Recovery of Voice After Reconstruction of the Recurrent Laryngeal Nerve and Adjuvant Nimodipine.

BACKGROUND: Transection injury to the recurrent laryngeal nerve (RLN) has been associated with permanent vocal fold palsy, and treatment has been limited to voice therapy or local treatment of vocal folds. Microsurgical repair has been reported to induce a better function. The calcium channel antagonist nimodipine improves functional recovery after experimental nerve injury and also after cranial nerve injury in patients. This study aims to present voice outcome in patients who underwent repair of the RLN and received nimodipine during regeneration. METHODS: From 2002-2016, 19 patients were admitted to our center with complete unilateral injury to the RLN and underwent microsurgical repair of the RLN. After nerve repair, patients received nimodipine for 2-3 months. Laryngoscopy was performed repeatedly up to 14 months postoperatively. The Voice Handicap Index (VHI) was administered, and patients' maximum phonation time (MPT) was recorded during the follow-up. RESULTS: All patients recovered well after surgery, and nimodipine was well tolerated with no dropouts. None of the patients suffered from atrophy of the vocal fold, and some patients even showed a small ab/adduction of the vocal fold on the repaired side with laryngoscopy. During long-term follow-up (>3 years), VHI and MPT normalized, indicating a nearly complete recovery from unilateral RLN injury. CONCLUSIONS: In this cohort study, we report the results of the first 19 consecutive cases at our center subjected to reconstruction of the RLN and adjuvant nimodipine treatment. The outcome of the current strategy is encouraging and should be considered after iatrogenic RLN transection injuries.

Continuous glucose monitoring by intravenous microdialysis: influence of membrane length and dialysis flow rate.

BACKGROUND: The benefit of tight glucose control in the intensive care unit is controversial. Part of the debate is around the frequency of glucose measurements, and therefore, a continuous glucose monitoring system is needed. Previously, we have shown that intravenous microdialysis has the potential for this purpose but that the accuracy must be improved. The aim of this study was to investigate the effects of the microdialysis membrane length and the perfusion rate on improving the accuracy. METHODS: Two volunteer studies were performed, one comparing intravenous microdialysis catheters with different lengths (10 and 20 mm) and one comparing different perfusion rates (0.5, 1 and 2 µl/min) with plasma glucose reference levels. Median values of seven samples taken over 70-min periods were compared using Bland-Altman plots. RESULTS: When microdialysis membranes of 10 and 20 mm perfused at a rate of 1 µl/min were used, the differences with measured plasma glucose levels were 30% ± 21% and 14% ± 13%. In comparison, plasma glucose measured in two different veins gave a difference of 3% ± 3%. In the second study, the differences between measured plasma glucose and that estimated with a microdialysis membrane of 30 mm perfused at 0.5, 1 and 2 µl/min were 8% ± 7%, 25% ± 19% and 39% ± 28%. Bland-Altman analyses gave the best line of equality (-0.11 mM) and the lowest limits of agreement (1.13 and -1.35 mM) when using the 30-mm membrane perfused with 0.5 µl/min. CONCLUSION: The agreement of the intravenous microdialysis with plasma glucose levels improved significantly when increasing the microdialysis membrane length, and thereby the membrane area, and decreasing the perfusion rate.

Neurophysiological evaluation of segmental motor neuron function of the thoracic cord in chronic SCI.

