Implantation of collagen punctal plugs for the reduction of post-keratoplasty ametropia.

In 1995, a 46-year-old woman was referred for refractive surgery. Eleven years earlier, she had undergone an uncomplicated penetrating keratoplasty in her right eye to treat a dense corneal opacity caused by contact lens-related microbial keratitis. Due to high myopia in the graft, she was unable to achieve useful vision and declined contact lens use. After extensive counseling, she elected to undergo radial keratotomy (RK) and arcuate keratotomy (AK) in her right eye. We recommended the insertion of collagen punctal plugs into the keratotomy incisions to increase the RK effect. She also decided to have RK in her left eye. Postoperatively, her uncorrected visual acuity was 20/25 OD and 20/30 OS. We were able to contact her and her ophthalmologist eleven years later, and eight of eleven collagen plugs were still present in the incisions, with no signs of rejection or inflammation. Later, we learned that she underwent a repeat penetrating keratoplasty due to corneal graft failure after a phacoemulsification procedure. The pathologic examination of the intact plugs and graft also showed no rejection or inflammation.

Virtual bronchoscopy as a dynamic modality in the diagnosis and treatment of suspected foreign body aspiration.

AIM: Rigid bronchoscopy (RB) is an invasive procedure and has its own risks. The place of virtual bronchoscopy (VB) in the treatment of patients with a clinical and radiological suspicion of foreign body aspiration was evaluated to see whether its usage can prevent rigid bronchoscopy. PATIENTS AND METHODS: The study was performed between December 2005 and May 2007 in 60 patients (35 M and 25 F) aged between 4 months and 7 years with clinical and radiographical suspicion of foreign body aspiration. Patients with radio-opaque foreign body aspiration were excluded from the study and treated directly by RB. VB was performed using 16 detector multislice computerized tomography (MDCT). If VB or clinical follow-up supported the diagnosis of foreign body, RB was performed for diagnosis and treatment. The results of RB were compared with the results of VB. RESULTS: All patients underwent VB. In 40 patients there was a suspicion of foreign body with VB. Two patients improved without RB: one had spontaneous discharge of the foreign body with coughing, and one experienced spontaneous clinical improvement. The remaining 38 patients underwent RB and a foreign body was found in the reported localization in 33. No foreign body was found with RB in 5 patients showing foreign body in VB. But we found bronchial vegetations in 2, obstructing mucus plug in 2 and external bronchial compression by neuroenteric cyst in one. In 20 patients there was no suspicion of foreign body with VB. Of these, 7 patients with presenting symptoms for more than one month underwent RB, but no foreign body was found. The 13 remaining patients were followed up clinically with improvement of symptoms. CONCLUSION: MDCT devices still require further investigation when used in pediatric surgical pathologies. Reconstructed images of VB can reveal images close to the real anatomy. In patients with a suspicion of foreign body ingestion, initial VB may help to determine the presence and exact localization of the foreign body and if negative, may reduce the number of unnecessary rigid bronchoscopies. None of the patients with negative VB had foreign bodies. Positive VB may help to shorten the operative time by providing information about the localization and size of the foreign body.

Central nervous system control of food intake and body weight.

The capacity to adjust food intake in response to changing energy requirements is essential for survival. Recent progress has provided an insight into the molecular, cellular and behavioural mechanisms that link changes of body fat stores to adaptive adjustments of feeding behaviour. The physiological importance of this homeostatic control system is highlighted by the severe obesity that results from dysfunction of any of several of its key components. This new information provides a biological context within which to consider the global obesity epidemic and identifies numerous potential avenues for therapeutic intervention and future research.

Polyethyleneimine as a transmembrane carrier of fluorescently labeled proteins and antibodies.

Polyethyleneimine (PEI) has been used previously as a nonviral DNA transfer vector. In this article, we demonstrate its use as a vehicle for transmembrane delivery of proteins in cell culture conditions. Linking proteins to PEI required no other treatment beyond mixing them with PEI. The bond between PEI and protein combined at optimal ratios was maintained in electrophoresis, even in the presence of 2.5% sodium dodecyl sulfate (SDS). The optimal time for delivery of proteins was determined to be 24 h. We have successfully delivered an Alexa 488-labeled avidin protein into human glioblastoma cells. A functional antibody against the nuclear protein lamin was delivered into human fibroblasts and reacted with lamin inside live cells. PEI-based delivery of antibodies and fluorescently labeled proteins can be used for fluorescent detection, tracking, and evaluation of cellular protein function in vivo.

