials assess the safety of agents never before administered to humans. In the field of oncology, this practice raises several important ethical questions. We examined the ethics of these trials by surveying phase I oncology investigators and institutional review board (IRB) chairpersons at major cancer research centers around the country. Questionnaires were mailed to 78 investigators and 47 chairpersons to obtain their views on the ethical propriety of conducting phase I oncology research, and on institutional practice regarding these trials. The response rate was 68% in each group. The majority of each group reported that phase I oncology trials face no more scrutiny or resistance in their institution's IRB process than other research protocols. Nevertheless, IRB chairpersons were more likely than investigators to favor special procedural safeguards to protect subjects in phase I oncology trials. Nearly all respondents agreed that although actual medical benefit was very uncommon, most patients entered for a chance at a therapeutic effect. Investigators were more likely than chairpersons to report that patients obtained psychologic benefit from participation in phase I trials. Although individual IRB chairpersons and oncology investigators may have important differences of opinion concerning the ethics of phase I trials, these disagreements do not represent a widespread area of ethical conflict in clinical research.


Peritoneal absorption of cefoperazone in rats.

The peritoneal absorption of cefoperazone, administered by intraperitoneal (ip) perfusion in a large volume (100 mg/40 ml), was investigated in rats. Its pharmacokinetics was also studied after ip or intravenous (iv) injection of 100 mg/kg in two groups of rats. The peritoneal uptake after the two modes of ip administration was rapid, peaking in less than 20 minutes and the means of peak concentrations were similar. The peak remained high in the group perfused with a large volume for at least 4 hours, which was the end of sample collection. In addition, the absorption half-life and the fraction (F) reaching systemic circulation were calculated and found to be 10.0 +/- 2.5 min and 0.93, respectively. A brief distribution phase (t1/2 alpha 8.0 +/- 0.67 minutes) appeared only after the iv bolus. Otherwise the decline in serum concentration was monoexponential with half-lives of 39.0 +/- 4.0 and 63.6 +/- 7.5 min for the iv and ip injected groups, respectively. The stability of cefoperazone in plasma was also investigated in this study. It was found to be unstable at physiological pH even at -30 degrees C and the samples collected should be buffered in acidic media to optimize stability. The degradation process is likely to contribute to its elimination kinetics during in vivo administration.


Penetration of ciprofloxacin into human peritoneal tissue following a single oral dose of 750 milligrams.

The penetration of ciprofloxacin into the peritoneal tissue was studied in 10 patients after a single oral dose of 750 mg given 5.6 hours (mean) before elective laparotomy. The mean tissue level was 0.29 micrograms/ml (range, 0.082 to 0.96 micrograms/ml) while the mean concomitant serum level was 1.3 micrograms/g (range, 0.52 to 2.57 micrograms/g). The achieved concentrations are above the minimum inhibitory concentrations (MICs) of ciprofloxacin for most gram-negative bacteria commonly involved in intra-abdominal infections.


Aztreonam versus colistin-neomycin for selective decontamination of the digestive tract in patients undergoing bone marrow transplantation: a randomized study.

Aztreonam (Az), a minimally absorbable monobactam antibiotic, was compared to colistin plus neomycin (CN), for intestinal decontamination during Bone Marrow Transplantation (BMT) in a controlled study. Thirty-four consecutive patients were randomized in two groups and evaluated for number of febrile episodes, days of fever, fecal cultures and clinical symptoms related to infections or colonizations. No significant differences were observed suggesting that Az is at least as effective as the CN regimen and may be considered as an alternative approach for intestinal decontamination in BMT patients.


Metastatic squamous cell carcinoma of an unknown primary tumor localized to the neck.

68 patients with metastatic squamous-cell carcinoma (SCC) of an unknown primary tumor localized to the neck were treated between 1981 and 1990. There were 11 patients treated with radiotherapy alone, 24 patients treated with surgery and radiotherapy and 33 patients treated with radiotherapy and chemotherapy. Male to female ratio was 1.9:1 and the median age was 55 years (range, 33 to 71 years). 41 (61%) patients had N3 disease, 18 (26%) patients had N2 disease and 9 (13%) patients had N1 disease. The majority of N3 patients were treated with radiotherapy + chemotherapy (n = 17) and surgery + radiotherapy (n = 17). The complete response (CR) to radiotherapy + chemotherapy was 73% with 19 patients having no evidence of disease currently. The median survival time (MST of this group was 34+ months. Of the 35 patients who had surgery and/or radiotherapy, 7 (20%) currently have no evident disease. The MST of these two groups (combined) was 22 months. Patients with N3 disease who received radiotherapy + chemotherapy had a higher CR rate and longer MST when compared with those without chemotherapy.


Salvage chemotherapy in colorectal cancer patients with good performance status and young age after failure of 5-fluorouracil/leucovorin combination.

Forty-one patients with metastatic colorectal cancer were treated every four weeks with methotrexate 25 mg/m2 i.v. days 1, 8, 15; vincristine 1 mg/m2 i.v. day 1; lomustine 100 mg/m2 p.o. day 1. Inclusion criteria were: failure of previous 5-fluorouracil/leucovorin treatment; performance status (ECOG) 0-2; age less than 60 years; presence of symptoms; absence of concomitant diseases. Metastatic sites were: liver 30, lung 4, abdominal/pelvic mass 7. Three patients achieved partial responses (2 liver, 1 lung metastases); 4 showed stable disease and 34 progressed on therapy. The median survival of patients with partial response, stable disease and progression was comparable (24, 21, 22 weeks respectively). The most common toxicity was hematologic (thrombocytopenia and leukopenia). Other side effects included nausea and vomiting, stomatitis and diarrhea. Symptoms were not affected by treatment. We conclude that salvage chemotherapy is not recommended in colorectal cancer after 5-fluorouracil/leucovorin treatment even in patients with generally considered favorable characteristics for response to chemotherapy.


Ewing's sarcoma: experience with 12 cases.

Twelve patients with localized Ewing's sarcoma were treated between 1980-1990 at the Istanbul School of Medicine, Department of Pediatric Oncology-Hematology, Oncology Research and Treatment Center and Our Children Leukemia Foundation. There were 8 boys and 4 girls, with a mean age of 8.1 (range 3-17) years. The tumors were in the femur in 3 patients, in the humerus and rib in 2 patients each and in the tibia, radius, vertebra, clavicula and pelvis in 1 patient each. Chemotherapy alone was applied in 2 patients, 1 patient had chemotherapy and radiotherapy. The remaining 9 cases were treated with Chemotherapy and radiotherapy (during the chemotherapy). The chemotherapy protocols were: VAC (n = 5), VACA (n = 3), IVAD (n = 3) and T.9 (n = 1). One patient died from the disease itself. Remissions were achieved in the other 11 patients. After 5 to 95 months (mean: 22 months) 7 patients had relapsed (4 had local and 3 had distant metastases). Three patients were not able to be followed, 3 died due to additional problems (infection, cardiotoxicity). The best prognosis was achieved when Ewing's sarcoma initiated in the long bones, with less than 100 ml tumor volumes and patients were under 5 years old. There were no significant differences among chemotherapy protocols.


Cyclophosphamide plus vincristine and prednisone in the treatment of severe pemphigus vulgaris refractory to conventional therapy.

Five patients with severe pemphigus vulgaris refractory to conventional therapy with azathioprine and corticosteroids were treated with cyclophosphamide, vincristine and prednisone. One patient was not evaluable, while the remaining four patients showed a complete response. Duration of response was in the range of 13-94 months. Toxicity was mainly represented by alopecia, myelosuppression and gastrointestinal side-effects such as nausea/vomiting. Although cyclophosphamide and vincristine may induce severe side-effects, this association may be useful in controlling severe disease resistant to previous conventional therapies.


In vitro assessment of rokitamycin against problem gram-positive cocci.

Rokitamycin was more active than erythromycin against erythromycin-sensitive strains of Staphylococcus aureus and enterococci, but somewhat less active against coagulase-negative staphylococci. Strains with inducible resistance to erythromycin were uniformly resistant to erythromycin, while rokitamycin was active against such strains. Strains with constitutive resistance to erythromycin were also uniformly resistant to erythromycin, and most were also resistant to rokitamycin. However, 5 of 21 coagulase-negative staphylococci and 2 of 20 enterococci remained sensitive to rokitamycin. This is a novel finding, perhaps suggesting a new mechanism of macrolide resistance.


High-level aminoglycoside resistance among enterococci: evaluation of an agar screen susceptibility test.

Seventy-five enterococci from infected (63 isolates) and colonized (12 isolates) patients hospitalized in various divisions of the Policlinico Umberto I, University of Rome, were in vitro studied for high-level resistance (HLR) to gentamicin (HLRG) and streptomycin (HLRS) with adoption of a standard broth dilution and an agar screen test. The employed procedures provided equal results for 100% of the 75 isolates. Of these, 21 (28%) showed HLRG and 43 (57%) HLRS. Combined HLRG and HLRS were found in 18 (24%) isolates, whereas HLRS or HLRG alone were found in 25 (33%) and 3 (4%) isolates respectively. It is concluded that HLR to aminoglycosides may represent a major problem in Italian institutions. Along with other established procedures, the agar screen test employed in the study may be used to detect this antibiotic resistance in enterococci.


