Biochemical comparisons of osteoarthritic human synovial fluid with calf sera used in knee simulator wear testing.

Osteoarthritic human synovial fluid was obtained from the knees of 20 patients and was compared with four different calf sera solutions frequently used as lubricants in knee simulator wear testing. Assuming that the fluid after arthroplasty was the same as the fluid in patients with osteoarthritis, the total protein concentration, protein constituent fractions, osmolality, trace element concentrations, and the thermal stability obtained via differential scanning calorimetry were determined. Human synovial fluid, with an average total protein concentration of 34 g/L, was significantly different from all undiluted calf sera. However, alpha-calf serum and iron-supplemented alpha-calf serum were closest in protein constituent fractions (albumin, alpha-1-globulin, alpha-2-globulin, ss-globulin, and gamma-globulin) to human synovial fluid. Diluting calf sera with low-ion distilled water to a total protein concentration of 17 g/L (as recommended by ISO 14243) produced non-clinically relevant total protein concentration and osmolality levels. Performing the same dilution of iron-supplemented alpha-calf serum with phosphate-buffered saline solution and 1.5 g/L hyaluronic acid produced an artificial lubricant with both a clinically relevant level of osmolality and clinically relevant thermal stability as seen in human synovial fluid from patients with osteoarthritis. The present study suggested that alpha-calf serum, phosphate-buffered saline solution and hyaluronic acid were essential constituents of an artificial lubricant to mimic the major biochemical properties of human synovial fluid for simulator wear testing of total knee replacements.

The Pannonian plain as a source of Ambrosia pollen in the Balkans.

This study aims to find likely sources of Ambrosia pollen recorded during 2007 at five pollen-monitoring sites in central Europe: Novi Sad, Ruma, Negotin and Nis (Serbia) and Skopje (Macedonia). Ambrosia plants start flowering early in the morning and so Ambrosia pollen grains recorded during the day are likely to be from a local source. Conversely, Ambrosia pollen grains recorded at night or very early in the morning may have arrived via long-range transport. Ambrosia pollen counts were analysed in an attempt to find possible sources of the pollen and to identify Ambrosia pollen episodes suitable for further investigation using back-trajectory analysis. Diurnal variations and the magnitude of Ambrosia pollen counts during the 2007 Ambrosia pollen season showed that Novi Sad and Ruma (Pannonian Plain) and to a lesser degree Negotin (Balkans) were located near to sources of Ambrosia pollen. Mean bi-hourly Ambrosia pollen concentrations peaked during the middle of the day, and concentrations at these sites were notably higher than at Nis and Skopje. Three episodes were selected for further analysis using back-trajectory analysis. Back-trajectories showed that air masses brought Ambrosia pollen from the north to Nis and, on one occasion, to Skopje (Balkans) during the night and early morning after passing to the east of Novi Sad and Ruma during the previous day. The results of this study identified the southern part of the Pannonian Plain around Novi Sad and Ruma as being a potential source region for Ambrosia pollen recorded at Nis and Skopje in the Balkans.

Are the birch trees in Southern England a source of Betula pollen for North London?

Birch pollen is highly allergenic. Knowledge of daily variations, atmospheric transport and source areas of birch pollen is important for exposure studies and for warnings to the public, especially for large cities such as London. Our results show that broad-leaved forests with high birch tree densities are located to the south and west of London. Bi-hourly Betula pollen concentrations for all the days included in the study, and for all available days with high birch pollen counts (daily average birch pollen counts>80 grains/m3), show that, on average, there is a peak between 1400 hours and 1600 hours. Back-trajectory analysis showed that, on days with high birch pollen counts (n=60), 80% of air masses arriving at the time of peak diurnal birch pollen count approached North London from the south in a 180 degree arc from due east to due west. Detailed investigations of three Betula pollen episodes, with distinctly different diurnal patterns compared to the mean daily cycle, were used to illustrate how night-time maxima (2200-0400 hours) in Betula pollen counts could be the result of transport from distant sources or long transport times caused by slow moving air masses. We conclude that the Betula pollen recorded in North London could originate from sources found to the west and south of the city and not just trees within London itself. Possible sources outside the city include Continental Europe and the Betula trees within the broad-leaved forests of Southern England.

