Brachial amyotrophic diplegia: a slowly progressive motor neuron disorder.

OBJECTIVE: To describe a sporadic motor neuron disorder that remains largely restricted to the upper limbs over time. BACKGROUND: Progressive amyotrophy that is isolated to the upper limbs in an adult often suggests ALS. The fact that weakness can remain largely confined to the arms for long periods of time in individuals presenting with this phenotype has not been emphasized. METHODS: We reviewed the records of patients who had a neurogenic "man-in-the-barrel" phenotype documented by examination at least 18 months after onset. These patients had severe bilateral upper-extremity neurogenic atrophy that spared lower-extremity, respiratory, and bulbar musculature. RESULTS: Nine of 10 patients meeting these criteria had a purely lower motor neuron disorder. During follow-up periods ranging from 3 to 11 years from onset, only three patients developed lower-extremity weakness, and none developed respiratory or bulbar dysfunction or lost the ability to ambulate. CONCLUSION: Patients presenting with severe weakness that is fully isolated to the upper limbs, without pyramidal signs, may have a relatively stable variant of motor neuron disease.     

P2u receptor-mediated release of endothelium-derived relaxing factor/nitric oxide and endothelium-derived hyperpolarizing factor from cerebrovascular endothelium in rats

BACKGROUND AND PURPOSE: Stimulation of P2u purinoceptors by UTP on endothelium dilates the rat middle cerebral artery (MCA) through the release of endothelium-derived relaxing factor/nitric oxide (EDRF/NO) and an unknown relaxing factor. The purpose of this study was to determine whether this unknown relaxing factor is endothelium-derived hyperpolarizing factor (EDHF). METHODS: Rat MCAs were isolated, cannulated, pressurized, and luminally perfused. UTP was added to the luminal perfusate to elicit dilations. RESULTS: Resting outside diameter of the MCAs in one study was 209+/-7 micrometer (n=10). The MCAs showed concentration-dependent dilations with UTP administration. Inhibition of NO synthase with NG-nitro-L-arginine methyl ester (L-NAME) (1 micromol/L to 1 mmol/L) did not diminish the maximum response to UTP but did shift the concentration-response curve to the right. Scavenging NO with hemoglobin (1 or 10 micromol/L) or inhibition of guanylate cyclase with ODQ (1 or 10 micromol/L) had effects on the UTP-mediated dilations similar to those of L-NAME. In the presence of L-NAME, dilations induced by 10 micromol/L UTP were accompanied by 13+/-2 mV (P<0.009) hyperpolarization of the vascular smooth muscle membrane potential (-28+/-2 to -41+/-1 mV). Iberiotoxin (100 nmol/L), blocker of the large-conductance calcium-activated K channels, sometimes blocked the dilation, but its effects were variable. Charybdotoxin (100 nmol/L), also a blocker of the large-conductance calcium-activated K channels, abolished the L-NAME-insensitive component of the dilation to UTP. CONCLUSIONS: Stimulation of P2u purinoceptors on the endothelium of the rat MCA released EDHF, in addition to EDRF/NO, and dilated the rat MCA by opening an atypical calcium-activated K channel.     

Migration of schwann cells in peripheral-nerve regeneration

Schwann cells play a central role in peripheral-nerve regeneration, in which it has been shown that the addition of exogenous Schwann cells enhances the temporal and spatial sequence of events observed in regeneration. In this study, the authors investigated the fate of exogenous cells in this process by using fluorescently tagged autogenous Schwann cells in an established rat model of peripheral-nerve regeneration. Tracking labeled cells over a 4-week period revealed early migration of Schwann cells into the proximal nerve segment, followed by a concentration of migrating Schwann cells, leading the proximal growth cone throughout the regenerative process. The early proximal distribution of labeled cells suggests active migration in response to nerve damage, with spatial localization at the center of the proximal nerve segment and not the epineural surface. These observations demonstrate an interaction of exogenous Schwann cells with intact nerve tissue in vivo and affirm their role in the directional growth of regenerating axons.     

Radiographic staging of juvenile angiofibroma

A staging system for juvenile angiofibroma based on computerized tomographic findings is suggested. The need for such an endeavor has come about because of a lack of standardization of tumor data in both individual series and interinstitutional reports. The various stages reflect the number of anatomic sites occupied by a lesion rather than the actual tumor size. The "simpler" tumors are confined to the medial part of the skull base and are entirely extracranial. As a tumor extends laterally and/or intracranially, the staging designation, and therefore the treatment plan, changes accordingly. Presumably, with the application of consistent diagnostic tools and standardized stage designations, the analysis of both morbidity and treatment data will become more meaningful.     

