In vivo molecular markers for pro-inflammatory cytokine M1 stage and resident microglia in trimethyltin-induced hippocampal injury.

Microglia polarization to the classical M1 activation state is characterized by elevated pro-inflammatory cytokines; however, a full profile has not been generated in the early stages of a sterile inflammatory response recruiting only resident microglia. We characterized the initial M1 state in a hippocampal injury model dependent upon tumor necrosis factor (TNF) receptor signaling for dentate granule cell death. Twenty-one-day-old CD1 male mice were injected with trimethyltin (TMT 2.3 mg/kg, i.p.) and the hippocampus was examined at an early stage (24-h post-dosing) of neuronal death. Glia activation was assessed using a custom quantitative nuclease protection assay. We report elevated mRNA levels for glia response such as ionizing calcium-binding adapter molecule-1 and glial fibrillary acidic protein (Gfap); Fas, hypoxia inducible factor alpha, complement component 1qb, TNF-related genes (Tnf, Tnfaip3, Tnfrsfla); interleukin-1 alpha, Cd44, chemokine (C-C motif) ligand (Ccl)2, Cc14, integrin alpha M, lipocalin (Lcn2), and secreted phosphoprotein 1 (Spp1). These changes occurred in the absence of changes in matrix metalloproteinase 9 and 12, neural cell adhesion molecule, metabotropic glutamate receptor (Grm)3, and Ly6/neurotoxin 1 (Lynx1), as well as, a decrease in neurotrophin 3, glutamate receptor subunit epsilon (Grin)-2b, and neurotrophic tyrosine kinase receptor, type 3. The M2 anti-inflammatory marker, transforming growth factor beta-1 (Tgfb1) was elevated. mRNAs associated with early stage of injury-induced neurogenesis including fibroblast growth factor 21 and Mki67 were elevated. In the "non-injured" temporal cortex receiving projections from the hippocampus, Lynx1, Grm3, and Grin2b were decreased and Gfap increased. Formalin fixed-paraffin-embedded tissue did not generate a comparable profile.

Evaluation of N-butylbenzenesulfonamide (NBBS) neurotoxicity in Sprague-Dawley male rats following 27-day oral exposure.

N-Butylbenzenesulfonamide (NBBS) is widely used as a plasticizer in polyacetals, polyamides, and polycarbonates and has been found in ground water and effluent from wastewater treatment sites. The compound is lipophilic and distributes rapidly to the brain but also clears rapidly and shows little evidence of accumulation. Limited studies in the literature report neurotoxicity of NBBS in rabbits and rats. Adult Sprague-Dawley male rats (Harlan) received corn oil vehicle or NBBS (100, 200, or 400mg/kg/d) via oral gavage (5 ml/kg bwt) daily/5d/week for 27 d. Deaths were observed in the 400mg/kg/d dose group in the first 5d and dosing was decreased to 300 mg/kg/d. No alterations were observed in gait, locomotor activity, and rearing behavior. No histological lesions were observed in the testis, seminal vesicles, coagulating gland, epididymis, and prostate. In the liver, minimal centrilobular hypertrophy was evident in all rats of the high dose group. Contrary to previous reports, there was no evidence of peripheral nerve lesions or gliosis in the hippocampus or cerebellum. mRNA levels for glial fibrillary acidic acid protein, interferon gamma, CXCR-3, intracellular adhesion molecule-1, and CD11b were not altered in the hippocampus while Iba-1 levels were decreased. These data do not support previous reports of neurotoxicity for NBBS within a 4-week exposure regimen; however, neuropathological injury occurring over an extended period of exposure cannot be ruled out and given the potential for human exposure requires further examination.

Gastrointestinal complications associated with ibuprofen therapy for patent ductus arteriosus.

OBJECTIVE: To review intestinal complications associated with ibuprofen treatment of patent ductus arteriosus (PDA). STUDY DESIGN: Data from preterm infants treated with ibuprofen were retrospectively reviewed. χ(2) test and Fischer's exact test were used for univariate analyses. Multivariate analyses with logistic regression modeling were used to identify risk factors. RESULT: One hundred and two infants were treated with ibuprofen for PDA. Nine (9/102, 8.8%) infants developed spontaneous intestinal perforation (SIP), whereas 93/102 (91.2%) did not. The mean (± s.d.) gestational age (GA) at birth in infants with and without SIP was 25.2 (± 1.3) vs 27.6 (± 2.4) weeks (P=0.02) and the median (interquartile) length of stay (LOS) was 109.5 (91.0 to 116.5) vs 75.0 (53.0 to 94.5) days (P=0.002), respectively. The mean (± s.d.) age at starting ibuprofen was 3.3 (± 1.3) vs 5.8 (± 3.5) days in infants with and without SIP, respectively (P=0.03). In logistic regression analyses, increasing GA and later initiation of ibuprofen treatment were protective against risk of SIP; odds ratio, 95% confidence interval (OR, 95% CI)=0.26 (0.09 to 0.75), P=0.01 and 0.63 (0.41 to 0.95), P=0.03, respectively. CONCLUSION: Infants at lower GA are at risk of SIP when treated early with ibuprofen for symptomatic PDA.

