A Panel Interview on the Ethical Practice of Neuropsychology

Neuropsychologists who have considerable experience reflecting, presenting, publishing, and advising on ethical matters are a rich resource for clinicians who have ethics questions. Consultation with such colleagues can be an important part of the ethical decision-making process. The purpose of the present article is to provide the opinions and perspectives of three neuropsychologists who, based on their experience and scholarly activities, served as panelists regarding ethical matters. Although the advice and opinions of colleagues are not a substitute for familiarity with relevant ethical requirements, guidelines, and professional literature, they offer valuable information that enhances the ethical decision-making process.     

Liver transplantation for acute liver failure in a SARS-CoV-2 PCR-positive patient

Current guidelines recommend deferring liver transplantation (LT) in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection until clinical improvement occurs and two PCR tests collected at least 24 hours apart are negative. We report a case of an 18-year-old, previously healthy African-American woman diagnosed with COVID-19, who presents with acute liver failure (ALF) requiring urgent LT in the context of SARS-CoV-2 polymerase chain reaction (PCR) positivity. The patient was thought to have acute Wilsonian crisis on the basis of hemolytic anemia, alkaline phosphatase:bilirubin ratio <4, AST:ALT ratio >2.2, elevated serum copper, and low uric acid, although an unusual presentation of COVID-19 causing ALF could not be excluded. After meeting criteria for status 1a listing, the patient underwent successful LT, despite ongoing SARS-CoV-2 PCR positivity. Remdesivir was given immediately posttransplant, and mycophenolate mofetil was withheld initially and the SARS-CoV-2 PCR test eventually became negative. Three months following transplantation, the patient has made a near-complete recovery. This case highlights that COVID-19 with SARS-CoV-2 PCR positivity may not be an absolute contraindication for transplantation in ALF. Criteria for patient selection and timing of LT amid the COVID-19 pandemic need to be validated in future studies.     

Alteplase stability and bioactivity after low-power ultrasonic energy delivery with the OmniSonics resolution system

PURPOSE: Low-power ultrasonic (US) energy is capable of clot dissolution in vivo. The combination of US energy plus alteplase may further accelerate clot lysis; however, the effects of cavitation could potentially denature and inactivate the lytic protein. The purpose of this study was to determine the bioactivity and stability of alteplase when exposed to US energy with use of a novel intravascular US wire in an in vitro model. MATERIALS AND METHODS: The model consisted of a 6.4-mm-diameter silicone tube closed at one end and filled with alteplase (1 mg/mL) in a water bath (37 degrees C). A 95-cm US wire (0.025-inch diameter, 20 kHz) was inserted into the tube and connected to a variable power generator. The wire delivers low-power acoustic energy 360 degrees around its 20-cm active length and was irrigated by a continuous infusion of purified water. Fresh 6-mL alteplase aliquots were exposed to US energy and tested in duplicates. Zero (control), 1 W, or 2 W of energy was delivered to individual test samples for zero (control), 0.5, 3, or 6 minutes. Alteplase samples were assayed for optical clarity and protein concentration with use of UV spectrophotometry, for percent protein monomer with use of high-performance size-exclusion chromatography, and for in vitro clot lysis activity. RESULTS: In the control samples, optical clarity was clear or colorless in all samples; protein concentration was 1.02 mg/mL +/- 0; protein monomer was 98%; and clot lysis activity was 108% per mg +/- 1. In the test samples, optical clarity was clear or colorless in all samples; protein concentrations at 0.5, 3, and 6 minutes were 0.98 mg/mL +/- 0.02, 0.93 mg/mL +/- 0.01, and 0.86 mg/mL +/- 0.02, respectively, at 1 W, and 1.00 mg/mL +/- 0.03, 0.94 mg/mL +/- 0.10, and 0.84 mg/mL +/- 0.17, respectively, at 2 W. Protein monomer was 98% for all samples. Clot lysis activity levels at 0.5, 3, and 6 minutes were 111% per mg +/- 1, 110% per mg +/- 1, and 115% per mg +/- 1, respectively, at 1 W, and 110% per mg +/- 0, 111% per mg +/- 1, and 116% per mg +/- 2, respectively, at 2 W. CONCLUSIONS: Alteplase solutions exposed to low-power US energy for as long as 6 minutes remained fully active and stable as determined by protein assays. Further investigation is warranted with use of combinations of US energy and alteplase.     

Direct assay for testosterone in saliva: relationship with a direct serum free testosterone assay

A direct non-extraction radioimmunoassay for salivary testosterone is described using a modified commercial kit procedure that is in use for total serum testosterone (T). Serum free testosterone was also measured by direct radioimmunoassay. A significant correlation (r = 0.83, p less than 0.01, n = 194) was obtained between salivary and serum free testosterone in matched serum and saliva samples over a wide range of concentrations. Within- and between-batch precision for the salivary testosterone method was 11% and 18%, respectively at a concentration of 170 pmol/l. Recovery of added T was 89% +/- 15% (mean +/- 2 SD) dilution of high samples showed parallelism. Salivary testosterone measured by direct radioimmunoassay offers a simple cheaper alternative to serum free testosterone measurement with the additional advantages of a stress-free non-invasive sampling procedure.     

