Four-Way Wada: SEEG-based mapping with electrical stimulation, high frequency activity, and phase amplitude coupling to complement traditional Wada and functional MRI prior to epilepsy surgery.

Presurgical evaluation of refractory epilepsy involves functional investigations to minimize postoperative deficit. Assessing language and memory is conventionally undertaken using Wada and fMRI, and occasionally supplemented by data from invasive intracranial electroencephalography, such as electrical stimulation, corticortical evoked potentials, mapping of high frequency activity and phase amplitude coupling. We describe the comparative and complementary role of these methods to inform surgical decision-making and functional prognostication. We used Wada paradigm to standardize testing across all modalities. Postoperative neuropsychological testing confirmed deficit predicted based on these methods.

Longitudinal neurodevelopmental profile of a pediatric patient with de novo SPTAN1, epilepsy, and left hippocampal sclerosis.

Pathogenic variants in SPTAN1 result in abnormal neurodevelopment but limited information is available on the spectrum of neurodevelopmental profiles associated with variations in this gene. We present novel data collected at two time points over a three-year period in a nine-year-old patient with heterozygous de novo SPTAN1 variant, drug-resistant epilepsy, and left hippocampal sclerosis. Across evaluations, our patient's performance was highly variable, ranging from below age expectation to within age-expected range. The patient exhibited relative cognitive strengths at both time points on verbal-expressive tasks. Weaknesses were seen in her attention, executive function, psychomotor processing speed, fine motor, visual-motor integration, and social skills. Memory findings were consistent those associated with left hippocampal sclerosis. Evaluations resulted in diagnoses including attention deficit hyperactivity disorder and autism spectrum disorder.

Health beliefs regarding pediatric cerebral palsy among caregivers in Botswana: A qualitative study.

BACKGROUND: Cerebral palsy (CP) is the most common motor disability worldwide with an incidence of 2.5 per 1,000 births globally. Health beliefs among caregivers may be major drivers of health-related behaviours and service utilization, but little is known regarding health beliefs around CP in Africa. METHODS: Between July 2013 and September 2015, children with CP were identified in Gaborone, Botswana, and their caregivers were invited to participate in a qualitative study utilizing semistructured in-person one-on-one interviews. Interview questions addressed their understanding of CP, challenges of caring for a handicapped child, and community response to children with CP. RESULTS: Sixty-two caregivers participated in the study. Common themes elicited were variable knowledge about CP, financial and physical burden, lack of therapies and educational resources, and the impact of stigma. Caregivers in Botswana generally subscribed to a biomedical explanation of CP but expressed concerns regarding more stigmatizing folks beliefs expressed in the community. CONCLUSION: Health beliefs regarding CP in Botswana likely have a significant impact on utilization of healthcare resources. Information from this study should inform future educational interventions for caregivers of children with CP.

White matter damage in asymptomatic patients with sickle cell anemia: screening with diffusion tensor imaging.

BACKGROUND AND PURPOSE: Ischemic injury to the brain is a common complication of SCA. To better understand the neurologic impact of SCA, TBSS were applied to DTI data to investigate white matter injuries in pediatric patients with SCA. MATERIALS AND METHODS: TBSS comparisons of a range of anisotropy and diffusion measures were carried out between age- and background-matched population groups: patients with SCA with no visible lesions, patients with SCA with mild gliosis, and normal controls. RESULTS: TBSS analysis revealed that both SCA populations exhibited reduced anisotropy and increased diffusivity compared with normal controls in multiple brain regions, including the corpus callosum and centrum semiovale. Furthermore, the results suggest that the severity of SCA is positively correlated with the white matter changes in the corpus callosum. CONCLUSIONS: The study demonstrates that TBSS is a viable technique in detecting subtle white matter damage in patients with SCA whose conventional anatomic MR imaging scans show no, or minimal, abnormalities and has the potential to evaluate the neurologic impact of the treatment of SCA.

NMR analysis of metabolic responses to extreme conditions of the temperature-dependent coral pathogen Vibrio coralliilyticus.