Microbiological considerations of the etiological agents of lower respiratory tract infections.

One hundred eight-four sputum specimens from the same number of patients with lower respiratory tract infections were examined to determine the bacterial count and the relationship between the microorganisms isolated and the presumptive pathology. The sputa were subdivided into three groups; "high probability", "low probability", and "contaminated sputa", following the criteria of the microscopic readings: sputum with more than 25 white cells and low numbers of squamous epithelial cells represents true lower respiratory tract infections (high probability); those with fewer than 25 white cells represent non-bacterial infections or non-infected sputa (low probability) while sputa with more than 25 squamous cells per field represent contaminated specimens (contaminated sputa). Statistical analysis was carried out to correlate these data. Haemophilus influenzae, Haemophilus parainfluenzae, Streptococcus pneumoniae, and Streptococcus pyogenes showed significant differences in the three groups considered.


Pneumonia complicating abdominal sepsis: an experimental model of hematogenous contamination of the lung.

Pulmonary infection complicating intra-abdominal sepsis is a major clinical problem. An experimental model for intra-abdominal sepsis was created with implantation of gelatin capsules, containing 3 x 10(8) cfu E. coli strain no. 2554, in the peritoneal cavity of 20 rats (10 animals received and 10 did not receive antibiotic therapy with ceftriaxone) in order to verify the role of the primary site of infection in the pathogenesis of pneumonia. Ten rats were sacrificed to determine the relative pulmonary weight and 10 were submitted to simple laparotomy and insertion of a germ-free capsule (sham-operated group). In this group of animals there was only one death (10%). All the rats that received antibiotic therapy survived until sacrifice while all the rats that did not receive ceftriaxone died, 7 within the 2nd and 3 on the 6th postoperative day. Pneumonia and peritonitis developed only in the animals that did not receive ceftriaxone. Bacteriological findings of material obtained from peritoneal and pleural cavities revealed the same strain of E. coli used for the experiment, suggesting that bacteria involved in the pleuro-pulmonary infections may originate in the primary site of infection and that antibiotic therapy started at the moment of contamination, can prevent this major complication.


Cefuroxime axetil in the treatment of acute otitis media in children.

Cefuroxime axetil was evaluated for clinical efficacy and tolerance in the treatment of acute otitis media in children. Fifty-five children, 5.0 to 10.8 years, were randomly assigned to receive 250mg cefuroxime axetil every 12 hours or 50mg/kg/day amoxicillin in three divided doses. Both treatment schemes lasted for 10 days. Acute otitis media was diagnosed by the presence of erythema and/or opacity with bulging of the tympanic membrane. A tympanogram was obtained upon enrollment to the study, as well as within 2 days after completion of therapy. Fifty-one children completed the treatment protocol. The cure rate was 74.1% for cefuroxime axetil and 75.0% for amoxicillin. Clinical improvement was noted in 25.9% of children treated with cefuroxime axetil and in 25.0% of those treated with amoxicillin. There was no clinical failure in the two treatment groups. None of the children experienced relapse of acute otitis media during the month following completion of therapy. The findings indicate that cefuroxime axetil given twice daily has comparable efficacy to amoxicillin given three times daily in the treatment of children with acute otitis media.


Subcutaneous nodules caused by Pseudomonas aeruginosa: healing without incision and drainage.

In a patient with multiple myeloma, numerous indurated, subcutaneous nodules and pyomyositis due to Pseudomonas aeruginosa were noted. These lesions resolved with ciprofloxacin plus ceftazidime therapy without surgical incision and drainage. Despite another course of cancer chemotherapy after total disappearance, there were no recurrences at the end of 3 months. Quinolones initially combined with other antipseudomonal beta-lactam agents may be the drugs of choice in the management of patients with subcutaneous nodules caused by P. aeruginosa.


Effects of endotoxin in mice bearing solid metastasizing tumors and treated with lysozyme hydrochloride.

The effects of the i.v. administration of endotoxin (6.25-50 micrograms/mouse on day 13 after tumor implantation) in mice treated orally with lysozyme hydrochloride (100 mg/kg on days 5-12 from tumor implantation) were examined using Lewis lung carcinoma in the C57Bl mouse and MCa mammary carcinoma of CBA mice. On primary tumor growth, endotoxin alone causes a dose-dependent and statistically significant reduction with a nadir on day +2 from endotoxin treatment. Combined with lysozyme, endotoxin causes an effect independent of the dose used, corresponding to the effect caused by endotoxin alone at the dose of 25 micrograms/mouse. No tumor regression was recorded in any of the treated groups. Endotoxin is virtually devoid of effects at the metastatic level. In the same conditions, lysozyme causes a reduction of primary tumor growth and a more pronounced inhibition of lung metastasis formation as expected from its already reported effects. The antitumor activity of endotoxin, unlike lysozyme, can be ascribed to tumor hemorrhagic necrosis due to tumor necrosis factor (TNF) production, as determined in tumor homogenates. Endotoxin does not increase the antitumor effects in mice treated with lysozyme, as expected from the data obtained with the more immunogenic SA1 sarcoma, although lysozyme increased the mitogenic response to ConA of ex vivo isolated splenocytes, in vitro cultured in the presence of IL-2.


Increased spontaneous cell detachment of F10 cells induced in vitro by some calcium-channel blockers.

We investigated the action of some Ca(++)-channel blockers such as flunarizine, nifedipine and verapamil on F10 cells in vitro. Cell adhesion to the growth substratum, evaluated by the technique of spontaneous detachment in culture medium, is reduced in Ca(++)-channel blocker treated cells by comparison with controls. In our opinion such an event could also explain the inhibitory effect on cell growth and colony forming ability.


Chemotherapy with cisplatin, epirubicin, methotrexate in the treatment of locally advanced or metastatic transitional cell cancer of the bladder (TCC).

Forty patients with advanced transitional cell cancer (TCC) of the bladder were treated with cisplatin, epirubicin, methotrexate (PEM, every 3-4 weeks). If creatinine clearance was reduced to 40 ml/min, the usual full doses of cisplatin and methotrexate, 50 mg/m2, were proportionally reduced. 23 patients had full-dose (FD) therapy, 17 had reduced dose (RD) (40-20 mg/m2). Two patients achieved complete response and 17 partial response. The overall response rate was 19/40 (47.5%), 11/23 (48%) for FD and 8/17 (47%) for RD (p = 1.000). 17/40 pts (42.5%) had no-change and 4/40 (10%) had disease progression. The median duration of CR and PR was 32 weeks, range 4-82 (22 weeks, range 12-52 for FD; 32 weeks, range 4-82 for RD, cisplatin p = .7362). The main side effect was vomiting (35/40 pts, 87.5%, 20/23 = 87% for FD, 15/17 = 90% for RD, p = 1.000). Leukopenia was observed in 12 patients (30%, nadir 3,240 range 900-3,800, 6/23 = 26% for FD, 6/17 = 35% for RD, p = .7285), alopecia in 18 patients (45%, 15/23 = 65% for FD, 3/17 = 18% for RD, p = .004). The results of this study show that a dose escalation to 50 mg/m2 for cisplatin, epirubicin and methotrexate in the PEM regimen results in an increase in overall response (OR) (19/40 = 47.5%) with respect to a historical control using the same drugs at doses of 40 mg/m2 (12/35 = 34%). In patients with normal renal function the escalated dose was tolerated without a corresponding increase in toxicity.(ABSTRACT TRUNCATED AT 250 WORDS)


Equivalent forgetting rates in long-term memory for diencephalic and medial temporal lobe amnesia.

Amnesia can result from damage to either the midline diencephalon or the medial temporal lobe. An important related question has been whether these two forms of amnesia result in similar or different kinds of memory impairment. Earlier studies raised the possibility that differences might exist in the rate of forgetting within long-term memory, specifically, that the forgetting rate is normal in diencephalic amnesia but abnormally rapid in medial temporal lobe amnesia. In the present study, forgetting was studied in five amnesic patients with damage to the medial temporal lobe, six amnesic patients with damage to the diencephalon, and 10 normal subjects. One hundred twenty pictures were presented to the control subjects for 1 sec each and to the amnesic patients for 8 sec each. Retention was then tested after 10 min, 2 hr, and 30-32 hr using four different procedures for testing recognition memory. The different exposure times for the pictures succeeded in matching the performance scores of both groups of amnesic patients and the control subjects at the 10 min retention interval. Both groups of amnesic patients also performed similarly to control subjects at retention delays of 2 hr and 30-32 hr. In addition, performance was nearly identical, regardless whether recognition memory was assessed by asking subjects to select the new items or the old items. The findings emphasize the similarities between medial temporal lobe and diencephalic amnesia.