Toward improving therapeutic regimens for Bacillus endophthalmitis.

PURPOSE: Bacillus cereus causes the most virulent and refractory form of endophthalmitis. The authors analyzed the effectiveness of early treatment with vancomycin or gatifloxacin, with or without dexamethasone, for experimental B. cereus endophthalmitis. METHODS: Rabbit eyes were injected intravitreally with 100 colony-forming units of B. cereus. At 2, 4, or 6 hours after infection, eyes were injected intravitreally with 0.1 mL gatifloxacin (0.3%), vancomycin (1.0%), either antibiotic plus dexamethasone, dexamethasone alone (1.0%), or PBS. Eyes were analyzed by electroretinography, bacterial quantitation, and antibiotic penetration analysis. Drug toxicity toward Müller cells, retinal pigment epithelium, and cones was also analyzed. RESULTS: Eyes treated at 2 hours with vancomycin or gatifloxacin, with or without dexamethasone, maintained higher ERG amplitudes than the dexamethasone alone and PBS control groups. Eyes treated with antibiotic plus dexamethasone at 6 hours had reduced retinal function compared to antibiotic treatment alone. With the exception of vancomycin with or without dexamethasone at 6 hours, all antibiotic treatments sterilized eyes. Only gatifloxacin reached aqueous concentrations greater than the minimal inhibitory concentration for B. cereus when measured at 8 hours. Neither gatifloxacin nor vancomycin was toxic to retinal cells in vitro. CONCLUSIONS: Early intravitreal injection of vancomycin or gatifloxacin improved the therapeutic outcome of B. cereus endophthalmitis. The addition of dexamethasone to antibiotic treatment did not provide a therapeutic benefit over antibiotics alone and appeared to reduce the antibiotic efficacy of vancomycin 6 hours after infection. In this model, delay in treatment past 6 hours significantly reduced the potential for salvaging useful vision.

The long-range transport of birch (Betula) pollen from Poland and Germany causes significant pre-season concentrations in Denmark.

BACKGROUND: Birch pollen is highly allergic and has the potential for episodically long-range transport. Such episodes will in general occur out of the main pollen season. During this time, allergy patients are unprotected and high pollen concentrations will therefore have a full allergenic impact. OBJECTIVE: To show that Denmark obtains significant quantities of birch pollen from Poland or Germany before the local trees start to flower. METHODS: Simultaneous observations of pollen concentrations and phenology in the potential source area in Poland as well as in Denmark were performed in 2006. The Danish pollen records from 2000 to 2006 were analysed for possible long-range transport episodes and analysed with trajectories in combination with a birch tree source map. RESULTS: In 2006, high pollen concentrations were observed in Denmark with bi-hourly concentrations above 500 grains/m(3) before the local trees began to flower. Poland was identified as a source region. The analysis of the historical pollen record from Copenhagen shows significant pre-seasonal pollen episodes almost every year from 2000 to 2006. In all episodes, trajectory analysis identified Germany or Poland as source regions. CONCLUSION: Denmark obtains significant pre-seasonal quantities of birch pollen from either Poland or Germany almost every year. Forecasting of birch pollen quantities relevant to allergy patients must therefore, take into account long-range transport. This cannot be based on measured concentrations in Denmark. The most effective way to improve the current Danish pollen forecasts is to extend the current forecasts with atmospheric transport models that take into account pollen emission and transport from countries such as Germany and Poland. Unless long-range transport is taken into account, pre-seasonal pollen episodes will have a full allergic impact, as the allergy patients in general will be unprotected during that time.

Examining Ambrosia pollen episodes at Poznan (Poland) using back-trajectory analysis.

