Neutrophil alterations in pregnancy-associated malaria and induction of neutrophil chemotaxis by Plasmodium falciparum.

Pregnancy-associated malaria (PAM) is a severe form of the disease caused by sequestration of Plasmodium falciparum-infected red blood cells (iRBCs) in the developing placenta. Pathogenesis of PAM is partially based on immunopathology, with frequent monocyte infiltration into the placenta. Neutrophils are abundant blood cells that are essential for immune defence but may also cause inflammatory pathology. Their role in PAM remains unclear. We analysed neutrophil alterations in the context of PAM to better understand their contribution to disease development. Pregnant women exposed to Plasmodium falciparum had decreased numbers of circulating neutrophils. Placental-like BeWo cells stimulated with malaria parasites produced the neutrophil chemoattractant IL-8 and recruited neutrophils in a trans-well assay. Finally, immunostaining of a PAM placenta confirmed neutrophil accumulation in the intervillous space. Our data indicate neutrophils may play a role in placental malaria and should be more closely examined as an etiological agent in the pathophysiology of disease.

Low-grade infection complicating silastic dural substitute 32 years post-operatively.

BACKGROUND: A complication of a silastic dural substitute is described, which appeared after 32 years-by far the longest latency period reported in the literature. METHODS: Case report and literature review. RESULTS: In 1971, a 20-year old woman suffered from an acute subdural haematoma and a temporal cerebral contusion due to a motorbike accident. She underwent an operation with evacuation of these and the dura was mended with a silastic duraplasty. Thirty-two years later she deteriorated with increased memory problems and dysphasia. CT revealed an expanding haemorrhagic mass around the previous duraplasty, which demanded surgery with removal of the silastic dural implant and evacuation of the haemorrhagic mass. Although the haemorrhagic mass enveloped the silastic implant, a contribution of the acrylate flap cannot be ruled out. Bacteriological cultures revealed Acinetobacter spp. in the CSF. Adequate post-operative antibiotic treatment was administered. The patient slowly improved, but the complication represented a major setback in her long-term cognitive and communicative functions. CONCLUSIONS: This case widens the previously reported time-frame of late complications by 60%, from 20 to 32 years, and will hopefully serve to increase the awareness of late infections and haemorrhages induced by silastic dural implants, thereby improving diagnosis and treatment in future cases.

CaMKII uses GTP as a phosphate donor for both substrate and autophosphorylation.

The vast majority of serine/threonine protein kinases have a strong preference for ATP over GTP as a phosphate donor. CK2 (Casein kinase 2) is an exception to this rule and in this study we investigate whether calcium/calmodulin-dependent protein kinase II (CaMKII) has the same extended nucleotide range. Using the Drosophila enzyme, we have shown that CaMKII uses Mg(2+)GTP with a higher K(m) and V(max) compared to Mg(2+)ATP. Substitution of Mn(2+) for Mg(2+) resulted in a much lower K(m) for GTP, while nearly abolishing the ability of CaMKII to use ATP. These similar results were obtained with rat alphaCaMKII, showing the ability to use GTP to be a general property of CaMKII. The V(max) difference between Mg(2+)ATP and Mg(2+)GTP was found to be due to the fact that ADP is a potent inhibitor of phosphorylation, while GDP has modest effects. There were no differences found between sites autophosphorylated by ATP and GTP, either by partial proteolysis or mass spectrometry. Phosphorylation of fly head extract revealed that similar proteins are substrates for CaMKII whether using Mg(2+)ATP or Mg(2+)GTP. This new information confirms that CaMKII can use both ATP and GTP, and opens new avenues for the study of regulation of this kinase.

Alternative splicing of the eag potassium channel gene in Drosophila generates a novel signal transduction scaffolding protein.

The Drosophila eag gene has been shown to regulate neuronal excitability, olfaction, associative learning and larval locomotion. Not all of the roles of this gene in these processes can be explained by its function as a voltage-gated potassium channel. In this study, we show that the eag gene is spliced in a PKA- and PKC-regulated manner to produce a protein lacking channel domains. This protein, in the context of activated PKA, can engage cellular signaling pathways that alter cell structure. Nuclear localization is necessary for C-terminal-mediated effects, which also require MAPK. The requirement for PKA/PKC activation in the synthesis and function of this novel protein suggests that it may couple membrane events to nuclear signaling to regulate neuronal function on long time scales.