Development of retinal displaced ganglion cells in the chick: neurogenesis and morphogenesis.

The time of birth of displaced ganglion cells (DGCs) was determined by autoradiography. DGCs start to leave the cell cycle early, on embryonic day 3, in the central and peripheral retina, and end on embryonic day 8, also in both areas of the retina. During the period of neurogenesis, unlabeled (born) DGCs do not appear distributed in spatial gradients as do the ganglion, amacrine, and other cell types in the retina (Prada et al., 1991). Our results show characteristic spatial and temporal patterns of DGC neurogenesis, which differ from those of the other retinal cell types. The morphogenesis of DGCs was studied by means of Golgi preparations. After leaving the cycle, DGC neuroblasts detach from the ventricular lining; they then move their soma through the vitreal process toward the final position at the same time that they emit the axon. Also during soma translocation, a transient sprouting of a few short processes is emitted from the vitreal process of the cell, close to where the soma is later located, suggesting that the "abnormal" position of DGCs could be specifically marked during the process of migration.


A novel T-type current underlies prolonged Ca(2+)-dependent burst firing in GABAergic neurons of rat thalamic reticular nucleus.

The inhibitory GABAergic projection of thalamic nucleus reticularis (nRt) neurons onto thalamocortical relay cells (TCs) is important in generating the normal thalamocortical rhythmicity of slow wave sleep, and may be a key element in the production of abnormal rhythms associated with absence epilepsy. Both TCs and nRt cells can generate prominent Ca(2+)-dependent low-threshold spikes, which evoke bursts of Na(+)-dependent fast spikes, and are influential in rhythm generation. Substantial differences in the pattern of burst firing in TCs versus nRt neurons led us to hypothesize that there are distinct forms of transient Ca2+ current (I(T)) underlying burst discharges in these two cell types. Using whole-cell voltage-clamp recordings, we analyzed I(T) in acutely isolated TCs and nRt neurons and found three key differences in biophysical properties. (1) The transient Ca2+ current in nRt neurons inactivated much more slowly than I(T) in TCs. This slow current is thus termed I(Ts). (2) The rate of inactivation for I(Ts) was nearly voltage independent. (3) Whole-cell I(Ts) amplitude was increased when Ba2+ was substituted for Ca2+ as the charge carrier. In addition, activation kinetics were slower for I(Ts) and the activation range was depolarized compared to that for I(T). Other properties of I(Ts) and I(T) were similar, including steady-state inactivation and sensitivities to blockade by divalent cations, amiloride, and antiepileptic drugs. Our findings demonstrate that subtypes of transient Ca2+ current are present in two different classes of thalamic neurons. The properties of I(Ts) lead to generation of long-duration calcium-dependent spike bursts in nRt cells. The resultant prolonged periods of GABA release onto TCs would play a critical role in maintaining rhythmicity by inducing TC hyperpolarization and promoting generation of low-threshold calcium spikes within relay nuclei.


A time course for the focal elevation of synthesis of basic fibroblast growth factor and one of its high-affinity receptors (flg) following a localized cortical brain injury.

Traumatic injury to the CNS initiates transient and unsuccessful regeneration of damaged neural pathways, accompanied by reactive gliosis, angiogenesis, and deposition of a dense fibrous glial/meningeal scar at the wound site. Basic fibroblast growth factor (basic FGF) is a CNS protein with potent effects on neurons, glia, fibroblasts, and vascular endothelial cells. Hybridization and immunocytochemical methods were used to examine temporal and spatial changes in distribution and levels of basic FGF protein and mRNA and also of its receptor mRNA (flg), following a defined wound to the cerebral cortex of adult rat brains. In the injured brain, a rapid, transient increase in basic FGF mRNA and protein is readily detectable within 7 d of surgery and thereafter declines in the tissues bordering the lesion. The increased expression is localized to multiple cell types including macrophages, neurons, astrocytes, and vascular endothelial cells. The changes in immunoreactive basic FGF parallel changes in the bioactivity of extracted heparin-binding proteins, which include basic FGF. Focal increases in flg mRNA appear 7 d after injury and subside by 14 d. The changes in local basic FGF synthesis, concentration, localization, and bioactivity suggest that this growth factor may contribute to the cascade of cellular events that occur in CNS wound repair.


Ectopic expression of ultraviolet-rhodopsins in the blue photoreceptor cells of Drosophila: visual physiology and photochemistry of transgenic animals.

We have generated transgenic flies expressing R7 cell-specific opsins in the major class of photoreceptor cells of the Drosophila retina and characterized their spectral properties using high-resolution microspectrophotometry and sensitivity recordings. We show that the Rh3 and Rh4 opsin genes encode UV-sensitive opsins with similar spectral properties (lambda max = 345 nm and 375 nm), and that Rh3 corresponds to the R7p and R7marg class of visual pigments. We have also generated Rh3 and Rh4 isoform-specific antibodies and present an R7 cell map of the Drosophila retina. In a related set of experiments, we show that it is possible to coexpress two different visual pigments functionally in the same cell and produce photoreceptors that display the summed spectral response of the individual pigments. These findings open up the possibility of tuning an animal's visual behavior by targeted expression of combinations of opsin genes to selective types of photoreceptors.


Distributed processing of sensory information in the leech. III. A dynamical neural network model of the local bending reflex.

The subpopulation of identified interneurons in the local bending reflex receive multiple inputs from dorsal and ventral mechanoreceptors and have outputs to dorsal and ventral motor neurons. Their connections suggest a distributed processing mechanism in which withdrawal from dorsal, ventral, or lateral stimuli is controlled by a single population of approximately 40 multifunctional interneurons, but it is unclear whether additional interneurons dedicated to particular inputs are needed to account for each kind of bend. We therefore asked whether a model could be constructed that reproduced all behaviors without dedicated interneurons. Interneurons in the model were constrained to receive both dorsal and ventral inputs. Connection strengths were adjusted by gradient descent optimization until the model reproduced the amplitude and time course of motor neuron synaptic potentials in intracellular recordings of the response to many different stimuli. After optimization, the similarity between model and identified interneurons showed that additional dedicated interneurons are not necessary to produce all forms of the behavior. Successful optimization of networks with many fewer interneurons showed that the 40-interneuron network is redundant, raising the possibility that the interneurons have additional functions. Finally, optimizing networks with additional constraints produced better matches to some of the identified interneurons and showed that local bending can be produced by two populations of interneurons: one with outputs consistent with dorsal bending, the other with ventral bending. This suggests a simple model in which two principal types of interneurons produce many different behaviors and predicts the type of interneuron that remains to be identified.


Olfactory sensory neurons are trophically dependent on the olfactory bulb for their prolonged survival.

In most neural systems, developing neurons are trophically dependent on contact with their synaptic target for their survival and for some features of their differentiation. However, in the olfactory system, it is unclear whether or not the survival and differentiation of olfactory sensory neurons depend on contact with the olfactory bulb (normally the sole synaptic target for these neurons). In order to address this issue, we examined neuronal life-span and differentiation in adult rats subjected to unilateral olfactory bulb ablation at least 1 month prior to use. Life-span of a newly generated cohort of olfactory neurons was determined by labeling them at their "birth" via the incorporation of 3H-thymidine. In the absence of the bulb, neurons are continually produced at a twofold greater rate. However, the epithelium on the ablated side is thinner, indicating that average neuronal life-span must be reduced in the targetless epithelium. Indeed, nearly 90% of the labeled neurons disappear from the bulbectomized side between 5 d and 2 weeks of neuronal age. Moreover, on electron microscopic examination, olfactory axons are degenerating in large numbers on the ablated side. Since labeled neurons migrate apically through the width of the epithelium during this same period, it appears that most, if not all, neurons on the ablated side have a life-span on the order of 2 weeks or less. In contrast, there is a more moderate degree of neuronal loss on the unoperated side of the same animals during the first 2 weeks after tracer injection, and that occurs while the neurons are concentrated in the deeper half of the epithelium, suggesting that there is a preexisting population of neurons in the control epithelium that does not die during this period. Likewise, degenerating axons are much less frequent on the unoperated side. We conclude that life-span is significantly shorter for olfactory neurons born in the targetless epithelium and that olfactory neurons are trophically dependent on the presence of the bulb for their prolonged survival. Neuronal differentiation in the absence of the bulb was assessed according to ultrastructural criteria and the pattern of protein expression using antisera to the growth associated protein GAP-43 and the olfactory marker protein. By both measures, most neurons in the epithelium on the bulbectomized side, but not all, are immature.(ABSTRACT TRUNCATED AT 400 WORDS)


Differential expression of somatostatin receptor subtypes in brain.

