Effect of bioabsorbable osseous fixation materials on dura mater and brain tissue

Bioabsorbable materials are frequently used in pediatric cranial surgery, but the effects of these materials on neural tissue are not known. The authors assessed the histologic alterations to dura mater and brain tissue associated with bioabsorbable plates. Fifteen Sprague-Dawley rats were given sham cranial surgery; an additional 30 underwent placement of 8 x 8-mm polylactic acid/poly-glycolic acid plates. The rats were assessed weekly for neurologic or behavioral changes suggesting neural damage. A portion of each group was killed at 3, 6, and 12 months for histologic analysis of cranium, dura mater, and brain tissue by standard hematoxylin and eosin stain. None of the animals showed any behavioral changes or neurologic deficits. The plates were gradually hydrolyzed over the study period, and all had disappeared by 12 months. The histologic examination showed fibrous encapsulation around the plates, accompanied by foreign body giant cell reaction and calcification. Focal gliosis, where evident, was mild and confined primarily to the superficial cortex of the brain beneath the plate. The infiltration of the dura mater and underlying brain parenchyma was negligible. In conclusion, the neurologic and histologic effect of bioabsorbable plates on neural tissue may be considered negligible in the early postoperative period.     

The effects of repeated bleedings on bone marrow and blood morphology in adult laboratory rats

There were slight and rapidly disappearing changes in the bone marrow and blood morphology of laboratory rats after repeated bleedings on consecutive days, except marked increases in the counts of circulating reticulocytes. However, the significantly elevated reticulocyte count was not accompanied by the similar increase in the count of marrow erythroid nucleated cells. Marked increments could be found in the counts of splenic erythroid nucleated cells and, therefore, it is possible for rat circulating reticulocytes to originate following repeated bleedings from the spleen. The validity of investigations of bone marrow and blood morphology for detecting haemorrhage is discussed with a view to preclinical safety drug evaluations performed on adult laboratory rats.     

Tremor, seizures and psychosis as presenting symptoms in a patient with chronic lyme neuroborreliosis (LNB)

Lyme borreliosis is a multisystem disorder caused by Borrelia burgdorferi (Bb). Neurological symptoms such as lymphocytic meningoradiculoneuritis (Bannwart's syndrome), cranial neuritis (II,III,IV,V,VI), encephalitis, transverse myelitis are found in about 10% of cases during the second phase of the disease. In the chronic stage, many months or years after the initial infection, other neurologic complications may occur, such as encephalomyelitis, epileptic crises, cognitive impairment, peripheral neuropathy and psychiatric disturbances such as depression, anxiety, panicc attacks, catatonia, psychosis etc. Some patient continue to experience symptoms of fatigue, insomnia or psychiatric disorder in the post borrelia syndrome. We describe here a patient with a triad of unusual symptoms in chronic LNB including tremor, seizures and psychosis. Standardized medical interview, neurologic examination, neuroimaging, serum and CSF serology as well as EEG and EMNG evaluation were performed. The patient was treated with intravenous ceftriaxone and doxycycline and responded with rapid clinical and functional improvement.Newertheless, he suffered from multiple systemic and neurologic sequelas that influenced his daily activities in post treatment period. Emphasis is placed on the atypical onset and evolution, the difficulties encountered in formulating diagnosis, early treatment and the uncertainties concerning the sequelae after treatment. In patients with non-specific long lasting symptoms in the absence of overt clinical signs suggesting CNS involvement, routine treatment with i.v. ceftriaxone is not to be encouraged.     

Chiari malformation, cervical spine anomalies, and neurologic deficits in velocardiofacial syndrome

