Venous Outflow for Brain Arteriovenous Malformations: Overview and Treatment Implications.

Introduction: Recent evidence has demonstrated a close relationship between the cerebral venous and lymphatic systems. Venous congestion has been implicated in a host of neurologic disorders, with relevance for vascular etiologies. Objective: The authors aim to review the literature as it pertains to brain arteriovenous malformations' (BAVMs) venous hemodynamics and glymphatic pathways, as well as the implications of BAVM treatment. Results: BAVMs offer a unique challenge, with sudden alteration in flow dynamics leading to increased hemorrhage risk and difficult challenges post-treatment. Conclusion: Recent progress in the understanding of CNS fluid dynamics and glymphatic pathways have revealed important implications for BAVM pathology and treatment. As imaging techniques and treatment modalities advance, there is a need to further investigate this relationship as it relates to therapeutic options and post-treatment sequalae.

Freud's baby: beyond autoerotism and narcissism.

The prevailing notion in the psychoanalytic literature is that Freud's thinking on neonatal object relations is completely captured in terms of his concepts of autoerotism and primary narcissism. Indeed, for Freud, autoerotism and primary narcissism conceptualize the earliest libido distributions, but these concepts do not exhaust Freud's model of early mental life. In this paper, the author endeavors to show that Freud's hypothetical infant arrives at autoerotism and narcissism at the expense of, and secondary to, primitive object-relatedness. More specifically, an appreciation of Freud's views on primitive object relations in light of the self-preservative instinct demonstrates his view that the infant is born into a state of mutual adaptation with the mother. The author makes detailed use of Freud's writings to show his conception of an infant who, from the inception of neonatal life, has the mental sophistication to maintain complex relations with instinctual objects, the sources of gratification or frustration, part-objects confusedly perceived because of cognitive immaturity and/or fantasy distortion. Such complexity includes the infant's capacity for primitive forms of perception, boundary formation, reality testing, and defensive, splitting-based projections and introjections.

Crusted scabies in association with human T-cell lymphotropic virus 1.

BACKGROUND: Human T-cell lymphotropic virus I (HTLV- 1) infection can lead to myelopathy/tropical spastic paresis and adult T-cell leukemia/lymphoma (ATLL). Infection with HTLV-1 has also been associated with clinically significant immunosuppression. Crusted scabies, also known as Norwegian scabies, is an uncommon presentation of scabies that may occur in conjunction with immunosuppression. Although crusted scabies has been reported in association with HTLV-1 infection, to our knowledge it has never been described in association with HTLV-1 associated myelopathy. OBJECTIVE: The aim is to describe a case of HTLV-1 associated myelopathy and concomitant crusted scabies. METHODS: This article includes a case report and a literature review. CONCLUSIONS: Crusted scabies is reported in association with HTLV-1 infection with or without concomitant ATLL. Crusted scabies should be considered in the differential diagnosis of a generalized cutaneous eruption in an HTLV-1 positive patient. Patients with crusted scabies from an HTLV-1 endemic population should be rested for a possible HTLV-1 infection. These patients may be at increased risk of progressing to ATLL.

Direct somatic embryogenesis in a selected tea clone, `TRI-2025' (Camellia sinensis (L.) O. Kuntze) from nodal explants.

An efficient method for the in vitro propagation of a tea (Camellia sinensis (L) O. Kuntze) clone, `TRI-2025', from somatic embryos is described. This technique involves two phases; the induction of adventitious buds from nodal cuttings followed by the development of somatic embryos. Single nodal cuttings were excised from 1-year-old in vitro axenic cultures and inoculated on MS medium with different combinations of IBA/BAP/GA3. Induction of multiple shoots from nodal explants occurred on MS medium with 0.5 mg l-1 BAP, 0.1 mg l-1 IBA and 0.0 mg l-1 GA3 within 6 weeks of incubation. The cultures with multiple shoots were transferred to fresh medium, incubated for 120 days and transferred to MS medium with half-strength macro nutrients, full-strength micronutrients and vitamins and no growth regulator. The direct induction of somatic embryos without callus formation occurred on this medium at 60% frequency within 4 weeks. The production of embryos continued upon transfer of the cultures to fresh medium and a four- to eightfold multiplication rate was obtained during each 6-week culture cycle. The plantlets from these embryos were acclimatised with a 90% success rate. All plants were vigorous and hardy, with well-developed tap-root systems.

Erythema elevatum diutinum associated with IgA paraproteinemia successfully controlled with intermittent plasma exchange.