Leptomeningeal cyst due to vacuum extraction delivery in a twin infant.

A rare case of a leptomeningeal cyst is reported in a twin male neonate delivered using a vacuum extractor, who presented a huge, non-pulsating, oedematous mass overlying the frontal fontanelle after birth. The mass was initially diagnosed as a cephalo haematoma. Ultrasonography indicated intracranial bleeding and a subsequent CT scan revealed an intraparenchymal bleeding above the left frontal horn, combined with a thin, left-sided, subdural haematoma and subarachnoid haemorrhage in the left Sylvian fissure. Apart from a bulging soft and round formation (2 x 2 x 3 cm) next to the anterior fontanel growing since birth, the neurological development of the infant was normal. MRI examination at the age of 7 months revealed that it consisted of a cystic mass (leptomeningeal cyst) connected to the left frontal horn, stretching right through the brain and also penetrating the dura mater. No signs of the perinatal haematomas were observed at this time. Surgical treatment, with fenestration of the cyst into the frontal horn and a watertight duraplasty with a periosteal flap and thrombin glue covered by small bone chips, was performed at 9 months of age. Due to a residual skull bone defect a second cranioplasty with autologous skull bone was performed three and half years later. During a follow-up period of 12 years the neurological and psychological development of the boy has been indistinguishable to that of his twin brother, indicating the satisfactory outcome of the treatment.

A new scaled microgauge for use in neurosurgery.

A new scaled microgauge is described for measuring anatomical structures during microsurgery. The instrument has a tip marked in millimetres, which can be positioned in any desired angle enabling measurement in confined areas.

Behçet's disease, associated with subarachnoidal heamorrhage due to intracranial aneurysm.

Behçet's disease is an unusual medical condition in central Europe and North America, however more common in Turkey and Japan. It was originally described in Turkey, characterized by recurrent oral ulcers, genital ulcers and also uveitis. A variety of vascular lesions such as venous occlusions, arterial aneurysms and varices account for the high rate of morbidity and mortality with this disease. Arterial aneurysms most commonly occur in the abdominal aorta, femoral arteries and in the pulmonary arteries. To our knowledge there have been seventeen documented reports of patient's with Behçet's disease combined with aneurysms of cerebral arteries. We describe a patient with Behçet's disease and subarachnoid haemorrhage due to a ruptured cerebral aneurysm.

Improved brain protection at decompressive craniectomy--a new method using Palacos R-40 (methylmethacrylate).

A new method is described for protecting the brain after decompressive craniectomy in which a temporary methylmethacrylate flap is formed, somewhat larger than the original bone flap, thus gaining "extra" volume for the oedematous brain in which to expand. The present procedure was developed as a part of ordinary clinical practice particularly in response to demands from the NICU staff and our colleagues at other clinics who were responsible for the care of the patient in the post NICU period. They made us keenly aware that these patients frequently lack optimal co-ordination and balance and therefore run an increased risk of trauma to the unprotected brain when falling. This prompted us to develop a method for brain protection after decompressive craniectomy aiding in the care and rehabilitation until the final installation of the patient's own bone flap can be performed.

Postoperative pseudoaneurysm of the superficial temporal artery (S.T.A.) treated with Thrombostat (thrombin glue) injection.

BACKGROUND: Pseudo-aneurysm is a rare complication of craniotomy. Blunt injury to the temporal artery region is the usual cause, but still a rare complication. CLINICAL PRESENTATION: A patient with subarachnoid hemorrhage was successfully treated by aneurysm clipping. The patient developed hydrocephalus, and was admitted for a shunt operation seventeen days later. The craniotomy had healed normally, but a palpable temporal lump was present in the skin incision. INTERVENTION: The pulsating mass proved to be a postoperative aneurysm of the superficial temporal artery (S.T.A.) and was successfully occluded with 500 units Thrombostat (thrombin glue) which was injected into the aneurysm sac using a 22-gauge needle guided by ultrasound. The permanency of the obliteration was verified by ultrasound examination.

Exploring sex differences in case fatality in acute myocardial infarction or coronary death events in the northern Sweden MONICA Project.