Local bleomycin injection in the treatment of lymphangioma.

AIM: We report here our experience with local bleomycin injection in lymphangioma. PATIENTS AND METHODS: Nine patients with lymphangioma were treated with locally injected bleomycin and followed prospectively. We performed an ultrasound study in all cases to delineate the size, location, nature, and number of compartments of the cyst prior to the injection. Under ultrasound guidance, the content of the cystic cavity was aspirated and 1 - 3 mg/kg bleomycin were injected. The patients were revisited monthly. No attempt at re-injection was made as long as the mass continued to decrease in size. RESULTS: Patients consisted of 4 boys and 5 girls aged between 14 days and 6 years. The localisation of the mass was cervical in 6, cervical, sublingual, and lingual in 1, axillary in 1 and axillary and thoracic in 1. In six children, the mass disappeared totally after a single injection. In one patient a second injection was needed, and surgical excision was performed in two patients with residual solid component. No complication related to bleomycin was seen. CONCLUSION: Local application of bleomycin in children with lymphangioma is a simple, safe, and effective method. In the majority of cases, total healing may be achieved with a single injection.

Expression of receptors for insulin and leptin in the ventral tegmental area/substantia nigra (VTA/SN) of the rat.

Recent studies have demonstrated that the metabolic hormones insulin and leptin can modulate behavioral performance in reward-related paradigms. However, specific anatomical substrate(s) within the CNS for these effects remain to be identified. We hypothesize that midbrain dopamine neurons, which have been implicated to be critical in the mediation of motivational and reward aspects of stimuli, contribute to these behavioral effects of insulin and leptin. As one approach to evaluate this hypothesis, we used double-labeling fluorescence immunohistochemistry to determine whether the midbrain dopamine neurons express insulin receptors or leptin receptors. Extensive co-expression of tyrosine hydroxylase (a marker for dopamine neurons) with both the insulin receptor and the leptin receptor was observed in the ventral tegmentum and substantia nigra. These findings suggest that midbrain dopamine neurons are direct targets of insulin and leptin, and that they participate in mediating the effects of these hormones on reward-seeking behavior.

Fos expression in rat celiac ganglion: an index of the activation of postganglionic sympathetic nerves.

To develop an index of the activation of abdominal sympathetic nerves, we used Fos immunostaining of the celiac ganglion (CG) taken from rats receiving nicotine, preganglionic nerve stimulation, or glucopenic agents. Subcutaneous nicotine injection moderately increased Fos expression in the principal ganglionic cells of the CG (17 +/- 4 Fos+ per mm(2), approximately 12% of all principal CG cells), whereas subcutaneous saline had no effect (0 +/- 0 Fos+ per mm(2); n = 7; P < 0.01). Greater Fos expression was obtained by applying nicotine topically to the CG (71 +/- 8 Fos+ per mm(2); 52% of all principal CG cells, n = 5; P < 0.01 vs. topical saline, n = 4) and by preganglionic nerve stimulation (126 +/- 9 Fos+ per mm(2); 94% of all principal CG cells, n = 11; P < 0.01 vs. nerve isolation, n = 7). Moderate Fos expression was also observed in the CG after intraperitoneal 2-deoxy-D-glucose (2DG) injection (21 +/- 2 Fos+ per mm(2); 16% of all principal CG cells, n = 5; P < 0.01 vs. saline ip) or insulin injection (16 +/- 2 Fos+ per mm(2); 12% of all principal CG cells, n = 6; P < 0.01 vs. saline ip). Furthermore, Fos expression induced by 2DG was dose and time dependent. These data demonstrate significant Fos expression in the CG in response to chemical, electrical, and reflexive stimulation. Thus Fos expression in the CG may be a useful index to describe various levels of activation of its postganglionic sympathetic neurons.

Lymphomatoid granulomatosis in a boy with long-term follow-up.

Lymphomatoid granulomatosis is an angiocentric lymphoreticular proliferative disease. Some patients go on to develop frank neoplasia. The authors describe a patient who presented at the age of 12 years with pulmonary nodules and hepatosplenomegaly and was followed up for 6 years, and who subsequently developed lymphoma after cessation of therapy.

Hypothalamic, metabolic, and behavioral responses to pharmacological inhibition of CNS melanocortin signaling in rats.