STUDY DESIGN: Pilot study. OBJECTIVES: The aim of the study was to develop a neurophysiological method to diagnose the cranial as well as the caudal level of a complete thoracic spinal cord injury (SCI) with higher precision than today's protocols. SETTING: SCI unit Karolinska University Hospital, Stockholm, Sweden. METHODS: Bipolar needle electromyography was recorded in intercostal spaces of five patients with chronic, complete thoracic SCI. Tests were performed during rest, during voluntary activation and during activation of lower body spasticity. Magnetic resonance imaging (MRI) was performed in each patient according to a protocol optimized for imaging near metal implants. RESULTS: Three distinct patterns were found in each patient. Above the lesion we found voluntary activated, normal motor unit potentials (MUPs). At the neurological level and a varying number of segments below, denervated intercostal segments with fibrillation potentials and positive sharp waves appeared. Below the neurological level, normal MUP activated in concert with lower body spasticity was found. The number of denervated segments showed a significant correlation to the length of spinal cord discontinuity on MRI (r=0.97, P<0.05). CONCLUSION: Intercostal neurophysiology in combination with MRI optimized for imaging near metal implants can be used to determine the extent of a chronic complete thoracic SCI, both anatomically and functionally. The described method increases the sensitivity to detect delicate neurological changes related to the dynamic of the pathology that follows SCI and may be useful in analyzing outcome in clinical trials.

Empirical evidence of underutilization of referrals for epilepsy surgery evaluation.

BACKGROUND: Epilepsy surgery is a treatment that can cure patients with intractable epilepsy. This study investigates whether referrals for epilepsy surgery evaluation are underutilized. METHODS: Patients with epilepsy aged 18-60 years were identified in a computerized registry held by public health care providers in a Swedish county using ICD codes. Clinical data and data on referral status for epilepsy surgery were obtained from the patients' medical records. Potential candidates for epilepsy surgery evaluation were identified using pre-specified criteria. Obstacles for referral were analysed by comparing clinical data in patients who were considered for referral and those who were not. Appropriateness of non-referral was evaluated against recommendations from the Swedish Council on Technology in Health Care (SBU). RESULTS: Of 378 patients with epilepsy in the registry, 251 agreed to participate. Of 251, 40 were already referred patients and 48 patients were identified as potential candidates for epilepsy surgery evaluation by study criteria. Referral had been considered but not performed in 15 of the potential candidates. Potential candidates not considered for referral were less likely to have seen a neurologist, to have had an EEG, CT and MRI, and more likely to have cognitive disturbances. Following the recommendations by the SBU, 28 of 48 potential candidates were identified as inappropriately not referred patients. CONCLUSION: The number of missed referrals for epilepsy surgery evaluation was estimated to be 60 per 100,000 inhabitants. Several important obstacles were found for not referring patients for epilepsy surgery evaluation.

Continuous glucose monitoring by intravenous microdialysis.

BACKGROUND: The conflicting results from studies over tight glucose control in intensive care unit (ICU) patients ask for a continuous on-line real-time glucose monitoring in future. Here, intravenous microdialysis was tested in ICU patients and healthy volunteers. Primary aims were technical feasibility and accuracy. METHODS: A microdialysis catheter was inserted into a peripheral vein. ICU patients (n=10) were studied for up to 5 days. Healthy volunteers (n=6) were studied on one occasion. Recordings were monitored during 70 min each 24-h period to allow for an estimate of variability over time. Microdialysis glucose and lactate were compared with plasma glucose and whole blood lactate. Results are presented as medians (quartiles) of the differences between microdialysis and plasma concentrations over each of the 70-min recording periods. RESULTS: Out of the included ICU patients, no exclusions or early terminations were due to failure of the microdialysis catheter. The concordance was highly variable. The difference of medians over the recording periods differed by -34% (-40, -16) in patients and -22% (-31, -15) for the volunteers. In contrast, the overall variability within the individual measurement periods was low. CONCLUSION: Technical feasibility was good, but the accuracy was not sufficient and the variability between the recording periods was high without calibrations. The non-availability of suitable peripheral veins was a problem in many patients screened but not included in the study. Intravenous microdialysis to obtain continuous on-line real-time glucose monitoring is technically feasible, but accuracy needs to be improved.

The optimal timing of baseline radiostereometric analysis of uncemented press fit cups.