Interleukin (IL)-1 and IL-6 regulation of neural progenitor cell proliferation with hippocampal injury: differential regulatory pathways in the subgranular zone (SGZ) of the adolescent and mature mouse brain.

Current data suggests an association between elevations in interleukin 1 (IL-1)α, IL-1ß, and IL-6 and the proliferation of neural progenitor cells (NPCs) following brain injury. A limited amount of work implicates changes in these pro-inflammatory responses with diminished NPC proliferation observed as a function of aging. In the current study, adolescent (21day-old) and 1year-old CD-1 male mice were injected with trimethyltin (TMT, 2.3mg/kg, i.p.) to produce acute apoptosis of hippocampal dentate granule cells. In this model, fewer 5-bromo-2'-deoxyuridine (BrdU)+ NPC were observed in both naive and injured adult hippocampus as compared to the corresponding number seen in adolescent mice. At 48h post-TMT, a similar level of neuronal death was observed across ages, yet activated ameboid microglia were observed in the adolescent and hypertrophic process-bearing microglia in the adult. IL-1α mRNA levels were elevated in the adolescent hippocampus; IL-6 mRNA levels were elevated in the adult. In subgranular zone (SGZ) isolated by laser-capture microdissection, IL-1ß was detected but not elevated by TMT, IL-1a was elevated at both ages, while IL-6 was elevated only in the adult. Naïve NPCs isolated from the hippocampus expressed transcripts for IL-1R1, IL-6Rα, and gp130 with significantly higher levels of IL-6Rα mRNA in the adult. In vitro, IL-1α (150pg/ml) stimulated proliferation of adolescent NPCs; IL-6 (10ng/ml) inhibited proliferation of adolescent and adult NPCs. Microarray analysis of SGZ post-TMT indicated a prominence of IL-1a/IL-1R1 signaling in the adolescent and IL-6/gp130 signaling in the adult.

The relative contribution of efflux and target gene mutations to fluoroquinolone resistance in recent clinical isolates of Pseudomonas aeruginosa.

The clinical utility of fluoroquinolones (FQs) for the treatment of Pseudomonas aeruginosa (PA) and other serious Gram-negative infections is currently decreasing due to the rapid emergence of resistance. Because previous studies have shown that efflux is a common mechanism contributing to FQ resistance in PA, one suggested approach to extend the longevity of this class of drugs is combination therapy with an efflux pump inhibitor (EPI). In order to determine the viability of this approach, it is necessary to understand the relative contribution of efflux- vs. target-mediated mechanisms of FQ resistance in the clinic. A set of 26 recent PA clinical isolates were characterized for antibiotic resistance profiles, efflux pump expression, topoisomerase mutations, and FQ susceptibility with and without an EPI. The contribution of OprM to the overall antibiotic resistance was assessed in a subset of these strains. Our results suggest that the co-administration of an EPI with FQs or other antibiotics currently in use would not be sufficient to combat the complexity of resistance mechanisms now present in many clinical isolates.

Troponin T elevation after implanted defibrillator discharge predicts survival.

BACKGROUND: Cardiac troponin T (cTnT) elevations have been reported to occur after implantable cardioverter-defibrillator (ICD) discharges, but their prognostic significance is unknown. OBJECTIVE: To evaluate whether cTnT elevations occurring after ICD discharges have an impact on survival. DESIGN: Prospective observational study. PATIENTS: 174 patients (mean (SD) age 68 (12) years, 32 women) who received spontaneous (n = 66) or induced (n = 108) ICD discharges were studied. The mean (SD) left ventricular ejection fraction was 29 (11)%. MAIN OUTCOME MEASURES: Troponin T was measured between 12 and 24 h after ICD discharge. Patients received between 1 and 19 discharges (mean (SD) 2.4 (2.4)), with total delivered energy ranging from 6 to 288 J (mean (SD) 41 (63) J). The relationship between cTnT levels and all-cause mortality was assessed in univariate and multivariate analyses. RESULTS: During a median follow-up period of 41.8 months (range 3-123), 56 patients died. Patients with a post-discharge cTnT level of >/=0.05 ng/ml had worse survival than those with cTnT <0.05 ng/ml. The significant relationship between raised cTnT and survival was retained in Cox multivariate analysis adjusted for total ICD energy delivered during an arrhythmia episode, age, sex, presence of coronary artery disease, left ventricular ejection fraction and serum creatinine. CONCLUSIONS: Elevation of troponin T after ICD discharge, even when it occurs after device testing, is a risk factor for mortality that is independent of other common clinical factors that predict survival in such patients.

