Epileptogenic Tubers Are Associated with Increased Kurtosis of Susceptibility Values: A Combined Quantitative Susceptibility Mapping and Stereoelectroencephalography Pilot Study.

BACKGROUND AND PURPOSE: Prior studies have found an association between calcification and the epileptogenicity of tubers in tuberous sclerosis complex. Quantitative susceptibility mapping is a novel tool sensitive to magnetic susceptibility alterations due to tissue calcification. We assessed the utility of quantitative susceptibility mapping in identifying putative epileptogenic tubers in tuberous sclerosis complex using stereoelectroencephalography data as ground truth. MATERIALS AND METHODS: We studied patients with tuberous sclerosis complex undergoing stereoelectroencephalography at a single center who had multiecho gradient-echo sequences available. Quantitative susceptibility mapping and R2* values were extracted for all tubers on the basis of manually drawn 3D ROIs using T1- and T2-FLAIR sequences. Characteristics of quantitative susceptibility mapping and R2* distributions from implanted tubers were compared using binary logistic generalized estimating equation models designed to identify ictal (involved in seizure onset) and interictal (persistent interictal epileptiform activity) tubers. These models were then applied to the unimplanted tubers to identify potential ictal and interictal tubers that were not sampled by stereoelectroencephalography. RESULTS: A total of 146 tubers were identified in 10 patients, 76 of which were sampled using stereoelectroencephalography. Increased kurtosis of the tuber quantitative susceptibility mapping values was associated with epileptogenicity (P = .04 for the ictal group and P = .005 for the interictal group) by the generalized estimating equation model. Both groups had poor sensitivity (35.0% and 44.1%, respectively) but high specificity (94.6% and 78.6%, respectively). CONCLUSIONS: Our finding of increased kurtosis of quantitative susceptibility mapping values (heavy-tailed distribution) was highly specific, suggesting that it may be a useful biomarker to identify putative epileptogenic tubers in tuberous sclerosis complex. This finding motivates the investigation of underlying tuber mineralization and other properties driving kurtosis changes in quantitative susceptibility mapping values.

Pasture-derived greenhouse gas emissions in cow-calf production systems.

There is a lack of information regarding carbon dioxide (CO), methane (CH), and nitrous oxide (NO) emissions from pasture soils and the effects of grazing. The objective of this study was to quantify greenhouse gas (GHG) fluxes from pasture soils grazed with cow-calf pairs managed with different stocking rates and densities. The central hypothesis was that irrigated low-density stocking systems (SysB) would result in greater GHG emissions from pasture soils than nonirrigated high-density stocking systems (SysA) and grazing-exclusion (GRE) pasture sites. The nonirrigated high-density stocking systems consisted of 120 cow-calf pairs rotating on a total of 120 ha (stocking rate 1 cow/ha, stocking density 112,000 kg BW/ha, rest period of 60 to 90 d). The irrigated low-density stocking systems consisted of 64 cow-calf pairs rotating on a total of 26 ha of pasture (stocking rate 2.5 cows/ha, stocking density 32,700 kg BW/ha, rest period of 18 to 30 d). Both systems consisted of mixed cool-season grass-legume pastures. Static chambers were randomly placed for collection of CO, CH, and NO samples. Soil temperature (ST), ambient temperature (temperature inside the chamber; AT), and soil water content (WC) were monitored and considered explanatory variables for GHG emissions. GHG fluxes were monitored for 3 yr (2011 to 2013) at the beginning (P1) and at the end (P2) of the grazing season, always postgrazing. Paddock was the experimental unit (3 pseudoreplicates per treatment), and chambers (30 chambers per paddock) were considered multiple measurements of each experimental unit. A completely randomized design considered the term year × period as a repeated measure and chamber nested within paddock and treatment as the random term. Generally, SysB had greater CO emissions than SysA and GRE pasture sites across years and periods ( < 0.01). Soil temperature, AT, and WC had effects on CO emissions. Methane and NO emissions were observed from pasture sites of the 3 systems, but the effect of grazing was not constantly significant for CH and NO emissions. In addition, ST, AT, and WC did not conclusively explain CH and NO emissions. No clear trade-offs between GHG were observed; generally, GHG emissions increased from 2011 to 2013, which was likely associated with weather conditions, such as higher daily temperature and precipitation events. The central hypothesis that SysB would result in greater GHG emissions from pasture soils than SysA and GRE was not confirmed.

Classification of EEG abnormalities in partial epilepsy with simultaneous EEG-fMRI recordings.