The tetradecapeptide somatostatin has been implicated as an important regulator of neuronal and neuroendocrine function in the CNS. The cellular actions of somatostatin are mediated by specific receptors. The genes encoding two different somatostatin receptors (SSTRs) have been isolated and characterized, and RNA blotting studies have shown that both SSTR1 and SSTR2 are expressed in the brain. In order to gain a better understanding of the functions of somatostatin in the CNS, the distribution of SSTR1 and SSTR2 mRNAs was determined using the technique of in situ hybridization. SSTR1 mRNA was present throughout the mouse brain, particularly in the supra- and infragranular layers of the cortex, the amygdala, hippocampus, bed nucleus of the stria terminalis, substantia innominata, hypothalamus, pretectum, substantia nigra, parabrachial nucleus, and nucleus of the solitary tract. SSTR2 mRNA was primarily observed in the infragranular layers of the cortex, the amygdala, claustrum, endopiriform nucleus, arcuate and paraventricular nuclei of the hypothalamus, and medial habenular nucleus. Several regions of the brain reported to contain dense somatostatin-like immunoreactive terminal fields and receptor binding sites were devoid of both SSTR1 and SSTR2 mRNA, suggesting the existence of additional SSTR subtypes.


Early development of glycine- and GABA-mediated synapses in rat spinal cord.

Motoneuron responses to the inhibitory amino acids glycine and GABA, and the contribution of inhibitory synapses to developing sensorimotor synapses were studied in rat spinal cords during the last week in utero. In differentiating motoneurons, glycine and GABA induced Cl(-)-dependent membrane depolarizations and large decreases in membrane resistance. These responses gradually decreased during embryonic development, and at birth they were significantly smaller than in embryos. In motoneurons of embryos and neonates, dorsal root stimulation produced only depolarizing potentials, some of which reversed at -50 mV membrane potential. Reduction of extracellular Cl- concentrations increased the amplitude of these potentials, suggesting that they are generated by Cl- current. Contribution of Cl(-)-dependent potentials to compound dorsal root-evoked potentials was studied by determining the effects of glycine and GABA antagonists on them. In motoneurons of embryos at days 16-17 of gestation (D16-D17), strychnine or bicuculline blocked dorsal root-evoked potentials. This suppression was neither the result of a decrease in neuronal excitability nor the inhibition of glutamate receptors. Strychnine-evoked depression was not blocked by atropine, indicating that it was not due to disinhibition of muscarinic synapses. By D19, strychnine and bicuculline significantly increased dorsal root-evoked potentials rather than blocking them. This reversed function did not result from an increase in neuronal excitability or changes in the specificity of strychnine and bicuculline antagonism. The number of glycine- and GABA-immunoreactive cells increased 20% between D17 and D19. The number of immunoreactive cells and fibers significantly increased in the motor nuclei and dorsal horn laminae. These morphological changes may contribute to establishment of new synaptic contacts on motoneurons, thus changing the actions of strychnine and bicuculline on dorsal root-evoked potentials.


Trigeminal ganglion cell processes are spatially ordered prior to the differentiation of the vibrissa pad.

The rodent trigeminal system is characterized by the punctate organization of its afferents and neurons that replicate the distribution of mystacial vibrissae and sinus hairs on the snout. We have examined the development of topographic equivalence between the sensory periphery on the snout and the brainstem trigeminal nuclei in rats. Lipophilic tracers Dil (1,1'-dioctodecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate) and DiA [4-(4-dihexadecylaminostyryl)-N-methylpyridinium iodide] were used to label trigeminal ganglion cells and their processes differentially from discrete regions of the presumptive vibrissa field in fixed embryos. Our results show that trigeminal ganglion cell processes are spatially ordered as they reach their peripheral and central targets on embryonic day 12 (E12). Peripheral processes of dorsomedially situated ganglion cells course dorsally toward the presumptive vibrissa field, and those of ventrolaterally situated ganglion cells project ventrally. On E13, the central processes of dorsomedially situated ganglion cells enter the brainstem medially whereas those of ventrolaterally situated ganglion cells enter laterally. This spatial order of trigeminal ganglion cell processes precedes the emergence of vibrissa rows in the periphery and the differentiation of brainstem trigeminal nuclei. Thus, the subsequent transfer of the vibrissa-related pattern to the brainstem trigeminal nuclei occurs along a preexisting, spatially aligned bridge formed by the trigeminal ganglion cells.


Cek5, a membrane receptor-type tyrosine kinase, is in neurons of the embryonic and postnatal avian brain.

Cek5 is a recently identified receptor-type tyrosine kinase of the Eph subclass that is nearly ubiquitously expressed during embryonic development (Pasquale, 1991). Cek5 is predominantly expressed in the avian CNS throughout development, and high levels remain apparent in adult neurons. By means of immunofluorescence microscopy and high-resolution immunoelectron microscopy, Cek5 was found to be expressed in many regions of the chicken brain at various developmental stages, most notably in the hippocampus and cerebellum. The highest concentration of Cek5 was observed in the molecular layer of the cerebellum, associated within the axons of mature granule cells (parallel fibers) and with the cell bodies of immature granule cells. In the axons of parallel fibers, Cek5 was concentrated in the fasciculated nonsynaptic portions. This localization, together with the "adhesion" motifs present in the Cek5 extracellular region suggest that Cek5 may interact with other cell surface-associated molecules and be involved in the growth, guidance, and/or bundling of certain unmyelinated axonal processes. Alternatively (or in addition), Cek5 may represent the receptor for a neurotrophic substance, similar to several other neuronal transmembrane tyrosine kinases.


Basic fibroblast growth factor: a potential regulator of proliferation and intermediate filament expression in the retina.

Proliferation of astrocytes, and a concomitant increase of intermediate filaments in astrocytes are two fundamental responses of the CNS to injury. We have previously identified these two events in the retina's response to detachment of the neural retina from the adjoining monolayer of retinal pigmented epithelium. In order to analyze the potential role of basic fibroblast growth factor (bFGF) in these responses, we studied cellular proliferation and intermediate filament protein expression in the retinas of cats and rabbits 4 d and 4 weeks after a single intravitreal injection of 1 microgram of bFGF. Our results show that bFGF stimulates both of these processes in an otherwise normal eye. The eyes that received bFGF had significantly elevated numbers of 3H-thymidine-labeled Müller cells, astrocytes, vascular cells, retinal pigmented epithelial cells, microglia, and macrophages by comparison to control eyes. This proliferation was apparent at 4 d after the injection of bFGF but not after 4 weeks. In control eyes, antibodies to glial fibrillary acidic protein and vimentin labeled intermediate filaments only in the inner (vitread) portion of the Müller cells, the specialized radial astrocytes that span the width of the retina. In eyes that had been injected with bFGF, almost the entire Müller cell cytoplasm was labeled at 4 d after injection; after 4 weeks, the cytoplasmic labeling intensity had increased significantly. Release or activation of endogenous stores of bFGF after injury or disease may be involved in the control of cellular proliferation and intermediate filament expression in the retina and elsewhere in the CNS.


Norepinephrine inhibits calcium currents and EPSPs via a G-protein-coupled mechanism in olfactory bulb neurons.

The most pronounced effect of norepinephrine (NE) in the olfactory bulb is disinhibition of mitral/tufted (M/T) cells. Although it has been previously proposed that the effects of NE are mediated by a direct inhibitory action on granule cells, we have demonstrated that NE could exert it effects through inhibition of excitatory synaptic transmission from M/T cells to granule cells (Trombley and Shepherd, 1992). In order to define further the mechanism underlying NE-mediated inhibition of synaptic transmission, the effects of NE on calcium channel currents were examined using whole-cell recording techniques on bulb neurons in primary culture. NE inhibited high-threshold calcium currents at concentrations that were effective in reducing synaptic transmission. Clonidine, but not isoproterenol, mimicked the effects of NE on calcium currents, suggesting that the effects were mediated through activation of presynaptic alpha-adrenergic receptors. The effects of NE on calcium currents were irreversible in the presence of internal GTP-gamma S and prevented by preincubation with pertussis toxin, results that are consistent with a G-protein-coupled mechanism. Preincubation with pertussis toxin also prevented the effects of NE on synaptic transmission, suggesting that a similar G-protein couple mechanism mediates both effects. Intracellular dialysis with staurosporin or calcium buffering with EGTA did not prevent the effects of NE, suggesting that neither protein phosphorylation nor elevated intracellular calcium were required. These results suggest that NE may inhibit synaptic transmission in the olfactory bulb by reducing calcium currents via a G-protein-coupled alpha-adrenergic receptor.


Denervation of the motor endplate results in the rapid expression by terminal Schwann cells of the growth-associated protein GAP-43.