BACKGROUND AND AIMS: The baseline radiostereometric analysis (RSA) is usually performed during the first postoperative week. We investigated the micromotion of two uncemented press fit acetabular cups during the first week after total hip arthroplasty. MATERIAL AND METHODS: All study patients had unilateral osteoarthritis of the hip and received an uncemented THA combination consisting of a CLS stem and either an Allofit or an Interop acetabular cup. The study group consisted of 24 patients who underwent RSA within 1 hour after skin closure, and at 1 and 7 days after surgery. RESULTS: The upper limit of the 95% confidence interval for micromotion was less than or close to the precision of the method for all studied directions during the first week after surgery. Mean values indicate proximal and medial translation of the uncemented cup at one week. CONCLUSIONS: We found only minimal micromotion, barely above the precision limit, measured as medial and proximal translations of these uncemented cups. This indicates that the first postoperative RSA measurement following a primary THA with an uncemented press fit ace-tabular cup should be made as early as possible after the first postoperative day.

Mammography-related breast pain is associated with migraine.

There is little information about the perception of experimentally induced extracephalic pain in migraine. This study investigates the associations between mammography-related pain and migraine. A neurologist clinically assessed 630 women aged 40-74 years attending a population-based breast cancer screening programme. Headache criteria proposed by the International Headache Society were used. Mammography-related pain was measured on a 100-mm visual analogue scale. High levels of mammography-related pain were associated with migraine. This association was related to mammographic examination during the early follicular phase and menopausal status, but unrelated to differences in age, compression pressure, education, current use of hormonal replacement therapy, anxiety, and recent use of analgesics and antimigraine medication. The results of the present study indicate that migraine and compression-induced breast pain are related.

Chemical modification of cyclomaltodextrin glucanotransferase from Bacillus circulans var. alkalophilus.

Counting of integral numbers of cysteine residues of the reduced and denaturated form of cyclomaltodextrin glucanotransferase (CGTase) from Bacillus circulans var. alkalophilus (ATCC 21783) showed two cysteine residues per enzyme molecule. Titrations of the enzyme with 5,5'-dithiobis-(2-nitrobenzoic acid) led to the same result. No free SH-group was detected in denatured form of CGTase, indicating that the two cysteine residues are linked by one disulfide bridge. Cyclizing activity of the GdmCl-denaturated and reduced enzyme was 13% of that of the native one. Incubation of CGTase with diethylpyrocarbonate (DEP) showed a pseudo-first-order inhibition with second-order rate constant of 3.2 M-1 s-1. Reaction with hydroxylamine and spectroscopic studies implied that inactivation of CGTase by DEP is due to modification of one histidine residue concomitantly with a 50% decrease in the cyclizing activity (t1/2 = 10.8 min). The inhibition was partially reversible. CGTase was protected against inactivation by alpha- and beta-cyclodextrins suggesting that the modified histidine residue is at or near the active site. Conversion of starch with DEP-modified enzyme resulted in a decreased formation of cyclodextrins while the relative amount of reducing sugars increased. Preliminary results on modification of CGTase with other reagents, e.g., Woodward's reagent K, 2,3-butanedione and carbodiimide are included.

The role of histidine residues in the catalytic act of cyclomaltodextrin glucanotransferase from Bacillus circulans var. alkalophilus.

Our previous study on cyclomaltodextrin glucanotransferase (CGTase) by chemical modification implied the importance of one or two histidine residues in the cyclization reaction of the enzyme. Based on a computer modelled three-dimensional structure of the CGTase, five histidine residues were chosen as targets for the site-directed mutagenesis. The histidine residues 98, 140, 233 and 327 were replaced by aspartate and His-177 by proline using polymerase chain reaction-mediated techniques. The CGTase variants H98D, H140D, H233D and H327D resulted in a profound decrease in the cyclizing and amylolytic activities, while mutation H177P had little influence on the activities but affected the thermal stability and the width of the pH optimum. It is suggested that His-98 functions as (or as a significant part of) the subsite 2 for the binding of the substrate in CGTase and therefore H98D destabilizes the intermediate for cyclization, but does not markedly affect the hydrolytic reactions. Mutants H140D and H233D produced only minor amounts of alpha-cyclodextrin, did not exhibit substrate inhibition with maltotriose and showed non-Michaelis-Menten kinetics. It is proposed that the variants H140D, H233D and H327D cause steric hindrances near the active center, while mutation H177D has similar consequences on the same site spatially.