Tumor resection in a shared-resource magnetic resonance operating room: experience at the University of Cincinnati.

INTRODUCTION: At the University of Cincinnati, we have developed a shared-resource magnetic resonance operating suite that facilitates performance of both neurosurgical and diagnostic procedures in a single unit. METHODS: The shared-resource magnetic resonance operating suite utilizes a Hitachi AIRIS II, 0.3-T, vertical field, open MRI unit located in the MROR. This magnet can be used for both diagnostic and interventional procedures. The addition of a rotating-operating table permits neurosurgical procedures to be performed outside of the 5-G line using standard neurosurgical equipment and operating microscopes. RESULTS: We review our results with the shared-resource magnetic resonance operating room including the tabulated results from 30 transsphenoidal procedures and 63 glioma procedures. In addition, 2832 diagnostic procedures have been performed in the first 4 years of use. CONCLUSION: The shared-resource intraoperative MRI facility produces high-quality intraoperative imaging studies, equal to those of high-resolution magnets, and is valuable in enabling the surgeon to achieve the planned degree of resection of glioma and pituitary tumors. The ability to perform diagnostic procedures in a shared unit has been a cost-effective solution for our institution.

Judging the quality of care at the end of life: can proxies provide reliable information?

A major challenge in research into care at the end of life is the difficulty of obtaining the views and experiences of representative samples of patients. Studies relying on patients' accounts prior to death are potentially biased, as they only represent that proportion of patients with an identifiable terminal illness, who are relatively well and therefore able to participate, and who are willing to take part. An alternative approach that overcomes many of these problems is the retrospective or 'after death' approach. Here, observations are gathered from proxies, usually the patient's next of kin, following the patient's death. However, questions have been raised about the validity of proxies' responses. This paper provides a comprehensive review of studies that have compared patient and proxy views. The evidence suggests that proxies can reliably report on the quality of services, and on observable symptoms. Agreement is poorest for subjective aspects of the patient's experience, such as pain, anxiety and depression. The findings are discussed in relation to literature drawn from survey methodology, psychology, health and palliative care. In addition to this, factors likely to affect levels of agreement are identified. Amongst these are factors associated with the patient and proxy, the measures used to assess palliative care and the quality of the research evaluating the validity of proxies' reports. As proxies are a vital source of information, and for some patients the only source, the paper highlights the need for further research to improve the validity of proxies' reports.

Effective methods of giving information in cancer: a systematic literature review of randomized controlled trials.

There is increasing evidence to suggest that patients with cancer require more information about their disease and its consequences than they receive. In an attempt to address these needs, a variety of methods have been used to facilitate the passage of information from health professionals and other cancer information sources to cancer patients and their families. These include written material, telephone help-lines, teaching and audiovisual aids. Although these efforts have been well received, little attention has been given to the effectiveness of the methods employed. The aims of this paper were to systematically review randomized controlled trials that have evaluated methods of information-giving to cancer patients and their families. Relevant literature was identified through computerized databases, Internet cancer sites and bibliography searches. Multiple reviewers independently analysed the methodological quality of the papers according to agreed criteria. From this process, 10 studies were identified. Interventions ranged from written information to audiotapes, audiovisual aids and interactive medium. Individually tailored methods such as patient care records and patient educational programmes were also reviewed. The evidence indicated that the interventions had positive effects on a number of patient outcomes, such as knowledge and recall, symptom management, satisfaction, preferences, health care utilization and affective states. This was above and beyond the usual care provision. In the majority of studies the interventions had no effect on psychological indices. Furthermore, the review highlighted that certain methods should be based on individual preferences for information rather than uniformly administered.

Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery.

