Surgical treatment of idiopathic transdural spinal cord herniation: a new technique to untether the spinal cord.

Idiopathic transdural spinal cord herniation is a rare but treatable cause of thoracic myelopathy caused by herniation of the spinal cord through a defect in the dura. The diagnosis is frequently missed or delayed, but the latest imaging techniques can document spinal cord herniation through a dural defect. Surgical treatment, consisting of reducing the herniation by closing the dural defect or widening the aperture to prevent spinal cord compression, is rather successful. We describe a new technique to untether the spinal cord by wrapping a dura graft around the myelum to prevent recurrent transdural herniation. Two patients and a review of the literature are discussed. We conclude that high-resolution T2 magnetic resonance imaging is the best imaging modality to detect the entity, and wrapping the myelum is an effective surgical technique to untether the spinal cord.

[Too young for a twisted painful back]. / Te jong voor een pijnlijke scheve rug.

One girl aged 13 years and 2 boys aged 18 and 14 years had a painful scoliosis. Plain radiographs, blood tests and MRI revealed no abnormalities. Bone scintigraphy and CT scans were needed to establish the diagnosis 'osteoid osteoma'. In the girl, the initial CT scan was also negative and the tumours could only be found after using thin slices. She had had the complaints for 6 months and both boys had had the complaints for more than a year, before the diagnosis was made. They all made a complete recovery after surgical resection. A chronic painful back in young patients is often caused by structural deformities. The differential diagnosis also includes an osteoid osteoma. If an osteoid osteoma is suspected, then after radiographs, bone scintigraphy is indicated, which if necessary can be followed up with targeted CT scans.

[Hemicraniectomy for treatment of malignant medial cerebral artery infarction in 3 patients]. / Hemicraniëctomie als behandeling bij 3 patiënten met een maligne A.-cerebri-media-infarct.

In three patients, a 52-year old man, a 54-year old man and a 17-year old woman, sudden neurological signs such as hemiparalysis and hemihypaesthesia developed, with diminished consciousness occurring at a later stage. Imaging revealed total infarction of the area supplied by the right middle cerebral artery with the threat of intracranial hypertension. Once informed consent had been obtained from the patient's representatives, hemicraniectomy with dural augmentation was performed. Although the primary neurological deficit persisted, the three patients assessed their quality of life as valuable with their Barthel scores ranging from 45 to 90. Total infarction of the middle cerebral artery may result in intracranial hypertension and transtentorial herniation owing to the development of cytotoxic oedema, particularly in young patients. The prognosis of this condition is poor partly due to the limited effect of non-surgical treatment. Hemicraniectomy with dural augmentation prevents secondary brain damage caused by the space-occupying effect of the infarct. This operation reduces mortality considerably. The findings in these patients along with the results in the literature warrant a randomised study of the results of hemicraniectomy in patients with malignant middle cerebral artery infarction.

Does CSF outflow resistance predict the response to shunting in patients with normal pressure hydrocephalus?

The value of the measurements of CSF outflow resistance (Rcsf) relative to predicting outcome after shunting was studied. In a group of 101 patients with mainly idiopathic normal pressure hydrocephalus (NPH) Rcsf was obtained by lumbar constant flow infusion. Gait disturbance and dementia were quantified using an NPH scale (NPHS) and disability by the Modified Rankin scale (MRS). Patients were assessed before and at 1, 3, 6, 9 and 12 months after surgery. Outcome measures were differences between the preoperative and last NPHS and MRS scores. Improvement was defined as a change of > or = 15% in NPHS and > or = 1 grade in MRS. Intention-to-treat analysis of all patients at one year yielded improvement of 57% in NPHS and 59% in MRS. Efficacy analysis, excluding comorbidity unrelated to NPH, revealed positive predictive values of around 80% at Rcsf < 18, and between 90% and 100% at Rcsf > or = 18 mm Hg/ml/min. For Rcsf > or = 18, the likelihood ratios were also higher. We conclude that the best predictor of the response to shunting is an Rcsf > or = 18 mm Hg/ml/min. Since two-thirds of the patients with Rcsf < 18 showed improvement as well, these patients should not be denied shunting.