Scalp EEG recordings and the classification of interictal epileptiform discharges (IED) in patients with epilepsy provide valuable information about the epileptogenic network, particularly by defining the boundaries of the "irritative zone" (IZ), and hence are helpful during pre-surgical evaluation of patients with severe refractory epilepsies. The current detection and classification of epileptiform signals essentially rely on expert observers. This is a very time-consuming procedure, which also leads to inter-observer variability. Here, we propose a novel approach to automatically classify epileptic activity and show how this method provides critical and reliable information related to the IZ localization beyond the one provided by previous approaches. We applied Wave_clus, an automatic spike sorting algorithm, for the classification of IED visually identified from pre-surgical simultaneous Electroencephalogram-functional Magnetic Resonance Imagining (EEG-fMRI) recordings in 8 patients affected by refractory partial epilepsy candidate for surgery. For each patient, two fMRI analyses were performed: one based on the visual classification and one based on the algorithmic sorting. This novel approach successfully identified a total of 29 IED classes (compared to 26 for visual identification). The general concordance between methods was good, providing a full match of EEG patterns in 2 cases, additional EEG information in 2 other cases and, in general, covering EEG patterns of the same areas as expert classification in 7 of the 8 cases. Most notably, evaluation of the method with EEG-fMRI data analysis showed hemodynamic maps related to the majority of IED classes representing improved performance than the visual IED classification-based analysis (72% versus 50%). Furthermore, the IED-related BOLD changes revealed by using the algorithm were localized within the presumed IZ for a larger number of IED classes (9) in a greater number of patients than the expert classification (7 and 5, respectively). In contrast, in only one case presented the new algorithm resulted in fewer classes and activation areas. We propose that the use of automated spike sorting algorithms to classify IED provides an efficient tool for mapping IED-related fMRI changes and increases the EEG-fMRI clinical value for the pre-surgical assessment of patients with severe epilepsy.

Concurrent secretion of aldosterone and cortisol from an adrenal adenoma - value of MRI in diagnosis.

A 43-year-old female with a 24-years history of hypertension presented for further investigation and management of primary hyperaldosternoism. Postural studies were not conclusive and magnetic resonance (MR) imaging demonstrated a 27 x 18 mm lesion of the right adrenal gland which showed no signal loss during in and out of phase imaging. Although these appearances were considered to be atypical of those seen on MR in patients with aldosterone producing adrenal adenomas the patient underwent an adrenalectomy with removal of a 3 x 3 x 2 cm right adrenal mass. Post-operatively she became hypotensive and a 0900 hours serum cortisol was undetectable (< 50 nmol/l), consistent with adrenal insufficiency. Following the administration of hydrocortisone there was normalization of the blood pressure and subsequent adrenal stimulation tests confirmed the presence of functioning adrenal tissue albeit with an inadequate response. Cortisol measurement from preoperative samples revealed loss of normal diurnal rhythm whereas DHEAS levels both pre and postoperatively were undetectable, consistent with ACTH supression resulting from autonomous cortisol secretion in addition to aldosterone. Concurrent secretion of cortisol should always be considered in Conn's adenomas particularly when atypical radiological features are present.

Renal dysplasia with secondary hyperparathyroidism and loose teeth in a young dog.

In a dog with renal dysplasia and secondary hyperparathyroidism, loose teeth resulted from excessive resorption of alveolar bone. Sharpey's fibers, still anchored in the cementum, were lost in the replacing fibrous tissue and few fibers found their way to distant bone fragments. The alveolar bone is the site of predilection for the excessive, generalized resorption of bone in hyperparathyroidism. Clinical radiographic examination of the jaws is a valuable tool in the detection of the disease.

Secretory leukoprotease inhibitor attenuates lung injury induced by continuous air embolization into sheep.

Continuous air embolization (CAE) into the pulmonary arterial circulation of sheep results in functional and structural changes of chronic pulmonary hypertension. Release of elastin peptides into lung lymph during CAE and attenuation of CAE-induced pulmonary hypertension by neutrophil depletion suggest that neutrophil elastase may contribute to these changes. To investigate this notion, we treated awake sheep with a potent neutrophil elastase inhibitor, recombinant secretory leukoprotease inhibitor (SLPI) (100 mg/day by aerosol), during 12 days of CAE (CAE+SLPI; n = 7). Controls included sheep receiving CAE + vehicle (VEH) (n = 6), VEH alone (n = 3), and SLPI alone (n = 3). SLPI significantly attenuated the CAE-induced increases in lung lymph flow (day 8; 2.3 +/- 0.5 vs. 5.6 +/- 1.7 ml/15 min), protein clearance (day 8; 1.36 +/- 0.32 vs. 3.08 +/- 0.84 ml/15 min), and elastin peptide concentration (day 8; 243 +/- 41 vs. 398 +/- 44 ng/ml). SLPI delayed the onset of sustained pulmonary hypertension from day 8 to day 12. Both CAE groups showed similar structural changes in the pulmonary arteries. SLPI was well tolerated in control sheep and did not affect hemodynamics or structure. We conclude that serine proteases may contribute to the early initiation of chronic pulmonary hypertension but do not play a striking role in its eventual development.