BACKGROUND AND PURPOSE: Tissue plasminogen activator (tPA) has been shown to be effective for acute ischemic stroke. However, if a high-grade cervical carotid stenosis remains despite tPA therapy, patients are at risk for recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in symptomatic patients with high-grade cervical carotid stenosis in reducing the risk of stroke, but it is unknown whether CEA can be performed safely after tPA thrombolysis. We describe our experience with 5 patients who underwent early (<48 hours) CEA for residual high-grade cervical carotid stenosis after thrombolytic therapy for acute ischemic stroke in the middle cerebral artery territory. METHODS: All patients had a critical (>99%) carotid artery stenosis on the symptomatic side after tPA therapy. All patients received intravenous tPA; 3 patients also received intra-aortic tPA. Three patients received intravenous heparin infusion immediately after administration of tPA. All patients showed marked improvement in their National Institutes for Health Stroke Scale scores after treatment with tPA. CEA was then performed within 45 hours (6 hours in 1 patient, 23 hours in 2, 26 hours in 1, and 45 hours in 1). RESULTS: All 5 patients underwent successful CEA. There were no complications related to surgery. At discharge, 2 patients had a normal examination, and the remaining patients had mild deficits. In a long-term follow-up of 5 to 22 months, no patient had a recurrent cerebrovascular event. CONCLUSIONS: Early CEA can be performed safely and successfully in patients after tPA treatment for acute ischemic stroke in appropriately selected patients.

After-death interviews with surrogates/bereaved family members: some issues of validity.

After-death interviews with bereaved respondents are an important tool in the repertoire of researchers evaluating the quality of end-of-life care or investigating the experiences of people at the end of life. Despite the importance of after-death interviews to our understanding of the last months of life, the validity of the information gathered has received little attention. In this article, we review some of the available information, drawing on evidence from cognitive psychology as well as from palliative care studies. Findings from cognitive psychology indicate that memory is a dynamic process, influenced by emotion state and the individual's perspective at the time of the event and at recall. Further research is therefore needed to understand better the circumstances, types of information and research questions for which bereaved relatives are valid surrogates for people who have died.

Quality of life in patients with prostate cancer.

OBJECTIVES: Quality of life (QOL) issues are important for patients with prostate cancer because side effects from treatment are substantial, while the disease itself may be indolent. This article reviews prostate cancer QOL studies. DATA SOURCES: Selected studies published on QOL in prostate cancer using validated patient-assessed tools from the last 5 years. CONCLUSIONS: Prostate cancer treatments are associated with side effects: prostatectomy has more urinary and sexual side effects, while external radiation therapy has more bowel symptoms. Side effects are not highly correlated with overall QOL. IMPLICATIONS FOR NURSING PRACTICE: Patients must be made aware of potential gains in life expectancy as well as side effects of treatments to make informed decisions about treatment.

A physical map of the human genome.

The human genome is by far the largest genome to be sequenced, and its size and complexity present many challenges for sequence assembly. The International Human Genome Sequencing Consortium constructed a map of the whole genome to enable the selection of clones for sequencing and for the accurate assembly of the genome sequence. Here we report the construction of the whole-genome bacterial artificial chromosome (BAC) map and its integration with previous landmark maps and information from mapping efforts focused on specific chromosomal regions. We also describe the integration of sequence data with the map.

Use of anti-infective agents during lactation: Part 2--Aminoglycosides, macrolides, quinolones, sulfonamides, trimethoprim, tetracyclines, chloramphenicol, clindamycin, and metronidazole.

Because many antibiotics are excreted into breast milk, it can be difficult for a practitioner to choose an antibiotic for a lactating patient that will have minimal risks to her nursing infant. This article is the second of a three-part series discussing the use of anti-infective agents during lactation. The authors review general information regarding use and common side effects for several classes of antibiotics. They also summarize information, including documented milk concentrations, milk-to-plasma ratios, and other pharmacokinetic properties, in a table that can help practitioners choose antibiotics that may be considered safe to use in the lactating mother.

Expression and regulation of type I BMP receptors during early avian sympathetic ganglion development.