Histopathologic review of prostate biopsies from patients referred to a comprehensive cancer center: correlation of pathologic findings, analysis of cost, and impact on treatment.

BACKGROUND: Clinicians at the Fox Chase Cancer Center (FCCC) base prostate carcinoma treatment decisions regarding need to treat, field size, total dose, and adjuvant hormonal therapy on known prognostic factors including clinical stage, Gleason score (GS), perineural invasion (PNI), and pretreatment prostate specific antigen levels. The pathology of every patient is reviewed at FCCC to confirm a diagnosis of malignancy. The objective of this study was to define differences between pathologic reviews and their impact on treatment between outside institutions and FCCC. METHODS: The authors reviewed 538 pathology reports of prostate biopsies performed at both outside pathology departments and FCCC on patients evaluated between January 1993 and December 1996. The outside pathology reviews represented 107 community hospitals, academic institutions, and private pathology laboratories. Patients who had received hormonal therapy, cryosurgery, or radical prostatectomy prior to prostate biopsy were excluded from analysis. Final FCCC pathology determinations were compared with pathology reports from outside institutions. Reports then were analyzed to determine whether differences in interpretation would have resulted in different treatment strategies. Differences in percentages according to institutional type were evaluated using the chi-square statistic. The cost was assessed and cost per change in treatment estimated. RESULTS: The 538 pathology reviews identified a nearly 40% change in GS and a 13% change in > or =2 GS between the FCCC pathology review and 107 outside academic institutions. The results of this study showed that 22% of community hospitals, 10% of private laboratories, and 8% of academic institutions demonstrated at least 2 GS changes compared with the FCCC pathology review (p = 0.001). There was no significant difference observed between types of institutions in the incidence of PNI. CONCLUSIONS: This analysis provides evidence of a significant difference in the pathologic reviews of prostate biopsies conducted at FCCC and outside pathology departments. There was a nearly 40% change in GS and a 13% change in > or =2 GS between the FCCC pathology review and 107 outside institutions. The second pathology review added approximately $104 per case for a total of $55,952 to review all 538 cases. Overall, the savings in health care dollars resulting from the second pathologic review totaled $12,997. This second review of outside pathology in prostate cancer appears to be justified based on the treatment changes and on cost.

[Pott's puffy tumor]. / 'Pott's puffy tumor'.

A 26-year-old man developed a fluctuating swelling of the forehead after twice being treated with antibiotics because of persistent sinusitis complaints. This swelling, a subperiostal abcess diagnosed as 'Pott's puffy tumor', is a complication of a frontal sinusitis, and may lead to serious neurological sequelae. The patient recovered after surgical drainage, ethmoidectomy and intravenous antibiotic treatment; no ablation of affected bone was necessary.

Dutch normal pressure hydrocephalus study: baseline characteristics with emphasis on clinical findings.

We present the baseline characteristics of 101 patients with normal pressure hydrocephalus (NPH), entering a study that evaluates the diagnostic reliability of CSF outflow resistance. Patients were assessed by a gait scale consisting of 10 features of walking and the number of steps and seconds necessary for 10 m, a dementia scale comprising the 10 word test, trail making, digit span and finger tapping, the modified Mini Mental State Examination (3MSE) and the modified Rankin scale (MRS). Inclusion criteria were a gait and dementia scale ≥ 12 (range 2-40), a MRS ≥ 2 and a communicating hydrocephalus on CT. Gait disorder and dementia varied from mild to severe leading to MRS 2 in 17%, MRS 3 in 34%, MRS 4 in 21%, MRS 5 in 16% and MRS 6, including akinetic mutism, in 12%. Only one patient showed both normal tandem walking and turning. Small steps, reduced foot floor clearance and wide base were also frequently seen in the 67 patients walking independently; 34 needed assistance or could not walk at all. Applying the 3MSE, 64% were demented; the remaining 36% exhibited a milder cognitive deficit. The 10 word test and trail making decreased with increasing dementia. Digit span and finger tapping declined in the most demented patients. This group of elderly patients with NPH, mostly of the idiopathic type, proved to be vulnerable because of considerable disability and comorbidity.