The CNS melanocortin (MC) system is implicated as a mediator of the central effects of leptin, and reduced activity of the CNS MC system promotes obesity in both rodents and humans. Because activation of CNS MC receptors has direct effects on autonomic outflow and metabolism, we hypothesized that food intake-independent mechanisms contribute to development of obesity induced by pharmacological blockade of MC receptors in the brain and that changes in hypothalamic neuropeptidergic systems known to regulate weight gain [i.e., corticotropin-releasing hormone (CRH), cocaine-amphetamine-related transcript (CART), proopiomelanocortin (POMC), and neuropeptide Y (NPY)] would trigger this effect. Relative to vehicle-treated controls, third intracerebroventricular (i3vt) administration of the MC receptor antagonist SHU9119 to rats for 11 d doubled food and water intake (toward the end of treatment) and increased body weight ( approximately 14%) and fat content ( approximately 90%), hepatic glycogen content ( approximately 40%), and plasma levels of cholesterol ( approximately 48%), insulin ( approximately 259%), glucagon ( approximately 80%), and leptin ( approximately 490%), whereas spontaneous locomotor activity and body temperature were reduced. Pair-feeding of i3vt SHU9119-treated animals to i3vt vehicle-treated controls normalized plasma levels of insulin, glucagon, and hepatic glycogen content, but only partially reversed the elevations of plasma cholesterol ( approximately 31%) and leptin ( approximately 104%) and body fat content ( approximately 27%). Reductions in body temperature and locomotor activity induced by i3vt SHU9119 were not reversed by pair feeding, but rather were more pronounced. None of the effects found can be explained by peripheral action of the compound. The obesity effects occurred despite a lack in neuropeptide expression responses in the neuroanatomical range selected across the arcuate (i.e., CART, POMC, and NPY) and paraventricular (i.e., CRH) hypothalamus. The results indicate that reduced activity of the CNS MC pathway promotes fat deposition via both food intake-dependent and -independent mechanisms.

How the brain regulates food intake and body weight: the role of leptin.

The brain plays a key role in the regulation of energy homeostasis, balancing food intake and energy expenditure to maintain adipose tissue mass. A widely accepted model proposes that energy homeostasis is modulated by hormones that circulate in the blood in proportion to adipose tissue mass. A major candidate 'adiposity signal' to the brain is the adipocyte hormone, leptin; this inhibits neuropeptide circuits that promote anabolic metabolism, and stimulates those that promote catabolic metabolism. It is hypothesized that leptin-responsive circuits in the hypothalamus project to caudal brainstem neuronal groups that integrate satiety signals converging on the brain from the stomach and intestine following ingestion of food. Leptin signaling to the brainstem via hypothalamic pathways potentially increases the brain's motor and autonomic responses to satiety signals, leading to smaller individual meals, reduced cumulative food intake, and a lower body weight. This mechanism explains how leptin deficiency or defects in the brain's processing of leptin signaling can result in a sustained increase in food intake and obesity.

Fluorescence in situ hybridization of scarce leptin receptor mRNA using the enzyme-labeled fluorescent substrate method and tyramide signal amplification.

To increase the sensitivity of fluorescence in situ hybridization (FISH) for detection of low-abundance mRNAs, we performed FISH on cryostat sections of rat hypothalamus with biotin-labeled riboprobes to leptin receptor (ObRb) and amplified the signal by combining tyramide signal amplification (TSA) and Enzyme-Labeled Fluorescent alkaline phosphatase substrate (ELF) methods. First, TSA amplification was done with biotinylated tyramide. Second, streptavidin-alkaline phosphatase was followed by the ELF substrate, producing a bright green fluorescent reaction product. FISH signal for ObRb was undetectable when TSA or ELF methods were used alone, but intense ELF FISH signal was visible in hypothalamic neurons when the ELF protocol was preceded by TSA. The TSA-ELF was combined with FISH for pro-opiomelanocortin (POMC) and neuropeptide Y (NPY) mRNAs by hybridizing brain sections in a cocktail containing digoxigenin-labeled riboprobes to NPY or POMC mRNA and biotin-labeled riboprobes to ObRb mRNA. Dioxigenin-labeled NPY or POMC mRNA hybrids were subsequently detected first with IgG-Cy3. Then biotin-labeled leptin receptor hybrids were detected with the TSA-ELF method. Combining the ELF and TSA amplification techniques enabled FISH detection of scarce leptin receptor mRNAs and permitted the identification of leptin receptor mRNA in cells that also express NPY and POMC gene products.

Hypothalamic melanin-concentrating hormone and estrogen-induced weight loss.