The pollen grains of Ambrosia spp. are considered to be important aeroallergens in parts of southern and central Europe. Back-trajectories have been analysed with the aim of finding the likely sources of Ambrosia pollen grains that arrived at Poznan (Poland). Temporal variations in Ambrosia pollen at Poznan from 1995-2005 were examined in order to identify Ambrosia pollen episodes suitable for further investigation using back-trajectory analysis. The trajectories were calculated using the transport model within the Lagrangian air pollution model, ACDEP (Atmospheric Chemistry and Deposition). Analysis identified two separate populations in Ambrosia pollen episodes, those that peaked in the early morning between 4 a.m. and 8 a.m., and those that peaked in the afternoon between 2 p.m. and 6 p.m.. Six Ambrosia pollen episodes between 2001 and 2005 were examined using back-trajectory analysis. The results showed that Ambrosia pollen episodes that peaked in the early morning usually arrived at Poznan from a southerly direction after passing over southern Poland, the Czech Republic, Slovakia and Hungary, whereas air masses that brought Ambrosia pollen to Poznan during the afternoon arrived from a more easterly direction and predominantly stayed within the borders of Poland. Back-trajectory analysis has shown that there is a possibility that long-range transport brings Ambrosia pollen to Poznan from southern Poland, the Czech Republic, Slovakia and Hungary. There is also a likelihood that Ambrosia is present in Poland, as shown by the arrival of pollen during the afternoon that originated primarily from within the country.

Therapy of ankylosing spondylitis. Part II: biological therapies in the spondyloarthritides.

Therapeutic options for patients with active and severe spondylarthritis (SpA) have been fairly limited in the past decades. There is now accumulating evidence that biological therapy with agents directed against tumour necrosis factor-alpha (TNF-alpha) is highly efficacious in the spondyloarthritides, especially in ankylosing spondylitis (AS) and psoriatic arthritis (PsA). The TNF blocking agents currently available, infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira), are approved for the treatment of rheumatoid arthritis (RA) in Europe and the USA. In contrast to rheumatoid arthritis (RA) disease-modifying anti-rheumatic drugs (DMARDs) have limited efficacy in SpA. No DMARDs are available for AS patients with active spinal disease. Thus, for AS patients whose condition is not sufficiently controlled with non-steroidal anti-inflammatory drugs (NSAIDs), therapy with TNF blockers may be considered as a first-line treatment. For infliximab, a dose of 3-5 mg/kg seems to be required, and intervals between 6 and 12 weeks are necessary to suppress disease activity continually. The standard dosage of etanercept is 2 x 25 mg subcutaneously (s.c.) per week. There are very few studies with adalimumab (standard dose in RA 20-40 mg s.c. every 1-2 weeks) in SpA. Infliximab and etanercept are now both approved for AS in Europe. There is some evidence that both agents also work in other SpA, especially in PsA. Withdrawal of long-term therapy in AS patients led to relapses of disease after several months. Less radiographic progression after 2 years of continuous treatment with infliximab compared to conventional therapy has been suggested in a small study. Serious adverse events on anti-TNF therapy have remained rare. However, severe infections, including tuberculosis, have been reported. These can be largely prevented by appropriate screening. The benefits of anti-TNF therapy in AS seem to outweigh these shortcomings.

Immunisation against Theileria parva in eastern Zambia: influence of maternal antibodies and demonstration of the carrier status.