New mechanism of action of the cancer chemotherapeutic agent 5-fluorouracil in human cells.

5-Fluorouracil (5-FlUra), a cancer chemotherapeutic agent used in the treatment of colon, breast, ovarian and prostate cancer, is incorporated into DNA as a result of its utilization as 5-FldUTP during DNA synthesis. This promutagenic DNA lesion is excised by the base excision repair enzyme uracil DNA glycosylase (UDG). In this report we describe for the first time a mechanism by which 5-FlUra as the free base specifically binds in vivo to the UDG in noncycling human cells, thereby inhibiting its activity. By using 5-FlUra concentrations which did not elicit demonstrable cell toxicity, a dose-dependent decrease in UDG activity was detected which approached 30% of that observed in control cells. In contrast, exposure of cells to equivalent concentrations of uracil, 5-fluorodeoxyuridine or 5-bromouracil had no effect on UDG activity. Subsequent studies demonstrated a reversible binding of 5-FlUra to the glycosylase. Kinetic analysis using nonlinear regression analysis demonstrated a competitive mode of inhibition and indicated a tight binding of 5-FlUra to UDG in vivo, although the 5-FlUra-UDG complex was easily dissociated in vitro. These findings describe a potentially new and novel mechanism of action of 5-FlUra in a nonproliferating human cell population. The potential relevance of these findings to the utility of 5-FlUra as a cancer chemotherapeutic agent is considered.

Cell cycle regulation of the glyceraldehyde-3-phosphate dehydrogenase/uracil DNA glycosylase gene in normal human cells.

The cell cycle regulation of the glyceraldehyde-3-phosphate dehydrogenase (GAPDH)/uracil DNA glycosylase (UDG) gene was examined in normal human cells. Steady state RNA levels were monitored by Northern blot analysis using a plasmid (pChug 20.1) which contained the 1.3 kb GAPDH/UDG cDNA. The biosynthesis of the 37 kDa GAPDH/UDG protein was determined using an anti-human placental GAPDH/UDG monoclonal antibody to immunoprecipitate the radiolabeled protein. Increases in steady state GAPDH/UDG mRNA levels were cell cycle specific. A biphasic pattern was observed resulting in a 19-fold increase in the amount of GAPDH/UDG mRNA. The biosynthesis of the 37 kDa GAPDH/UDG protein displayed a similar biphasic regulation with a 7-fold increase. Pulse-chase experiments revealed a remarkably short half life of less than 1 hr. for the newly synthesized 37 kDa protein, comparable to that previously documented for a number of oncogenes. GAPDH/UDG mRNA levels were markedly reduced at 24 hr. when DNA synthesis was maximal. These results define the GAPDH/UDG gene as cell cycle regulated with a characteristic temporal sequence of expression in relation to DNA synthesis. The cell cycle synthesis of a labile 37 kDa monomer suggests a possible regulatory function for this multidimensional protein. Further, modulation of the GAPDH/UDG gene in the cell cycle may preclude its use as a reporter gene when the proliferative state of the cell is not kept constant.

Proliferative dependent regulation of the glyceraldehyde-3-phosphate dehydrogenase/uracil DNA glycosylase gene in human cells.

