Difficulties in screening for peripheral neuropathies in children with diabetes.

AIMS: To assess the diagnostic utility of a novel abbreviated monofilament test in comparison with the tuning fork test to detect diabetic peripheral neuropathy in children. METHODS: A total of 88 children with Type 1 diabetes mellitus were screened for diabetic peripheral neuropathy using the monofilament test and the tuning fork. Nerve conduction studies were performed according to the 'gold standard' for neuropathy. We assessed the diagnostic utility and inter-rater agreement of the two screening methods. RESULTS: A total of 43 (49%) children (aged 6-18 years) had at least one abnormal nerve conduction study result. Diagnostic utility and inter-rater agreement were very low for both screening methods. The monofilament test yielded a sensitivity of 18% and a specificity of 80%. The tuning fork yielded a sensitivity of 0% and a specificity of 98%. CONCLUSION: The present study found that an abbreviated monofilament test has low diagnostic utility for the detection of early diabetic peripheral neuropathy because of its low reliability. The problem of reliability needs to be more thoroughly addressed in order to improve the screening procedures in diabetes management in childhood and adolescence.

Childhood diabetic neuropathy: functional impairment and non-invasive screening assessment.

AIM: Sensory diabetic neuropathy, determined by nerve conduction studies, is common in children with Type 1 diabetes. Diabetic neuropathy diagnoses are rarely made in paediatric daily care because they are asymptomatic, vibration detection is mostly normal and nerve-conduction testing is impractical. The present study aims to: (1) describe somatosensory dysfunction in children with diabetes, (2) test whether diabetes duration and HbA(1c) are related to somatosensory dysfunction and (3) identify the best screening test for large-fibre dysfunction, as indicated by nerve conduction studies. METHODS: Forty-five children (age 13.2 ± 2.5 years) with Type 1 diabetes for 6.7 ± 2.5 years and matched control subjects were assessed by neurological examinations, nerve conduction tests and quantitative sensory testing on the feet using the protocol of the German Research Network on Neuropathic Pain. Abnormal nerve conduction was used as gold standard to define neuropathies. RESULTS: We found a high prevalence of mechanical (38%) and thermal (24%) hypoesthesia often associated with hyperalgesia (47%). Tactile hypoesthesia (33%) was more frequent than pallhypaesthesia (11%). Only cold detection and mechanical pain thresholds were related to HbA(1c). Tactile hypoesthesia had the highest sensitivity (75%), specificity (89%) and positive (75%) and negative (89%) predictive values for neuropathies defined by nerve conduction tests (31% abnormal). CONCLUSIONS: Almost half of the children with diabetes have subclinical large- and small-fibre neuropathies. Tactile detection was better than vibration for neuropathy assessment. Quantitative sensory testing is a valuable tool for assessment of neuropathy as well as a target of interventional studies in children with diabetes.

Clinical and immunological overlap between autoimmune lymphoproliferative syndrome and common variable immunodeficiency.

Autoimmune lymphoproliferative syndrome (ALPS) is mainly caused by defects in the CD95 pathway. Raised CD3+TCRαß+CD4-CD8- double negative T cells and impaired T cell apoptosis are hallmarks of the disease. In contrast, the B cell compartment has been less well studied. We found an altered distribution of B cell subsets with raised transitional B cells and reduced marginal zone B cells, switched memory B cells and plasma blasts in most of 22 analyzed ALPS patients. Moreover, 5 out of 66 ALPS patients presented with low IgG and susceptibility to infection revealing a significant overlap between ALPS and common variable immunodeficiency (CVID). In patients presenting with lymphoproliferation, cytopenia, hypogammaglobulinemia and impaired B cell differentiation, serum biomarkers were helpful in addition to apoptosis tests for the identification of ALPS patients. Our observations may indicate a role for apoptosis defects in some diseases currently classified as CVID.

Posaconazole salvage treatment in paediatric patients: a multicentre survey.