Secretory leukocyte protease inhibitor and lung inflammation in developing bronchopulmonary dysplasia.

OBJECTIVE: To investigate secretory leukocyte protease inhibitor (SLPI) concentrations in tracheal lavage fluids of neonates with an endotracheal tube in place during the first month of life, and to evaluate the relationship of SLPI to neutrophil counts and elastase activity in patients in whom bronchopulmonary dysplasia (BPD) developed versus those in whom it did not. DESIGN: A prospective, inception cohort study. SETTING: University children's hospital neonatal intensive care unit. PATIENTS: Fifty-three neonates who weighed < 2000 gm at birth, and who had an endotracheal tube in place, were enrolled. Forth-one patients survived to 28 days; BPD developed in 24 but not in 17 patients. MAIN OUTCOME MEASURES: Tracheal lavage was performed on days 1, 2, 4, 7, 14, 21, and 28, and analyzed for neutrophils, elastase activity, and SLPI. Results were evaluated longitudinally for 28 days, and were compared between BPD and no-BPD groups during the first week. RESULTS: SLPI concentrations increased significantly for all patients during the study period. During the first week, SLPI concentrations were similar between BPD and no-BPD groups; neutrophil counts and elastase activity were higher in the BPD group. CONCLUSIONS: Patients in whom BPD ultimately developed had early evidence of increased pulmonary inflammation and a significantly less favorable protease-antiprotease balance. If elastase-induced injury contributes to the development of BPD, early therapy with recombinant SLPI might be beneficial by increasing the antielastase capacity of epithelial lining fluid.

Insulin-mediated inhibition of the induction of tyrosine aminotransferase by dexamethasone.

Insulin-mediated regulation of glucocorticoid-induced expression of the liver-specific gene tyrosine aminotransferase was studied in a clone of the Reuber rat hepatoma cells. Insulin inhibited dexamethasone-induced chloramphenicol acetyltransferase expression from approximately 4 kb of TAT 5' flanking sequence. The degree of this inhibition was comparable to the response of the endogenous gene. A construct of approximately 3 kbp of 5' flanking sequence exhibited no significant basal expression but retained sensitivity to glucocorticoids and to insulin inhibition of the glucocorticoid response. Results of further analysis of the insulin response in deletion constructs and constructs containing glucocorticoid responsive elements ligated to a heterologous promoter suggest that in addition to the glucocorticoid response elements a region close to the start site in the TAT promoter is necessary for insulin to inhibit glucocorticoid-mediated induction of expression.

Insulin-responsive tyrosine aminotransferase transcription requires multiple promoter regions.

This study used transient transfection analysis to determine the DNA regions which mediate basal and insulin-sensitive transcription from the gene encoding tyrosine aminotransferase (TAT; EC 2.6.1.5). Basal expression requires at least parts of two regions: a region at -3600 and a region from -208 to + 62. Insulin sensitivity requires at least one region of the promoter not required for basal expression. Thus, insulin cannot act solely by direct modification of any of the components required for basal transcription. Previous results from this laboratory suggest that the insulin effects on basal and glucocorticoid-induced TAT transcription require different regions of the proximal promoter.

Inhibition of collagenolytic activity and metastasis of tumor cells by a recombinant human tissue inhibitor of metalloproteinases.