The purpose of this investigation was to evaluate the prevalence of Chiari malformation, cervical spine anomalies, and neurologic deficits in patients with velocardio-facial syndrome. This study was a prospective evaluation of 41 consecutive patients with velocardiofacial syndrome, documented by fluorescence in situ hybridization, between March of 1994 and September of 1998. The 23 girls and 18 boys ranged in age from 0.5 to 15.2 years, with a mean age of 6.7 years. Nineteen patients were assessed with magnetic resonance imaging, 39 underwent lateral cephalometric radiography, and all patients were examined for neurologic deficits. Eight of 19 patients (42 percent) had anomalies of the craniovertebral junction, including Chiari type I malformations (n = 4), occipitalization of the atlas (n = 3), and narrowing of the foramen magnum (n = 1). One patient with Chiari malformation required suboccipital craniectomy with laminectomy and decompression. Fourteen of 41 patients (34 percent) had demonstrated neurologic deficits; 10 patients (24 percent) had velar paresis (6 unilateral and 4 bilateral). Chiari malformations, cervical spine anomalies, and neurologic deficits are common in velocardiofacial syndrome. Because these findings may influence the outcome of surgical intervention, routine assessment of patients with velocardiofacial syndrome should include careful orofacial examination, lateral cephalometric radiography, and magnetic resonance imaging of the craniovertebral junction.     

Movement, dive behavior, and survival of California sea lions (Zalophus californianus) posttreatment for domoic acid toxicosis

Domoic acid (DA) is a neuroexcitatory toxin increasingly causing strandings and mortality of marine mammals. The hippocampus of mammalian brains, associated with learning, memory, and spatial navigation, is one of the predominant regions affected by DA exposure. California sea lions stranding from 2003 to 2006 as a result of DA toxicosis were classified as having acute ( n = 12) or chronic neurologic ( n = 22) clinical signs. Chronic neurologic cases were examined by magnetic resonance imaging to determine the extent of brain damage related to DA exposure. Brain damage included hippocampal and parahippocampal atrophy, temporal horn enlargement, and pathological T2 hyperintensity. Posttreatment, animals were fitted with satellite transmitters and their movement and dive behaviors compared with those of a control group. The only significant difference between acute and chronic animals was distance traveled per day. There were, however, significant differences between chronic neurologic cases and controls: chronic neurologic cases dove shallower for shorter durations, traveled further from shore, and spent less time hauled out and more time surface swimming than control animals. There was no relationship between severity of brain damage and behavioral patterns for chronic neurologic cases. Sea lions with chronic neurologic changes had a poor prognosis for survival following release.     

Relationship between mercury concentration in blood, cognitive performance, and blood pressure, in an elderly urban population

Concentration of mercury (Hg) in whole blood in an elderly urban population with a mean age of 87 years was studied in relation to cognitive function, arterial blood pressure (arterial BP), age, gender, body mass index (BMI) and smoking habits. This population-based study consisted of 106 subjects both males and females. Clinical assessment of the subjects included medical and social history, physical and neurologic examination and assessment of cognitive functions with Mini-Mental State Examination (MMSE). Information on use of all potentially anti-hypertensive drugs was collected. Whole blood from 106 subjects were collected and analysed for mercury by Cold Vapour Atomic Absorption Spectrometry (Milton Ray ASS-CV) with Seronorm Trace Element as matrix matched quality control. Males and females did not differ in blood-mercury (B-Hg) concentrations or in any of the other studied variables. B-Hg concentrations did not differ between smokers and non-smokers. Females were treated more often than males with antihypertensive drugs. There was no relation found between B-Hg concentration and cognitive function, arterial BP, age, gender or BMI. In conclusion, no relations were found between B-Hg concentrations and the studied variables.     

Effects of ketamine anaesthesia, stress and repeated bleeding on the haematology of vervet monkeys

Haematology values are presented for the vervet monkey (Cercopithecus aethiops), and the relative effects of high dose ketamine anaesthesia, stress of capture and repeated bleedings assessed. Anaesthesia resulted in decreased WBC and RBC values, attributed to depression of cardiovascular function. These effects were the reverse of those of alarm and strenuous exercise (leukocytosis and polycythaemia) during capture. Stress resulted in relatively high white and low red blood cell counts. Opposing effects of stress and anaesthesia led to comparable haematological values for trained, non-anaesthetized vervets and stressed, anaesthetized vervets. Effects of repeated bleedings were opposite in anaesthetized and non-anaesthetized animals. These effects, however, along with those of ketamine anaesthesia and stress, were relatively insignificant compared with the wide variation in haematological values found among individuals. The biological importance of these effects thus appeared to be slight. The concept of 'normal values' is discussed.     

Contributions of the history,physical examination,and laboratory investigation in making medical diagnoses.

