Implementation and dissemination of an African American popular opinion model to improve lupus awareness: an academic-community partnership.

OBJECTIVE: Lupus is a chronic, autoimmune disease that disproportionately affects African Americans. We adapted the Centers for Disease Control and Prevention's Popular Opinion Leader model to implement an intervention tailored for African American individuals that leverages an academic-community partnership and community-based social networks to disseminate culturally appropriate lupus education. METHODS: Academic rheumatologists, social scientists, and researchers in Boston, MA and Chicago, IL partnered with local lupus support groups, community organizations, and churches in neighborhoods with higher proportions of African Americans to develop curriculum and recruit community leaders with and without lupus (Popular Opinion Leaders; POLs). POLs attended four training sessions focused on lupus education, strategies to educate others, and a review of research methods. POLs disseminated information through their social networks and recorded their impact, which was mapped using a geographic information system framework. RESULTS: We trained 18 POLs in greater Boston and 19 in greater Chicago: 97% were African American, 97% were female; and the mean age was 57 years. Fifty-nine percent of Boston POLs and 68% of Chicago POLs had lupus. POLs at both sites engaged members of their social networks and communities in conversations about lupus, health disparities, and the importance of care. Boston POLs documented 97 encounters with 547 community members reached. Chicago POLs documented 124 encounters with 4083 community members reached. CONCLUSIONS: An adapted, community-based POL model can be used to disseminate lupus education and increase awareness in African American communities. Further research is needed to determine the degree to which this may begin to reduce disparities in access to care and outcomes.

Yersinia pestis biofilm in the flea vector and its role in the transmission of plague.

Transmission by fleabite is a relatively recent evolutionary adaptation of Yersinia pestis, the bacterial agent of bubonic plague. To produce a transmissible infection, Y. pestis grows as an attached biofilm in the foregut of the flea vector. Biofilm formation both in the flea foregut and in vitro is dependent on an extracellular matrix (ECM) synthesized by the Yersinia hms gene products. The hms genes are similar to the pga and ica genes of Escherichia coli and Staphylococcus epidermidis, respectively, that act to synthesize a poly-beta-1,6-N-acetyl-d-glucosamine ECM required for biofilm formation. As with extracellular polysaccharide production in many other bacteria, synthesis of the Hms-dependent ECM is controlled by intracellular levels of cyclic-di-GMP. Yersinia pseudotuberculosis, the food- and water-borne enteric pathogen from which Y. pestis evolved recently, possesses identical hms genes and can form biofilm in vitro but not in the flea. The genetic changes in Y. pestis that resulted in adapting biofilm-forming capability to the flea gut environment, a critical step in the evolution of vector-borne transmission, have yet to be identified. During a flea bite, Y. pestis is regurgitated into the dermis in a unique biofilm phenotype, and this has implications for the initial interaction with the mammalian innate immune response.

Genetic and clonal diversity for Myrica cerifera along a spatiotemporal island chronosequence.

Changes in genetic diversity and clonal structure were investigated along a spatiotemporal island chronosequence for the shrub Myrica cerifera. On our study site, Hog Island, Virginia, USA, island movement creates a sequence of dune ridges and intervening swales along an east-west axis of the island that produces an age-structured geomorphology. This substrate-mediated age structure, called the chronosequence, superimposes itself upon cohorts of M. cerifera that colonize behind nascent dune ridges as they are formed. This chronosequence allowed comparisons of levels of genetic diversity and clonal structure among different aged cohorts of M. cerifera. We observed little change in allelic diversity along the chronosequence and no evidence for heterosis, although there was moderate change in genotypic diversity. The spatial distribution of individuals within 10 plots established along three transects intersecting the island chronosequence identified a nonrandom spatial distribution of individuals in all cohorts, with increasing aggregation of above-ground stems into multistemmed clusters in the older sites. This aggregation of individuals did not correspond to a significant increase in clonal growth with cohort age, nor was there significant spatial genetic autocorrelation within any of the plots.

