Galactose neuropathy. Structural changes evaluated by nuclear magnetic resonance spectroscopy

We examined the hypothesis that the polyol accumulation resulting from chronic galactose supplementation in the diet produces endoneurial edema that can be prevented by inhibition of aldose reductase. We explored the potential of nuclear magnetic resonance (NMR) spectroscopy to quantitate and characterize the water accumulation in the sciatic nerve in this "galactose neuropathy." The data demonstrate a 16% increase in gravimetrically determined total water content of nerve in the galactose-fed rat after 8 mo of this diet and a 50% increase in the T1 relaxation time for nerve water as determined by NMR spectroscopy. Prolongation of the T1 relaxation time reflects increased rotation of water in a magnetic field, consistent with an extracellular site of the additional water. Simultaneous feeding of sorbinil to inhibit aldose reductase resulted in normalization of both total nerve water and of the prolongation of T1 relaxation time. These data define the NMR-spectroscopic state of endoneurial edema in the galactose-fed rat and suggest specific application to the investigation of the role of aldose reductase in human diabetic neuropathy.     

Effect of cigarette smoke on autoimmunity in murine and human systemic lupus erythematosus.

Several studies have found that smoking cigarettes is a risk factor for systemic lupus erythematosus (SLE). To examine this issue in a mouse model, we subjected pre-autoimmune MRL-lpr/lpr mice for 4 weeks to cigarette smoke to provide standardized smoke effluents equivalent to moderate or to heavy smoking habits for people. The spontaneous production of IgG anti-chromatin but not IgM anti-chromatin, anti-denatured DNA, or rheumatoid factor antibodies was lower in mice exposed to 250 mg/m3 particulates from mainstream smoke, and this suppression of autoimmunity was sustained for 8 weeks (p < 0.02). In contrast to control mice anti-chromatin activity in smoke-exposed mice began to increase in 16-week-old mice, reaching levels at 6 months that were two- to three-fold higher than controls for IgG (p < 0.03) and 10-fold higher for IgM (p < 0.001). There was no significant effect on total IgG or IgM. In newly diagnosed SLE patients, smoking was negatively correlated with IgG anti-DNA antibodies (p < 0.03). However, of nine patients who discontinued smoking prior to diagnosis, eight had elevated IgG anti-DNA compared to 29/79 never smokers and 9/31 smokers (p < 0.01 compared to former smokers). Inhaled cigarette smoke appears to have a long-lasting immunosuppressive effect on T-cell-dependent autoimmune responses, although autoantibodies increase to supra-elevated levels after the suppressive effect has abated.     

Surgical safety checklist and operating room efficiency: results from a large multispecialty tertiary care hospital

Background

The Surgical Safety Checklist (SSC) improves patient safety and outcomes; however, barriers to effective use include the perceived negative impact on operating room (OR) efficiency. The purpose of this study was to determine the effect of SSC implementation on OR efficiency.

Methods

All operations at our large multispecialty tertiary care hospital were reviewed for 1-year pre- and 1-year post-SSC implementation. OR efficiency included operating room time, operation time, first starts on time, same-day cancellations, and OR disposable cost.

Results

A total of 35,570 operations were reviewed: 17,204 pre-SSC and 18,366 post-SSC. There was no difference between groups for operating room time (P = .93), operation time (P = .66), first starts on time (P = .15), and same-day cancellations (P = .57). The mean OR disposable cost was significantly lower ($70/operation) for the post-SSC group (P < .01).

Conclusions

The implementation of an SSC does not negatively impact OR efficiency and should not be considered a barrier to effective use. Our data suggest that SSC use can reduce overall cost per surgical procedure.     

A novel technique to study the brain's response to pain: proton magnetic resonance spectroscopy

Glutamate, a major excitatory neurotransmitter, has been implicated as an important mediator in the neurotransmission, potentiation, and negative affect associated with pain. We present results showing that a painful stimulus elicits a dynamic increase in glutamate (9.3% from baseline) concentrations in the anterior cingulate cortex, detectable using proton Magnetic Resonance Spectroscopy ((1)H-MRS). Increases in glutamine levels were also seen, which correlate strongly with the subjective level of pain experienced by participants (r(2) = 0.58, P < 0.01). These novel findings are the first time a dynamic change in glutamate and glutamine levels from baseline in response to an external stimuli has been measured in a single proton MRS scanning session. As such, this report demonstrates the efficacy of (1)H-MRS as a non-invasive tool for the study of neural responses to pain in vivo. The paradigm used in this study demonstrates that dynamic glutamate/glutamine changes due to stimulation are measurable by proton MRS, and could provide a means of testing novel pharmaceutical agents and other treatments for chronic pain.     

Needle phobia and stress-reducing medical devices in pediatric and adult chemotherapy patients.

Needle phobia--fear of medical devices--is a significant problem in pediatric and adult chemotherapy patients. Stress-reducing medical devices is a new, effective cognitive therapy for needle phobia. Twenty-five pediatric and 25 adult chemotherapy patients were randomly exposed to conventional or stress-reducing decorated butterfly needles and syringes. Emotional stress responses were determined with the Visual Aversion Scale, Visual Analogue Fear Scale, Visual Analogue Anxiety Scale, and Visual Overall Stress Score for each needle and syringe design. Sixty-eight percent of the pediatric and 52% of the adult patients were overtly needle phobic, but children demonstrated significantly more aversion and stress (P < .001). Stress-reducing medical devices effectively and significantly reduced aversion, anxiety, fear, and overall stress, and were 76% effective in preventing overt needle phobia in children and 92% effective in adults (P < .001). One hundred percent of children and adults felt that stress-reducing medical devices should be available in chemotherapy clinics. Needle phobia and stress in pediatric and adult chemotherapy patients are significantly reduced by the use of stress-reducing medical devices.     

