A rare case of Ramsay Hunt syndrome following temporomandibular joint surgery.

Surgical approaches to the temporomandibular joint (TMJ) have been designed specifically to minimize injury to the temporal branch of the facial nerve. In spite of this, facial nerve dysfunction occurs in 1-32% of patients undergoing TMJ surgery. Ramsay Hunt syndrome is characterized by peripheral facial paralysis that often involves other cranial nerves, mostly cranial nerve VIII. The pathology is attributed to the reactivation of latent varicella zoster virus in the geniculate ganglion. The diagnosis is based mostly on history and physical findings. Surgical procedures have been known to reactivate varicella zoster virus, but Ramsay Hunt syndrome subsequent to TMJ surgery has not been described yet. This report describes a case of Ramsay Hunt syndrome associated with TMJ surgery. Because of the relatively high incidence of facial nerve dysfunction associated with TMJ surgery, patients with varicella zoster virus reactivation may initially be misdiagnosed with iatrogenic facial palsy, or vice versa.

Limited mouth opening of unknown cause cured by diagnostic coronoidectomy: a new clinical entity?

Limited mouth opening is a constant annoyance and can be life-threatening should intubation be needed. The causes are numerous and are categorised as intra-articular or extra-articular, which are often difficult to distinguish. We present what we regard as a new clinical entity - long-standing limited mouth opening of unknown cause - and describe our treatment. Four female patients presented with limited mouth opening and lateral and protrusive movements within normal limits, which were typical of restriction of extra-articular origin. However, the radiological findings were within normal limits, with no visible cause of the restriction. All four were treated by bilateral coronoidectomy that resulted in the immediate return of mouth opening to within normal limits that was preserved over subsequent years. Histopathological examination showed atrophy and degenerative changes in the temporalis band that had been attached to the coronoid, which accounts for the stiffness of the temporalis muscle but does not explain the pathogenesis. In the light of this "diagnostic coronoidectomy" further studies are required to document the underlying pathological changes and to develop more accurate imaging that will enable correct diagnosis in future.

An evaluation of computer-aided disproportionality analysis for post-marketing signal detection.

To understand the value of computer-aided disproportionality analysis (DA) in relation to current pharmacovigilance signal detection methods, four products were retrospectively evaluated by applying an empirical Bayes method to Merck's post-marketing safety database. Findings were compared with the prior detection of labeled post-marketing adverse events. Disproportionality ratios (empirical Bayes geometric mean lower 95% bounds for the posterior distribution (EBGM05)) were generated for product-event pairs. Overall (1993-2004 data, EBGM05> or =2, individual terms) results of signal detection using DA compared to standard methods were sensitivity, 31.1%; specificity, 95.3%; and positive predictive value, 19.9%. Using groupings of synonymous labeled terms, sensitivity improved (40.9%). More of the adverse events detected by both methods were detected earlier using DA and grouped (versus individual) terms. With 1939-2004 data, diagnostic properties were similar to those from 1993 to 2004. DA methods using Merck's safety database demonstrate sufficient sensitivity and specificity to be considered for use as an adjunct to conventional signal detection methods.

The effect of corn silage particle size on eating behavior, chewing activities, and rumen fermentation in lactating dairy cows.

The objective of this experiment was to evaluate effects of reducing corn silage particle size on eating behavior, chewing activity, and rumen fermentation in lactating dairy cows. Four cannulated, multiparous cows averaging 110 +/- 4 d in milk and weighing 675 +/- 70 kg were randomly assigned to a 4 x 4 Latin square. During each of four 14-d periods, animals were offered one of four diets that were chemically similar but varied in corn silage particle size: short (SH), mostly short (MSH), mostly long (MLG), and long (LG), with a geometric mean particle length of 7.4, 7.8, 8.3, and 8.8 mm, respectively. Reducing particle size increased dry matter intake (DMI) linearly (28.0, 26.8, 26.8, and 25.7 kg/d for SH, MSH, MLG, and LG respectively). At 8, 16, and 24 h postfeeding, the neutral detergent fiber (NDF) concentration of feed remaining in the bunk decreased linearly with reduced particle size. Time spent eating or ruminating was not different across treatments; however, total chewing activity (TC; sum of time spent eating and ruminating) exhibited a quadratic response with highest chewing activities observed for diets with shortest and longest particle size. Eating or ruminating time per kilogram of DMI was not affected by corn silage particle size, but TC per kilogram of DMI decreased linearly with decreasing particle size. In comparison, when expressed as minutes per unit of NDF intake (NDFI), ruminating, and TC were linearly reduced as particle size decreased. Rumen pH was not affected by corn silage particle size even though total concentration of volatile fatty acids increased linearly from 89.1 mM/L to 93.6 mM/L as diet particle size decreased. A quadratic effect was observed in molar proportion of acetate and propionate with the highest concentration observed in animals consuming diets of intermediate particle size. Results of this experiment suggest that reducing corn silage particle size may increase DMI, positively affect rumen fermentation, and reduce sorting behavior. Because both chewing activity and sorting tendencies increased when proportion of TMR particles > 19.0 mm increased, results suggest that particle size measurement as estimated by the PSPS is useful in understanding some factors that affect feeding behavior.