Evidence of quorum sensing in the rumen ecosystem: detection of N-acyl homoserine lactone autoinducers in ruminal contents.

Acyl-homoserine lactone (AHL) based quorum-sensing systems are widespread among gram-negative bacteria, particularly in association with plants and animals. As yet, there have been no reports of AHL signaling in the anaerobic rumen environment, an ecosystem of great complexity in which cell-cell signaling is likely to occur. We detected multiple AHL autoinducers in the rumen contents of 6 out of 8 cattle fed a representative selection of diets. The signals were not associated with feed. Surprisingly, no pure cultures produced AHLs in vitro when grown under the laboratory conditions we tested. Our observations suggest that either (a) a factor specific to the rumen ecosystem is required for the rumen isolates we tested to produce AHLs or (b) a strain (or strains) that we were not able to culture but which grows to a high cell density in the rumen produces the AHLs we detected.

Delayed cerebrovascular complications of intrathecal colloidal gold.

OBJECTIVE: Therapy with intrathecal colloidal gold has been used in the past as an adjunct in the treatment of childhood neoplasms, including medulloblastoma and leukemia. We describe the long-term follow-up period of a series of patients treated with intrathecal colloidal gold and emphasize the high incidence of delayed cerebrovascular complications and their management. METHODS: Between 1967 and 1970, 14 children with posterior fossa medulloblastoma underwent treatment at the University of Minnesota. Treatment consisted of surgical resection, external beam radiotherapy, and intrathecal colloidal gold. All patients underwent long-term follow-up periods. RESULTS: Of the 14 original patients, 6 died within 2 years of treatment; all experienced persistent or recurrent disease. The eight surviving patients developed significant neurovascular complications 5 to 20 years after treatment. Three patients died as a result of aneurysmal subarachnoid hemorrhage, and five developed ischemic symptoms from severe vasculopathy that resembled moyamoya disease. CONCLUSION: Although therapy with colloidal gold resulted in long-term survival in a number of cases of childhood medulloblastoma, our experience suggests that the severe cerebrovascular side effects fail to justify its use. The unique complications associated with colloidal gold therapy, as well as the management of these complications, are presented. We recommend routine screening of any long-term survivors to exclude the presence of an intracranial aneurysm and to document the possibility of moyamoya syndrome.

Extracranial-intracranial bypass for ischemic cerebrovascular disease refractory to maximal medical therapy.

OBJECTIVE: To examine the potential role of cerebral revascularization in the treatment of patients with symptomatic occlusive cerebrovascular disease refractory to medical therapy. METHODS: Twenty patients with symptomatic occlusive cerebrovascular disease underwent 22 extracranial-intracranial bypass procedures after failing maximal medical therapy. The average follow-up time was 3.5 years, and no patient was lost to follow-up. RESULTS: All patients presented with repeated transient ischemic attacks refractory to medical therapy. Angiographic findings included internal carotid artery occlusion in 8 patients, middle cerebral artery stenosis or occlusion in 4, moyamoya disease in 4, internal carotid artery dissection in 2, and supraclinoid internal carotid artery stenosis in 2. Outcome was excellent in 17 patients and good in 3. The only surgical complication occurred in one patient, who experienced postoperative seizures and required anticonvulsant therapy. There were no deaths in this series. CONCLUSION: Although the Cooperative Study on Extracranial-Intracranial Bypass failed to show a benefit from the bypass procedure, we have continued to perform the operation in selected cases. Carefully selected individuals with occlusive cerebrovascular disease and persistent ischemic symptoms, despite maximal medical therapy, seem to obtain demonstrable and durable benefit from cerebral revascularization.

The fate of intracranial microaneurysms treated with bipolar electrocoagulation and parent vessel reinforcement.

