Priorities, opportunities, and challenges for integrating microorganisms into Earth system models for climate change prediction.

Climate change jeopardizes human health, global biodiversity, and sustainability of the biosphere. To make reliable predictions about climate change, scientists use Earth system models (ESMs) that integrate physical, chemical, and biological processes occurring on land, the oceans, and the atmosphere. Although critical for catalyzing coupled biogeochemical processes, microorganisms have traditionally been left out of ESMs. Here, we generate a "top 10" list of priorities, opportunities, and challenges for the explicit integration of microorganisms into ESMs. We discuss the need for coarse-graining microbial information into functionally relevant categories, as well as the capacity for microorganisms to rapidly evolve in response to climate-change drivers. Microbiologists are uniquely positioned to collect novel and valuable information necessary for next-generation ESMs, but this requires data harmonization and transdisciplinary collaboration to effectively guide adaptation strategies and mitigation policy.

Endoscopic resection of colloid cysts: indications, technique, and results during a 13-year period.

OBJECTIVE: Questions of recurrence and inadequacy of follow-up length persist regarding endoscopic treatment of colloid cysts. In this retrospective review, we report our long-term follow-up during a 13-year period in 35 patients who underwent endoscopic resection of colloid cysts. METHODS: The 19 males and 16 females (age range 14 to 58 years, mean 35.9 years) who had symptomatic colloid cysts that ranged in size from 5 mm to 4 cm underwent endoscopic resection in the period from 1991 to 2004. RESULTS: Of 2 patients who developed recurrences at 5.9 years and 4.3 years (1 and 6 mm, respectively) both remain asymptomatic. The rate of late asymptomatic recurrence in this series is 6.3%. Three endoscopic resections were converted to an open craniotomy. Three operative complications occurred (i.e., introducer tract hemorrhage, thalamic stroke secondary to thermal injury, epidural hematoma that required evacuation). Four patients noted minimal short-term memory loss without interference in daily living. Of 3 patients with shunts preoperatively, all have no evidence of hydrocephalus after shunt removal. Two patients have asymptomatic ventriculomegaly. Prophylactic anticonvulsants were not prescribed and no seizures were reported. No infections were recorded with antibiotic administration preoperatively, and 24 hours postoperatively. CONCLUSIONS: Our series represents the longest follow-up (mean of 7.8 years) of colloid cysts after endoscopic resection. We now use this technique as the first line of treatment for colloid cysts. The risk of recurrence is minimal with gross total resection and/or coagulation of the cyst wall.

Gradual formation of an operative corridor by balloon dilation for resection of subependymal giant cell astrocytomas in children with tuberous sclerosis: specialized minimal access technique of balloon dilation.

BACKGROUND: Major sources of morbidity and mortality in patients with tuberous sclerosis who develop subependymal giant cell astrocytomas (SEGAs) relate to tumor growth and resultant hydrocephalus. We describe a modification of a specialized minimal access resection technique in which an operative corridor is formed with balloon dilation over the course of a week prior to tumor resection. METHODS: Three patients with tuberous sclerosis who had an enlarging SEGA and concomitant hydrocephalus underwent surgical resection with this modified technique. A frontal craniotomy was performed and the optimal trajectory for tumor resection was confirmed by image guidance. After initial insertion of the deflated balloon into the ventricle and removal of the peel-away sheath, inflation of the balloon with a 1-mL saline injection sealed the tract. Additional 1-mL saline injections were continued during the next week until the balloon reached a 15-mm diameter, thus creating the operative corridor. One week after the first operation, the balloon was deflated and removed, and the patient underwent tumor resection via the newly formed operative corridor. RESULTS: Three patients with tuberous sclerosis underwent gross total resections of SEGAs and experienced subsequent resolution of ventricular dilation. Postoperative imaging confirmed minimal cortical disruption. CONCLUSIONS: Use of balloon dilation for the gradual formation of an operative corridor eliminated the need for additional retraction during SEGA resection, potentially decreasing injury to the surrounding neural tissue. In our three patients, the dilation tract retained its integrity during the operation and had sealed completely on postoperative imaging.

The timing of physiologic closure of the metopic suture: a review of 159 patients using reconstructed 3D CT scans of the craniofacial region.