While a paediatric dosage has not been defined, posaconazole is occasionally being used in children. We conducted a multicentre retrospective survey and identified 15 patients (median age 10 years [range 3.6-17.5]) who received posaconazole salvage therapy for proven (9 patients) or probable (6 patients) invasive fungal infections. Posaconazole was administered for a median of 32 days (range 4-262) at a median dosage of 21 mg/kg (range 4.8-33.3). None of the patients discontinued therapy due to adverse events, which were mostly mild and observed in 11 patients. Complete or partial responses were observed in 4/7 patients with zygomycosis, 3/4 patients with invasive mould infection, 1/2 patients with invasive aspergillosis and 1/2 patients with chronic disseminated candidiasis. We conclude from the data that posaconazole displays favourable safety and tolerance and may be useful for management of individual paediatric patients with invasive infections.

Pharmacological analysis of cortical circuitry.

The cortical circuitry of the visual cortex has been worked out in great detail. Anatomical investigations reveal stereotyped connections within cortical columns and specific long-range connections between distant columns. Pharmacological techniques for blocking the activity in individual cortical layers or columns allow the microdissection of the cortical circuit. These studies could relate specific functional roles to particular cortical connections.

The pattern of ocular dominance columns in macaque visual cortex revealed by a reduced silver stain.

A pattern of alternating dark and pale bands was observed in the striate cortex of the macaque monkey. The bands, which ran parallel to the surface, were seen in tangential sections stained with a reduced silver method for normal fibers and were most clear in layer 4C alpha, immediately deep to the line of Gennari. The dark bands were about 300 mu wide and showed blind endings and bifurcations. The light bands were about 50 mu wide and did not branch or terminate within area 17. Because the dark bands were similar in width to the bands of terminal degeneration which have been shown to result from single-layer lesions of the lateral geniculate body, it seemed possible that they corresponded to ocular dominance columns. To test this idea, the boundaries of ocular dominance columns were marked in a physiological experiment: tangential electrode penetrations were made in an anesthetized monkey and, as the electrode was advanced horizontally in the fourth layer, the eye preference of single units and of the background activity was monitored. Small electrolytic lesions were placed at the points where a change in eye preference occurred. The brain was subsequently fixed, sectioned tangentially and stained with the silver method. All the lesions--total of 12 --fell directly on the pale bands. Moreover, the electrode had not passed over any pale bands without a lesion being placed. It was concluded that the dark bands do correspond to single ocular dominance columns and the pale bands to the boundaries between columns. The banding appearance is due to a greater density of tangential fibers within columns than at the borders of columns. These tangential fibers are in part the preterminal arborizations of geniculocortical axons, since some of them have been shown to degenerate after geniculate lesions. The ocular dominance columns were mapped for most of the striate cortex, using serial tangential sections stained with the silver method. The overall pattern was ,imilar in several monkeys, though the details of the branching arrangements varied from animal to animal. The columns met the 17-18 border at right angles. On the outer surface of the hemisphere the columns converged from the 17-18 border, turned medially with repeated fusions of columns, and streamed over the lip of the calcarine fissure. In the roof of the fissure they met a second system of columns oriented parasagittally. In terms of the visual field, the columns ran roughly horizontally for the central 10 degrees of the field, and circumferentially beyond that. The columns were not mapped in the stem of the fissure, the area corresponding to the far periphery of the field. The constancy of column width across the cortex probably allows a functional matching between ocular-dominance and orientation columns.

Immunolabelling by a newt retinal pigment epithelium antibody during retinal development and regeneration.