Melanin-concentrating hormone (MCH) is an orexigenic neuropeptide produced by neurons of the lateral hypothalamic area (LHA). Because genetic MCH deficiency induces hypophagia and loss of body fat, we hypothesized that MCH neurons may represent a specific LHA pathway that, when inhibited, contributes to the pathogenesis of certain anorexia syndromes. To test this hypothesis, we measured behavioral, hormonal, and hypothalamic neuropeptide responses in two models of hyperestrogenemia in male rats, a highly reproducible anorexia paradigm. Whereas estrogen-induced weight loss engaged multiple systems that normally favor recovery of lost weight, the expected increase of MCH mRNA expression induced by energy restriction was selectively and completely abolished. These findings identify MCH neurons as specific targets of estrogen action and suggest that inhibition of these neurons may contribute to the hypophagic effect of estrogen.

SOCS-3 expression in leptin-sensitive neurons of the hypothalamus of fed and fasted rats.

Treatment of rodents with exogenous leptin increases SOCS-3 mRNA levels in the arcuate nucleus (ARC) and dorsomedial nucleus (DMN) of the hypothalamus. To determine if SOCS-3 gene activity in the hypothalamus could be influenced by changes in physiological levels of circulating leptin, we performed in situ hybridization (ISH) and immunostaining for SOCS-3 expression in fed vs. fasted (48 h) rats. The ARC and DMN were the only regions of the diencephalon that showed SOCS-3 ISH and the autoradiographic ISH signal for SOCS-3 mRNA was visibly less in the ARC and DMN of fasted rats. The ISH signal for SOCS-3 mRNA was decreased 70% in the ARC and 90% in the DMN (to background levels) when animals were fasted (P<0.01), consistent with decreased immunostaining for SOCS-3 protein observed in the fasted rats. Double fluorescence ISH (FISH) analyses showed colocalization of SOCS-3 mRNA with mRNAs for NPY and POMC in the ARC. These findings are consistent with increased leptin signaling to the NPY and POMC neurons in the ARC by physiological levels of circulating leptin during normal feeding. Therefore, changes in SOCS-3 mRNA levels in the ARC and DMN can be viewed as an indicator of relative physiological leptin signaling to the hypothalamus and also identify cells responding directly to leptin signaling through its cognate receptor.

CNS melanocortin system involvement in the regulation of food intake.

Accumulating evidence indicates that the central melanocortin (MC) system plays a key role in the regulation of food intake and energy balance. This evidence includes findings that either spontaneous genetic mutations or targeted gene deletions that impair melanocortin signaling cause disrupted food intake and body-weight control. In addition, expression of the mRNA that encodes the endogenous agonists and antagonists for CNS melanocortin receptors is regulated by changes in energy balance and body-adiposity signals. Finally, administration of both natural and synthetic ligands to MC receptors produces changes in food intake. The data collectively suggest a critical role for melanocortin signaling in the control of energy balance.

Effects of streptozotocin-induced diabetes and insulin treatment on the hypothalamic melanocortin system and muscle uncoupling protein 3 expression in rats.

Hypothalamic melanocortins are among several neuropeptides strongly implicated in the control of food intake. Agonists for melanocortin 4 (MC-4) receptors such as alpha-melanocyte-stimulating hormone (alpha-MSH), a product of proopiomelanocortin (POMC), reduce food intake, whereas hypothalamic agouti-related protein (AgRP) is a MC-4 receptor antagonist that increases food intake. To investigate whether reduced melanocortin signaling contributes to hyperphagia induced by uncontrolled diabetes, male Sprague-Dawley rats were studied 7 days after administration of streptozotocin (STZ) or vehicle. In addition, we wished to determine the effect of diabetes on muscle uncoupling protein 3 (UCP-3), a potential regulator of muscle energy metabolism. STZ diabetic rats were markedly hyperglycemic (31.3 +/- 1.0 mmol/l; P < 0.005) compared with nondiabetic controls (9.3 +/- 0.2 mmol/l). Insulin treatment partially corrected the hyperglycemia (18.8 +/- 2.5 mol/l; P < 0.005). Plasma leptin was markedly reduced in STZ diabetic rats (0.4 +/- 0.1 ng/ml; P < 0.005) compared with controls (3.0 +/- 0.4 ng/ml), an effect that was also partially reversed by insulin treatment (1.8 +/- 0.3 ng/ml). Untreated diabetic rats were hyperphagic, consuming 40% more food (48 +/- 1 g/day; P < 0.005) than controls (34 +/- 1 g/day). Hyperphagia was prevented by insulin treatment (32 +/- 2 g/day). In untreated diabetic rats, hypothalamic POMC mRNA expression (measured by in situ hybridization) was reduced by 80% (P < 0.005), whereas AgRP mRNA levels were increased by 60% (P < 0.01), suggesting a marked decrease of hypothalamic melanocortin signaling. The change in POMC, but not in AgRP, mRNA levels was partially reversed by insulin treatment. By comparison, the effects of diabetes to increase hypothalamic neuropeptide Y (NPY) expression and to decrease corticotropin-releasing hormone (CRH) expression were normalized by insulin treatment, whereas the expression of mRNA encoding the long form of the leptin receptor in the arcuate nucleus was unaltered by diabetes or insulin treatment. UCP-3 mRNA expression in gastrocnemius muscle from diabetic rats was increased fourfold (P < 0.005), and the increase was prevented by insulin treatment. The effect of uncontrolled diabetes to decrease POMC, while increasing AgRP gene expression, suggests that reduced hypothalamic melanocortin signaling, along with increased NPY and decreased CRH signaling, could contribute to diabetic hyperphagia. These responses, in concert with increased muscle UCP-3 expression, may also contribute to the catabolic effects of uncontrolled diabetes on fuel metabolism in peripheral tissues.