Technical note--a comparison of methods used to measure eating and ruminating activity in confined dairy cattle.

Detailed knowledge of chewing and rumination activities is critical to fully understand the dietary factors affecting normal rumen function. An automatic system for the digital recording of the jaw movements in free-ranging grazing cattle has been described, but its ability to measure chewing activity of cattle housed in confinement and fed total mixed rations has not yet been evaluated. The eating and ruminating behaviors of eight lactating dairy cows were recorded simultaneously by a wireless automatic system and by 5-min interval observation over 24-h periods. Results indicated that both methods agreed on identification of eating and ruminating bouts. Mean differences between methods for total time eating (8.7 min +/- 12.8) and ruminating (42.9 min +/- 12.0) were significantly different. The time recorded by observation in both eating and rumination was 3.6 and 10.3% higher compared with the automatic system. Differences indicate inaccuracies in the observational method itself. The automatic system may prove useful in further studies examining eating and rumination activities in cattle.

Steroid regulation of octopamine expression during metamorphic development of the moth Manduca sexta.

Octopamine (OA), a biogenic amine similar to norepinephrine, has profound and well-documented actions on the nervous systems of invertebrates. In the insect, Manduca sexta, we examined the developmental plasticity of OA synthesis, studied its endocrine regulation, and observed previously undescribed OA-immunoreactive (ir) neurons. We found that levels of tyramine beta-hydroxylase (TbetaH), an essential enzyme for the biosynthesis of OA, increase during metamorphosis. Based on the established and influential roles of the steroid hormone 20-hydroxyecdysone (20-HE) during development, we tested the hypothesis that increases in TbetaH levels and OA immunoreactivity are regulated by the rise in 20-HE occurring during pupal-adult development. We determined that the levels of TbetaH in the terminal abdominal ganglion (neuromeres 6-9) remain at a constant level during pupal development and the early stages of adult development. Beginning at ca. pupal stage 8, however, the levels of TbetaH begin to rise, reaching a maximum level by pupal stage 12. By removing the source of ecdysteroid hormone through ligation, and by subsequent replacement of 20-HE via infusion, we found evidence indicating that the preadult rise of 20-HE is both necessary and sufficient for the increased levels of TbetaH. During the course of our study, we also identified previously unreported OA-ir neurons. In particular, adult-specific OA-ir lateral cells were found, as were relatively small OA-ir dorsal median pairs that doubled in size during adult development. Abdominal ganglia not exposed to the preadult rise in 20-HE possessed neither the OA-ir lateral neurons nor the somatic growth of the smaller OA-ir median neurons. These newly described OA-ir neurons probably contribute to the steroid-induced elevations of TbetaH observed at the end of metamorphosis.

Characterization and developmental regulation of tyramine-beta-hydroxylase in the CNS of the moth, Manduca sexta.

Octopamine (OA) is present in insect nervous tissue, but little is known about its biosynthesis. In the CNS of Manduca sexta, OA levels increase markedly during postembryonic adult development. To study this increase, we developed an assay for tyramine-beta-hydroxylase, the putatively rate-limiting enzyme for OA biosynthesis. Tyramine-beta-hydroxylase activity in extracts of M. sexta CNS tissue: (1) was time- and protein-dependent, and with protein concentrations up to 2 microg/microl, was linear for 20 min; (2) had a pH optimum of 7.0 for conversion of tyramine to OA; (3) required ascorbate, copper, and catalase; and (4) had an apparent K(M, tyramine) of 0.22+/-0.04 mM. These characteristics resemble those of the mammalian enzyme dopamine-beta-hydroxylase, suggesting that these two enzymes are functionally related. During adult development, tyramine-beta-hydroxylase activity increased 11-fold in the brain and 9-fold in the abdominal ganglia, paralleling increases in OA levels in those CNS structures during metamorphosis. The apparent kinetic constants of tyramine-beta-hydroxylase suggested that the amount of this enzyme present in the tissues increases. The increase in OA levels during adult development thus appears to be due to an increase in the level of enzyme available for OA synthesis and may reflect an increase in the number of octopaminergic neurons.