Neuronal survival and glial reactions after recurrent laryngeal nerve resection in the rat.

OBJECTIVES/HYPOTHESIS: Complete axonal injury to the recurrent laryngeal nerve (RLN) leads to permanent loss of coordinated function of the intrinsic muscles of the larynx. The aim of the present study was to investigate retrograde reactions, neuronal survival, and glial reactions in the nucleus ambiguus after a distal resection of the RLN to evaluate the potential need for neuroprotective substances. STUDY DESIGN AND METHODS: A segment of the left RLN was resected in 31 adult rats. Before sacrifice of the animals at 2 to 28 days postlesion, the motor neurons in the nucleus ambiguus were retrogradely traced by the use of Fluorogold. Brainstems were isolated and processed for neuron quantification and immunohistochemical analysis. Neuron counts were performed in the nucleus ambiguus on serial sections. Glial reactions were investigated in the nucleus ambiguus using immunohistochemistry. RESULTS: No decrease in the number of motor neurons in the nucleus ambiguus could be demonstrated up to 1 month postlesion. Astroglia and microglia showed increased immunoreactivity at 7 to 14 days postinjury, followed by a slight decline in glial reaction. Microglia revealed no signs of transformation into macrophages during the study period, further indicating the absence of neuronal loss. CONCLUSIONS: Neuronal death does not occur within 1 month postlesion as a result of resection of the RLN in the adult rat, and neuroprotective substances should therefore be of minor value after RLN injury. Glial reactions appear in a similar fashion as after other peripheral nerve lesions not causing neuronal loss.

Nimodipine and microsurgery induced recovery of the vocal cord after recurrent laryngeal nerve resection.

Transection of the recurrent laryngeal nerve leads to permanent palsy of the vocal cord. Experimental studies have confirmed that nimodipine increases the pace of axonal regeneration. We present a case of a 19-year-old male, suffering a thyroid cancer disease, who was subjected to unilateral resection of the recurrent laryngeal nerve during surgery. The nerve was repaired with a nerve graft and the patient further treated with nimodipine for 3 months. Evaluation of the patient showed normalization of voice, movement of the vocal cord on the injured side, and electromyography evidence of reinnervation of the larynx muscles at 15 months after surgery.

Resorbable cement for the augmentation of internally-fixed unstable trochanteric fractures. A prospective, randomised multicentre study.

We undertook a multicentre, prospective study of a series of 112 unstable trochanteric fractures in order to evaluate if internal fixation with a sliding screw device combined with augmentation using a calcium phosphate degradable cement (Norian SRS) could improve the clinical, functional and radiological outcome when compared with fractures treated with a sliding screw device alone. Pain, activities of daily living, health status (SF-36), the strength of the hip abductor muscles and radiological outcome were analysed. Six weeks after surgery, the patients in the augmented group had significantly lower global and functional pain scores (p < 0.003), less pain after walking 50 feet (p < 0.01), and a better return to the activities of daily living (p < 0.05). At follow-up at six weeks and six months, those in the augmented group showed a significant improvement compared with the control group in the SF-36 score. No other significant differences were found between the groups. We conclude that augmentation with calcium phosphate cement in unstable trochanteric fractures provides a modest reduction in pain and a slight improvement in the quality of life during the course of healing when compared with conventional fixation with a sliding screw device alone.

Missense mutations affecting a conserved cysteine pair in the TH domain of Btk.