We report an attempt to quantitate the relative contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. In this prospective study of 80 medical outpatients with new or previously undiagnosed conditions, internists were asked to list their differential diagnoses and to estimate their confidence in each diagnostic possibility after the history, after the physical examination, and after the laboratory investigation. In 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists'' confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians'' confidence in their diagnoses.     

Primary malignant melanoblastosis of the meninges. Clinical, cytologic and neuropathologic findings in a case

A 66-year-old man presented with a six-month history of neurologic symptoms suggestive of a craniospinal tumor or a diffuse inflammatory process in the subarachnoid space. Cytologic examination of cerebrospinal fluid (CSF) revealed inflammatory changes and malignant melanin-containing cells, leading to a diagnosis of meningeal spread of a melanoma. There was no history of skin excisions and no clinical evidence of primary melanoma of the eye. Neuroradiologic investigations, including CT and myelography, to confirm the diagnosis were negative. Despite intrathecal cytostatic therapy, the patient died eight months after the onset of symptoms. Autopsy disclosed diffuse meningeal melanoblastosis of the spinal cord and the base of the brain, confirming the cytologic diagnosis. In addition, two micrometastases in the liver were found as only extraneural manifestation. This case emphasizes the importance of CSF cytology in the diagnosis of diffuse infiltrating processes in the subarachnoid space.     

Cervical spine arthrodesis in rheumatoid arthritis: a long-term follow-up.

Forty-one patients with rheumatoid arthritis involving the cervical spine had a posterior cervical arthrodesis. They were followed for a minimum period of seven years. The diagnoses prior to surgery included cranial settling, atlantoaxial subluxation, subaxial subluxation, and any combination of these three. All patients had posterior arthrodesis, with or without methylmethacrylate, and iliac crest autogenous bone graft. In addition, one patient had an anterior vertebrectomy, and two had transoral resection of the odontoid. Follow-up consisted of a subjective questionnaire, standard radiographs, and physical examination, including a neurologic exam. This information was compared to preoperative data available in the patient''s medical record, postoperative data, and the information obtained in a similar study undertaken in 1987. At the time of follow-up, thirteen patients were known to be dead. One patient could not be located. Of the remaining twenty-six patients, eighteen underwent the full examination, including physical exam and radiographs. The remaining nine patients were contacted and interviewed, but were unavailable for exam and radiographs. All patients considered the operation a success. Only one patient at follow-up had a non-union. This was stable over time. No patient had a deterioration in neurologic function. There was no significant degeneration or instability seen at levels adjacent to the fused segments as compared to the rest of the cervical spine. Posterior cervical spine arthrodesis for rheumatoid involvement of the neck is a safe, efficacious procedure with no significant deterioration of effects over time.     

Vesical Hemorrhages in Male Aleutian Mink Caused by Hypersensitivity to Sulphadimidine

During an outbreak of Salmonella abortion in mink farms receiving food from a central feed plant, sulphamezathine (a 16 % solution of sulphadimidine sodium) was added to the food to combat the infection. After 3 days of medication, some males of the Aleutian type developed severe urinary bleedings. The serum concentration of the drug was not above the recommended value in 2 severely affected animals (1.5 and 1.7 mg/100 ml, respectively). Screening tests for the extrinsic (Thrombotest and Normotest) and intrinsic (cephalin time) coagulation mechanism, fibrinogen assay, fibrinolysis (plasma clot lysis time), and platelet count were not much different from normal. Coagulation or platelet defects did not therefore seem to be the cause of the bleedings. Some of the diseased animals died, and the only necropsy finding was a greatly distended urinary bladder filled with clotted blood. Histologically, hemorrhages and necrotic changes of varying severity were found in the vesical wall. In several cases, the arteries were the structures most evidently affected, indicating that the hemorrhages were due to vascular injury (Fig. 1). The damaged vessels were sporadically occluded by thrombi. The lesions were often most evident in subserosal arteries and in the relatively large arteries situated between the inner circular and the outer longitudinal muscular layer, whereas the submucosal structures were obscured by massive extravasations of red blood cells. Occasionally, the necrotic arteries were surrounded by incipient circumferential cellular accumulations, predominantly mononuclear cells, but some eosinophils were also present (Fig. 2). Thus, in these cases the vascular damage was similar to vascular lesions frequently accompanying viral plasmacytosis (periarteritis nodosa). The possibility exists that the animals were in an early developmental stage of plasmacytosis, but no extravesical changes suggesting plasmacytosis were discovered during the microscopic examination. Although other sulphonamides have occasionally shown toxic properties when administered to mink, this preparation has not, to the authors’knowledge, previously been recorded as injurious to this species. The following experiment was performed to elucidate the toxicity of sulphadimidine sodium to male Aleutian mink.     