OBJECTIVE: Although direct clipping remains the treatment of choice for intracranial aneurysms, not all aneurysms can be clipped. This report reviews the results of bipolar coagulation followed by parent vessel reinforcement for the treatment of intracranial microaneurysms (maximal diameter of < or =3 mm), with immediate and delayed postoperative angiographic evaluation in all cases. METHODS: During a 1-year period, 20 intracranial microaneurysms in 12 patients were treated with bipolar electrocoagulation followed by reinforcement of the parent artery with muslin gauze. All patients underwent intraoperative or immediate postoperative angiographic evaluation, and all underwent follow-up angiographic evaluation approximately 1 year later. No patient was lost to follow-up monitoring. RESULTS: Microaneurysms involved the middle cerebral artery (eight cases), internal carotid artery (six cases), anterior cerebral/anterior communicating artery (five cases), and superior cerebellar artery (one case). In all cases, the patient was undergoing a craniotomy for clipping of a larger aneurysm, and the microaneurysms were treated concurrently. At the time of the immediate angiographic examinations, 19 of 20 (95%) microaneurysms were no longer visible and 1 was substantially smaller (< 1-mm irregularity on the parent vessel). No patient experienced an adverse event related to microaneurysm treatment. In the 1-year follow-up examinations, there was no angiographic evidence of recurrence in the 19 cases with complete obliteration; the one residual aneurysm remained stable. CONCLUSION: At 1 year, direct coagulation followed by parent vessel reinforcement seems to provide a satisfactory treatment option for intracranial microaneurysms.

Cost-effectiveness of carotid endarterectomy.

Carotid endarterectomy (CEA) reduces the risk of stroke in symptomatic patients with high-grade carotid stenosis. In this study, we evaluated the long-term, societal cost-benefit ratio of endarterectomy using a decision analysis model. We reviewed the results of 150 CEAs performed at an academic center and established a Markov model comparing cohorts of patients who experienced transient ischemic attacks and then underwent observation, aspirin therapy, or CEA. The cost-effectiveness of CEA was estimated using perioperative complication rates from our review and from the North American Symptomatic Carotid Endarterectomy Trial. Stroke and mortality rates were estimated from the literature. Cost estimates were based on medicare reimbursement data. Among the 150 CEAs reviewed, complications included major stroke (0.67%), minor stroke (1.33%), myocardial infarction (1.33%), pulmonary edema (0.67%), and wound hematoma (3.33%). There were no deaths or intracerebral hemorrhages. Using complication rates from our review, CEA produced cost savings of $5730.62 over the cost of observation and $3264.66 over the cost of aspirin treatment. CEA extended the average quality-adjusted life expectancy 15.8 months over that of observation and 13.2 months over that of aspirin. Substituting the North American Symptomatic Carotid Endarterectomy Trial results, CEA yielded savings of $2997.50 over the cost of observation and $531.54 over the cost of aspirin. Quality-adjusted life expectancy was extended 13.8 months compared with observation and 11.2 months compared with aspirin therapy. This analysis demonstrates that when performed with low perioperative morbidity and mortality rates, CEA is a highly cost-effective therapy for symptomatic carotid stenosis and results in substantial societal cost and life savings.

Intrathecal granuloma complicating chronic spinal infusion of morphine. Report of three cases.

Intrathecal morphine delivered by implanted pumps has been used in the treatment of pain caused by terminal cancer. Some authors supports its use in benign pain as well. The authors present three cases in which chronic infiltration of intraspinal narcotic medication was complicated by the formation of a granulomatous mass that became large enough to exert mass effect and induce neurological dysfunction.

Spinal tuberculosis: a diagnostic and management challenge.