Tec family protein tyrosine kinases have in their N-terminus two domains. The PH domain is followed by Tec homology (TH) domain, which consists of two motifs. The first pattern, Btk motif, is also present in some Ras GAP molecules. C-terminal half of the TH domain, a proline-rich region, has been shown to bind to SH3 domains. Mutations in Bruton's tyrosine kinase (Btk) belonging to the Tec family cause X-linked agammaglobulinemia (XLA) due to developmental arrest of B cells. Here we present the first missense mutations in the TH domain. The substitutions affect a conserved pair of cysteines, residues 154 and 155, involved in Zn2+ binding and thereby the mutations alter protein folding and stability.

Nimodipine promotes regeneration and functional recovery after intracranial facial nerve crush.

The calcium flow inhibitor, nimodipine, has been shown to promote motor neuron survival in the facial nucleus after intracranial facial nerve transection. However, it has not been known whether the neuroprotective effects primarily involve survival of nerve cell bodies or outgrowth and/or myelination of nerve fibers. Here, we studied the effects of nimodipine in a different injury model in which the facial nerve was unilaterally crushed intracranially. This lesion caused complete anterograde degeneration and partial retrograde degeneration that were studied with a combination of several stereological methods. Nimodipine did not attenuate the modest lesion-induced neuronal loss (13%) but accelerated the time course of functional recovery and axonal regrowth, inducing increased numbers and sizes of myelinated axons in the facial nerve. It is interesting to note that nimodipine also enlarged the axons and the myelin sheaths in the nonlesioned facial nerve, which points to the possibility of using this substance for new clinical applications to promote axonal growth and remyelination.

Bruton tyrosine kinase (BTK) in X-linked agammaglobulinemia (XLA).

X-linked agammaglobulinemia (XLA) is a heritable immunodeficiency disorder that is caused by a differentiation block leading to almost complete absence of B lymphocytes and plasma cells. The affected protein is a cytoplasmic protein tyrosine kinase, Bruton's agammaglobulinemia tyrosine kinase (Btk). Btk along with Tec, Itk, Bmx and Txk belong to a distinct family of protein kinases. These proteins contain five regions; PH, TH, SH3, SH2 and kinase domains. Mutations causing XLA may affect any of these domains. About 380 unique mutations have been identified and are collected in a mutation database, BTKbase. Here, we describe the structure, function, and interactions of the affected signaling molecules in atomic detail.

BTK, the tyrosine kinase affected in X-linked agammaglobulinemia.

X-linked agammaglobulinemia (XLA) is a heritable immunodeficiency disorder that is caused by a differentiation block leading to almost complete absence of B lymphocytes and plasma cells. The affected protein is a cytoplasmic protein tyrosine kinase, Bruton's agammaglobulinemia tyrosine kinase (Btk). Btk along with Tec, Itk and Bmx belong to a distinct family of protein kinases. These proteins contain five regions; PH, TH, SH3, SH2 and kinase domains. Mutations causing XLA may affect any of these domains. About 200 unique mutations have been identified and are collected in a mutation database, BTKbase. Here, we describle, the structure, function, and interactions of the affected signaling molecules in atomic detail.

Complement activation and CD59 expression in the motor facial nucleus following intracranial transection of the facial nerve in the adult rat.

Intracranial transection of the facial nerve has been shown to cause a massive neuronal cell death in the motor facial nucleus. Complement activation has been proposed to contribute to neuronal degeneration following axotomy. Using immunocytochemistry and in situ hybridization we show in the present study that there is complement activation in the facial nucleus after intracranial facial nerve transection as well as increase of the complement regulators CD59 and clusterin. We propose a neuroprotective role for the complement regulators CD59 and clusterin against homologous attack of complement to facial motor neurons.

Complement and clusterin in the spinal cord dorsal horn and gracile nucleus following sciatic nerve injury in the adult rat.