Immunisation of calves by the infection and treatment method (I & T) has been extensively used in the eastern province of Zambia to control East Coast fever (ECF), a protozoan tick-borne disease. This paper presents the results of a field longitudinal study, which included a total of 148 Angoni calves. After immunisation against ECF, they were monitored for a full rainy season, coinciding with the main peak of activity of the vector of Theileria parva, the tick Rhipicephalus appendiculatus. Dysimmunisation (acute reaction generated by I & T immunisation), seroconversion and mortality are among the parameters recorded. The effect of maternal antibodies on these parameters was analysed and also studied in experimental conditions on two calves. Before immunisation, young calves had a higher seroprevalence than older animals (maternal antibodies) but their post-immunisation seroprevalence was lower. There was no evidence that their immunoprotection was weaker but this indicates that the post-immunisation seroconversion is probably not a reliable tool to monitor the efficacy of calf immunisation. The carrier state of cattle after immunisation was investigated in experimental conditions on three bovines whereas in the field, the infection prevalence in the ticks was estimated using the relation between the tick burden and the T. parva contacts with the calves. The ability of larval and nymphal R. appendiculatus ticks to pick-up T. parva from carriers and to transmit it to naïve animals after moulting was assessed. It was found that both instars are able to transmit clinical and lethal ECF but that the prevalence of T. parva infection in nymphs is much lower than in adults, confirming the primary role of adults in the transmission of ECF in endemic conditions. Similar results were obtained from the field whereby the ECF peak corresponds with the peak of adult R. appendiculatus activity. The infection prevalence in the ticks was however much lower in the field than in experimental conditions indicating that an important proportion of them feed on alternative hosts. Old ticks seemed to have lost part of their infectivity.

Oxytocin and vasopressin neurones in principal and accessory hypothalamic magnocellular structures express Fos-immunoreactivity in response to acute glucose deprivation.

Neurohypophyseal secretion of oxytocin and vasopressin is elevated in response to decreased systemic glucose availability. In these studies, dual-label immunocytochemistry was used to identify hypothalamic neuropeptidergic magnocellular neurones that are transcriptionally activated in response to glucose substrate imbalance. Two h after i.p. injection of the glucose antimetabolite, 2-deoxy-D-glucose (2DG), or the vehicle, saline, groups of adult male rats were anaesthetized by i.p. injection with sodium pentobarbital and killed by transcardial perfusion. Sections (25 microm) through anterior and tuberal levels of the hypothalamus were processed for nuclear Fos- and cytoplasmic neuropeptide immunoreactivity (-ir). A high proportion of oxytocin-ir neurones in the supraoptic, paraventricular, and adjunct structures, including the anterior commissural, periventricular magnocellular, posterior perifornical, recurrent supraoptic, medial forebrain, and circular nuclei, were colabelled for nuclear Fos-ir following administration of 2DG. Large numbers of vasopressin neurones in the supraoptic, circular, posterior perifornical, and medial forebrain nuclei, and posterior magnocellular division and posterior subnucleus of the paraventricular nucleus were also immunostained for Fos in rats injected with the antimetabolite. These results show that decreased glucose metabolism is a stimulus for activation of the Fos stimulus-transcription cascade within oxytocin-and vasopressin-immunopositive neurones in several hypothalamic loci, findings that reflect activation of the Fos-stimulus transcription cascade within large proportions of these cell populations during this metabolic challenge. These data suggest that both peripheral hormonal and central modulatory functions of these neuropeptidergic neurones may be influenced by cellular glucose availability.

Extraspinal enthesopathy caused by isotretinoin therapy.

OBJECTIVE: To discuss a case of diffuse peripheral enthesopathy in a patient previously treated with long-term isotretinoin (Accutane) for severe acne. CLINICAL FEATURES: A 47-year old man with 1 month history of moderate neck and right upper extremity pain, with hypoesthesia of the right second and third fingers. Palpable bony prominences around multiple superficial joints were noted on physical examination, raising the initial question of osteochondromatosis. Multiple active acne pustules were noted. A limited skeletal survey demonstrated diffuse peripheral enthesophyte formation and hyperostoses, resembling those of diffuse idiopathic skeletal hyperostosis, but without accompanying spinal changes. A history of long-term Accutane therapy was then elicited. INTERVENTION AND OUTCOME: The enthesopathy was believed to represent an asymptomatic, longstanding, iatrogenically induced abnormality. No specific therapy or follow-up was indicated. The patient had discontinued use of Accutane years ago. Cervical symptoms improved with four sessions of cervical traction and nonsteroidal anti-inflammatory medications, but upper extremity symptoms were refractory. CONCLUSION: Accutane-induced enthesopathy should be considered in individuals with correlating radiologic and clinical features and history of retinoic acid therapy for acne. This should be a diagnosis by exclusion, after eliminating other potential causes of peripheral enthesopathy, particularly diffuse idiopathic skeletal hyperostosis, seronegative spondylarthropathy, and fluorosis.