The binding of RPE-1, a mouse monoclonal antibody selective for newt retinal pigment epithelium, was followed in eyes undergoing embryonic development and retinal regeneration. Using the indirect immunofluorescence technique on frozen sections, we observed bright and continuous labelling exclusively in the retinal pigment epithelium (RPE) of normal adult newts, but labelling became diminished near the ora serrata region and stopped abruptly at the ciliary margin. During development, labelling was not detected in the retinal pigment epithelium (RPE) until the formation of photoreceptor outer segments and was not observed in any other ocular tissue. There was no correlation between the appearance of pigment in retinal pigment epithelial cells and their labelling with the RPE-1 antibody. Furthermore, albino salamander embryos showed the same pattern of labelling with RPE-1 as that seen in age-matched pigmented animals. During retinal regeneration, RPE cells were labelled less intensely, but heavy labelling was observed in the newly formed retinal cells. With time, labelling in regenerated retina receded, so that by the end of regeneration, labelling by RPE-1 was once more restricted to the RPE cells. The identification of RPE-1 as a marker for postmitotic retinal neurons about to undergo differentiation provides a promising approach for further studies of regeneration with the help of molecular tools.

Targets of horizontal connections in macaque primary visual cortex.

Pyramidal neurons within the cerebral cortex are known to make long-range horizontal connections via an extensive axonal collateral system. The synaptic characteristics and specificities of these connections were studied at the ultrastructural level. Two superficial layer pyramidal cells in the primate striate cortex were labeled by intracellular injections with horseradish peroxidase (HRP) and their axon terminals were subsequently examined with the technique of electron microscopic (EM) serial reconstruction. At the light microscopic level both cells showed the characteristic pattern of widespread, clustered axon collaterals. We examined collateral clusters located near the dendritic field (proximal) and approximately 0.5 mm away (distal). The synapses were of the asymmetric/round vesicle variety (type I), and were therefore presumably excitatory. Three-quarters of the postsynaptic targets were the dendritic spines of other pyramidal cells. A few of the axodendritic synapses were with the shafts of pyramidal cells, bringing the proportion of pyramidal cell targets to 80%. The remaining labeled endings were made with the dendritic shafts of smooth stellate cells, which are presumed to be (GABA)ergic inhibitory cells. On the basis of serial reconstruction of a few of these cells and their dendrites, a likely candidate for one target inhibitory cell is the small-medium basket cell. Taken together, this pattern of outputs suggests a mixture of postsynaptic effects mediated by consequence the horizontal connections may well be the substrate for the variety of influences observed between the receptive field center and its surround.

Increase in axial length of the macaque monkey eye after corneal opacification.

The cornea of one eye was opacified in two young macaque monkeys by multiple stromal injections of a suspension of polystyrene particles (latex). Ultrasound measurements showed that the eye with opaque cornea grew at a faster rate, so that after 1 year it was more than 1 mm longer than the normal eye. This difference in axial length was due to elongation of the posterior segment, since lens thickness, depth of anterior chamber, and corneal curvature were identical in both eyes. At histological examination, no pathological changes were observed in the anterior segment of the latex-injected eye except for a scant vascularization of the corneal opacity. The result of this experiment demonstrates that opacification of the corneal has effects on axial length similar to, although less marked than, those on lid fusion and therefore supports our previous conclusion that the myopia caused by lid fusion is triggered by the abnormal visual impact and involves central visual pathways.

Effect of dark-rearing on experimental myopia in monkeys.

When lids are surgically fused in rhesus monkeys before eye growth is completed, a high degree of myopia develops, which is caused by an elongation of the eye globe. The present study shows that in monkeys raised in the dark after monocular lid fusion, refraction and axial length were normal in both the closed and the open eye. Myopia, however, readily developed and the eye elongated when a monkey raised in the dark was transferred to illuminated quarters. These findings indicate that visual stimulation through the translucent lids was necessary for the development of this experimental ametropia.

Effects of monocular exposure to oriented lines on monkey striate cortex.