Developing and regenerating neurons express high levels of the growth-associated phosphoprotein GAP-43. This membrane protein is not confined to neurons, however, as a number of studies have demonstrated GAP-43 immunoreactivity in central and peripheral glia in vitro and in vivo. We have found that the Schwann cells overlying the terminal motor axon at adult rat skeletal muscle endplates, and the motor axons themselves, are normally not GAP-43 immunoreactive. Within 24 hr of denervation, however, the terminal Schwann cells are positive for a GAP-43 mRNA in situ hybridization signal and are GAP-43 immunoreactive. The immunoreactive GAP-43 cells possess elaborate processes that branch from the endplate region into the perisynaptic zone and stain with defined Schwann cell markers: the calcium binding protein S100 and the low-affinity NGF receptor (NGFr), but not with a fibroblast marker, Thy-1. Reinnervating motor axons are GAP-43 positive, with an appearance quite different from the GAP-43-positive Schwann cells. The reappearance of nerve endings at the motor endplate is followed by the disappearance of GAP-43 labeling in the Schwann cells and of a retraction of their processes. GAP-43 expression in Schwann cells is therefore state dependent, apparently regulated by neural contact. This protein, which is associated in neurons with neurite formation, may participate in the elaboration of processes by Schwann cells when their contact with axons is disrupted.


Colocalization of NGF binding sites, trk mRNA, and low-affinity NGF receptor mRNA in primary sensory neurons: responses to injury and infusion of NGF.

The distributions of mRNAs for the protooncogene trk and the low-affinity NGF receptor (LNGFR) were studied by hybridization with oligonucleotide probes on sections of adult rat primary sensory and sympathetic ganglia. For comparison with high-affinity binding sites, adjacent sections were processed for NGF receptor radioautography. Among neurons in lumbar dorsal root ganglia and trigeminal ganglia, trk mRNA and NGF-binding sites were closely colocalized; this finding together with previous direct evidence in other cell types is taken to indicate that trk protein is an essential component of the high-affinity NGF receptor in adult sensory neurons. In lumbar dorsal root ganglia and trigeminal ganglia, abundant LNGFR mRNA was found in all neurons with strong 125I-NGF labeling and on additional neurons lacking high-affinity NGF-binding sites. The presence of abundant LNGFR in neurons with high-affinity receptors could be the cause and/or consequence of their ability to respond to NGF. Neurons with abundant LNGFR mRNA but few high-affinity NGF-binding sites may have receptors for other members of the neurotrophin family. In nodose ganglia, neurons with high concentrations of LNGFR mRNA greatly outnumbered the small percentage with abundant trk mRNA. Following intrathecal infusion of NGF to otherwise normal dorsal root ganglia, the concentrations of LNGFR mRNA but not those of trk mRNA and NGF-binding sites were increased in NGF-responsive neurons. The usual single normal pattern of frequency histograms of LNGFR labeling indices became bimodal in response to NGF. Concentrations of NGF-binding sites, LNGFR mRNA, and trk mRNA were all decreased by peripheral nerve transection and restored by exogenous NGF, the restoration being complete for LNGFR mRNA and partial for trk mRNA and NGF-binding sites. The data indicate that NGF can regulate both LNGFR and trk mRNAs but do not clarify the possible contribution of the LNGFR protein to high-affinity binding sites.


A confocal laser microscopic study of enkephalin-immunoreactive appositions onto physiologically identified neurons in the rostral ventromedial medulla.

Neurons in the rostral ventromedial medulla (RVM) are important in the opioid modulation of dorsal horn nociceptive transmission. Systemically administered morphine inhibits one class of RVM cells, the on-cells; excites a second class of RVM cells, the off-cells; and has no effect on a third class, neutral cells. In contrast, iontophoretic application of morphine inhibits on-cells but does not alter the activity of either off- or neutral cells. The present study addresses whether the differential sensitivity to exogenous opioids is correlated with a differential termination pattern onto the three classes of RVM neurons by afferents containing endogenous opioids. Intracellular recordings were made from RVM neurons in rats under light halothane anesthesia. Physiologically characterized neurons were injected with Neurobiotin and then subsequently visualized with a Texas red fluorophore. Thick (50 microns) sections containing labeled RVM cells were processed for enkephalin immunoreactivity (ENK-IR) using an FITC fluorophore and then optically sectioned at 1.5 micron intervals using a dual-channel confocal laser scanning microscope. ENK-IR appositions were found on the somata and dendrites of all on-cells. Although ENK-IR varicosities were also apparently apposed to off- and neutral cells, the density of such appositions was significantly less than the density of ENK-IR appositions onto on-cells. The greater overall density of ENK-IR appositions onto on-cells was apparently due to a concentration of appositions on the soma and proximal dendrites of these neurons. These results support a model of RVM function in which endogenous opioid peptides produce an antinociceptive action by a direct inhibitory action on on-cells that facilitate nociceptive transmission. This on-cell inhibition may produce an additional antinociceptive effect by removing a possible on-cell inhibition of off-cells, which are thought to inhibit nociceptive transmission.


The G-protein-coupled receptor kinases beta ARK1 and beta ARK2 are widely distributed at synapses in rat brain.

The beta-adrenergic receptor kinase (beta ARK) phosphorylates the agonist-occupied beta-adrenergic receptor to promote rapid receptor uncoupling from Gs, thereby attenuating adenylyl cyclase activity. Beta ARK-mediated receptor desensitization may reflect a general molecular mechanism operative on many G-protein-coupled receptor systems and, particularly, synaptic neurotransmitter receptors. Two distinct cDNAs encoding beta ARK isozymes were isolated from rat brain and sequenced. The regional and cellular distributions of these two gene products, termed beta ARK1 and beta ARK2, were determined in brain by in situ hybridization and by immunohistochemistry at the light and electron microscopic levels. The beta ARK isozymes were found to be expressed primarily in neurons distributed throughout the CNS. Ultrastructurally, beta ARK1 and beta ARK2 immunoreactivities were present both in association with postsynaptic densities and, presynaptically, with axon terminals. The beta ARK isozymes have a regional and subcellular distribution consistent with a general role in the desensitization of synaptic receptors.


Cortical area V4 and its role in the perception of color.

The color and lightness vision of three monkeys with bilateral removal of cortical area V4 and three unoperated controls were tested by measuring their ability to discriminate between two rows of colored or gray stimuli. In one row, the stimuli were ordered in terms of either chromaticity or luminance, whereas in the other row they were disordered. Their ability to select the odd-one-out in an array of colors or grays and to select the colored patch from an array of achromatic grays was also assessed. Unlike an achromatopsic patient tested previously in an identical fashion, monkeys with V4 lesions performed indistinguishably from controls in the oddity test. The animals lacking V4 were slightly impaired at discriminating between ordered and disordered arrays of colors or grays, but the color impairment was no more severe than the impairment with grays. These deficits were readily accounted for in terms of the conspicuous deficits in pattern discrimination apparent in a nine-choice pattern oddity task. The results do not support the view that cortical area V4 in the monkey is the homolog of the cortical "color center" in humans, located in the lingual and fusiform gyri and damage to which leads to the clinical syndrome of cerebral achromatopsia, unless it is the additional damage to underlying white matter that leads to the severe color disorder in patients.


Electrophysiological and morphological properties of rat basolateral amygdaloid neurons in vitro.

Electrophysiological and morphological properties of neurons in the rat basolateral amygdala (BLA) were assessed using intracellular recordings in brain slice preparations. The vast majority of cells studied were identified as pyramidal cells on the basis of their accommodation response and by a prominent afterhyperpolarization that followed a current-evoked burst of action potentials. The second class of cells consisted of late-firing neurons that were distinguished electrophysiologically by their very negative resting membrane potential (-82 mV) and conspicuous delay in the onset of spike firing in response to depolarizing current injection. The third class of cells, termed fast-firing neurons, possessed many of the features of intrinsic inhibitory interneurons found elsewhere in the brain. These included very brief action potentials (0.7 msec), a relatively depolarized resting membrane potential (-62 mV), and spontaneous firing at a high rate and the absence of spike frequency accommodation. Intracellular labeling with Lucifer yellow of electrophysiologically identified pyramidal and late-firing cells showed them to have pyramidal to stellate cells bodies and spine-covered dendrites. Although having an overall pyramidal-like morphology, late-firing neurons possessed cells bodies and dendritic fields that were smaller than those of pyramidal cells. Lucifer yellow-labeled fast-firing neurons had a nonpyramidal morphology, with somata that were spherical to multipolar in shape and spine-sparse or aspiny dendrites. The morphological features of these cells corresponded closely to those of GABA-containing interneurons that have been described previously in the rat BLA using immunohistochemical techniques (McDonald, 1985b). Thus, it seems likely that activation of fast-firing neurons underlies inhibitory synaptic events that are recorded in the rat BLA. Our data support the conclusion derived from previous anatomical studies that pyramidal neurons constitute the predominant cell type in the BLA and function as projection neurons in this region of the amygdala. The determination of whether late-firing cells constitute a unique class of projection neurons distinct from pyramidal cells must await the outcome of studies in which the anatomical terminations of this cell type are specified.