AIMS: To identify and understand the presence of metabolites responsible for the variation in the metabolic profile of Vibrio coralliilyticus under extreme conditions. METHODS AND RESULTS: Multiple batches of V. coralliilyticus were grown under normal conditions. Four samples in one batch were subjected to extreme conditions via a freeze-thaw cycle during lyophilization. Polar metabolites were extracted using a combination of methanol, water and heat. Nuclear magnetic resonance (NMR)-based metabolic profiles indicated significant differences between the normal and stressed samples. Three compounds identified in the stressed metabolome were maltose, ethanolamine, and the bioplastic-type compound (BTC) 2-butenoic acid, 2-carboxy-1-methylethyl ester. This is the first report of the production of this BTC by V. coralliilyticus. CONCLUSIONS: The presence of maltose and ethanolamine indicates a state of acute nutrient limitation; therefore, we hypothesize that the cell's metabolism turned to its own cell wall, or perhaps neighbouring cells, for sources of carbon and nitrogen. The presence of the BTC also supports the acute nutrient limitation idea because of the parallels with polyhydroxyalkanoate (PHA) production in other gram-negative bacteria, including other Vibrio species. SIGNIFICANCE AND IMPACT OF THE STUDY: Recent metabolomics research on the temperature-dependent coral pathogen V. coralliilyticus has led to the discovery of several compounds produced by the organism as a response to high density, low nutrient conditions. The three metabolites, along with (1) H NMR metabolic fingerprints of the nutrient limited samples, are proposed to serve as metabolic markers for extremely stressful conditions of V. coralliilyticus.

An evaluation of contaminated estuarine sites using sediment quality guidelines and ecological assessment methodologies.

Toxic contaminants may enter estuarine ecosystems through a variety of pathways. When sediment contaminant levels become sufficiently high, they may impact resident biota. One approach to predict sediment-associated toxicity in estuarine ecosystems involves the use of sediment quality guidelines (ERMs, ERLs) and site-specific contaminant chemistry while a second approach utilizes site-specific ecological sampling to assess impacts at the population or community level. The goal of this study was to utilize an integrated approach including chemical contaminant analysis, sediment quality guidelines and grass shrimp population monitoring to evaluate the impact of contaminants from industrial sources. Three impacted sites and one reference site were selected for study. Grass shrimp populations were sampled using a push-netting approach. Sediment samples were collected at each site and analyzed for metals, polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs) and pesticides. Contaminant levels were then compared to sediment quality guidelines. In general, grass shrimp population densities at the sites decreased as the ERM quotients increased. Grass shrimp densities were significantly reduced at the impacted site that had an ERM exceedance for chromium and the highest Mean ERM quotient. Regression analysis indicated that sediment chromium concentrations were negatively correlated with grass shrimp density. Grass shrimp size was reduced at two sites with intermediate levels of contamination. These findings support the use of both sediment quality guidelines and site-specific population monitoring to evaluate the impacts of sediment-associated contaminants in estuarine systems.

An evaluation of polycyclic aromatic hydrocarbon (PAH) runoff from highways into estuarine wetlands of South Carolina.