Polymerase chain reaction used to detect candidemia in patients with candiduria.

OBJECTIVES: Candiduria has been shown to be an early marker of disseminated fungal infection in critically ill patients who have undergone surgery. The management of candidemia and disseminated candidiasis depends on rapid and definitive identification of Candida. Routine or fungus-specific blood cultures are unreliable and require a large quantity of blood for incubation. We describe the importance of the polymerase chain reaction (PCR) procedure in the early detection of candidemia in critically ill patients who develop candiduria and the favorable outcome in treating these patients with systemic antifungal therapy. METHODS: We compared the results of cultures and PCR to detect the presence of C. albicans in the blood of two critically ill patients with clinical candidiasis and candiduria. RESULTS: PCR detected the presence of C. albicans deoxyribonucleic acid (DNA) in urine and blood specimens of both patients in spite of negative blood cultures and did not detect fungal DNA after systemic antifungal therapy. CONCLUSIONS: Candiduria manifests as an early sign of candidemia, and systemic antifungal therapy timed appropriately based on the clinical condition and onset of candiduria will improve outcome. Detection of fungal DNA in blood by PCR is of value in establishing the diagnosis. Additional studies with a larger sample size are required to evaluate the specificity and sensitivity of PCR as a routine diagnostic test for candidemia.

Effect of ethnicity on adherence to diabetic regimen.

OBJECTIVE: Evaluating the effectiveness of treatment of diabetic patients in our institution led us to seek the relationship between adherence to diabetic regimens and several demographic variables. Of primary importance was ethnicity, which the practitioners believed affected adherence. Other variables researched were: marital status, gender, weight, age, type and duration of diabetes, socioeconomic status, occupation and education. PATIENTS: Adult diabetic patients (215) seen in the diabetic clinic of a large health maintenance organization who had their diabetes for at least 6 months. METHODS: Data were collected from interviews and medical records over a two-year period. RESULTS: Ethnicity, the major test variable, did not show a relationship to adherence. Two variables, gender and weight, showed a trend to significant relationship to adherence. Chi square and t tests were used, depending on the type of data. CONCLUSIONS: Since there is no difference in adherence between ethnic groups, standardized care protocols are warranted, since they are cost-efficient.

Characterization of crustacean cardioactive peptide-like immunoreactivity in the horseshoe crab, Limulus polyphemus.

The localization of crustacean cardioactive peptide-like immunoreactivity in the horseshoe crab Limulus polyphemus was investigated with enzyme-linked immunosorbent assay and fluorescence microscopy. Immunoreactivity was quantified in the opisthosomal nervous system (67.7 +/- 11.4 ng/g), cardiac ganglion (45.0 +/- 10.3 ng/g), prosomal nervous system (28.5 +/- 6.6 ng/g), and midgut (24.6 +/- 6.7 ng/g). In the brain, immunoreactive somata were observed in ganglion cells of the central body, in the medullary group and within the ventral medial group. Clusters of immunoreactive cells were found in each of the circumesophageal, pedal ganglia, and in the opisthosomal, abdominal ganglia. In the periphery, immunoreactive varicose fibers were observed in branches of the intestinal nerves, and near longitudinal and circular muscle fibers of the midgut. Immunoreactivity was observed in the cardiac ganglion and myocardium of the neurogenic heart. Synthetic crustacean cardioactive peptide had slight excitatory effects on the cardiac rhythm at doses up to 10(-6) M. This peptide had excitatory effects on the midgut at nanomolar doses. Ventral nerve cord extracts were partially purified with reverse phase high performance liquid chromatography. Two regions of immunoreactivity were detected, one of which coeluted with the authentic peptide. The distribution of crustacean cardioactive peptide immunoreactivity is compared with other transmitter systems in the Limulus nervous system, and myotropic actions of this peptide are discussed with respect to peptidergic modulation of intestinal motility.

Crustacean cardioactive peptide in the sphinx moth, Manduca sexta.