The authors reviewed 29 cases of spinal tuberculosis treated from 1973 to 1993 with an average follow-up time of 7.4 years. Clinical findings included back pain, paraparesis, kyphosis, fever, sensory disturbance, and bowel and bladder dysfunction. Twenty-two patients (76%) presented with neurological deficit; 12 (41%) were initially misdiagnosed. Sixteen patients (55%) had predominant vertebral body involvement; nine had marked bone collapse with neurological compromise. Eleven individuals (39%) had intraspinal granulomatous tissue causing neurological dysfunction in the absence of bone destruction, and two (7%) had intramedullary tuberculomas. All patients received antituberculous medications: 13 were initially treated with bracing alone, eight underwent laminectomy and debridement of extra- or intradural granulomatous tissue, and eight underwent anterior, posterior, or combined fusion procedures. No patient with neurological deficit recovered or stabilized with nonoperative management. Thirteen patients were readmitted with progression of inadequately treated osteomyelitis; 12 (92%) of these required new or more radical fusion procedures. Anterior fusion failure was associated with marked preoperative kyphosis and multilevel disease requiring a graft that spanned more than two disc spaces. Courses of antibiotic medications shorter than 6 months were invariably associated with disease recurrence. It was concluded that 1) patients should receive at least 12 months of appropriate antituberculous therapy; 2) individuals with neurological deficit should undergo surgical decompression; 3) laminectomy and debridement are adequate for intraspinal granulomatous tissue in the absence of significant bone destruction; 4) when vertebral body involvement has produced wedging and kyphosis, aggressive debridement and fusion are indicated to prevent delayed instability and progression of disease.

Papilledema and intraspinal lumbar paraganglioma.

Optic nervehead swelling is most frequently caused by ocular or intracranial lesions. The case presented here demonstrates that the spinal subarachnoid space must also be considered as a potential site for a lesion causing optic nervehead swelling. A 56-year-old man is presented with an intraspinal lumbar paraganglioma associated with increased cerebrospinal fluid protein, papilledema, transient obscurations of vision, and back pain. This may be the first reported case of a paraganglioma associated with optic nervehead swelling. Magnetic resonance imaging of the lumbosacral region revealed the lesion noninvasively. The papilledema, transient obscurations of vision, and back pain resolved after resection of the tumor. The mechanisms are not defined for optic nervehead swelling in association with spinal tumors in general and paraganglioma in particular. The measured abnormal elevation of cerebrospinal fluid protein may have resulted in increased intracranial pressure and papilledema.

Control of intractable spasticity with intrathecal morphine sulfate.

Three years ago we reported our preliminary results regarding treatment of intractable spasticity with use of intrathecal morphine. This paper is a follow-up report of 12 patients who underwent implantation of a pump or reservoir for delivery of intrathecal morphine sulfate for control of spasticity. Our primary concern initially was that patients would ultimately become drug tolerant and lose the beneficial effect of the morphine. Only one of these 12 patients has developed drug tolerance. The longest follow-up period has been 4.3 years, and this patient has maintained excellent control of his spasticity with a stable dose of 2 mg of morphine daily.

Optic nerve decompression for osteopetrosis in early childhood.

Visual failure in osteopetrosis may result from retinal degeneration or compression of the optic nerve in the narrowed optic canals. We report the evaluation and treatment of five children with osteopetrosis whose optic nerve dysfunction seems to have been related to the latter etiology. Evaluation of visual function was carried out by means of behavioral observation and flash visual evoked responses. Of six nerves evaluated both pre- and postoperatively, the visual evoked responses seemed to improve in four. Three nerves were serially evaluated without an operation, and one showed changes consistent with maturation. One nerve was evaluated with serial postoperative evoked potentials and showed no change. We conclude that surgical decompression of the optic nerve in patients with documented optic nerve dysfunction and osteopetrosis allows improvement in visual function and is, therefore, an important consideration in the evaluation and management of patients with this disease.

The treatment of Moyamoya disease by superficial temporal-middle cerebral artery (STA-MCA) anastomosis.