Focus: Bioethics: Components of Mid-clerkship Feedback in a Neurology Clerkship and their Impact on Subsequent Student Performance

Feedback during clinical rotations can be valuable in improving medical student education, but it is unclear what effect such feedback has on subsequent clinical performance and also which feedback topics are the most important in student growth and education. We compared medical student clinical performance before and after mid-clerkship feedback in a Neurology clerkship, with evaluators at the mid-clerkship and at the end blinded to the others’ comments. We found that the most important areas holding back student clinical performance were communication, interpersonal interactions, and work ethic rather than textbook knowledge, or the ability to take a history, and do a physical and neurologic examination. Further, students who had concerning comments at the mid-clerkship feedback session usually continued to have the same problems after the feedback (in an admittedly short clerkship). The results suggest that more attention should be given to communication and other interpersonal skills and involvement in the clinical service during feedback sessions and that feedback continue over a much longer period than during a relatively brief Neurology clerkship alone.     

Carbon monoxide poisoning and nonoliguric acute renal failure.

Carbon monoxide poisoning in a 37-year-old man was complicated by neurologic damage, skin changes, muscle necrosis and nonoliguric renal failure. The relation between nontraumatic rhabdomyolysis and acute renal failure in carbon monoxide poisoning is reviewed. Recognition of the acute renal failure in such cases is important, for this complication can be fatal; the prognosis is excellent, however, if proper medical management is provided.     

Tuberculous meningitis in children: a retrospective study of 79 patients,with an analysis of prognostic factors.

A study of 79 cases of tuberculous meningitis in children, with an emphasis on prognostic factors, was conducted by means of a review of hospital records and completion of a follow-up questionnaire. The survival rate was 62%. Stage 3 disease (with severe changes in the sensorium and often severe neurologic abnormalities) at the time of admission, age 3 years or less, associated miliary tuberculosis and delay in the initiation of therapy correlated significantly with poor outcome. Severe neurologic complications in the acute phase were also related to poor outcome and severe sequelae. General recommendations pertaining to treatment are made.     

Brain beta-adrenergic and GABA-ergic receptors in rats after exposure to high doses of ionizing radiation

The radioactive ligands, [3H]dihydroalprenolol and [3H]muscimol, were used to estimate the condition of beta-adrenoreceptors of the brain cortex and GABA-receptors of the cerebellum during transient neurologic disorders caused by irradiation of rats with high-energy (20 MeV) electrons of 200 Gy. No significant changes were observed in the GABA-ergic brain system while the changes in beta-adrenoreceptors of the brain were pronounced and manifested by the loss by the receptors of their ability to bind the specific ligand, dihydroalprenolol. The changes observed were reversible and correlated with the development of neurologic disorders.     

Iliopsoas hemorrhage in hemophilic children

Sixty-nine children with hemophilia were treated in our center between 1968 and 1983. About 1 per cent of hemorrhagic complications were bleedings localized in the iliopsoas muscle of 12 patients ranging in age from 9 to 15 years. The typical sign of the bleeding is a tight, palpable tumour above the inguinal fold. Today mass bleedings of the muscle with retroperitoneal localization are diagnosed safely by help of computer tomography or sonography. Psoas muscle bleedings in children are characterized by a high recurrence rate (41.5%) and often by an associated damage of the femoral nerve. Surgery was necessary only in 1 patient where a huge psoas hematoma with cystic transformations had to be removed. High substitution doses led to a complete recovery within 3 weeks in all other children.     