BACKGROUND: We review the literature and report a case of refractory erythema elevatum diutinum associated with IgA paraproteinemia that was successfully controlled with intermittent plasma exchange (PLEX). OBSERVATIONS: Typical lesions of erythema elevatum diutinum developed in a 72-year-old patient with IgA paraproteinemia; the condition predictably flared whenever IgA levels reached a threshold of 8 g/L. After 8 years of unsuccessful treatment with various agents, we instituted a trial of PLEX during an acute flare. Following 6 exchanges over a period of 2 weeks, the IgA level decreased from 8 to 2 g/L and the skin lesions cleared. Three weeks later, new skin lesions developed and the IgA level had rebounded from 2 to just over 8 g/L. A second course of PLEX was administered, with excellent results, and a 3-month course of oral chlorambucil (2 mg/d) was initiated. The patient's condition remained in clinical remission for 10 months. Over the ensuing 9 years, she suffered 11 further flares, each of which was associated with IgA levels of 8 to 10 g/L and each responding dramatically to 3 to 5 PLEXs followed by a consolidative dose of intravenous cyclophosphamide (250-500 mg). CONCLUSION: We believe that PLEX may have an important role in the management of severe erythema elevatum diutinum associated with monoclonal paraproteinemia refractory to other therapy.

An electronic patient record project in the United Kingdom: can it succeed?

The Department of Health in the United Kingdom has set up a three-year research and development project to develop an electronic patient record (EPR). It will be working with clinicians, managers, vendors, and possibly academic informaticians to build two working demonstrators in acute hospitals. Because so many similar projects have failed to meet expectations, a study was commissioned from the Open University in the UK to use the Systems Failures Method, which had been developed in the University to identify factors critical to the successful implementation of an electronic patient record system in acute hospitals. This paper outlines the Electronic Patient Record Project and summarizes the study and its findings.

A double-blind evaluation of topical capsaicin in pruritic psoriasis.

BACKGROUND: Substance P, an undecapeptide neurotransmitter, has been implicated in the pathophysiology of psoriasis and pruritus. OBJECTIVE: Safety and efficacy of topical capsaicin, a potent substance P depletor, were evaluated in patients with pruritic psoriasis. METHODS: Patients applied capsaicin 0.025% cream (n = 98) or vehicle (n = 99) four times a day for 6 weeks in this double-blind study. Efficacy was based on a physician's global evaluation and a combined psoriasis severity score including scaling, thickness, erythema, and pruritus. RESULTS: Capsaicin-treated patients demonstrated significantly greater improvement in global evaluation (p = 0.024 after 4 weeks and p = 0.030 after 6 weeks) and in pruritus relief (p = 0.002 and p = 0.060, respectively), as well as a significantly greater reduction in combined psoriasis severity scores (p = 0.030 and p = 0.036, respectively). The most frequently reported side effect in both treatment groups was a transient burning sensation at application sites. CONCLUSION: Topically applied capsaicin effectively treats pruritic psoriasis, a finding that supports a role for substance P in this disorder.

TARS. Their role in the treatment of psoriasis.

The clinical experience reported by these studies does not definitively answer the question of whether or not all or even most tars are effective in the treatment of psoriasis. Information supports both views. With the present data, the following statements seem appropriate: 1. Tar alone may be helpful for a subset of individuals with mild to moderate psoriasis. Because the majority of patients with psoriasis have less than severe disease, this group numerically represents the majority of office-treated patients. For these patients, tars are not unreasonable to use in appropriate clinical circumstances. 2. Crude coal tar is not likely more beneficial than modified tar or gels. These latter preparations have much better patient acceptance and compliance because of decreased odor, staining, and messiness. 3. Overall, the potential severity of side effects from tars is less than that from anthralin and much less than that from topical corticosteroids (atrophy, rebound). 4. Clinical experience confirms that tar preparations can be effective when other modalities fail or cannot be used for reasons of adverse effects or otherwise. 5. Tar shampoos are considered useful therapeutic agents for active clearing therapy and for maintenance. 6. When combined with suberythemogenic ultraviolet light B, tar can be a useful agent. It has fewer side effects in terms of burning and irritation than does aggressive ultraviolet B therapy alone. The effect of maximal erythemogenic ultraviolet light B therapy is not enhanced with tar. Practically speaking, however, the majority of psoriatic patients do not require, or are not able to avail themselves of, convenient controlled ambulatory ultraviolet light therapy.

A multicentre, parallel-group comparison of calcipotriol ointment and short-contact dithranol therapy in chronic plaque psoriasis.