Evidence for conditional neuronal activation following exposure to a cocaine-paired environment: role of forebrain limbic structures.

The reinforcing properties of cocaine can readily become associated with salient environmental stimuli that acquire secondary reinforcing properties. This form of classical conditioning is of considerable clinical relevance as intense craving can be evoked by the presentation of stimuli previously associated with the effects of cocaine. To understand better the neurobiology of cocaine-induced environment-specific conditioning, Fos expression was examined in the forebrain of rats exposed to an environment in which they had previously received cocaine. These results were compared to those observed following an acute injection of cocaine. Consistent with its stimulant actions, cocaine produced an increase in locomotion that was accompanied by an increase in Fos expression within specific limbic regions (cingulate cortex, claustrum, piriform cortex, lateral septal nucleus, paraventricular nucleus of the thalamus, lateral habenula, and amygdala) as well as the basal ganglia (dorsomedial striatum and nucleus accumbens). Exposure of rats to the cocaine-paired environment also produced an increase in locomotion, as compared to various control groups. In addition to this behavioral effect, conditioned subjects exhibited a significant increase in Fos expression within the cingulate cortex, claustrum, lateral septal nucleus, paraventricular nucleus of the thalamus, lateral habenula, and the amygdala, suggesting increased neuronal activity within these regions. In contrast to the dramatic effects observed within these structures, no conditional activation was observed within the piriform cortex, nucleus accumbens, or dorsal striatum, suggesting that these brain areas are not involved in the conditioned response. The present findings indicate that specific limbic regions exhibit increased neuronal activation during the presentation of cocaine-paired cues and may be involved in the formation of associations between cocaine's stimulant actions and the environment in which the drug administration occurred. Although the nucleus accumbens is necessary for the reinforcing and locomotor effects of cocaine, it does not exhibit a conditional Fos response, suggesting that different neural circuits are involved in the unconditioned and conditioned effects of cocaine.


Postsynaptic spike firing reduces synaptic GABAA responses in hippocampal pyramidal cells.

Using intracellular recording techniques in CA1 cells in the hippocampal slice, we studied the responses of cells to synaptically released and iontophoretically applied GABA. With high-resistance, Cl(-)-filled electrodes, which inverted and enlarged the responses at normal resting potentials, we examined spontaneous GABA-mediated IPSPs. Usually we recorded the spontaneous events in the presence of carbachol (10-25 microM), which significantly increased IPSP frequency and blocked potentially confounding K+ conductances. Following a train of action potentials, spontaneous IPSPs were transiently suppressed. This suppression could not be accounted for by membrane conductance changes following the train or activation of a recurrent circuit. Whole-cell voltage-clamp recordings in the slice indicated that the amplitudes of the spontaneous GABAA inhibitory postsynaptic currents (IPSCs) were also diminished following the action potential train. In some cases BAY K 8644, a Ca2+ channel agonist, enhanced the suppression of IPSPs, while buffering changes in [Ca2+]i with EGTA or BAPTA prevented it. The monosynaptically evoked IPSC in the presence of 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and dl-2-amino-5-phosphonovaleric acid (APN) was also diminished following a train of action potentials; however, iontophoretically applied GABA responses did not change significantly. These studies suggest that localized physiological changes in postsynaptic [Ca2+]i potently modulate synaptic GABAA inputs and that this modulation may be an important regulatory mechanism in mammalian brain.


The AANS: the national and international organization for neurological surgery.

The President of the American Association of Neurological Surgeons (AANS) validates the AANS as the national neurosurgical organization. He describes improved management of major committees of neurological surgery by the Joint Officers of the AANS and the Congress of Neurological Surgeons. A strong argument and proclamation are presented to expand the international role of the former Harvey Cushing Society.


Long-term evaluation of decompressive surgery for degenerative lumbar stenosis.

One-hundred patients who had undergone decompressive surgery for lumbar stenosis between 1980 and 1985 were evaluated as to their long-term outcome. Four patients with postfusion stenosis were included. A 5-year follow-up period was achieved in 88 patients. The mean age was 67 years, and 80% were over 60 years of age. There was a high incidence of coexisting medical diseases, but the principal disability was lumbar stenosis with neurological involvement. Results were categorized as either a surgical success or a failure, depending upon the achievement of preset goals within the context of lifestyle and needs. There were no perioperative complications. Initially there was a high incidence of success, but recurrence of neurological involvement and persistence of low-back pain led to an increasing number of failures. By 5 years this number had reached 27% of the available population pool, suggesting that the failure rate could reach 50% within the projected life expectancies of most patients. Of the 26 failures, 16 were secondary to renewed neurological involvement, which occurred at new levels of stenosis in eight and recurrence of stenosis at operative levels in eight. Reoperation was successful in 12 of these 16 patients, but two required a third operation. The incidence of spondylolisthesis at 5 years was higher in the surgical failures (12 of 26 patients) than in the surgical successes (16 of 64). Spondylolisthetic stenosis tended to recur within a few years following decompression. To forestall recurrences, it is suggested that stabilization be carried out at levels of spondylolisthetic stenosis and the initial decompression include adjacent levels of threatening symptomatic stenosis. However, the heterogenicity of this patient population, with varying patterns and levels of symptomatic stenosis, precludes application of rigid surgical protocols.


The significance for postoperative hearing of preserving the labyrinth in acoustic neurinoma surgery.

Among 186 patients with preoperative hearing, a total of 189 acoustic neurinomas were removed through a lateral suboccipital approach with anatomical preservation of the cochlear nerve. Functional hearing was preserved in 92 (49%) of these patients; despite anatomical preservation of the cochlear nerve, deafness was the result in 51% of the series. Many factors have been considered to cause hearing loss in patients whose cochlear nerve was intact after surgery; these include nerve retraction, nerve or cochlear ischemia, overheating and vibration damage to the nerve, and opening of the labyrinth. To evaluate the significance of injury to the labyrinth in postoperative hearing loss, a prospective study was undertaken. High-resolution computerized tomography studies through the inner ear with bone algorithm were performed pre- and postoperatively. The postoperative status of the labyrinth was classified into three patterns: intact, fenestrated, and widely opened. Injury to the labyrinth occurred in 30% of the cases. The most frequently injured labyrinth structures were the crus commune of the posterior and superior semicircular canals (52%), the posterior semicircular canal (23%), the vestibule (21%), and the superior semicircular canal (4%). A statistically significant relationship was found between injury to the labyrinth and deafness, elevated thresholds, and lower discrimination values at pure-tone audiograms and speech audiometry (p < 0.0001). The degree of the injury (comparison between fenestration and wide opening of the labyrinth) was also significantly related to postoperative deafness (p < 0.0001). Disturbance of the inner-ear fluids was considered to be the cause of the hearing loss. In 12 patients labyrinth injury was not associated with deafness. This finding may support the existence of mechanisms of cochlear protection. The homeostatic function of the endolymphatic sac was considered to play an important role in recovery of damaged hearing in these 12 cases.


Late course of preserved hearing and tinnitus after acoustic neurilemoma surgery.

The late course of preserved hearing and tinnitus following retrosigmoid transmeatal surgery for acoustic neurilemoma is reported. Over a period of 5 years, useful hearing was preserved in 15 patients after preservation was attempted in 42 patients. In five patients the hearing was better than the preoperative level; in three it was worse. Three patients developed delayed worsening and fluctuations of hearing in the surgically treated ear during a median follow-up period of 2 1/2 years. While the exact reason for such worsening was not clear in two patients, in one patient it appeared that the muscle graft placed in the internal auditory canal after tumor resection resulted in fibrosis and compromise of the cochlear nerve. The causes of delayed worsening of hearing in the absence of tumor recurrence are analyzed, and possible treatment and methods of prevention of worsening are suggested. In six patients, tinnitus persisted after surgery in the ear with successful preservation of hearing, but hearing was not worsened and the tinnitus was not bothersome to the patient. In one patient with preoperative tinnitus, hearing was not preserved and tinnitus persisted sufficiently to necessitate reexploration and cochlear nerve section.


The benign course of cavernous carotid artery aneurysms.

Recently, the benign nature of aneurysms of the cavernous carotid artery has been questioned. In a review of cases evaluated from 1980 to 1990 with this developmental aneurysm, the authors found 70 patients with 79 cavernous carotid artery aneurysms. As expected, the great majority (59 patients) had ophthalmoplegia as the initial problem. Retro-orbital pain (three cases) and a carotid-cavernous fistula (five cases) were infrequently the sole manifestation. Mirror-image asymptomatic aneurysms were found in nine patients and asymptomatic cavernous aneurysms were found in three additional patients. Thirty-four patients not surgically treated were followed for a mean of 2.8 years, and 36 surgical patients were followed for a mean of 4.1 years prior to treatment. Of the 79 aneurysms, one (1.3%) ruptured into the subarachnoid space during this period. Other than optic neuropathy or cranial neuropathy, no patient had a permanent neurological deficit; the 12 asymptomatic aneurysms remained asymptomatic. It is concluded that an aneurysm of the cavernous carotid artery is rarely associated with life-threatening complications, and treatment should be considered principally for patients with intolerable pain or problems related to vision.