Mechanism of action, development and clinical experience of recombinant FVIIa

Recombinant FVIIa has been developed for treatment of bleedings in hemophilia patients with inhibitors, and has been found to induce hemostasis even during major surgery such as major orthopedic surgery. Recombinant FVIIa is being produced in BHK cell cultures and has been shown to be very similar to plasma-derived FVIIa. The use of rFVIIa in hemophilia treatment is a new concept of treatment and is based on the low affinity binding of FVIIa to the surface of thrombin activated platelets demonstrated in a cell-based in vitro model. By the administration of pharmacological doses of exogenous rFVIIa the thrombin generation on the platelet surface at the site of injury is enhanced independently of the presence of FVIII/FIX. As a result of the increased and rapid thrombin formation, a tight fibrin hemostatic plug is being formed. A tight fibrin structure has been found to be more resistant to fibrinolytic degradation thereby helping to maintain hemostasis. The general mechanism of action of pharmacological doses of rFVIIa shown to induce hemostasis not only in hemophilia, but also in patients with platelet defects, and with profuse bleedings triggered by extensive surgery or trauma, may very well be the capacity of generating a tight fibrin hemostatic plug through the increased thrombin generation. Such a fibrin plug will help to resist the overwhelming mostly local release of fibrinolytic activity triggered by the vast tissue damage occurring in extensive trauma. A release of fibrinlytic activity locally has also been demonstrated to occur in the gastrointestinal tract as well as during profuse postpartum bleedings. Pharmacological doses of rFVIIa have in fact, also been shown to induce hemostasis in such cases.     

Influence of restraint and ketamine anesthesia on adrenal steroids, progesterone, and gonadotropins in rhesus monkeys

Changes in gonadotropins, progesterone, cortisol, DHA, and DHAS were monitored in 10 female rhesus monkeys (Days 20-23 of the menstrual cycle) subjected to cage restraint with or without ketamine anesthesia for successive venipunctures. All animals were bled without sedation for 2 hr at 30-min intervals. Then 4 of the animals were anesthetized with ketamine-HCl and bleedings in all animals were continued for an additional 2.5 hr. FSH and progesterone were not appreciably affected by either restraint technique. LH declined steadily for the duration of the bleedings (P less than 0.05). Serum levels of cortisol and the adrenal androgens increased twofold (P less than 0.05). Anesthesia with ketamine had no effect on any of the six variables when compared with saline controls. Cortisol and dehydroepiandrosterone (DHA) levels tended to plateau (P less than 0.01) after 2 hr in both treated and control groups. In contrast, dehydroepiandrosterone sulfate (DHAS) levels increased continuously throughout the entire study period. These data indicate that ketamine anesthesia does not alter endocrine responses to venipuncture when administered following cage restraint of conscious animals. These findings further confirm the difficulties in obtaining estimates of basal levels of hormones which are responsive to stress and suggest that the first sample may provide the best estimate.     

Baseline,diurnal variations,and stress-induced changes of stress hormones in three captive beluga whales,Delphinapterus leucas

Concentrations of plasma adrenocorticotropic hormone (ACTH), cortisol, and aldosterone were investigated in three adult beluga whales (Delphinapterus leucas), held in a large outdoor public aquarium exhibit. The purpose of this study was to evaluate resting concentrations of these hormones and associated diurnal variations with routine interactions and medical procedures. Resting blood samples were collected voluntarily from the ventral fluke veins at predetermined times of the day to evaluate diurnal changes in analyte concentrations. In addition, hematology and serum chemistry analyses were performed to monitor health status and evaluate changes related to physical exam procedures. Analogous sampling was conducted during out-of-water physical examinations and before and after wading-contact sessions (WCS). Baseline stress hormone concentrations (± SD) were as follows: plasma ACTH (8.41 ± 5.8 pg/mL), serum cortisol (1.80 ± 0.71 g/dL), and serum aldosterone (11.42 ± 5.5 pg/mL). Plasma ACTH and cortisol concentrations were consistently higher in early morning than evening, while aldosterone was higher in the evening. All stress-related hormones were significantly elevated during physical examination. Plasma ACTH concentrations were most increased, 5–10-fold, during physical examination, whereas cortisol and aldosterone showed 2–4-fold elevations. Stress response analytes measured during the WCS did not differ significantly from baseline concentrations.