Short-contact treatment with dithranol (anthralin) is a widely used treatment for chronic plaque psoriasis. Although effective, it causes staining and irritation, and is therefore inconvenient. Calcipotriol is a recently developed vitamin D analogue which is effective and easy to use. To evaluate the relative efficacy, safety and acceptability of these treatments a multicentre, open, randomized, parallel-group comparison was performed. Four hundred and seventy-eight patients with chronic plaque psoriasis were randomized to use one of the two treatments for 8 weeks. One group applied calcipotriol ointment (50 micrograms/g) twice daily. The other used a single application for 30 min each day of Dithrocream in the highest concentration tolerated. Severity of psoriasis was assessed by modified PASI score at baseline, and after 2, 4, and 8 weeks of treatment. A five-point scale was used by subjects and by investigators as an additional assessment of overall response, and a similar scale was used by subjects to grade acceptability. Total serum calcium was monitored at baseline and after 2 and 8 weeks on treatment. The mean PASI score fell from 9.1 to 4.7 after 8 weeks on dithranol (P < 0.001), and from 9.4 to 3.4 on calcipotriol (P < 0.001). The difference between the two treatments was significant in favour of calcipotriol at 2 weeks (P < 0.001), and remained so at subsequent assessments. At 8 weeks the difference between mean improvements in scores for the two groups was 1.6 (95% confidence interval 0.5-2.7). Efficacy grading by subjects and investigators, and acceptability grading by subjects, were all significantly better for calcipotriol.(ABSTRACT TRUNCATED AT 250 WORDS)

Serial passage of murine K-papovavirus in primary cultures of mouse embryo cells. Brief report.

Murine K-papovavirus was serially passaged 10 times in primary cultures of mouse embryo cells, using cell suspensions and media from infected cultures to inoculate fresh flasks at each passage level. Titers of K virus infectivity in cell suspensions and media rose during serial passage, but viral hemagglutinating activity was not detected in cells or media before the 10th passage. Although the infectivity of K virus for mouse embryo cultures was enhanced by serial passage, lethality of the virus for suckling mice was lost. The present study represents the first successful serial transmission of K virus infection in vitro.

Reactivation of persistent papovavirus K infection in immunosuppressed mice.

Papovavirus K (K virus) is a murine papovavirus that produces a fatal interstitial pneumonia in newborn mice and a clinically inapparent infection in older animals. The present study was conducted to determine whether the virus produces latent infection in animals surviving acute infection and whether the infection can be reactivated by immunosuppression. Mice were inoculated by the oral route with 100 newborn mouse 50% lethal doses at 12 days of age and followed for 8 months by using immunofluorescence staining. Cells positive for K virus capsid antigen were found in lungs, livers, kidneys, intestines, and brains for 6 months, but not thereafter. Organ examined at 8 months were negative for virus by tissue culture assay, mouse inoculation, explantation, and cocultivation. Immunosuppression of the remaining animals with 8 weekly injections of cyclophosphamide (150 mg/kg) resulted in the reappearance of viral antigen and infectious virus in multiple organs including brains. The highest titers of virus were present in kidneys. One animal sacrificed after 42 days of immunosuppression was found to have a small pulmonary adenoma or alveologenic carcinoma, but efforts to explant this tumor into tissue culture were unsuccessful. The present study demonstrates that K virus produces a latent infection that is reactivated by immunosuppression, and our results raise questions as to whether reactivated infection may occasionally be associated with the development of neoplasia.

Do interpreters affect consultations?

Mass migration leads to problems with language and cultural integration and has significant medical implications. The effect of interpreters on the diagnosis of mental diseases and ill-defined conditions was investigated in the primary care department of the Riyadh Al Kharj Hospital Programme, Saudi Arabia. Two groups of general practitioners working in the same health centre with the same patients were compared--10 Arabic-speaking and 10 non-Arabic-speaking. No differences in diagnosis were found that could be attributed to the use of interpreters, although there was a significant difference between experienced and less experienced doctors. The reasons for this finding are discussed, along with suggestions for the organization of an interpreting service.

An in vitro assay for K-papovavirus of mice.

Primary cultures of mouse embryo cells were inoculated with K virus, a murine papovavirus, and were examined for cytopathic effect (CPE) of for the development of fluorescent antibody staining specific for K virus V antigen. CPE was not observed. However, numerous cells in infected cultures exhibited positive nuclear fluorescence, and the presence of papovavirus virions was demonstrated by electron microscopy. Extracts from infected cultures produced typical K virus pneumonia in newborn mice. Inoculation of cultures with serial dilutions of virus demonstrated that these cells provide a fluorescent antibody assay for K virus equal in sensitivity to animal inoculation methods. Although specific K virus fluorescence was also detected in cultures of fetal mouse endocardial cells, livers, placentas, and brains, positive cells were much less abundant in these cultures than in cultures of mouse embryo cells. The mouse embryo culture assay described in the present paper represents the first method of measuring K virus infectivity in vitro.