This study investigated the concentrations and potential toxicity of polycyclic aromatic hydrocarbons (PAHs) associated with highway runoff into adjacent estuarine wetlands from road segments representing three levels of average daily traffic (ADT): low (<5,000 ADT), moderate (10,000-15,000 ADT), and high use (>25,000 ADT) based on SC Department of Transportation data. Sediments from three estuarine wetland habitats (tidal creeks, Spartina marsh, and mud flats) adjacent to these road segments were sampled to represent nine highway use class/habitat type combinations. Surficial sediments were collected at 3, 25, and 50 meters from the upland/wetland interface along transects established perpendicular to the road at each site, with additional samples taken from the road berm. Average PAH concentrations, representing 25 compounds, ranged from 3.9 to 11,000 ng/g dry weight. Berm samples had significantly greater total PAH concentrations than samples taken in any of the wetland habitats. Average total PAH concentrations decreased with increasing distance from the road berm within the wetland habitats sampled, but the differences were not statistically significant. Average total PAH concentrations also were not significantly different among the wetland habitats compared. Analysis of PAH profiles indicated that the PAH source was dominated by pyrogenic combustion products rather than from petrogenic sources. This, combined with the presence of dibenzothio-phene, which is a tire oxidation product, indicated that the primary source of PAHs was related to vehicles. Two sites with total PAH concentrations exceeding published bioeffects levels were resampled for bioassay tests using the amphipod Ampelisca verrilli, the polychaete Streblospio benedicti, and the clam, Mercenaria mercenaria, with the first two assays conducted under UV lighting since previous studies had demonstrated enhanced UV toxicity of PAHs for these species. No toxicity was observed in the amphipod or polychaete assays. Toxicity was observed in the juvenile clam assay at one site, possibly due to the combined effects of PAHs and other contaminants present.

The effects of the contemporary-use insecticide (fipronil) in an estuarine mesocosm.

To examine the effects of environmentally realistic fipronil concentrations on estuarine ecosystems, replicated mesocosms containing intact marsh plots and seawater were exposed to three treatments of fipronil (150, 355, and 5000 ng/L) and a Control. Juvenile fish (Cyprinidon variegatus), juvenile clams (Mercenaria mercenaria), oysters (Crassostrea virginica), and grass shrimp (Palaemonetes pugio) were added prior to fipronil in an effort to quantify survival, growth, and the persistence of toxicity during the planned 28-day exposure. Results indicated that there were no fipronil-associated effects on the clams, oysters, or fish. Shrimp were sensitive to the highest two concentrations (40% survival at 355 ng/L and 0% survival at 5000 ng/L). Additionally, the highest fipronil treatment (5000 ng/L) was toxic to shrimp for 6 weeks post dose. These results suggest that fipronil may impact shrimp populations at low concentrations and further use in coastal areas should be carefully assessed.

Toxicological studies in tropical ecosystems: an ecotoxicological risk assessment of pesticide runoff in South Florida estuarine ecosystems.

A multiyear study in the C-111 canal system and associated sites in Florida Bay was undertaken to determine the potential pesticide risk that exists in South Florida. After the examination of extensive pesticide concentration data in surface water, tissues, and semipermeable membrane devices (SPMDs), canal contamination seems to be derived from the extensive agricultural production that drains into the C-111 canal. The results of this study indicate that runoff from agricultural processes led to quantifiable pesticide residues in both canal and bay surface water, which occasionally exceeded current water quality criteria. The major pesticide of concern was endosulfan, which was detected at 100% of the sites sampled. Endosulfan exposure did not cause any acute effects in fish and crustaceans deployed in field bioassays. Chronic effects were observed in copepods, clams, and oysters but could not be attributed to endosulfan exposure. The decision to alter the C-111 canal flow and allow increased freshwater flow into the adjacent Everglades National Park may result in discharges of pesticides into the Everglades. Continued monitoring in this area is needed during this change in flow regime.

Mechanism of action of and resistance to quinolones.

A topoisomerase was identified as the bacterial target site for quinolone action in the late 1970s. Since that time, further study identified two bacterial topoisomerases, DNA gyrase and topoisomerase IV, as sites of antibacterial activity DNA gyrase appears to be the primary quinolone target for gram-negative bacteria. Topoisomerase IV appears to be the preferential target in gram-positive organisms, but this varies with the drug. Three mechanisms of resistance against quinolones are mutations of topoisomerases, decreased membrane permeability, and active drug efflux. Although these mechanisms occur singly, several resistance factors are often required to produce clinically applicable increases in minimum inhibitory concentrations. Appropriate drug selection and dosage and prudent human and veterinary interventions are important factors in controlling the emergence of resistance.

Telithromycin: an oral ketolide for respiratory infections.

