Multi-channel orbicularis oculi stimulation to restore eye-blink function in facial paralysis.

Facial paralysis due to facial nerve injury results in the loss of function of the muscles of the hemiface. The most serious complication in extreme cases is the loss of vision. In this study, we compared the effectiveness of single- and multiple-channel electrical stimulation to restore a complete and cosmetically acceptable eye blink. We established bilateral orbicularis oculi muscle (OOM) paralysis in eight dogs; the OOM of one side was directly stimulated using single-channel electrical stimulation and the opposite side was stimulated using multi-channel electrical stimulation. The changes in the palpebral fissure and complete palpebral closure were measured. The difference in current intensities between the multi-channel and single-channel simulation groups was significant, while only multi-channel stimulation produced complete eyelid closure. The latest electronic stimulation circuitry with high-quality implantable electrodes will make it possible to regulate precisely OOM contractions and thus generate complete and cosmetically acceptable eye-blink motion in patients with facial paralysis.

Regulation of antioxidant metabolism by translation initiation factor 2alpha.

Oxidative stress and highly specific decreases in glutathione (GSH) are associated with nerve cell death in Parkinson's disease. Using an experimental nerve cell model for oxidative stress and an expression cloning strategy, a gene involved in oxidative stress-induced programmed cell death was identified which both mediates the cell death program and regulates GSH levels. Two stress-resistant clones were isolated which contain antisense gene fragments of the translation initiation factor (eIF)2alpha and express a low amount of eIF2alpha. Sensitivity is restored when the clones are transfected with full-length eIF2alpha; transfection of wild-type cells with the truncated eIF2alpha gene confers resistance. The phosphorylation of eIF2alpha also results in resistance to oxidative stress. In wild-type cells, oxidative stress results in rapid GSH depletion, a large increase in peroxide levels, and an influx of Ca(2+). In contrast, the resistant clones maintain high GSH levels and show no elevation in peroxides or Ca(2+) when stressed, and the GSH synthetic enzyme gamma-glutamyl cysteine synthetase (gammaGCS) is elevated. The change in gammaGCS is regulated by a translational mechanism. Therefore, eIF2alpha is a critical regulatory factor in the response of nerve cells to oxidative stress and in the control of the major intracellular antioxidant, GSH, and may play a central role in the many neurodegenerative diseases associated with oxidative stress.

A computer analysis of reflex eyelid motion in normal subjects and in facial neuropathy.

OBJECTIVE: To demonstrate how computerized eyelid motion analysis can quantify the human reflex blink. DESIGN: Seventeen normal subjects and 10 patients with unilateral facial nerve paralysis were analyzed. BACKGROUND: Eyelid closure is currently evaluated by systems primarily designed to assess lower/midfacial movements. The methods are subjective, difficult to reproduce, and measure only volitional closure. Reflex closure is responsible for eye hydration, and its evaluation demands dynamic analysis. METHODS: A 60Hz video camera incorporated into a helmet was used to analyze blinking. Reflective markers on the forehead and eyelids allowed for the dynamic measurement of the reflex blink. Eyelid displacement, velocity and acceleration were calculated. The degree of synchrony between bilateral blinks was also determined. RESULTS: This study demonstrates that video motion analysis can describe normal and altered eyelid motions in a quantifiable manner. CONCLUSIONS: To our knowledge, this is the first study to measure dynamic reflex blinks. Eyelid closure may now be evaluated in kinematic terms. This technique could increase understanding of eyelid motion and permit more accurate evaluation of eyelid function. Dynamic eyelid evaluation has immediate applications in the treatment of facial palsy affecting the reflex blink. Relevance No method has been developed that objectively quantifies dynamic eyelid closure. Methods currently in use evaluate only volitional eyelid closure, and are based on direct and indirect observer assessments. These methods are subjective and are incapable of analyzing dynamic eyelid movements, which are critical to maintenance of corneal hydration and comfort. A system that quantifies eyelid kinematics can provide a functional analysis of blink disorders and an objective evaluation of their treatment(s).

Sequential segmental neuromuscular stimulation reduces fatigue and improves perfusion in dynamic graciloplasty.