Metalloproteinases secreted by tumor cells play an important role in metastasis. In the present study, we determined whether an inhibitor of these proteinases could inhibit the ability of tumor cells to degrade collagen and to metastasize. Metalloproteinases with degradative activities for type I collagen, type IV collagen, gelatin, and casein were secreted by a highly metastatic rat embryo cell line (4R) transfected by c-Ha-ras1 (also known as HRAS1). These metalloproteinases were identified by sodium dodecyl sulfate substrate-polyacrylamide gel electrophoresis as 92-kilodalton and 68-kilodalton gelatinolytic enzymes and 48-kilodalton and 45-kilodalton caseinolytic proteinases. A recombinant human tissue inhibitor of metalloproteinases (rTIMP) completely inhibited the proteolytic activities of these enzymes and was also a potent inhibitor of the proteolytic degradation of collagen by intact c-Ha-ras1-transfected cells. The ability of these cells to colonize the lungs after intravenous injection into nude mice was inhibited by 83% when rTIMP was repeatedly injected intraperitoneally into the animals. These data demonstrate that rTIMP is a potent inhibitor of the metalloproteinase activities of these cells and can also inhibit their metastatic potential.

Selective defect in gonadotrophin secretion in patients with autonomic failure.

We studied the neuroendocrine effects of a condition associated with abnormal hypothalamic amines. Hypothalamo-anterior pituitary function was assessed in five male subjects with autonomic failure (AF) and in five age and sex-matched controls. All subjects showed normal gonadotrophin and TSH responses to GnRH and TRH, respectively. In control subjects, intravenous infusion of naloxone caused a significant rise in overall LH concentrations as well as increased frequency and amplitude of LH pulses. In contrast, in AF subjects naloxone did not alter LH concentrations or increase LH pulse frequency. Naloxone also caused an increase in neurosecretory GH pulses not only in AF subjects but also in the controls. These results suggest that in man, ascending catecholamine pathways are important in the control of gonadotrophin secretion. The markedly different response of GH to an opioid antagonist in elderly subjects should be further investigated.

Inhibition by human recombinant tissue inhibitor of metalloproteinases of human amnion invasion and lung colonization by murine B16-F10 melanoma cells.

The human tissue inhibitor of metalloproteinases (TIMP) is a glycoprotein with a molecular weight of 28,000. It appears to be ubiquitous in human mesoderm tissues and has previously been shown to be identical to the collagenase inhibitor isolated from human skin fibroblasts. TIMP inhibits type I- and IV-specific collagenases and other neutral metalloendoproteinases that may be responsible for the degradation of extracellular matrix in tumor cell metastasis. In this work we have utilized recombinant human TIMP (rTIMP) obtained by expression of its cDNA gene (Carmichael et al., Proc. Natl. Acad. Sci. USA, 83:2407, 1986). The rTIMP is shown to have similar inhibition properties as natural TIMP against human skin fibroblast collagenase. In an in vitro amnion invasion assay system, rTIMP inhibited the invasion of B16-F10 murine melanoma cells through the human amniotic membrane at an identical concentration to that reported previously for natural TIMP. The mechanism by which rTIMP inhibits amniotic membrane invasion was compared to the mechanism by which the fibronectin receptor binding peptide RGDS and the aminin receptor binding peptide YIGSR inhibit amnion invasion. RGDS and YIGSR inhibited strong binding of the tumor cells to the amniotic membrane. In contrast rTIMP did not inhibit the cell adhesion step in amnion invasion, but actually increased the number of tumor cells that were tightly bound to the amnion. Thus rTIMP appears to inhibit a later step in the amnion invasion process, following B16-F10 cell adhesion. C57BL/6 mice treated with i.p. injections of rTIMP every 12 h for 6.5 days showed a significant inhibition of metastatic lung colonization by B16-F10 murine melanoma cells. While the rTIMP inhibited the number of metastatic lung tumors formed, it had no significant effect on the size of the lung tumors. Furthermore, tumors grown s.c. in mice receiving 12-h i.p. injections of rTIMP for 6.5 days, as in the in vivo colonization assay, showed no difference in size from controls. Thus the anticolonization effect of rTIMP appears not be due to an effect on tumor growth, but on the invasion step itself. The inhibition of lung colonization in C57BL/6 mice by rTIMP is one of the first examples showing an antimetastatic effect of a selective metalloproteinase inhibitor in a mammalian animal model, and supports an essential role for metalloproteinase(s) in the extravasation and invasion of tumor cells during lung colonization by blood-borne tumor cells.

Comparative pharmacokinetics of free doxorubicin and doxorubicin entrapped in cardiolipin liposomes.