Effect of massage technique on sentinel lymph node mapping for cancer of the breast

Sentinel lymph node (SLN) mapping has substantially changed the nature of surgery for cancer of the breast. Variables such as tracer type, volume, injection site, timing, and surgical experience have all been extensively evaluated. However, little attention has been paid to the technique of massage for SLN procedures. We sought to evaluate the effects of three different massage techniques on mapping success or accuracy of SLN mapping for breast cancer. All lymphatic mapping procedures for breast cancer at our tertiary-care center were performed by three experienced surgeons using both colloid and dye followed by a 5-minute massage. All data pertaining to SLN identification, histopathology, tumor characteristics, and patient demographics were entered into the Breast Care Center database. Consistent and uniquely differing massage techniques classified as resuscitative, buffer, or knead-like were each used by a specific surgeon. The last 25 consecutive cases performed by two surgeons and the last 24 by one surgeon were evaluated. The overall rate of SLN identification was 97 per cent, and the overall accuracy was 98.7 per cent. There was no statistically significant difference in the rate of SLN identification or accuracy between techniques. The proportions of blue-stained SLNs were similar, but the resuscitative technique yielded fewer hot SLNs (Fisher's exact test, P = 0.02). This method also yielded one false negative case. The three different massage techniques yielded a similar number of blue-stained SLNs. The resuscitative technique yielded fewer hot SLNs than the kneading and buffer methods. Our results failed to demonstrate a superior breast massage technique for identifying sentinel nodes. A larger randomized trial is needed to confirm these findings.     

Intracellular mechanisms involved in the stimulation of growth hormone release from rat anterior pituitary cells by Russell's viper venom.

We have previously shown that a heat-stable component of Russell's viper venom (RVV) releases GH in a dose-dependent manner from cultured rat anterior pituitary cells. We have now investigated the intracellular mechanisms involved in RVV-stimulated GH release by concomitant administration of RVV with known intracellular mediators in rat pituitary cells. 3-Isobutyl-1-methylxanthine (IBMX; 0.5 mmol/l), added to cultured rat anterior pituitary cells simultaneously with RVV, at concentrations up to a maximally effective dose of 10 micrograms/ml, increased GH release (3.7-fold, 4.0-fold and 2.0-fold; P less than 0.001) compared with the effect of venom alone. These effects were additive, indicating that RVV and IBMX stimulate through different intracellular messengers. RVV failed to increase the formation of basal or IBMX-stimulated intracellular cyclic AMP (cAMP), confirming that RVV affects GH release through a cAMP-independent pathway. 12-0-Tetradecanoylphorbol-13-acetate (TPA; 0.1 mumol/l), added simultaneously with various doses of RVV (0.1-10 micrograms/ml), did not increase GH release beyond the maximal effect of RVV. This result indicates that RVV might be stimulating GH release through a similar mechanism to that of TPA (by activating protein kinase C). When pituitary cells were perifused with Ca(2+)-free medium or verapamil (50 mumol/l), RVV-stimulated GH release was inhibited by 65 and 42% respectively. This reflects the recognized requirement of Ca2+ for secretory processes. However, RVV (10 micrograms/ml) had no significant effect on intracellular free Ca2+ concentrations as measured using the fluorescent Ca2+ probe quin-2.(ABSTRACT TRUNCATED AT 250 WORDS)     

Flow cytometric analysis of functional anterior pituitary cells from female rats

Laser-light scatter signals generated from living cells provide useful information with regard to both cell size (forward-angle light scatter) and granularity (ninety-degree or perpendicular light scatter). By measuring angles of light scatter and fluorescence, a fluorescence-activated cell sorter is capable of analysing and sorting cells on the basis of their size, granularity and cell-surface fluorescence. Using an electronically programmable individual cell sorter we were able to analyse single, viable, dispersed anterior pituitary cells of the female rat on the basis of their laser light scatter characteristics. Two distinct populations of differing granularity were defined: 26 +/- 2.2% (mean +/- S.E.M.) were more granular and 74 +/- 3.5% less granular. Acutely dispersed anterior pituitary cells were labelled with antibodies against four of the anterior pituitary hormones, and cell size and granularity were compared amongst the different hormonal cell types. Somatotrophs were the most granular cell type, gonadotrophs were the largest and corticotrophs the smallest, whilst lactotrophs were of intermediate size. Labelling was demonstrated to be dependent upon the secretory state of the cell. Hypothalamic stimulating factors increased cell-surface labelling, whilst dopamine and somatostatin decreased labelling. These changes compare favourably with published data obtained by immunocytochemistry. Using dual-colour fluorescence cell surface labelling we were unable to define a population of cells secreting both prolactin and growth hormone (mammosomatotrophs).     

Reliability of assessing the coronal curvature of children with scoliosis by using ultrasound images

Purpose

To investigate the intra- and inter-observer reliability of the coronal curvature asymmetry of children with adolescent idiopathic scoliosis (AIS) using the center of lamina (COL) method on ultrasound (US) images.

Methods

A cadaver spinal column phantom which was manipulated to present 30 scoliotic curves of varying severity of scoliotic deformities was scanned using both the US and laser scanner (LS) systems. Three observers of varying experience and skill measured the coronal curvature using the Cobb method on the LS images and the COL method on the US images. All of the measurements were performed twice, with a 1-week interval to reduce memory bias. The intra-class correlation coefficient (ICC), the mean absolute differences (MAD), and the error index (EI) were calculated to determine the agreement on selecting the end vertebrae. In addition, five AIS subjects were scanned using the US system. One observer measured the coronal curvature on the US images twice, and the measurements were compared with the Cobb angle reported in the clinical records.

Results

In the phantom study, the COL method showed high intra- and inter-observer reliabilities, with all ICC values >0.88. The maximum MAD of the COL measurements between different sessions among all observers was <4.1°. The EI values of the US method had similar end-vertebra selections as the LS method. The results of the pilot study showed a high intra-reliability for the US measurements. The measured difference between the Cobb and COL methods was 0.7° ± 0.5°.

Conclusions

The COL method using US images appears to be a very reliable method for measuring the coronal curvature in AIS without the need to expose the patient to radiation.