Dynamic graciloplasty is used as a treatment modality for total urinary incontinence caused by a paralyzed sphincter. A problem with this application is undesirable fatigue of the muscle caused by continuous electrical stimulation. Therefore, the neosphincter must be trained via a rigorous regimen to transform it from a fatigue-prone state to a fatigue-resistant state. To avoid or shorten this training period, the application of sequential segmental neuromuscular stimulation (SSNS) was examined. This form of stimulation proved previously to be highly effective in acutely reducing fatigue caused by electrical stimulation. The contractile function and perfusion of gracilis muscles employed as neosphincters were compared between conventional, single-channel, continuous stimulation, and multichannel sequential stimulation in 8 dogs. The sequentially stimulated neosphincter proved to have an endurance 2.9 times longer (as measured by halftime to fatigue) than continuous stimulation and a better blood perfusion during stimulation (both of which were significant changes, p < 0.05). Clinically, this will not antiquate training of the muscle, but SSNS could reduce the need for long and rigorous training protocols, making dynamic graciloplasty more attractive as a method of treating urinary or fecal incontinence.

Sequential segmental neuromuscular stimulation: an effective approach to enhance fatigue resistance.

Electrical stimulation of skeletal muscle flaps is used clinically in applications that require contraction of muscle and force generation at the recipient site, for example, to assist a failing myocardium (cardiomyoplasty) or to reestablish urinary or fecal continence as a neo-sphincter (dynamic graciloplasty). A major problem in these applications (muscle fatigue) results from the nonphysiologic manner in which most of the fibers within the muscle are recruited in a single burst-like contraction. To circumvent this problem, current protocols call for the muscle to be put through a rigorous training regimen to transform it from a fatigue-prone to a fatigue-resistant state. This process takes several weeks during which, aside from becoming fatigue-resistant, the muscle loses power and contraction speed. This study tested the feasibility of electrically stimulating a muscle flap in a more physiologic way; namely, by stimulating different anatomical parts of the muscle sequentially rather than the entire muscle all at once. Sequential segmental neuromuscular stimulation (SSNS) allows parts of the muscle to rest while other parts are contracting. In a paired designed study in dogs (n = 7), the effects of SSNS on muscle fatigability and muscle blood perfusion in gracilis muscles were compared with conventional stimulation: SSNS on one side and whole muscle stimulation on the other. In SSNS, electrodes were implanted in the muscles in such a way that four separate segments of each muscle could be stimulated separately. Then, each segment was stimulated so that part of the muscle was always contracted while part was always resting. This type of stimulation permitted sequential yet continuous force generation. Muscles in both groups maintained an equal amount of continuous force. In SSNS muscles, separate segments were stimulated so that the duty cycle for any one segment was 25, 50, 75, or 100 percent, thus varying the amount of work and rest that any segment experienced at any one time. With duty cycles of 25, 50, and 75 percent, SSNS produced significantly (p < 0.01) enhanced resistance to fatigue. In addition, muscle perfusion was significantly (p < 0.01) increased in these sequentially stimulated muscles compared with the controls receiving whole muscle stimulation. It was concluded that SSNS reduces muscle fatigue and enhances muscle blood flow during stimulation. These findings suggest that using SSNS in clinical myoplasty procedures could obviate the need for prolonged training protocols and minimize problems associated with muscle training.

Gene therapy: trials and tribulations.

The art and science of gene therapy has received much attention of late. The tragic death of 18-year-old Jesse Gelsinger, a volunteer in a Phase I clinical trial, has overshadowed the successful treatment of three children suffering from a rare but fatal immunological disease. In the light of the success and tragedy, it is timely to consider the challenges faced by gene therapy--a novel form of molecular medicine that may be poised to have an important impact on human health in the new millennium.

Retroviral vector targeting to human immunodeficiency virus type 1-infected cells by receptor pseudotyping.

We report the generation of retroviral vectors based on Moloney murine leukemia virus that specifically transduce cells infected with T-cell-tropic human immunodeficiency virus type 1 (HIV-1). This vector was pseudotyped with T-cell-tropic HIV-1 receptors CD4 and CXCR4. We demonstrate that transduction is contingent upon HIV-1 gp120 and gp41 expression.

A demonstration of validity of 3-D video motion analysis method for measuring finger flexion and extension.