STA-MCA anastomosis was performed in a total of eight patients ranging in age from five to 42 years for treatment of symptomatic Moyamoya disease. All of the patients presented with symptoms of cerebral ischemia. In most cases bilateral procedures were performed at separate operations. No patients have experienced increased neurological deficits as a result of surgery, while the ischemic symptoms have been relieved completely in most cases. The surgical procedure is especially demanding in the treatment of Moyamoya disease, but remains one of the few solutions to the treatment of this disease.

Control of spasticity by implantable continuous flow morphine pump.

Continuous flow pumps are being used for the delivery of morphine sulfate to the intrathecal and epidural space for control of pain. We have encountered several patients who had a combination of pain and spasticity or who had spasticity so intense that it was the source of pain. One to two milligrams of intrathecal morphine dramatically relieved their spasticity and pain. Three such patients have subsequently undergone pump implantation with prolonged control of their spasticity. This has initiated a formal clinical investigation directed at determining the physiological mechanism of this phenomenon, as well as its long term efficacy.

The relative gonadal index: an alternative index for quantification of reproductive condition.

Gonadal indices (i.e. GSI = gonadal wt/body wt X 100) commonly are used to quantify reproductive condition in fishes. These indices may be inappropriate with specimens of different sizes, however, for gonadal growth often is allometric. A new gonadal index (relative gonadal index, RGI) was developed to quantify the reproductive condition of animals independent of body size. The RGI is based on the underlying model W = alpha i X S beta i, where W is gonadal weight, S is body size (less gonadal weight if body weight is used), and alpha i and beta i are parameters to be estimated for gonadal developmental stage i. Assuming that a multiplicative lognormal error is appropriate, parameter estimates for alpha i and beta i were obtained by linear least squares regression for the log-transformed model ln(W) = beta i X ln(S) + ln(alpha i), where, in this form, beta i is the slope and ln(alpha i) is the intercept. Only if estimates of beta i do not differ significantly among ovarian developmental stages, as in our case, can a pooled estimate of beta be used to obtain the relative gonadal index, RGI = alpha i = W/S beta. Applicability of the RGI was tested using ovaries of three ecologically distinct fish species. The RGI was found to be more appropriate than the gonosomatic index for all three species.

Extreme lateral disc herniation: diagnosis by computed tomographic scanning.

Extreme lateral disc herniation with compression of the nerve root as it exits through the foramen has been a recognized entity for a number of years. Until recently, this diagnosis was made infrequently except at the time of operation. Reported here are 12 cases of root compression from disc herniation at the level of the pedicle or farther laterally in the foramen (extreme lateral disc herniation). Diagnosis and localization of the root compression were determined preoperatively in 11 of 12 cases based on the computed tomographic (CT) scan appearance of the lesion. Myelography was performed in 9 cases and was interpreted as normal in 6 and abnormal in 3 instances. In each of the 3 abnormal studies, the actual abnormality was at a different level than that predicted by the myelogram. The clinical presentations in these patients were not distinct except that a positive straight leg raising test was present in only 7 of 12. Preoperative knowledge of the site of nerve root compression as delineated by CT scanning was essential in planning the operative procedure. It prevented unnecessary exploration of uninvolved levels and directed the surgeon to the far lateral site of the herniation. Illustrative examples are presented.

Tuberous sclerosis: a review for the neurosurgeon.

The clinical, radiological, and pathological characteristics of tuberous sclerosis are reviewed. Neurosurgical intervention in the syndrome is discussed in light of two recently treated cases and a literature review.

Aspergillus infections of the lumbar disc spaces. Report of three cases.

Three cases of lumbar vertebral interspace infection due to the Aspergillus fungus are presented. Two patients responded to vigorous surgical therapy in combination with prolonged administration of antifungal agents. The third patient died of complications related to the antibiotic therapy. Possible etiologies of this unusual problem are reviewed in light of the changing spectrum of nosocomial and spontaneously acquired infectious processes. Combined aggressive medical and surgical therapy is discussed with respect to the known difficulties in eradicating deep-seated osseous mycotic infections.