Safety and efficacy of erythropoietin in children with chronic renal failure.

A prospective randomized study of the use of recombinant human erythropoietin (rHuEPO) in children with chronic renal disease was conducted to assess dosing requirements and side effects. Forty-four children with chronic renal failure, aged 4 months to 21 years, were studied. Twenty-five patients were pre dialysis, 10 on peritoneal dialysis, and 9 on hemodialysis. Patients received either 150 U/kg per week or 450 U/kg per week divided thrice weekly of rHuEPO for 12 weeks or until target hemoglobin (Hb) was attained. Dose was then adjusted to maintain a normal Hb. Eighty-two percent of patients reached target Hb by 7.9+/-5.6 weeks (mean+/-SD); 95% of patients in the high-dose group and 66% in the low-dose group reached target Hb within 12 weeks. The overall median rHuEPO dose at target Hb was 150 U/kg per week. Hemodialysis patients tended to require more rHuEPO to maintain a normal Hb (median 250 U/kg per week). Transfusion requirements and panel-reactive antibody levels decreased during the 12 weeks. Iron deficiency and/or hypertension occurred in 30% of children. In conclusion, rHuEPO at 150 U/kg per week is safe and effective in treating anemia in children with chronic renal disease.

Prophylactic effects of isometamidium- and ethidium-sustained release devices against Trypanosoma congolense in cattle.

Two successive experiments were carried out in which three cows were treated by intramuscular injection of either 0.5 mg/kg isometamidium or 1 mg/kg ethidium and compared with another group of three cows which received a subcutaneously implanted sustained release device (SRD) containing the same dose of drug. The prophylactic effect of both drug formulations was evaluated by exposing the animals at monthly intervals to Glossina morsitans morsitans infected with Trypanosoma congolense. The average protection period using the isometamidium- and the ethidium-SRD was extended by a factor of 3.2 and 2.8, respectively in comparison with the intramuscular injection of the drugs. In the analysis of isometamidium concentrations in the serum of the animals using a competitive drug-ELISA the drugs remained present for much longer periods in the sera of the implanted animals than in those of the intramuscularly treated cattle. The animals were still protected, however, a long time after the disappearance of detectable drug levels in the serum. No difference in drug sensitivity could be observed, when breakthrough isolates were compared from animals which received the ethidium-SRD and those treated intramuscularly, although a slight loss sensitivity occurred in the breakthrough isolates as compared to the parent trypanosome population.

Randomised study of cognitive effects of iron supplementation in non-anaemic iron-deficient adolescent girls.

BACKGROUND: Up to 25% of adolescent girls in the USA are iron deficient. This double-blind, placebo-controlled clinical trial assessed the effects of iron supplementation on cognitive function in adolescent girls with non-anaemic iron deficiency. METHODS: 716 girls who enrolled at four Baltimore high schools were screened for non-anaemic iron deficiency (serum ferritin < or = 12 micrograms/L with normal haemoglobin). 98 (13.7%) girls had non-anaemic iron deficiency of whom 81 were enrolled in the trial. Participants were randomly assigned oral ferrous sulphate (650 mg twice daily) or placebo for 8 weeks. The effect of iron treatment was assessed by questionnaires and haematological and cognitive tests, which were done before treatment started and repeated after the intervention. We used four tests of attention and memory to measure cognitive functioning. Intention-to-treat and per-protocol analyses were done. FINDINGS: Of the 81 enrolled girls with non-anaemic iron deficiency, 78 (96%) completed the study (39 in each group). Five girls (three control, two treatment) developed anaemia during the intervention and were excluded from the analyses. Thus, 73 girls were included in the per-protocol analysis. Ethnic distribution, mean age, serum ferritin concentrations, haemoglobin concentrations, and cognitive test scores of the groups did not differ significantly at baseline. Postintervention haematological measures of iron status were significantly improved in the treatment group (serum ferritin 27.3 vs 12.1 micrograms/L, p < 0.001). Regression analysis showed that girls who received iron performed better on a test of verbal learning and memory than girls in the control group (p < 0.02). INTERPRETATION: In this urban population of non-anaemic iron-deficient adolescent girls, iron supplementation improved verbal learning and memory.