PURPOSE: The purpose of this study was to determine the normal physiologic timing of the closure of the metopic suture in non-craniosynostotic patients. METHODS: This clinical study involved a consecutive series of infants and young children who underwent 3D CT-scan evaluation for deformational plagiocephaly or suspected traumatic head injury. All patients with evidence of craniosynostosis were excluded from the study. Every infant and child referred to our Craniofacial Team for deformational plagiocephaly between 1997 and 2000 (n = 84) received a baseline pre-treatment 3D CT-scan of the head. Our study also included a series of selected pediatric trauma patients (1 to 24 months of age) between 1997 and 2000 (n = 75) who received CT-scan to rule out head injury. The CT scan results were reviewed for closure of metopic suture by a single observer. RESULTS: The earliest evidence of metopic suture closure was at 3 months, the age at which 33% of patients (4/12) were closed. At 5 months of age, 59% (13/22) of sutures were closed. At 7 months of age, 65% (15/23) were closed. At 9 months of age, 100% (10/10) were closed. All patients greater than 9 months of age within the study had complete metopic suture closure. CONCLUSION: Our findings suggest that normal or physiologic closure of the metopic suture occurs much earlier than what has been previously described. This study establishes that metopic fusion may normally occur as early as 3 months of age, and that complete fusion occurred by 9 months of age in all patients in our series. Therefore, 3-D CT scans showing complete closure of the metopic suture at an early age (3 to 9 months) cannot be considered as evidence of metopic synostosis, and thus, should not be the decisive factor for early surgical intervention.

Neurodevelopment in children with single-suture craniosynostosis and plagiocephaly without synostosis.

The objective of this study was to determine whether children with nonsyndromic craniosynostosis and plagiocephaly without synostosis demonstrated cognitive and psychomotor delays when compared with a standardized population sample. This was the initial assessment of a larger prospective study, which involved 21 subjects with nonsyndromic craniosynostosis (mean age, 10.9 months) and 42 subjects with plagiocephaly without synostosis (mean age, 8.4 months). Each child was assessed using the Bayley Scales of Infant Development-II (BSID-II) for cognitive and psychomotor development before therapeutic intervention (surgery for craniosynostosis and molding-helmet therapy for plagiocephaly without synostosis). The distribution of the scores was divided into four groups: accelerated, normal, mild delay, and significant delay. The distributions of the mental developmental index (MDI) and the psychomotor developmental index (PDI) were then compared with a standardized Bayley's age-matched population, using Fisher's exact chi-square test. Within the craniosynostosis group, the PDI scores were significantly different from the standardized distribution (p < 0.001). With regard to the PDI scores, 0 percent of the subjects in the craniosynostosis group were accelerated, 43 percent were normal, 48 percent had mild delay, and 9 percent had significant delay. In contrast, the MDI scores were not statistically different (p = 0.08). Within the group with plagiocephaly without synostosis, both the PDI and MDI scores were significantly different from the normal curve distribution (p < 0.001). With regard to the PDI scores, 0 percent of the subjects in the group with plagiocephaly without synostosis were accelerated, 67 percent were normal, 20 percent had mild delay, and 13 percent had significant delay. With regard to the MDI scores, 0 percent of the subjects in this group were accelerated, 83 percent were normal, 8 percent had mild delay and 9 percent had significant delay. This study indicates that before any intervention, subjects with single-suture syndromic craniosynostosis and plagiocephaly without synostosis demonstrate delays in cognitive and psychomotor development. Continued postintervention assessments are needed to determine whether these developmental delays can be ameliorated with treatment.

Reossification of the orbital wall following ventral translocation of the fronto-orbital bar and cranial vault remodeling.

The purposes of this study were to determine the extent of ossification of the orbit following ventral translocation of the fronto-orbital bar and to find out whether age at the time of the procedure and presence of a concomitant syndrome adversely affect ossification. A retrospective review of 27 patients with craniosynostosis was conducted at the St. Louis Children's Hospital and the Children's Hospital of Oklahoma. Patients with preoperative, perioperative, and postoperative three-dimensional computed tomography scans were included. Eighty-eight percent of the lateral orbital wall defects and 92 percent of the defects within the roof of the orbit ossified completely in the postoperative period. When syndromic patients were compared with nonsyndromic patients (based on clinical findings only), three of the 19 syndromic defects and three of the 30 nonsyndromic defects demonstrated incomplete ossification in the lateral orbital wall (p > 0.05). Similarly, two of the 19 syndromic defects and two of the 30 nonsyndromic defects demonstrated incomplete ossification within the roof of the orbit (p > 0.05). With respect to age at the time of the procedure, four of the 37 defects and two of the 12 defects demonstrated incomplete ossification in the lateral orbital wall for age at the time of the procedure less than 12 months and greater than 12 months, respectively (p > 0.05). Similarly, two of the 37 defects and two of the 12 defects had incomplete ossification within the roof of the orbit for age at the time of the procedure less than 12 months versus more than 12 months, respectively (p > 0.05). Ossification of the orbital wall and roof is complete in the majority of cases within 1 year after the procedure, and neither age at the time of the procedure nor presence of a concomitant syndrome adversely affects ossification of the orbit after ventral translocation of the fronto-orbital bandeau.

Tretinoin cream 0.02% for the treatment of photodamaged facial skin: a review of 2 double-blind clinical studies.