Cell-mediated immunity in severely head-injured patients: the role of suppressor lymphocytes and serum factors.

Severe head injury results in suppression of cellular immunity associated with defective in vitro functioning of effector lymphocytes, such as helper T cells and cytotoxic T cells. It is not known whether this suppression in effector lymphocyte function is due to intrinsic lymphocyte dysfunction, to suppressor peripheral blood mononuclear cells (PBMC's) such as suppressor lymphocytes or suppressor monocytes, or to serum factors capable of inhibiting effector lymphocyte function. The purpose of this study was to determine whether a subpopulation of PBMC's and/or serum factor(s) are responsible for this observed suppression in cell-mediated immunity. Cell-mediated immune activity was determined measuring in vitro lymphokine-activated killer (LAK) cytotoxicity following incubation of PBMC's from 15 head-injured patients with those from 15 heterologous normal subjects. The PBMC's were separated into lymphocyte-enriched and monocyte-enriched subpopulations by plastic adherence techniques, and the effect of each population on LAK cytotoxicity was determined. Additionally, the effect on cytotoxicity of serum from the head-injured patients was determined in a dose-response fashion. There was significant depression in LAK cytotoxicity when: 1) PBMC's from normal subjects were incubated with PBMC's from head-injured patients (p < 0.001); 2) lymphocytes (PBMC's depleted of monocytes) from head-injured patients were incubated with PBMC's from normal subjects (p < 0.001); and 3) PBMC's from normal subjects were incubated with serum from head-injured patients (p < 0.001). No suppression in cellular immunity was noted when lymphocytes from normal subjects were incubated with monocytes from head-injured patients. The results indicate that lymphocytes rather than monocytes actively inhibit cellular immunity following severe head injury. The detection of immunosuppressive serum factors suggests a mechanism by which lymphocytes might be modulated by severe head injury.


Pediatric spinal injury: review of 174 hospital admissions.

Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. A review of 174 pediatric patients is presented, representing 5.4% of all patients admitted with spinal injury. Spinal cord injury was present in 45% of patients. A distinct injury profile, explained by anatomical and biomechanical features, distinguishes the young patient with an immature spine from older adolescents with a more mature, adult-like spine. The younger patients, while less likely to have spinal injury, had a higher incidence of neurological injury, in addition to a higher frequency of both spinal cord injury without radiological abnormality and upper cervical cord injury. In addition, younger patients with spinal cord injury and no radiological abnormality were more likely to have complete or severe cord injury. Prognosis was determined by the severity of spinal cord injury. Patients with complete cord injuries showed little improvement, while patients with incomplete injuries generally fared much better, with 74% showing significant improvement and 59% experiencing a complete recovery of neurological functions. There were six deaths, but none was attributed solely to spinal injury. The authors conclude that outcome is quite good after pediatric spinal cord injury that does not produce a physiologically complete cord deficit.


Pediatric spinal injury: review of 61 deaths.

Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. The authors present a unique review of 61 pediatric deaths associated with spinal injury. This group represented 28% of the total pediatric spine-injured population and 45% of the total pediatric spinal cord-injured group studied. The ratio of pediatric to adult spinal injury mortality was 2.5:1. Of the 61 children, 54 (89%) died at the accident scene. Thirty patients underwent a complete autopsy, 19 of whom had an Abbreviated Injury Scale Grade 6 injury (maximum score, untreatable). Spinal cord injury was found to be the cause of death in only eight children and was associated with injury to the high cervical cord and cardiorespiratory arrest. These children typically sustained severe multiple trauma. In this population, there appears to be little room for improved outcome through changes in treatment strategy.


The subtemporal, transcavernous, anterior transpetrosal approach to the upper brain stem and clivus.

The temporal lobe, posterolateral cavernous sinus, tentorium, and petrous apex restrict anterolateral surgical access to lesions of the upper brain stem and clivus. The authors describe a modified transpetrosal approach that enhances the exposure of clival chordomas and aneurysms of the basilar artery bifurcation. An intradural and extradural subtemporal approach is combined with division of the tentorium and superior petrosal sinus, posterolateral dissection of the cavernous sinus, and intradural removal of the petrous bone from its apex to the cochlea. The indications, advantages, and disadvantages of this subtemporal, transcavernous, anterior transpetrosal approach are described in detail, along with its use in six patients.


Endovascular treatment of intracranial dural arteriovenous fistulas with spinal perimedullary venous drainage.

Intracranial dural arteriovenous (AV) fistulas with spinal perimedullary venous drainage are rare lesions that have distinctive clinical, radiological, and therapeutic aspects. Five patients presented with an ascending myelopathy, which extended to involve the brain stem in three cases. Myelography and magnetic resonance imaging showed slightly dilated spinal perimedullary vessels. Spinal angiograms were normal in the arterial phase. Diagnosis was only possible after cerebral angiography, which demonstrated posterior fossa AV fistulas fed by meningeal arteries and draining into spinal perimedullary veins. Endovascular treatment alone resulted in angiographic obliteration of the lesion in three patients. Two patients required surgery in addition to endovascular therapy. One patient died postoperatively, and in one a transient complication of embolization was observed. Improvement after treatment was good in two cases and fair in two. Transverse sinus thrombosis was observed in three cases and was probably the cause of the aberrant venous drainage of the fistula into the spinal perimedullary veins. The pathophysiology is related to spinal cord venous hypertension. These lesions were classified as Type 5 in the Djindjian and Merland classification of dural intracranial AV fistulas. Endovascular therapy is a safe effective method in the treatment of these fistulas and should be tried first.


Hypoglossal-facial nerve anastomosis for facial nerve palsy following surgery for cerebellopontine angle tumors.

Hypoglossal-facial nerve anastomosis is one of the procedures frequently performed to restore function after facial palsy secondary to surgery for removal of cerebellopontine angle tumors. The published results of hypoglossal-facial nerve anastomosis have been variable, and there are still questions about the indications, timing, and surgical techniques for this procedure. The goals of the present retrospective analysis of 22 cases of hypoglossal-facial nerve anastomosis were to assess the extent of the functional recovery and to analyze the factors affecting this recovery. The 22 cases of complete facial palsy were gleaned from a series of 245 cases of cerebellopontine angle tumors treated surgically by one of the authors. Twenty patients had an acoustic neuroma (average size 3.5 cm), one patient had a petrous meningioma, and one patient had a facial neuroma. The average age of the patients was 47.3 years (range 19 to 69 years). The average interval from tumor surgery to hypoglossal-facial nerve anastomosis was 6.4 months (range 12 days to 17 months), and the average follow-up period after the procedure was 65 months. The results were graded as good, fair, poor, or failure according to a new method of classifying facial nerve function after hypoglossal-facial nerve anastomosis. The results were good in 14 cases (63.6%), fair in three (13.6%), and poor in four (18.2%); one (4.5%) was a failure. Good and fair results occurred with higher frequency in younger patients who were operated on within shorter intervals, although these relationships were not statistically significant. There were no surgical complications. Good or fair results were achieved in 17 (77.3%) of the 22 cases, and thus hypoglossal-facial nerve anastomosis is considered an effective procedure for most patients with facial palsy after surgery for cerebellopontine angle tumors.


99mTc-hexamethylpropyleneamine oxime leukocyte scintigraphy and C-reactive protein levels in the differential diagnosis of brain abscesses.

The demonstration and accurate localization of intracerebral mass lesions are commonly performed with computerized tomography (CT), which often cannot determine the nature of the lesion. As an aid in the differential diagnosis between brain abscess and neoplasm, the authors have evaluated both 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) leukocyte scintigraphy and the serum C-reactive protein level. Of 23 patients with intracranial mass lesions, 22 individuals showed ring-like contrast enhancement on CT scans; the one exception was a patient treated for a meningioma who had a negative CT scan despite clinical suspicion of intra- or extracranial abscess. The final diagnosis was invariably established by microscopic examination of tissue specimens. In 10 patients the final diagnosis was brain abscess; the other 13 patients harbored a brain neoplasm (glioma in nine, astrocytoma in one, and metastasis in three). The 99mTc-HMPAO leukocyte scintigraphy detected all cases of abscess. There were no false-positive results. An elevated C-reactive protein level (> 13 mg/liter) was found in all but one patient with abscess and in three patients with neoplasm; two of these three patients had dental root infections which could account for the elevation of C-reactive protein. It is concluded that 99mTc-HMPAO leukocyte scintigraphy should be performed when there is a possibility that a brain abscess may exist. Any steroid treatment should be discontinued for 48 hours prior to leukocyte scintigraphy. Also, C-reactive protein determination should be performed and is useful even when steroids are given.


Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury.