This study demonstrates the validity of using 3-D video motion analysis to measure hand motion. Several researchers have devised ingenious methods to study normal and abnormal hand movements. Although very helpful, these earlier studies are static representations of a dynamic phenomenon. Despite the many studies of hand motion using scientifically impeccable techniques, little is known about digital motion, and there are still few researchers investigating dynamic three-dimensional motion of the hand. Results from a three-camera video motion analysis system were compared to those from the "gold standard", 2-D lateral view fluoroscopy. We used these two methods to record hand motion simultaneously during unrestricted flexion and extension of the index finger of the dominant hand in 6 neurologically normal, healthy volunteers. After collection and post-processing, the waveforms of the PIP, DIP and MCP joint angles were compared using the adjusted coefficient of multiple determination (R2(a), or CMD). The mean CMD values for the MCP, PIP and DIP joint angle waveforms were 0.96, 0.98 and 0.94, respectively, suggesting a close similarity between motion of comparable joints analyzed by the 2-D and 3-D methods. This shows that the method of 3-D motion analysis is capable of accurately quantifying digital joint motion. It is anticipated that 3-D motion analysis, in addition to being used as a research tool, will also have clinical applications such as surgical planning in neuromuscular disorders and the documentation of abnormal motion in many other pathological hand conditions.

LFG: an anti-apoptotic gene that provides protection from Fas-mediated cell death.

Programmed cell death regulates a number of biological phenomena, and the apoptotic signal must itself be tightly controlled to avoid inappropriate cell death. We established a genetic screen to search for molecules that inhibit the apoptotic signal from the Fas receptor. Here we report the isolation of a gene, LFG, that protects cells uniquely from Fas but not from the mechanistically related tumor necrosis factor alpha death signal. LFG is widely distributed, but remarkably is highly expressed in the hippocampus. LFG can bind to the Fas receptor, but does not regulate Fas expression or interfere with binding of an agonist antibody. Furthermore LFG does not inhibit binding of FADD to Fas.

Three parameters optimizing closed-loop control in sequential segmental neuromuscular stimulation.

In conventional dynamic myoplasties, the force generation is poorly controlled. This causes unnecessary fatigue of the transposed/transplanted electrically stimulated muscles and causes damage to the involved tissues. We introduced sequential segmental neuromuscular stimulation (SSNS) to reduce muscle fatigue by allowing part of the muscle to rest periodically while the other parts work. Despite this improvement, we hypothesize that fatigue could be further reduced in some applications of dynamic myoplasty if the muscles were made to contract according to need. The first necessary step is to gain appropriate control over the contractile activity of the dynamic myoplasty. Therefore, closed-loop control was tested on a sequentially stimulated neosphincter to strive for the best possible control over the amount of generated pressure. A selection of parameters was validated for optimizing control. We concluded that the frequency of corrections, the threshold for corrections, and the transition time are meaningful parameters in the controlling algorithm of the closed-loop control in a sequentially stimulated myoplasty.

Distal Interphalangeal Joint Arthrodesis Using Intramedullary and Interosseous Fixation.

Multiple fixation techniques have been developed for distal interphalangeal (DIP) joint arthrodesis. Delayed and nonunion rates varying from 0% to 20% have been reported. The senior author has refined a technique for DIP joint arthrodesis by using an intramedullary Kirschner wire and an interosseous wire for fusion of the DIP joint and interphalangeal (IP) joint of the thumb. In 24 joint arthrodeses in 19 patients, the nonunion rate was 4%, and the minor complication rate was 12%. The advantages of this technique include the absence of protruding hardware that would necessitate removal; consistency in achieving osteosynthesis, with a low nonunion rate; and technical simplicity.

The motion path of the digits.

This study investigates whether the path taken by the fingertips of the human hand during unrestricted flexion and extension follows a precise mathematical pattern: an equiangular spiral. Eight normal subjects participated in the study. Subjects performed numerous flexion and extension trials at a random speed. Motion was recorded by a 6-camera, 3-dimensional motion analysis system with 24 retroreflective markers affixed to the dominant hand at predetermined locations. Four hundred eighty flexion-extension arcs were analyzed. We used the coefficient of multiple determination to compare the flexion and extension motion arc of each finger to an equiangular spiral curve derived mathematically. Our results indicate that the path of the hand during flexion and extension closely follows the path of an equiangular spiral with the coefficient of multiple determination values consistently above 0.95.