We have investigated the expression and regulation of the mRNAs for the type I BMP receptors, BMPR-IA and BMPR-IB, in quail embryos in vivo and in neural crest cultures in vitro. BMPR-IB mRNA was expressed in the primordial sympathetic ganglia at stage 17, soon after the first expression of Cash-1 mRNA, the avian homolog of the Drosophila transcription factor achaete-scute. BMP-4 mRNA was detected in the dorsal aorta at stage 17, coincident with BMPR-IB mRNA expression in the sympathetic ganglia. BMPR-IA mRNA was first expressed in the sympathetic ganglia at stage 18. Moreover, BMP-4 ligand mRNA was detected in the sympathetic ganglia starting at stage 18. BMPR-IA and BMPR-IB were differentially regulated in cultured neural crest cells. BMPR-IB was expressed in primary outgrowths of neural crest cells but was downregulated after primary outgrowths were harvested and replated in secondary cultures. In secondary cultures of neural crest cells, exogenous BMP-2 and BMP-4 increased the expression of BMPR-IA but decreased the expression of BMPR-IB. The expression of both type I BMP receptors was inhibited by exogenous TGF-beta1. Our results suggest distinct roles for BMPR-IA and BMPR-IB in the development of the sympathoadrenal phenotype from cells of the neural crest.

Coil occlusion of the parent artery for treatment of symptomatic peripheral intracranial aneurysms.

BACKGROUND AND PURPOSE: Peripheral intracranial aneurysms can be difficult to treat with traditional surgical or embolization techniques that spare the parent vessel. We report the results of our use of coil occlusion of the parent vessel for the treatment of nine peripheral intracranial aneurysms. METHODS: During approximately a 4-year period, nine patients (six men and three women, 27 to 68 years old; average age, 42 years) presented to our institution with peripheral intracranial aneurysms. The aneurysms were located on branches of the right posterior inferior cerebellar artery (n = 2), the right superior cerebellar artery (n = 1), the right anterior inferior cerebellar artery (n = 1), the right posterior cerebral artery (n = 3), the left middle cerebral artery (n = 1), and the left anterior cerebral artery (n = 1). Parent vessel occlusion was performed using microcoils after test injection with amobarbital (Amytal) in eight of the nine cases (one patient was comatose and could not be tested before occlusion). RESULTS: Angiography immediately after the procedure showed aneurysmal occlusion in every patient. Follow-up arteriography, performed in six patients 2 to 12 months after treatment, documented continued aneurysmal occlusion in every case. Three patients exhibited mild, nondisabling neurologic deficits after coil placement; the rest had no new deficits, although one patient was severely disabled from the initial hemorrhage and one patient died of an unrelated cause. CONCLUSION: Our results lend support to the use of parent vessel occlusion for peripheral aneurysms that are difficult to treat surgically or that are not amenable to intra-aneurysmal coil placement.

Destabilizing effects of mental stress on ventricular arrhythmias in patients with implantable cardioverter-defibrillators.

BACKGROUND: The incidence of sudden cardiac death increases in populations who experience disasters such as earthquakes. The physiological link between psychological stress and sudden death is unknown; one mechanism may be the direct effects of sympathetic arousal on arrhythmias. To determine whether mental stress alters the induction, rate, or termination of ventricular arrhythmias, we performed noninvasive programmed stimulation (NIPS) in patients with defibrillators and ventricular tachycardia (VT), which is known to be inducible and terminated by antitachycardia pacing, at rest and during varying states of mental arousal. METHODS AND RESULTS: Eighteen patients underwent NIPS in the resting-awake state (nonsedated). Ten underwent repeat testing during mental stress (mental arithmetic and anger recall). Induced VT was faster in 5 patients (P=0.03). VT became more difficult to terminate in 5 patients during mental stress; 4 required a shock (P=0.03). There was no change in ease of induction with mental stress. There was no evidence of ischemia on ECG or continuous ejection fraction monitoring. Eight patients received a shock in the resting-awake state and did not perform mental stress. Four underwent repeat NIPS after sedation; 3 then had induced VT terminated with antitachycardia pacing. All patients with an increase in norepinephrine of >50% had alterations in VT that required shock for termination (P<0.01). CONCLUSIONS: Mental stress alters VT cycle length and termination without evidence of ischemia. This suggests that mental stress may lead to sudden death through the facilitation of lethal ventricular arrhythmias.

Use of anti-infective agents during lactation: Part 1--Beta-lactam antibiotics, vancomycin, quinupristin-dalfopristin, and linezolid.

Because many antibiotics are excreted into the breast milk, it can be difficult for a practitioner to choose an antibiotic for a lactating patient that will have minimal risks to her nursing infant. This article is the first of a three-part series discussing the use of anti-infective agents during lactation. The authors review general information regarding use and common side effects of several classes of antibiotics. They also summarize information, including documented milk concentrations, milk-to-plasma ratios, and other pharmacokinetic properties, in a table that can help practitioners choose antibiotics that may be considered safe for the lactating mother.