In extensive clinical studies and practical use since its US Food and Drug Administration approval in 1995, tretinoin emollient cream 0.05% has been shown to be safe and effective in the treatment of fine facial wrinkles, mottled hyperpigmentation, and skin roughness. To provide additional prescribing flexibility for various patient needs, a new lower concentration formulation, tretinoin cream 0.02% was chosen for further development. Two multicenter, randomized, double-blind, vehicle-controlled clinical., studies were conducted to evaluate the safety and efficacy of the lower concentration tretinoin formulation in the treatment of moderate-to-severe facial photodamage. Results indicate statistically significant improvement in fine wrinkling, coarse wrinkling, and yellowing with the use of tretinoin cream 0.02% at week-24 end point, compared with placebo. Therapy with tretinoin cream 0.02% was well tolerated overall and demonstrated a favorable safety profile. Both studies demonstrated that tretinoin cream 0.02% is safe and effective for the treatment of moderate-to-severe photodamaged facial skin.

Combined simultaneous distraction osteogenesis of the maxilla and mandible using a single distraction device in hemifacial microsomia.

Facial asymmetry in hemifacial microsomia can be corrected by an effective procedure of gradual distraction of the mandible. In younger children with deciduous dentition, changes in dental occlusion secondary from mandibular distraction can be easily corrected with orthodontic treatment. In older patients, mandibular elongation through distraction osteogenesis can produce good aesthetics but can create a severe alteration in occlusion requiring complex orthodontic treatment during an extended period. A Le Fort I osteotomy was performed simultaneously with mandibular corticotomy to avoid this problem. We present an 11-year-old patient with grade II hemifacial microsomia with facial asymmetry that was corrected with a combined simultaneous distraction of the maxilla and mandible using a single mandibular distraction device and an interdental splint. Excellent facial symmetry was achieved while maintaining preexisting dental occlusion.

Giant Merkel cell carcinoma involving the upper extremity.

We report a case of Merkel cell carcinoma involving the upper extremity that exceeded 23 cm x 18 cm in size. To the best of our knowledge, this represents the largest tumor of this type reported.

Leptin is a negative acute phase protein in chronic hemodialysis patients.

BACKGROUND: Hypoalbuminemia strongly predicts death in hemodialysis patients and results from both inflammation and malnutrition. One potential link between malnutrition and inflammation is appetite suppression triggered by inflammation. Leptin is secreted by adipose tissue and suppresses appetite, and it is also a positive acute phase protein in the rat. Factored for body weight, leptin is known to be increased in hemodialysis patients, but its relationship to inflammation is unknown. METHODS: We examined the relationship between spontaneously occurring activation of the acute phase response and leptin levels in 29 chronic hemodialysis patients. Serum samples were obtained three times weekly for six weeks and then monthly from 29 chronic hemodialysis patients, and the levels of the positive acute phase proteins [C-reactive protein (CRP), alpha1-acid glycoprotein (alpha1 AG), serum amyloid A, ceruloplasmin] and the negative acute phase proteins (albumin and transferrin) as well as leptin and interleukin-6 (IL-6) were measured. RESULTS: Positive and negative acute phase proteins were evaluated at the maximum CRP (mean, 9.42 +/- 1.14 mg/dL) and minimum values (mean, 0.41 +/- 0.09 mg/dL). When CRP was elevated, leptin levels were significantly reduced, as were the negative acute phase proteins albumin and transferrin. Serum amyloid A, ceruloplasmin, alpha1 acid glycoprotein, and IL-6 were all significantly increased at the maximum CRP level, compatible with general activation of the acute phase response. The change in leptin correlated negatively with the change in CRP (R = 0.437, P = 0.018), as did changes in albumin (R = 0.620, P < 0.001). CONCLUSIONS: Leptin is not increased as a consequence of inflammation in hemodialysis patients, but behaves as a negative rather than as a positive acute phase protein. Inflammation is unlikely to reduce appetite in dialysis patients through a leptin-mediated mechanism.

Folic acid and preconceptional care.

If all women capable of becoming pregnant consumed 400 µg (0.4 mg) of the B vitamin folic acid daily before conception and during the first trimester, the annual number of neural-tube birth defect (NTD)-affected pregnancies in this country could be reduced by 50% to 70%. Despite this important relationship, most women are not aware that folic acid prevents NTDs, and folic acid supplementation rates remain low. If folic acid consumption is to succeed as a public health intervention on a societal scale, physicians who care for reproductive-age women must become informed about the folic acid-NTD prevention linkage. Next, they must be encouraged to counsel patients about the need to consume sufficient folic acid before conception. Studies reveal that few physicians have adequate knowledge of the appropriate timing and dosage of folic acid supplementation. Studies also show that women are more likely to get important folic acid information not from their physicians but from other sources. This article provides information about ways in which physicians can improve their folic acid knowledge and education practices.