The relationship between the proliferative dependent expression of the glyceraldehyde-3-phosphate dehydrogenase (GAPDH)/uracil DNA glycosylase (UDG) gene and the induction of uracil DNA glycosylase activity was examined in human cells. Three different cell types were studied to determine whether the growth-dependent regulation of this multifunctional gene was a common characteristic of human cells. These included WI-38 normal embryonic lung fibroblasts, a Japanese Bloom's syndrome non-transformed skin fibroblast cell strain (GM-05289) and a lymphoblastoid cell line transformed by the Epstein-Barr virus. The Japanese Bloom's syndrome cells displayed the altered immunoreactivity with marker monoclonal antibody 40.10.09 which characterizes cells from this human genetic disorder. In noncycling human cells Northern blot analysis using a plasmid (pChug 20.1) which contained the human GAPDH/UDG cDNA revealed a single 1.6 kb transcript. In each case, the expression of this gene was increased during cell proliferation. This increase in GAPDH/UDG gene expression was identical to that observed for UDG enzyme activity. Further, using anti-human UDG monoclonal antibodies, there was a growth-dependent rise in immunoreactivity suggesting an increase in the level of antigenic protein. These results demonstrate that: (i) the expression of the GAPDH/UDG gene was dependent on the proliferative state of the cell; and (ii) a correlation existed between the transcription of this gene and the level of uracil DNA glycosylase enzyme activity.

A human nuclear uracil DNA glycosylase is the 37-kDa subunit of glyceraldehyde-3-phosphate dehydrogenase.

We have isolated and characterized a plasmid (pChug 20.1) that contains the cDNA of a nuclear uracil DNA glycosylase (UDG) gene isolated from normal human placenta. This cDNA directed the synthesis of a fusion protein (Mr 66,000) that exhibited UDG activity. The enzymatic activity was specific for a uracil-containing polynucleotide substrate and was inhibited by a glycosylase antibody or a beta-galactosidase antibody. Sequence analysis demonstrated an open reading frame that encoded a protein of 335 amino acids of calculated Mr 36,050 and pI 8.7, corresponding to the Mr 37,000 and pI 8.1 of purified human placental UDG. No homology was seen between this cDNA and the UDG of herpes simplex virus, Escherichia coli, and yeast; nor was there homology with the putative human mitochondrial UDG cDNA or with a second human nuclear UDG cDNA. Surprisingly, a search of the GenBank data base revealed that the cDNA of UDG was completely homologous with the 37-kDa subunit of human glyceraldehyde-3-phosphate dehydrogenase. Human erythrocyte glyceraldehyde-3-phosphate dehydrogenase was obtained commercially in its tetrameric form. A 37-kDa subunit was isolated from it and shown to possess UDG activity equivalent to that seen for the purified human placental UDG. The multiple functions of this 37-kDa protein as here and previously reported indicate that it possesses a series of activities, depending on its oligomeric state. Accordingly, mutation(s) in the gene of this multifunctional protein may conceivably result in the diverse cellular phenotypes of Bloom syndrome.

Subdural hematoma after lumbar puncture: two case reports and review of the literature.

Two cases of intracranial subdural hematoma following lumbar puncture are presented. A review of all previously reported cases shows that subdural hematoma after lumbar puncture is a rare but serious complication. The pathogenesis of subdural hematoma after lumbar puncture is probably related to that of post lumbar puncture headache. Application of an epidural blood patch may therefore be a safe way not only to treat typical post lumbar puncture headache but also to prevent subdural hematoma after lumbar puncture.

Regulation of Schwann cell nerve growth factor receptor by cyclic adenosine 3',5'-monophosphate.

Previous studies indicated that Schwann cells in immature nerves express nerve growth factor (NGF) receptors, and that this expression is down regulated during development but re-induced by Wallerian degeneration. It was also shown that immature Schwann cells are induced to express galactocerebroside and other molecules characteristic of mature Schwann cells by either contact with an axon or treatment with the cyclic adenosine 3',5'-monophosphate (cAMP) analogues dibutyryl cAMP (dbcAMP) and 8-bromo cAMP or the adenylate cyclase activator forskolin. In the present study, NGF receptors on the surface of cultured Schwann cells were demonstrated by binding of an anti-rat NGF receptor monoclonal antibody or of radioiodinated NGF. Treatment of cultured Schwann cells with cAMP analogues or forskolin resulted in a progressive decrease in both immunoreactive NGF receptors and radioiodinated NGF binding. The cultured Schwann cells contained a polyadenylated RNA species homologous with human melanoma NGF receptor mRNA in sequence and size. The amount of this NGF mRNA was lower in cAMP analogue-treated than in untreated Schwann cells.