OBJECTIVES: To investigate sex differences in reaching diagnosis, medical management and case fatality (CF) in acute myocardial infarction (AMI) in the population aged 35-64 years in northern Sweden. METHODS: Within the framework of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) Project, definite AMI was monitored in people aged 35-64 years from 1989 through 1995 (target population 510 000 in 1991). SETTING: In a population based coronary register, all coronary events were recorded in nine hospitals in 1989-95. RESULTS: The number of events included in the definite coronary myocardial infarction register was 2483 men and 669 women. On admission, a higher proportion of men with definite AMI had chest pain or ECG changes typical for AMI (P < 0.0001). Disagreement between clinical diagnosis and classification by MONICA criteria occurred more often in women (P=0.008). A significantly higher proportion of men was admitted in the coronary care unit and they were significantly more often treated with thrombolytics, nitroglycerine, beta-blockers, or antiplatelet agents. Women received significantly more diuretics, inotropics or calcium antagonists. Diabetes, conferring a worse prognosis, was more common in women (20 vs. 15%; P=0.003). Prehospital CF was significantly higher in men (24.1 vs. 18.3%; P=0.005), but in patients treated in hospital, the CF was significantly lower in men (12.7 vs. 21.2%; P < 0.001). Total CF was equal in men and women. CONCLUSIONS: Several factors contributing to the excess in-hospital CF in women were identified, including greater problems in diagnosis of AMI in women which may be one of the reasons for less intensive treatment in women. Differences in co-morbidity, most notably diabetes and medical treatment between men and women with acute AMI may also have played a part.

Mobile computerized tomography scanning in the neurosurgery intensive care unit: increase in patient safety and reduction of staff workload.

OBJECT: Transportation of unstable neurosurgical patients involves risks that may lead to further deterioration and secondary brain injury from perturbations in physiological parameters. Mobile computerized tomography (CT) head scanning in the neurosurgery intensive care (NICU) is a new technique that minimizes the need to transport unstable patients. The authors have been using this device since June 1997 and have developed their own method of scanning such patients. METHODS: The scanning procedure and radiation safety measures are described. The complications that occurred in 89 patients during transportation and conventional head CT scanning at the Department of Radiology were studied prospectively. These complications were compared with the ones that occurred during mobile CT scanning in 50 patients in the NICU. The duration of the procedures was recorded, and an estimation of the staff workload was made. Two patient groups, defined as high- and medium-risk cases, were studied. Medical and/or technical complications occurred during conventional CT scanning in 25% and 20% of the patients in the high- and medium-risk groups, respectively. During mobile CT scanning complications occurred in 4.3% of the high-risk group and 0% of the medium-risk group. Mobile CT scanning also took significantly less time, and the estimated personnel cost was reduced. CONCLUSIONS: Mobile CT scanning in the NICU is safe. It minimizes the risk of physiological deterioration and technical mishaps linked to intrahospital transport, which may aggravate secondary brain injury. The time that patients have to remain outside the controlled environment of the NICU is minimized, and the staff's workload is decreased.

Mite fauna in the home and sensitivity to house-dust and storage mites.

In search of potential new indoor allergen sources, all mites in dust from homes of 55 asthmatic children living in three climatic regions in Sweden were counted and identified by light microscope. Antibodies of the IgE class against three house-dust mites and three storage mites were measured in corresponding serum samples. Mites were found in all but two homes from the northernmost area, where levels also were lower than in the other regions. The highest mite densities were most often found in bedrooms (50%) and living rooms (40%). Mite density was increased in homes with high humidity and was higher in bungalows than in flats. House-dust mites predominated in the south and storage mites in the east central area, particularly in kitchens and bathrooms. Mite-density and IgE-antibody levels against house-dust mites were significantly associated. The same association applied to storage mites. Other species numbered around 100 mites/g dust in some homes. Microscopy helps to identify potentially important mites. Analysing home dust only for house-dust mites will underestimate mite exposure. Storage mites may be as relevant to sensitivity as house-dust mites. As other species occasionally were found in high numbers, their relevance should also be assessed.

A new bone dust packer for use in neurosurgery.

A new tool for the packing of bone dust has been developed. The instrument compresses a mixture of bone dust and saline into suitable cylindrical plugs, fitting neatly into craniotomy burrholes. The skullbone at the craniotomy area will heal neatly also assuring the best healing possibilities for the overlying skin. The cosmetic results are excellent as no skin dents or cavities will be formed over the burrholes.

Late complications of Silastic duraplasty: low-virulence infections. Case report.