The ketolides represent a new subclass of antibiotics among the macrolide-lincosamide-streptogramin group. Telithromycin, the first ketolide to be awarded approvable status for clinical use, demonstrates in vitro activity against community-acquired respiratory pathogens including penicillin- and erythromycin-resistant Streptococcus pneumoniae. An extended half-life permits once-daily oral administration. Telithromycin is a substrate for cytochrome P450 (CYP) 3A4 and also inhibits drugs metabolized by CYP3A4. A relatively high frequency of mild-to-moderate gastrointestinal adverse effects has been reported. Similar clinical and microbiologic efficacy has been demonstrated with oral dosing in comparative clinical trials for community-acquired pneumonia, acute sinusitis, acute exacerbations of chronic bronchitis, and pharyngitis. Although limited data on penicillin-resistant S. pneumoniae and erythromycin-resistant Streptococcus pyogenes are available from clinical trials, this drug appears promising for respiratory infections caused by these pathogens.

The effect of amiloride on amphotericin B-induced hypokalaemia.

Amiloride was administered to 19 oncology patients exhibiting marked amphotericin B-induced electrolyte wasting. Mean serum potassium concentrations increased in the 5 days preceding and following administration (3.4 +/- 0.5 versus 3.9 +/- 0.8 mmol/L, P = 0.002). A trend towards decreased potassium supplementation was also observed (48.0 +/- 66.5 versus 29.4 +/- 43.2 mmol/day, P = 0.12). Amiloride is a therapeutic option to decrease potassium wasting in patients being treated with amphotericin B.

Quinupristin-dalfopristin: an overview.

Synercid (RP 59500), the first injectable streptogramin antibiotic, is composed of two semisynthetic pristinamycin derivatives, quinupristin and dalfopristin. Individually, each component has bacteriostatic activity against staphylococci and streptococci, but together, the agents exhibit synergy, leading to bactericidal activity. The combination drug, however, is bacteriostatic against Enterococcus faecium and has poor activity against Enterococcus faecalis. Despite a short half-life, an extended postantibiotic effect allows the agent to be dosed every 8-12 hours. Both drugs are largely hepatically metabolized and excreted in bile. Although not metabolized by cytochrome P450 3A4, quinupristin-dalfopristin can inhibit agents that are metabolized through this pathway. Dosage adjustments may be necessary in patients with hepatic dysfunction. Alterations in renal function have minimal effects on the agent's pharmacokinetics. Adverse events include arthralgia, myalgias, and infusion-related pain. Based on available data, quinupristin-dalfopristin appears to have a role in treating severely ill patients with infections due to multiresistant gram-positive pathogens.

The NDP-sugar co-substrate concentration and the enzyme expression level influence the substrate specificity of glycosyltransferases: cloning and characterization of deoxysugar biosynthetic genes of the urdamycin biosynthetic gene cluster.

BACKGROUND: Streptomyces fradiae is the principal producer of urdamycin A. The antibiotic consists of a polyketide-derived aglycone, which is glycosylated with four sugar components, 2x D-olivose (first and last sugar of a C-glycosidically bound trisaccharide chain at the 9-position), and 2x L-rhodinose (in the middle of the trisaccharide chain and at the 12b-position). Limited information is available about both the biosynthesis of D-olivose and L-rhodinose and the influence of the concentration of both sugars on urdamycin biosynthesis. RESULTS: To further investigate urdamycin biosynthesis, a 5.4 kb section of the urdamycin biosynthetic gene cluster was sequenced. Five new open reading frames (ORFs) (urdZ3, urdQ, urdR, urdS, urdT) could be identified each one showing significant homology to deoxysugar biosynthetic genes. We inactivated four of these newly allocated ORFs (urdZ3, urdQ, urdR, urdS) as well as urdZ1, a previously found putative deoxysugar biosynthetic gene. Inactivation of urdZ3, urdQ and urdZ1 prevented the mutant strains from producing L-rhodinose resulting in the accumulation of mainly urdamycinone B. Inactivation of urdR led to the formation of the novel urdamycin M, which carries a C-glycosidically attached D-rhodinose at the 9-position. The novel urdamycins N and O were detected after overexpression of urdGT1c in two different chromosomal urdGT1c deletion mutants. The mutants lacking urdS and urdQ accumulated various known diketopiperazines. CONCLUSIONS: Analysis of deoxysugar biosynthetic genes of the urdamycin biosynthetic gene cluster revealed a widely common biosynthetic pathway leading to D-olivose and L-rhodinose. Several enzymes responsible for specific steps of this pathway could be assigned. The pathway had to be modified compared to earlier suggestions. Two glycosyltransferases normally involved in the C-glycosyltransfer of D-olivose at the 9-position (UrdGT2) and in conversion of 100-2 to urdamycin G (UrdGT1c) show relaxed substrate specificity for their activated deoxysugar co-substrate and their alcohol substrate, respectively. They can transfer activated D-rhodinose (instead of D-olivose) to the 9-position, and attach L-rhodinose to the 4A-position normally occupied by a D-olivose unit, respectively.