The extraneuronal compartments for the distribution of isoprenaline in the rat heart

The distribution of 3H-isoprenaline in the perfused rat heart was re-examined. After initial loading with 3H-isoprenaline hearts were washed out with amine-free solution; the efflux curves were subjected to the peeling technique, and half times for efflux and compartment sizes were determined. In contrast to earlier reports from his department (B?nisch et al. 1974;l B?nisch 1978), 3H-isoprenaline was found to distribute mainly into one extra-neuronal compartment, irrespective of whether COMT was intact or inhibited (by the presence of U-0521). It was also not influenced by pretreatment of the animals with reserpine. This type of distribution was influenced neither by the concentration of isoprenaline nor by the duration of the loading of the tissue with the amine. The one major extra-neuronal distribution compartment of 3H-isoprenaline has the characteristics of the "old" compartment III: it has a relatively short half time for the efflux of 3H-isoprenaline and it has a high activity of COMT. Moreover, corticosterone inhibits the inward and outward flux of 3H-isoprenaline into and from compartment III. The Ki for the inhibition by corticosterone of the efflux of 3H-isoprenaline (2 mumol/l) is very similar to the Ki for impairment of uptake2 (determined by B?nisch 1978). Apart from the major distribution compartment III, two minor distribution compartments were detected: On the one hand, experiments with hearts which had an intact COMT revealed that a minor distribution compartment IV (characterized by a long half time for efflux and by an absence of COMT activity) may exist, although its magnitude does not exceed one tenth of the former compartment IV. In addition, part of the quickly equilibrating (and rather small) compartment II was corticosterone-sensitive. When the results of Azevedo et al. (1983 are considered together with the present results, compartment III appears to represent the uptake of 3H-isoprenaline into myocardial cells, while it is likely that radioactivity accumulated in the smooth muscle of blood vessels may constitute the corticosterone-sensitive part of compartment II.     

Economic evaluation of treatments for respiratory disease

Considerable quantities of health service resources are being devoted to tackling the problems posed by respiratory diseases and this can be expected to continue as the prevalence of such diseases increases. This paper provides an assessment of the most efficient use of these healthcare resources by reviewing the literature on economic evaluation relating to interventions in the field of respiratory medicine. Currently, this literature largely comprises cost-minimisation studies of both management and educational interventions. Asthma educational interventions, whether targeted at adults or children, appear to be effective in improving patient self-management and adherence to medications, and appear to be associated with a lower overall use of healthcare resources. In terms of management interventions the overall picture is rather less clear although there is some support for the greater efficiency of patient administration of beta-adrenergic agonists by metered dose inhalers over therapist-administered up-draft nebulisation. Two features of respiratory disease make evaluation in this field somewhat unusual: there are alternative methods of delivering therapy to patients, which makes patient compliance an important issue, and since most respiratory diseases are chronic conditions the long-term effectiveness of interventions must be assessed. The scarcity of cost-effectiveness and cost-utility studies in this field may, in part, reflect the difficulties of measuring outcomes in respiratory disease.     

Transparent blocks—an aid in simulation

The use of standard cutouts made of pressed wood¹ and lead solder is advocated for treatment simulation of blocked fields. The advantages offered are the ability to see “through” the block and the capability of planning simple or complex blocking within the limits of existing lead block shapes.     

Improved freedom from PSA failure with whole pelvic irradiation for high-risk prostate cancer

Purpose: To determine the impact of whole pelvic irradiation on the risk of PSA failure in prostate cancer patients, at high predicted risk for lymph node involvement, receiving definitive radiotherapy.

Materials and Methods: Between October 1987 and December 1995, 506 patients with clinically localized prostate cancer were treated with definitive radiotherapy at UCSF and affiliated institutions. Treatment consisted of 4-field whole pelvic irradiation followed by a prostate-only boost, or prostate-only treatment (median follow-up was 35 months and 30 months, respectively). PSA failure was defined as: 1. a PSA value ≥ 1 ng/ml; or 2. a PSA value that rose ≥ 0.5 ng/ml in ≤ 1 year posttreatment on two consecutive measurements, with the first rise defined as the time of failure. The calculated risk of lymph node positivity (%rLN+) was defined as (iPSA) + 10(GS-6), and high risk was defined as %rLN+ ≥ 15%. Univariate and multivariate analyses were performed.

Results: A total of 201 high-risk patients were identified. High-risk patients who received whole pelvic irradiation had significantly improved freedom from PSA failure compared to those who received prostate-only treatment (median PFS = 34.3 months vs. 21.0 months; p = 0.0001). Potential confounding variables, including initial PSA, Gleason score, T stage, radiation dose, year of treatment, use of three-dimensional (3D) conformal techniques, and use of hormone therapy, did not account for the observed difference in time to PSA failure. Multivariate analysis revealed type of radiation treatment to be the most significant independent predictor of outcome.

Conclusion: Whole pelvic radiotherapy significantly improves the PSA failure-free survival in patients with a high calculated risk of lymph node positivity.