The initiation and sequence of digital joint motion. A three-dimensional motion analysis.

We studied the initiation and sequence of digital joint motion during unrestricted flexion and extension using a 3-D motion analysis of all fingers moving simultaneously. Our results showed that motion started in a single joint in 83%, of flexion and 80%, of extension cycles. The DIP joint initiated flexion and extension in the index, middle, and ring fingers, but in the little finger, flexion started in the PIP joint, and extension in the MP joint. The two most frequent sequences of joint movement during flexion of the three radial fingers were DIP-PIP-MP and PIP-DIP-MP. The two most frequent sequences during extension of the three radial fingers were DIP-MP-PIP followed by DIP-MP/PIP. In the little finger, however, the most frequent sequences during flexion were PIP-DIP-MP followed by DIP-PIP-MP and during extension, DIP-MP/PIP followed by PIP/DIP-MP.

Generation of targeted retroviral vectors by using single-chain variable fragment: an approach to in vivo gene delivery.

We report the generation of a retroviral vector that infects human cells specifically through recognition of the low density lipoprotein receptor. The rationale for this targeted infection is to add onto the ecotropic envelope protein of Moloney murine leukemia virus, normally trophic for murine cells, a single-chain variable fragment derived from a monoclonal antibody recognizing the human low density lipoprotein receptor. This chimeric envelope protein was used to construct a packaging cell line producing a retroviral vector capable of high-efficiency transfer of the Escherichia coli beta-galactosidase gene to human cells expressing low density lipoprotein receptor. This approach offers a generalized plan to generate cell and tissue-specific retroviral vectors, an essential step toward in vivo gene therapy strategies.

Phenotypic correction of a human cell line (46BR) with aberrant DNA ligase I activity.

Ligation of DNA after replication and repair is a prerequisite for the preservation of DNA and chromosome structure and function. Biochemical studies with Bloom's syndrome cells have revealed an abnormal DNA ligase I activity. However, genetic analysis has not revealed any differences in transcript levels or in the cDNA sequences of DNA ligase I between Bloom's syndrome and normal cells. Another human cell line, 46BR, derived from an immunodeficient patient, also has an abnormal DNA ligase I. This cell line has recently been demonstrated to harbour two different missense mutations, one at each allele of DNA ligase I. These mutations resulted in a decreased ability of partially purified cell extracts to form an enzyme-adenylate reaction intermediate. We show that 46BR hypersensitivity to an alkylating agent, ethyl methanesulphonate, and to the polyADP-ribose polymerase inhibitor 3-aminobenzamide, is rescued by transfection of wild-type DNA ligase I sequences. This provides additional genetic evidence that the defect in 46BR is at the DNA ligase I locus.

Cloning and sequence of a beta-tubulin cDNA from Pneumocystis carinii: possible implications for drug therapy.

This work describes the isolation and characterization of a full-length cDNA clone encoding beta-tubulin from the pathogen Pneumocystis carinii. P. carinii contains a single gene encoding beta-tubulin. The complete sequence of this cDNA has been determined and its inferred amino acid sequence compared with the beta-tubulins from other organisms. This analysis augments the data indicating that P. carinii should be classified as a fungal organism. Further comparisons between the P. carinii beta-tubulin and those of fungal beta-tubulins resistant to benomyl, a beta-tubulin-binding drug, indicate a difference which may be exploited in the development of a new drug therapy for P. carinii pneumonitis. These results suggest that, theoretically, a drug presently administered for treatment of nematode worm infections may be an effective agent against P. carinii, without being toxic to the mammalian host. This possibility is currently being investigated.

Increased factor VIII as an index of vascular injury in cyclosporine nephrotoxicity.

Very high plasma concentrations of factor-VIII-related antigen (RAG) (VIII-RAG) were found in renal allograft recipients during periods of nephrotoxicity induced by cyclosporine. In eight recipients, who were investigated at weekly intervals, levels of factor-VIII-RAG fell toward normal as the dose of cyclosporine was reduced. Plasma levels of C-reactive protein, an acute phase reactant protein, were never raised in these recipients. These findings are further evidence that toxic doses of cyclosporine are associated with vascular injury.