The comparative pharmacokinetics of free doxorubicin and doxorubicin entrapped in cardiolipin liposomes was evaluated in rats at a dose of 6 mg/kg i.v. Doxorubicin was entrapped in cardiolipin liposomes by using 11.2 mumol of drug, 5.6 mumol of cardiolipin, 28.5 mumol of phosphatidylcholine, 19.5 mumol of cholesterol, and 11.1 mumol of stearylamine. The peak plasma concentration with free doxorubicin at 5 min was 1.7 micrograms/ml which was reduced to 0.3 micrograms/ml by 1 h. With cardiolipin liposomes, the peak plasma concentration of doxorubicin achieved at 5 min was 20.9 micrograms/ml. The plasma levels of doxorubicin decreased gradually and by 1 h the drug concentration in plasma was 10 micrograms/ml. The plasma levels of free doxorubicin and doxorubicin entrapped in liposomes were fitted to a 3-compartment computer model. The terminal half-life with free doxorubicin in plasma was 17.3 h whereas it was 69.3 h with drug entrapped in liposomes. The area under the plasma concentration curve with liposomal doxorubicin was 81.4 micrograms X h X ml-1 compared to 1.95 micrograms X h X ml-1 observed with free doxorubicin. The steady state volume of distribution with free doxorubicin was about 23-fold higher than liposomal doxorubicin. The terminal half-life with free doxorubicin in cardiac tissue was 17.9 h compared to 12.6 h with drug encapsulated in liposomes. The terminal half-lives in liver and spleen following administration of liposomal doxorubicin were 15- and 2.3-fold higher, respectively, compared to free drug; furthermore, the concentration X time values of liposomal doxorubicin in liver were 26-fold higher and in spleen 6-fold higher than the free drug. Free doxorubicin and doxorubicin entrapped in liposomes demonstrated 17 and 20% excretion in bile of the injected dose, respectively, in rats. The present studies demonstrate that liposomal encapsulation of doxorubicin significantly alters its pharmacokinetics in plasma and tissues compared to free drug.

Detection and investigation of renal artery stenosis.

A retrospective analysis was done on 235 hypertensive patients undergoing renal arteriography. Of the 85 patients with renal artery stenosis 50 underwent 56 operations or angioplasties and have been followed up for at least a year. 41 (73%) of these procedures were curative or led to improved blood-pressure control. These results make it worthwhile identifying hypertensive patients with renal artery stenosis who may benefit from surgery or angioplasty. Vascular disease, epigastric bruit, and impaired renal function were commoner in the renal artery stenosis patients than in the 81 with normal arteriograms, but there were no features pathognomonic of stenosis. Intravenous urography had a sensitivity of 83% and a specificity of 69.5% in identifying renal artery stenosis; those for isotope renography were 90.5% and 38.5%, respectively. Divided renal vein renins did not predict the outcome of intervention. Arteriography should, if there are no contraindications to intervention, be the first and definitive investigation when renal artery stenosis is suspected--for instance, in hypertensive patients with accelerated or malignant hypertension, those whose blood pressure is poorly controlled by multiple therapy, and those who have had recent deterioration in blood-pressure control or renal function.

Epiploic disorders. Conditions of the epiploic appendages.

Disorders of the epiploic appendages are rarely diagnosed preoperatively and usually result from torsion with subsequent infarction. No diagnostic test or clinical symptoms are pathognomonic of this process, which is a disease of middle age and rarely life-threatening, and the most common preoperative diagnosis is acute appendicitis. An analysis of case information reported in the surgical literature has been combined with our recent experience involving ten cases. Fifty-eight percent of the patients in this collected series were male, and the average age in both sexes was 42 years. The sigmoid colon was the most frequent site of these disorders (41.5%), and acute appendicitis was the most common preoperative diagnosis (37.7%). The treatment is ligation, excision, and occasionally seromuscular inversion. When encountered at exploration, this entity may represent the sole etiology of the abdominal pain if exploration is otherwise negative.

Kaposi's sarcoma of the bowel--presenting as apparent ulcerative colitis.

Persistent diarrhoea with mucus-production developed in a 37 year homosexual man, and an initial diagnosis of ulcerative colitis was made after barium enema examination and rectal biopsy. The patient later developed cutaneous lesions which proved to be Kaposi's sarcoma, and the bowel lesion was also subsequently shown to be Kaposi's sarcoma. This tumour occurred as a manifestation of the acquired immune deficiency syndrome (AIDS). The patient was treated with alpha interferon, with partial regression of the skin lesions, but progression of the bowel tumour. Because of severe bowel symptoms, including episodes of subacute intestinal obstruction, the localised bowel disease was treated with radiotherapy. In view of the increasing incidence of AIDS, a diagnosis of Kaposi's sarcoma must be considered in homosexual men presenting with persistent diarrhoea, for which no infectious cause can be demonstrated.