Dosage adjustments for antibacterials in obese patients: applying clinical pharmacokinetics.

Obesity is associated with physiological changes that can alter the pharmacokinetic parameters of many drugs. Vancomycin and the aminoglycosides are the only antibacterials that have been extensively investigated in the obese population. The apparent volume of distribution (Vd) and total body clearance of vancomycin are increased in obese patients and have a better correlation with total bodyweight (TBW) than with ideal bodyweight (IBW). The Vd of aminoglycosides is increased in obesity and can be estimated from an adjusted bodyweight that accounts for a fraction of the excess bodyweight (TBW - IBW). These observed changes in pharmacokinetic parameters of vancomycin and aminoglycosides in obese patients may necessitate a deviation from the commonly recommended dosages administered to non-obese individuals. There are limited data regarding the pharmacokinetics of other antibacterial classes in obese patients. The available information for cephalosporins suggests that dosages may need to be increased in obese patients in order to obtain similar serum and tissue concentrations as in non-obese patients. Additional pharmacokinetic studies of other antibacterial classes are required in this special patient population.

Detection of human asialo-alpha(1)-acid glycoprotein using a heterosandwich immunoassay in conjunction with the light addressable potentiometric sensor.

Highly specific detection of human alpha 1-acid glycoprotein (AGP) and asialo-alpha 1-acid glycoprotein (asialo-AGP) was made possible by use of a sandwich immunoassay. The glycoproteins were sandwiched between biotinylated and fluoresceinated polyclonal rabbit anti-human AGP antibodies. Additionally, asialo-AGP could be distinctly detected, apart from AGP, via the formation of a heterosandwich immunoassay using biotinylated polyclonal rabbit anti-human AGP and the lectin, fluoresceinated ricin toxin. Streptavidin was added to the formed immunocomplexes and the immunocomplexes captured on a biotinylated nitrocellulose membrane. The signal generator, urease conjugate of an anti-fluorescein antibody, was then bound to the complex on the membrane. The rate of pH change under microvolume conditions (0.6 microliters) was monitored using a silicon chip-based, light addressable potentiometer sensor. Results indicated that AGP and asialo-AGP can be detected to the 2 pg level when two antibodies are used to form the immunocomplex. Asialo-AGP can be detected down to 250 pg when the heterosandwich immunoassay is used; this assay exhibited no response up to 10 ng for native AGP or asialofetuin. Both immunoassays can be used to quantify the level of AGP and asialo-AGP in solution. Although the assay presented is very specific for AGP, asialo-AGP and terminal galactose, it is readily adaptable for the detection of any glycoprotein and terminal carbohydrate (or branched structure) by use of a protein-specific antibody and various lectins.

Age, race, and gender variation in the utilization of coronary artery bypass surgery and angioplasty in SHEP. SHEP Cooperative Research Group. Systolic Hypertension in the Elderly Program.