The authors describe three patients with expanding hemorrhagic mass lesions who presented 13 to 18 years after undergoing Silastic duraplasty. In all patients, results of bacteriological cultures of the masses obtained intraoperatively were positive, revealing low-virulence bacteria. Two of the patients were treated with antibiotic drugs and made a good recovery. The third did not receive antibiotic medications initially and later developed an epidural empyema that necessitated reoperation, but subsequently made a complete recovery. Vascularized neomembranes are generally agreed to be causes of the expanding masses, but the possibility that patients could be harboring chronic infections must be considered. Thus, on removal of duraplasty materials a complete bacteriological culture should be obtained, and if it is positive the proper antibiotic therapy should be administered. Furthermore, the creation of a registry of patients who have received implants is advocated to facilitate tracking of implanted material in case of complications.

Reversibility of severe sagittal sinus thrombosis with open surgical thrombectomy combined with local infusion of tissue plasminogen activator: technical case report.

OBJECTIVE: To explore the controversial issue of anticoagulant therapy and indications for surgery in association with severe sinus thrombosis. METHODS: During the last 4 years, we have treated three patients with severe sinus thrombosis of the dural sinuses. All three patients received systemic anticoagulant therapy and, after experiencing neurological deterioration, underwent open thrombectomy and local thrombolysis. After the operation, aggressive intensive care was given and included cerebral perfusion monitoring, barbiturate administration, hyperventilation, and osmotherapy. The treatment was guided by repeated neuroradiological investigations. RESULTS: All three patients returned to their normal lives. CONCLUSION: Intracranial sinus thrombosis, even in the worst neurological state, should be treated aggressively. A cornerstone in treatment is systemic anticoagulant therapy and repeated neuroradiological studies. When, despite adequate anticoagulant therapy and intensive care, neurological deterioration occurs, a combination of open thrombectomy and local thrombolytic therapy should be considered.

Environmental assessment of Dermatophagoides mite-allergen levels in Sweden should include Der m 1.

The major allergen of Dermatophagoides microceras, Der m 1, as well as the allergens of D. pteronyssinus and D. farinae, Der p 1 and Der f 1, were analyzed in the homes of 111 asthmatic children in three climatic regions in Sweden. The numbers and species of mites were determined by microscopy, and circulating IgE antibodies against mites were measured. Der f 1 was the predominant house-dust-mite (HDM) allergen, Der p 1 the least often found, and Der m 1 represented 31% of the allergen load. However, in the Linköping area, Der m 1 was the major HDM allergen (58%). Mite counts and allergen levels correlated well. Current exposure to HDM allergens at home was associated with the serum IgE antibody response to HDM in the children with no threshold level. Of the children with IgE antibodies against HDM, 67% reacted to all three mites. Mite sensitization rates were marginally increased (7%) by the addition of IgE analysis of D. microceras to the routine analysis of IgE antibodies against D. pteronyssinus and D. farinae. Thus, Der m 1 may be an important HDM allergen and should be considered when HDM exposure data are assessed in areas with a climate like that of Sweden.

The dual-tube microsurgical suction instrument.

A dual-tube suction instrument intended for both macro- and microsurgery has been developed. A detachable air-tight inner tube is fitted into a conventional suction instrument; extending the ordinary sucking tube. The inner tube can easily be fitted, as well as removed from the other tube; a particular advantage in case the inner tube becomes obstructed. On removal of the inner tube the outer tube becomes cleaned and is at once, ready for re-use. Since the suction instrument does not have to be removed from the suction hose, valuable time is saved, enabling permanent sucking capacity.

Determination of the kinetic constants of tissue factor/factor VII/factor VIIA and antithrombin/heparin using surface plasmon resonance.

Association of factor VIIa (FVIIa) with tissue factor (TF) is generally believed to be a critical step in the initiation of blood coagulation. In this study the rate constants for the complex formation and dissociation between FVII/FVIIa and TF were studied in real time using surface plasmon resonance, the BIAcore technique. Employing this technique ka and kd were determined and yielded a KD of 1 nM for FVII and 0.5 nM for FVII, respectively. The association and dissociation between antithrombin (AT) and the FVIIa/TF complex was also studied. In the presence of heparin, AT was bound to the FVIIa/TF complex in a dose-dependent manner with ka of 2 x 10(3) M-1 s-1. The binding of AT to FVIIa/TF increased the dissociation of FVIIa from TF about 20-fold.