Trial of d-alpha-tocopherol in Huntington's disease.

OBJECTIVE: Evidence suggests that the neuropathology of Huntington's disease, a neuropsychiatric disorder due to a mutation on chromosome 4, results from excessive activation of glutamate-gated ion channels, which kills neurons by oxidative stress. Therefore, the authors hypothesized that alpha-tocopherol, which reduces oxyradical damage to cell membranes, might slow the course of Huntington's disease. METHOD: A prospective, double-blind; placebo-controlled study of high-dose d-alpha-tocopherol treatment was carried out with a cohort of 73 patients with Huntington's disease who were randomly assigned to either d-alpha-tocopherol or placebo. Patients were monitored for changes in neurologic and neuropsychologic symptoms. RESULTS: Treatment with d-alpha-tocopherol had no effect on neurologic and neuropsychiatric symptoms in the treatment group overall. However, post hoc analysis revealed a significant selective therapeutic effect on neurologic symptoms for patients early in the course of the disorder. CONCLUSIONS: Antioxidant therapy may slow the rate of motor decline early in the course of Huntington's disease.

Extended myectomy-myotomy. A therapeutic alternative for total intestinal aganglionosis.

OBJECTIVE: That total intestinal aganglionosis (extended Hirschsprung's disease) is uniformly incompatible with life as reported in 1985, is challenged by this series of patients treated over the last 7 years with an alternative therapy, extended myectomy-myotomy of the small bowel. SUMMARY BACKGROUND DATA: A total of 16 neonates worldwide presented with intestinal obstruction secondary to total (extending to the stomach) or near total (to 40 cm of jejunum) intestinal aganglionosis confirmed at one or more leveling operations. METHODS: A patient questionnaire was answered by the surgeon of all 16 patients. RESULTS: The sex distribution was eight boys and eight girls. The definitive operation included extending an antimesenteric myectomy-myotomy from the ganglionic-aganglionic transition zone for variable lengths, the operative design being to create sufficient small bowel length to support life (40-cm minimum, total small bowel maximum). The myectomized bowel was terminated as an end-stroma or as an isolated jejuno-ileal segment. Ten of 16 patients have survived (62.5%) whose length of ganglionated bowel varies from 0 to 40 cm (mean, 12.4 cm; median, 6.0 cm). Six patients have died from 1 to 33 months after operation (mean, 9.5 months; median, 5.0 months) of gut-induced infection (n = 5) and respiratory failure (n = 1); their ganglionated bowel length was similar to survivors (range, 0-26 cm; mean, 9.2 cm; median, 8.0 cm). Of the 16 patients, 15 have received enteral nutrients through the myectomized bowel. Of ten survivors, strikingly two are totally gut nourished (2 cm, 7-cm length of ganglionated bowel), six receive from 1/5 to 4/5 of total calories enterally, and one receives minimal enteral feeding. CONCLUSIONS: From these patients we have learned that (1) extended myectomy-myotomy relieves the obstruction of extended Hirschsprung's disease; (2) aganglionic bowel after extended myectomy-myotomy acts as a passive conduit for proximally propulsed nutrients; and (3) aganglionic bowel after extended myectomy-myotomy undergoes adaptive change and is capable of absorbing life-supporting nutrients. These data demonstrate extended myectomy-myotomy to be a therapeutic option for otherwise fatal extended Hirschsprung's disease, either as a potentially definitive therapy or as a putative bridge to intestinal transplantation.

Pathogenetic role of Chlamydia, Yersinia and Borrelia in undifferentiated oligoarthritis.