We provide evidence for activation of the complement cascade in the dorsal horn of the spinal cord and in the gracile nucleus in the brainstem following sciatic nerve transection in the adult rat. Immunocytochemical analyses showed immunoreactivity for endogenous immunoglobulin G as shown by immunostaining with F(ab')2 antibodies, as well as complement factors C1, C1q, C3, C3d and C9 in the appropriate central termination areas of the injured sciatic nerve. Results from double labelling immunocytochemistry showed a strong association between immunoglobulin and complement factors on the one hand and reactive microglia on the other. However, some complement immunoreactivity was also found in the neuropil, possibly representing secreted complement. In situ hybridization with an oligonucleotide probe showed a marked increase in C3 messenger RNA, indicating local synthesis of C3 protein. In parallel with activation of complement, there was an increased immunoreactivity for the putative complement inhibitor clusterin, which co-localized with glial fibrillary acidic protein-positive astrocytes. In situ hybridization showed an increased labelling of clusterin messenger RNA. These findings indicate that complement activation and up-regulation of complement inhibitors are prominent central responses to peripheral sensory nerve injury. These responses may therefore be important elements underlying so-called transganglionic degenerative changes in primary sensory axons and terminals.

The novel pyrrolopyrimidine PNU-101033-E improves facial motor neuron survival following intracranial axotomy of the facial nerve in the adult rat.

Neuronal survival is important to functional restitution following axotomy. Proximal lesions of the facial nerve, due to head trauma or tumor growth, for example, may cause long-standing or even permanent facial nerve palsy. Betamethasone has been used by several neurosurgical clinics for the treatment of postoperative facial nerve palsy; however, this practice is based only on clinical experience. The aim of the present study was to explore the putative effect on facial motor neuron survival of a novel lazaroid (pyrrolopyrimidine, PNU-101033-E) and furthermore to compare the effects with those of betamethasone, following intracranial transection of the facial nerve in adult rats. Both agents are known to inhibit lipid peroxidation by free radical scavenging. The lesion model used has recently been reported to induce massive neuronal cell death with a relative survival of 26.8 +/- 11.3% 1 month after lesion. Oral administration of lazaroids or daily injections of betamethasone followed surgery for 1 month, after which quantification of motor neuronal profiles was performed in the facial nucleus. Lazaroid-treated animals showed a significantly enhanced neuronal survival (68.0 +/- 9.8%), whereas no significant difference was found in betamethasone-treated animals (33.1 +/- 11.7%). The microglial and astrocytic responses in the facial nucleus were intense on the operated sides in betamethasone-treated as well as lazaroid-treated animals, and no differences in comparison with untreated animals were found. In conclusion, we found that the novel pyrrolopyrimidine PNU-101033-E, but not betamethasone, significantly enhanced nerve cell survival. This agent may therefore serve as a useful neuroprotective agent following intracranial trauma to the facial nerve and should be further evaluated for clinical use.

Complement activation in the human brain after traumatic head injury.

The complement cascade has been suggested to be involved in the development of secondary brain injuries following brain contusions, based on animal experiments. The aim of the present study was to examine the possible involvement of the complement cascade following traumatic head injury in the human brain. Sixteen patients were included in this study, 12-77 years of age, treated at the neurointensive care unit for traumatic brain contusions. All of these patients were operated with frontal or temporal lobe resection due to intractable intracranial hypertension. The resected tissue was analyzed with regard to components related to complement activation. The time interval between accident and operation was 2-82 h. Brain tissue from three patients operated with hippocampectomy due to epilepsy, including temporal lobe resection, were used as controls. We found increased immunoreactivity for complement components C1q, C3b, and C3d and the membrane attack complex (MAC), C5b-9, in the immediate vicinity of neurons in the penumbra area of the contusion. These findings constitute histological evidence for activation of the complement cascade in the penumbra of cortical contusions in the human brain. Using in situ hybridization, we also found C3-mRNA in the penumbra, suggesting a local synthesis of complement. Furthermore, upregulation of the endogenous complement regulator clusterin was found in some neurons in the same area. We suggest that unknown compounds in the debris from injured neurons or myelin breakdown products trigger complement activation, including formation of C5b-9. Activated complement components may stimulate accumulation of inflammatory cells and formation of brain edema, as well as having membrane destructive effects by the end product MAC, thereby being mediators in the development of secondary brain damage.