This study examines the extent to which the restriction of visual experience to lines of a single orientation influences the organization of the striate cortex in infant monkeys (Macaca mulatta). Previous studies of kittens raised with monocular exposure to a single line orientation have consistently shown the response preference of cells driven by that eye to be biased towards the experienced orientation. Studies of binocular exposure to restricted orientations have been equivocal. In the infant monkey cortex responses to oriented lines have virtually all the specificity of responses seen in the adult animal. In an effort to clarify the phenomenon and the mechanism by which orientation bias might be obtained, we examined the effects of monocular exposure to a restricted orientation in infant macaques. Three monkeys were used. Each monkey was raised with one open eye exposed to lines of a single orientation and one eye occluded by lid suture. As in other cases of monocular deprivation in either cat or monkey, few binocularly driven cells were recorded and the majority of cells were dominated by the open eye. Cells driven by the open eye had normal representation of all orientation preferences and there was no overall increase in the number of cells preferring the orientation to which the eye had been exposed. The cells dominated by the occluded eye, however, showed a lack of cells responding to orientations to which the open eye had been exposed. These findings suggest that a competitive mechanism operates between the two eyes to provide an orientation selective advantage to the open eye.

Mode of termination of retinotectal fibers in macaque monkey: an autoradiographic study.

The distribution of retinotectal projections was studied in 4 macaque monkeys by examining the tectum autoradiographically 3-21 days after eye injection with radioactive proline or a proline-fucose mixture. Contrary to previous reports the optic fibers project to all regions of the tectum including a relatively sparse but nevertheless very clear projection to the anterolateral one-third, where the fovea is represented. Here the terminals were distributed within the superficial grey layer of the tectum at a depth extending from about 50 mum to 125 mum and in a patchy fashion, with a tendency to aggregation in clumps 0.1-0.5 mm wide from one or other eye. Further posteromedially, corresponding to more peripheral retinal regions, the input from the contralateral eye became more continuous superficially, with tongues extending more deeply in the superficial grey, apparently enclosing clumps of ipsilateral terminals. These deeper ipsilateral clumps occupied a rather well defined layer extending in depth from about 100 mum to about 175 mum. Still further posteromedially, in the temporal crescent representation, only the continuously distributed label from the contralateral eye was found. Continuous label was also seen in the optic disc region on the ipsilateral side; on the corresponding area contralaterally, label was absent. Both ipsilaterally and contralaterally, the pattern of input was roughly symmetrical about the representation of the horizontal meridian, which ran from anterolateral to posteromedial. The regional aggregations of input from one or other eye were to some extent reflected physiologically in a regional variation in eye dominance, though this was perhaps less than might have been expected from the marked heterogeneity of the inputs.

Intrinsic connectivity and receptive field properties in visual cortex.

In order to obtain insights into the mechanisms by which the cells in primary visual cortex generate their receptive field properties, we have investigated the intrinsic cortical circuitry by intracellular recording and dye injection. The dye injection technique in combination with 3-dimensional computer graphic reconstructions from serial sections allows us to visualize the full dendritic and axonal arbors of cells. We have also studied cells that are postsynaptic to the injected cells by serial EM reconstruction of the postsynaptic dendrites. Taken together, this methodology has extended our knowledge of interlaminar and horizontal cortical connections, and we present hypotheses on the relationship between these connections and specific receptive field features.

The influence of contextual stimuli on the orientation selectivity of cells in primary visual cortex of the cat.

Perception of a visual attribute, such as orientation, is strongly dependent on the context within which a feature is presented, such as that seen in the tilt illusion. The possibility that the neurophysiological basis for this phenomenon may be manifest at the level of cells in striate cortex is suggested by anatomical and physiological observations of orientation dependent long range horizontal connections which relate disparate points in the visual field. This study explores the dependency of the functional properties of single cells on visual context. We observed several influences of the visual field area surrounding cells' receptive field on the properties of the receptive field center: inhibition or facilitation dependent on the orientation of the surround, shifts in orientation preference and changes in the bandwidth of orientation tuning. To relate these changes to perceptual changes in orientation we modeled a neuronal ensemble encoding orientation. Our results show that the filter characteristics of striate cortical cells are not necessarily fixed, but can be dynamic, changing according to context.