We studied the cellular and humoral immune response to Chlamydia trachomatis, Yersinia enterocolitica and Borrelia burgdorferi in paired samples of peripheral blood and synovial fluid (SF) in undifferentiated oligoarthritis, reactive arthritis (ReA) and rheumatoid arthritis. Antigen specific lymphocyte proliferation was found in SF of 43% of patients with ReA and 34% of patients with undifferentiated oligoarthritis. C. trachomatis was the most frequent single agent. HLA-B27 was positive in 83% of patients with ReA and in 62% of patients with undifferentiated oligoarthritis with antigen specific lymphocyte proliferation. Antigen specific lymphocyte proliferation correlated poorly with the specific antibody response. Only chlamydial antigen was detected in SF cells using monoclonal antibodies. We conclude that some patients with undifferentiated oligoarthritis may have a forme fruste of ReA. This finding is important in view of recent evidence supporting the efficacy of antibiotic therapy in ReA.

Ophthalmology's botanical heritage.

Many of today's important ophthalmic pharmaceuticals have a rich ethnobotanical history. Solanaceous plants, the source of atropine, have contributed to medical therapy since the beginning of Western civilization. The botanical source of physostigmine played a pivotal role as an ordeal poison in the culture of Old Calabar, West Africa. Native peoples of Amazonia treasured plants containing pilocarpine as panaceas because of their impressive diaphoretic effect. Nineteenth century scientists examining these plants because of their folkloric reputations discovered their active compounds and documented their physiological effects. Ophthalmologists such as Argyll Robertson, Laqueur, and Weber built upon this research to bring these pharmaceuticals into therapeutic use. The ongoing loss of the world's tropical rain forests threatens to destroy a vast storehouse of untested biological compounds.

[Extremity-threatening ischemia in ergotism. Successful treatment with the intra-arterial administration of nifedipine]. / Extremitätenbedrohende Ischämie bei Ergotismus. Erfolgreiche Behandlung durch intraarterielle Gabe von Nifedipin.

A 39-year-old woman suffering from migraine took two suppositories of an ergotamine-containing proprietary drug (Cafergot, containing 2 mg ergotamine tartrate) for the first time again after an abstinence of two years. Twenty-four hours later she developed symptoms of decreased peripheral blood flow in all four limbs. Walking distance without pain was reduced to 100 m, but the severest changes affected the right arm, with livid discolorations and complete immobility 16 hours after the onset of symptoms. Despite administration of morphine derivatives the pain progressively increased. Angiography demonstrated spastic narrowing of all arm arteries below the axillary artery. No vessels were visualized below the lower-arm bifurcation. Thereupon 4 mg nifedipine were injected through the angio-catheter within 30 min (five individual doses of 0.8 mg each). This was followed by intravenous infusion of 0.5 mg/h. The pain immediately decreased and the livid discoloration as well as impaired arm movement improved. A residual deficit, incomplete lesion of the median nerve, persisted but gradually regressed during the following two months.

Diencephalic amnesia.

The anatomical basis and cognitive profile of diencephalic amnesia remain unclear. We report a two-part study. First, we studied 4 patients with bilateral medial thalamic infarctions using magnetic resonance imaging and comprehensive neuropsychological testing. All patients were followed for more than 1 year. Using a stereotactic method, we plotted the lesions in an atlas delineating the probable structure involved. Secondly, in 2 monkeys, using autoradiography, we traced the pathway from the amygdala to the dorsomedial nucleus, paying particular attention to the intrathalamic course of the amygdalothalamic projections. Our findings were (1) patients develop amnesia when infarctions are located anteriorly; (2) in patients with amnesia, the lesions can be small and strategically located, probably interfering with both hippocampal-related neural structures such as the mamillothalamic tract, and amygdala-related neural structures such as the ventroamygdalofugal pathway; and (3) a specific component of the latter is situated lateral but immediately adjacent to the mamillothalamic tract in the monkey, enabling both structures to be damaged bilaterally by small mirror image lesions. The amnesia is characterized by deficits in anterograde verbal and visual learning and in retrograde amnesia, but motor learning is preserved. We raise the possibility that bilateral diencephalic lesions may interfere particularly with temporal aspects of memory.