The isolation, identification, and actions of crustacean cardiactive peptide (CCAP) have been examined in the sphinx moth Manduca sexta. A sensitive and specific enzyme-linked immunosorbent assay (ELISA) was used to quantify CCAP-like immunoreactivity in the nervous system. The CCAP-like immunoreactivity from the abdominal CNS was then purified, and its sequence was ascertained by amino acid analysis, mass spectral analysis, and HPLC. These studies showed that the nervous system of M. sexta contains a peptide with the sequence Pro-Phe-Cys-Asn-Ala-Phe-Thr-Gly-Cys-NH2, identical to CCAP originally isolated and sequenced from the shore crab Carcinus maenas. The actions of CCAP on the isolated heart of M. sexta and the extensor-tibia muscle of Schistocerca americana were tested. Crustacean cardioactive peptide had excitatory actions on both preparations: a dose-dependent increase in the rate of contractions was observed on the heart, and an increase in the rate of the myogenic rhythm was observed in the leg muscle. Moreover, purified and synthetic CCAP had identical effects on the isolated heart. We conclude that CCAP occurs in M. sexta and exerts potent neurotransmitter or neurohormonal actions on a variety of muscles.

Anti-tumor activity of a blocked ricin immunotoxin with specificity against the cluster-5A antigen associated with human small-cell lung cancer.

The monoclonal antibody (MAb SEN31, a mouse IgG1 which recognizes the cluster-5a antigen on small-cell lung cancer (SCLC) cells, was used to prepare a selective and potent blocked ricin immunotoxin. In a series of experiments in vitro and in a SCLC xenograft model in nude mice, the tumor localization potential of the radiolabeled antibody SEN31 and the anti-tumor activity of the immunotoxin SEN31-bR, the non-specific binding activity of which had been greatly reduced by blocking of the galactose binding domains of the B-chain, was determined. Radiolabeling of SEN31 was performed by linking a 67Ga-labeled desferrioxamine moiety to the oligosaccharide side chains of the antibody in order to preserve the specific cell-binding activity. 67Ga-SEN31 bound to the antigenic sites on cells of the SW2 SCLC cell line, with a dissociation constant of 3.5 nM and, when injected i.v., selectively localized at the site of s.c.-growing SW2 tumor xenografts in nude mice, with a tumor-to-blood ratio of 3.5. The immunotoxin SEN31-bR was potently and selectively active against SCLC cell lines both of classic and of variant morphologies. At a concentration of 300 pM the immunotoxin selectively eliminated 4.5 logs of clonogenic tumor cells. In nude mice, SEN31-bR was cleared from the blood with biphasic kinetics following i.v. injection and maintained a stable serum level during continuous i.p. infusion. The growth of s.c. SW2 solid-tumor xenografts was delayed following a single i.v. injection or a continuous i.p. infusion, each at a non-toxic dose.

Nurse practitioner managed care for persons with HIV infection.

This exploratory study examined whether outcomes of care for HIV-infected patients are related to whether the patient's primary provider is a physician (MD) or a nurse practitioner (NP). Functional status, symptom occurrence, self management, health service use and patients' assessment of their care were evaluated for 87 HIV-infected patients in a teaching hospital outpatient setting. NP patients were three times as likely to report their health status as only fair or poor (odds-ratio = 3.06, p = .028), and reported significantly more unpleasant symptoms over a four-week period. Despite being in poorer health than patients cared for by physicians, NP patients functioned at comparable levels and used no more health care services than MD patients. NP patients reported 45 percent fewer problems with their care (p = 0.003). Findings suggest that more extensive use of nurse practitioners could safely enhance access to care for persons with HIV-related illnesses.

First time experiences in infancy: when they appear to be pleasant, do they activate the adrenocortical stress response?

The effect of a positive first-time experience on adrenocortical activity was examined in 48 6- to 13-month-old infants who took part in two sessions of a YMCA-like mother-infant swim class. Experience was manipulated by comparing Novice swimmers with infants who previously had taken a swim class, and by examining responses to first versus second class session. In addition, the effects of temperamental fear of novelty were examined by maternal report prior to the first session. Preswim and Postswim cortisol levels were compared to measures obtained at the same time of day in two comparison groups, one tested at home and one tested in a playroom at the University. The results yielded no evidence of an adrenocortical stress response (elevated cortisol) to the swim sessions for either the Novice or Experienced swimmers. Infant temperamental fearfulness predicted behavioral but not adrenocortical responses during swimming. Postswim cortisol levels were significantly lower than posttest levels in the two baseline comparison groups, and lower postswim cortisol levels were associated with less negative and more positive emotional behavior and engagement of the swimming experience. These results are consistent with the hypothesis that emotions serve as a major pathway influencing adrenocortical activity, and provide no support for the uncertainty hypothesis of adrenocortical activation.