A randomized, controlled trial of the reciprocating procedure device for local anesthesia

The purpose of this study was to determine whether the new reciprocating procedure device (RPD) is superior to the conventional syringe for the administration of local anesthesia. There were 209 local lidocaine anesthesia procedures randomized between the RDP and the conventional syringe. Outcome measures included administration time, anesthesia pain, procedure pain, and operator satisfaction. The RPD significantly reduced anesthesia administration time by 49% (RPD: 0.68 +/- 0.59 min, Syringe: 1.32 +/- 1.01 min, p < 0.001, 95% confidence interval [CI] for % reduction: 36%-60%), reduced anesthesia pain by 27% (RPD visual analog pain scale score: 4.05 +/- 2.64; Syringe: 5.55 +/- 3.00; p < 0.001, 95% CI 14%-38%), reduced significant procedure pain by 74% (p < 0.001, 95% CI 60%-87%), and improved physician satisfaction by 63% (p < 0.001, 95% CI 53%-74%). The RPD markedly reduces the pain associated with lidocaine anesthesia administration, reduces administration time, and maintains the effectiveness of local anesthesia. The RPD is superior to and significantly more effective than the conventional syringe for the administration of local lidocaine anesthesia.     

Fluid Attenuated Inversion Recovery (FLAIR) imaging in neuropsychiatric systemic lupus erythematosus

OBJECTIVE: To compare fluid attenuated inversion recovery (FLAIR) imaging with proton density/T2 weighted (PD/T2) imaging in neuropsychiatric systemic lupus erythematosus (NPSLE). Magnetic resonance imaging (MRI) is commonly used to evaluate NPSLE. However, the specific role of FLAIR versus conventional PD/T2 methods in NPSLE remains uncertain. METHODS: We studied 28 patients with NPSLE classified using the 1999 American College of Rheumatology Case Definitions for NPSLE. NPSLE disease activity and brain injury were estimated with the neurologic components of SLEDAI and SLICC, respectively. Axial T1, PD/T2, and FLAIR MR images were obtained at 1.5 Tesla. Lesions visible on PD/T2 and FLAIR imaging were quantitated, classified, and the lesion conspicuity was determined. Statistical comparisons were then made between imaging techniques. RESULTS: FLAIR detected significantly more lesions than PD/T2 (p < 0.001), resulting in a 5% greater diagnostic sensitivity, but infarct, leukoencephalopathy, and normal from abnormal were similar between the 2 methods (p > 0.7). Numbers of lesions by FLAIR correlated closely with lesions by PD/T2 (r2 = 0.97, p < 0.0001). Conspicuity of individual lesions by FLAIR was greater than by PD/T2 in cortical, subcortical, and periventricular locations (p < 0.01). Both FLAIR and PD/T2 observations were similarly associated with NPSLE activity and NPSLE brain injury (p < 0.02). CONCLUSION: FLAIR is more sensitive and demonstrates greater lesional conspicuity than conventional PD/T2 in NPSLE. Lesions on FLAIR are more obvious and less likely to be confused with nonlesional structures, thus FLAIR images have obvious advantages for both clinical care and didactic rounds. FLAIR is a reasonable addition to a NPSLE MRI examination, and will increase diagnostic sensitivity by about 5%.     

Depletion of high-energy phosphates in the central nervous system of patients with systemic lupus erythematosus, as determined by phosphorus-31 nuclear magnetic resonance spectroscopy

Systemic lupus erythematosus (SLE) can produce profound disturbances in the central nervous system, characterized by encephalopathy, focal neurologic deficits, cerebral infarction, psychosis, and seizures. We used 31P nuclear magnetic resonance (NMR) spectroscopy to determine the in vivo levels of high-energy phosphates in the central nervous system of 10 patients with SLE and 10 age-matched normal controls. 31P NMR spectroscopy was performed on a 1.5-Tesla unit equipped with a dual-tuned 1H-31P surface coil and a software-directed DRESS (depth resolved surface coil spectroscopy) pulse sequence. This procedure detected ADP, ATP, sugar phosphates, phosphocreatine (PCr), inorganic phosphate, phosphomonoesters, and phosphodiesters in the brain tissue of all study subjects. Levels of ATP in the deep white matter of 10 SLE patients were significantly decreased compared with the levels in 10 normal controls, as quantitated by the ratio of ATP:ATP + ADP (mean +/- SD 0.81 +/- 0.11 versus 0.91 +/- 0.05; P less than 0.02). In a subgroup of 4 patients, PCr levels were decreased to a greater extent than the ATP levels. NMR spectroscopic alterations were not related to obvious anatomic lesions, as determined by standard cranial proton magnetic resonance imaging. In 4 SLE patients with markedly abnormal 31P NMR spectra, treatment with prednisone (80 mg/day) normalized the levels of ATP and PCr. Restoration of a normal 31P profile was accompanied by an obvious improvement in the patients' mental status and clinical symptoms. 31P NMR spectroscopy is a powerful new technique for monitoring high-energy phosphate metabolism, and may be particularly useful for characterizing central nervous system disease in patients with neuropsychiatric SLE.