OBJECTIVE: To assess variability in the use of coronary artery bypass grafting (CABG) and percutaneous transluminal angioplasty (PTCA) in the Systolic Hypertension in the Elderly Program (SHEP) cohort with incident coronary heart disease (CHD) by age, sex, and race. DESIGN: Retrospective analysis of a multicenter prospective cohort study. SETTING: Community-based ambulatory population in academic centers. PATIENTS: Among 4736 subjects initially enrolled in SHEP, there were 432 incident cases of CHD, excluding those patients who experienced rapid or sudden cardiac death. MAIN OUTCOME MEASURE: Incident cases of CHD who underwent CABG or PTCA. RESULTS: Of those participants > or = 60 and < 75 years of age, 7.3% underwent PTCA, compared with 3.9% of those > or = 75 years (P = 0.14). 15.4% of those < 75 underwent CABG surgery, compared with 7.8% of those 75 and older (P = 0.018). When both of these endpoints, CABG and PTCA, were combined, 22.4% of those < 75 underwent a procedure, while only 11.7% of the older cohort did (P = 0.005). Twenty-six percent of men underwent either CABG or PTCA, while only 9.1% of women did (P < 0.001). Of those < 75 years of age, 31.1% of men and 12.3% of women underwent CABG or PTCA (P < 0.001). In the 75 and older age category, 19.5% of men underwent these interventions, compared with 5.9% of women (P = 0.005). Active treatment group was significantly associated with decreased use of procedures in participants < 75 year old with CHD. Race, activity limitations, number of comorbid conditions, education level, marital status, employment status, and social support were not significantly associated with CABG or PTCA use. When the variables studied were entered into a logistic regression model, increased age and female sex remained independently associated with decreased CABG and PTCA use. CONCLUSION: In the SHEP trial older patients and women, regardless of comorbid conditions, socioeconomic status, and social support, underwent less intensive cardiovascular interventions than did younger patients and men when they developed CHD.

Age-related variability in the use of cardiovascular imaging procedures.

OBJECTIVE: To determine if older patients undergo fewer cardiovascular imaging procedures (CIPs) than younger patients when admitted to a tertiary care academic medical center for an acute myocardial infarction (MI), after adjusting for disease severity and comorbidities. DESIGN: Non-current prospective cohort study. SETTING: Urban tertiary care academic medical center. PATIENTS: Medical records of 294 patients admitted and diagnosed with an acute MI between January 1990 and April 1991 were reviewed. MEASUREMENTS: The total number of different CIPs performed during hospitalization was determined. Cardiac catheterizations, echocardiograms, radionuclide ventriculograms, and thallium scans counted as CIPs. Disease severity was assessed by the Acute Physiology Score (APS) of APACHE II, admission Killip's Classification, and peak creatine phosphokinase (CPK) levels. Comorbidities were assessed using a modified Comorbidity Damage Index of Charlson. RESULTS: The mean (+/- SD) number of different CIPs performed during hospitalization was significantly less for those > or = 75 years old (1.3 +/- 1.0) than for those < 75 years old (1.7 +/- 1.0) (P = 0.01), and CIP number negatively correlated with age (Spearman r = -0.178; P = 0.01). Mean CIP number decreased from 2.0 +/- 1.1 for those < 45 years old to 0.9 +/- 0.6 for those > or = 85 years old (P = 0.02). Other factors positively associated (P < 0.10) with CIP number were: CPK values in the highest quartile of the study population (> 355 U/L); admission to a cardiology, medical, or family practice service; no CIP performed at an outside hospital prior to transfer; admission Killip's Classification of less than IV, and a Q-wave MI. After adjusting for these variables in a multiple regression model, age > or = 75 remained an independent predictor of decreased CIP use (P = 0.003). The modified comorbidity index score and the APS score, a general measure of severity of illness, were not significantly associated with CIP use. When procedures were examined individually, no significant age-related differences were noted in the use of thallium scans, radionuclide ventriculograms, or echocardiograms. Older patients did, however, remain less likely to undergo cardiac catheterizations (P < 0.001). CONCLUSION: Older patients, regardless of underlying disease severity or comorbidities, undergo fewer invasive cardiovascular evaluations than younger patients when admitted to a tertiary care academic medical center for an acute MI.