The clinical value of analyzing various fluids and exudates for beta 2-transferrin (beta 2-Tfn) to detect cerebrospinal fluid (CSF) leakage following head trauma was reviewed in a series of 11 cases. Qualitative detection of beta 2-Tfn was performed by agarose gel electrophoresis of tears, ear and nose exudates, cerebral cyst fluid, and wound discharge fluid in different cases. In each instance the presence of beta 2-Tfn in the analyzed fluid supported the diagnosis of a CSF leak. Equally, the demonstration of the absence of beta 2-Tfn in the fluid excluded the diagnosis of such a leak. Neither false-positive nor false-negative results were found, as indicated by separate radiological investigations and/or subsequent clinical assessment of patients. The detection of beta 2-Tfn in suspect fluids thus provides a highly sensitive and selective, rapid, and noninvasive test for the detection of CSF leakage in cases of head trauma.


Is vasospasm related to proliferative arteriopathy?

Although proliferative arteriopathy has been postulated to play a role in the etiology of vasospasm after subarachnoid hemorrhage (SAH), histological and morphological studies examining cerebral vasospasm have produced conflicting results. To help settle this controversy, the authors used an in vivo label of cell division, bromodeoxycytidine, to assess cell proliferation in a primate model of SAH. Fifteen cynomolgus monkeys received a clot of either whole blood (11 animals) or red blood cells (four animals) placed around the right middle cerebral artery (MCA). On the day of surgery continuous intravenous infusion of bromodeoxycytidine was begun and continued until the animal was sacrificed immediately after arteriography on Day 7, 12, or 27 following surgery. Sections from the right and left MCA's were stained with a monoclonal antibody against bromodeoxcytidine, and labeled cells were counted. Arteriographic evidence of vasospasm occurred in nine monkeys on Day 7. On Day 12 and Day 27 no monkeys had persistent vasospasm. Placement of subarachnoid clot around the right MCA increased proliferative activity across all layers of the arterial wall. Most of the labeled cells were in the adventitia and the endothelium. Although there were more dividing cells in all layers of the right MCA than the left MCA (p < 0.01), the number of stained cells per section was limited (range 0.1 to 21.2, mean 8) and the occurrence of vasospasm was not associated with the number of dividing cells in the right MCA on Day 7, 12, 27, or for all days combined (p > 0.6). Cerebral vasospasm after SAH was not associated with the extent of proliferation of cells in the vessel wall, nor could the intensity of the limited proliferative changes have been responsible for narrowing of the vessel diameter.


Expression of cell adhesion molecule E-cadherin in human arachnoid villi.

Calcium-dependent epithelial cell adhesion molecules designated as E-cadherin (also known as uvomorulin or L-CAM) were identified in human arachnoid villi by immunoblotting and immunocytochemical analyses using a monoclonal antibody HECD-1 raised against human mammary carcinoma MCF-7 cells. Immunoblot analysis showed that HECD-1 recognizes E-cadherin with a molecular weight of 124 kD. In all arachnoid cells of an arachnoid villus, E-cadherin was detected by immunolight microscopy within the cytoplasm rather than the cellular boundaries as seen in the control group. Furthermore, the extent of expression by immunolight microscopy varied from portion to portion. The expression was usually weak in the syncytial cluster which was ultrastructurally composed of tightly juxtaposed cells characterized by few extracellular cisterns and numerous cell junctions, while it was intense in the reticular cluster and the surface layer which were ultrastructurally characterized by abundant extracellular cisterns and smaller numbers of cell junctions. The cells of the reticular cluster and the surface layer contained more free ribosomes than those of the syncytial cluster. Immunoelectron microscopy showed that E-cadherin was localized not only to the opposing plasma membranes and the cytoplasm around the free ribosomes or the rough endoplasmic reticulum but also to the extracellular cisterns. As the expression of E-cadherin was closely related to the arachnoid cells adjacent to the cerebrospinal fluid pathway, it is suggested that, instead of the cell junctions, E-cadherin may play an important role in the flexible adhesion of arachnoid cells even in the presence of the cerebrospinal fluid.


Antitumor activity against established intracerebral gliomas exhibited by cytotoxic T lymphocytes, but not by lymphokine-activated killer cells.

Specific immune responses against malignant brain tumors have been difficult to demonstrate. Moreover, immunotherapy has met with little success, despite using lymphocytes with high levels of cytotoxicity against brain tumor cells. Lymphokine-activated killer (LAK) cells that nonspecifically kill brain tumor cells are produced by stimulating resting precursors with high concentrations of interleukin-2 (IL-2). Cytotoxic T lymphocytes that specifically kill brain tumor cells are produced by stimulating antigen receptor-positive immune-cell precursors with tumor cells. In an attempt to gain insight into immune cell function against brain tumors, the present study compared the in vitro and in vivo activities of LAK cells and cytotoxic T lymphocytes produced against RT2, a fast-growing rat glioma cell line. Lymphokine-activated killer cells were produced by stimulating normal rat spleen cells with 1000 units of IL-2, and RT2-specific cytotoxic T lymphocytes were produced by priming them in vivo with RT2 and Corynebacterium parvum and restimulating primed spleen cells with RT2 in vitro. Lymphokine-activated killer cells were highly cytotoxic for a panel of syngeneic and allogeneic brain tumor and non-brain tumor target cells, including RT2, as measured in a 4-hour 51Cr release assay. Cytotoxic T lymphocytes were highly cytotoxic only for syngeneic brain tumor target cells. Lymphokine-activated killer cells and cytotoxic T lymphocytes were tested for in vivo antitumor activity against intracerebral RT2 by intravenous adoptive transfer of activated lymphocytes. Untreated rats died in approximately 2 weeks. Lymphokine-activated killer cells plus IL-2 failed to affect survival when treatment was initiated as early as 1 day following tumor inoculation. Cytotoxic T lymphocytes and IL-2 administered as late as Day 5 rejected progressing intracerebral tumor. Thus, although both cytotoxic T lymphocytes and LAK cells exhibited high levels of in vitro killing of glioma cells, only cytotoxic T lymphocytes rejected progressing intracerebral tumors.


Inhibition of delayed arterial narrowing by the iron-chelating agent deferoxamine.

The potential role of iron in cerebral vasospasm was examined in the rat femoral artery model by the perivascular application of deferoxamine, a ferric ion chelator and antioxidant. In 25 rats, platelet-rich plasma or fresh autologous whole blood containing deferoxamine at concentrations of 1, 5, 10, or 15 mg/ml was applied to the adventitial surface of the femoral artery in a Silastic cuff to insure chronic exposure to the vessel wall. At 7 days, contralateral femoral arteries exposed to whole blood showed a 70% reduction in luminal cross-sectional area and morphological changes associated with vasospasm. Application of platelet-rich plasma or whole blood containing deferoxamine at 25 mg/ml produced no significant arterial narrowing or structural changes; significant intermediate reductions in arterial narrowing were observed at deferoxamine concentrations of 5 and 10 mg/ml. Presaturation deferoxamine (10 mg/ml) with excess ferric ion prior to application eliminated the protective effect. In addition, deferoxamine chelated the ferric ion released from incubated whole blood in vitro over 7 days in a dose-dependent manner consistent with its protective effect in vivo. Ferric ion may influence the development of chronic arterial narrowing after subarachnoid hemorrhage by a variety of mechanisms.


Experimental repair of the oculomotor nerve: the anatomical paradigms of functional regeneration.

In adult guinea pigs, the oculomotor nerve was sectioned proximally (at the tentorial edge) or more distally (at the orbital fissure) and immediately repaired by reapproximation. During a 24-week postoperative period, extrinsic eye motility was assessed by analyzing the vestibulo-ocular reflexes. The regenerated oculomotor nerve was studied morphometrically on semi-thin histological sections at 16 and 24 weeks postinjury. The selectivity of muscle reinnervation was investigated by injection of both single (horseradish peroxidase) and double (fluorescent dyes) retrograde axonal tracers into the eye muscles. Following proximal repair of the oculomotor nerve, the degree of recovery of extraocular motility varied among different animals and remained stable over long-term observations. In animals with poor recovery, aberrant eye movements were always found, and the somatotopic map of the reinnervated eye muscles was greatly altered. Distortions of the central representation were also seen in those animals in which a good level of functional recovery was seen. However, in animals with good recovery, a topographic bias was re-established by about 65% of the original neuronal population, as opposed to 26% in the animals with poor recovery. Neurons located contralateral to the axotomized nucleus sprouted intra-axially and projected their axons to denervated eye muscles. The number and diameter of the regenerated axons, the number and soma diameter of the axotomized neurons, and the ratio of distal axonal branches to proximal supporting neurons were all related to the degree of functional recovery. Following repair of the oculomotor nerve at the orbital fissure, extraocular motility had recovered in all of the animals at 16 weeks without aberrant phenomena. Functional regeneration of the distally transected oculomotor nerve is thought to be the result of selective muscle reinnervation.