Central nervous system control of food intake.

New information regarding neuronal circuits that control food intake and their hormonal regulation has extended our understanding of energy homeostasis, the process whereby energy intake is matched to energy expenditure over time. The profound obesity that results in rodents (and in the rare human case as well) from mutation of key signalling molecules involved in this regulatory system highlights its importance to human health. Although each new signalling pathway discovered in the hypothalamus is a potential target for drug development in the treatment of obesity, the growing number of such signalling molecules indicates that food intake is controlled by a highly complex process. To better understand how energy homeostasis can be achieved, we describe a model that delineates the roles of individual hormonal and neuropeptide signalling pathways in the control of food intake and the means by which obesity can arise from inherited or acquired defects in their function.

Transient speech compromise following sublabial transsphenoidal surgery: a case report and findings of a small preliminary study.

Sublabial transsphenoidal surgical removal of pituitary tumors is a common procedure with minimal complications. Although many investigators have reported oral sensory compromises following surgery, none has reported any postoperative compromise in speaking ability. In this article, we describe the case of a 33-year-old woman who developed transient but severe speech symptoms after she underwent sublabial transsphenoidal surgery. This case prompted us to undertake a brief retrospective analysis of our experience with this procedure in other patients, which revealed that speech compromise is far more common than heretofore realized.

Human and behavioral factors contributing to spine-based neurological cockpit injuries in pilots of high-performance aircraft: recommendations for management and prevention.

In high-performance aircraft, the need for total environmental awareness coupled with high-g loading (often with abrupt onset) creates a predilection for cervical spine injury while the pilot is performing routine movements within the cockpit. In this study, the prevalence and severity of cervical spine injury are assessed via a modified cross-sectional survey of pilots of multiple aircraft types (T-38 and F-14, F-16, and F/A-18 fighters). Ninety-five surveys were administered, with 58 full responses. Fifty percent of all pilots reported in-flight or immediate post-flight spine-based pain, and 90% of fighter pilots reported at least one event, most commonly (> 90%) occurring during high-g (> 5 g) turns of the aircraft with the head deviated from the anatomical neutral position. Pre-flight stretching was not associated with a statistically significant reduction in neck pain episodes in this evaluation, whereas a regular weight training program in the F/A-18 group approached a significant reduction (mean = 2.492; p < 0.064). Different cockpit ergonomics may vary the predisposition to cervical injury from airframe to airframe. Several strategies for prevention are possible from both an aircraft design and a preventive medicine standpoint. Countermeasure strategies against spine injury in pilots of high-performance aircraft require additional research, so that future aircraft will not be limited by the human in control.

Food intake and the regulation of body weight.

This chapter reviews the recent literature on hormonal and neural signals critical to the regulation of individual meals and body fat. Rather than eating in response to acute energy deficits, animals eat when environmental conditions (social and learned factors, food availability, opportunity, etc.) are optimal. Hence, eating patterns are idiosyncratic. Energy homeostasis, the long-term matching of food intake to energy expenditure, is accomplished via controls over the size of meals. Individuals who have not eaten sufficient food to maintain their normal weight have lower levels of adiposity signals (leptin and insulin) in the blood and brain, and one consequence is that meal-generated signals (such as CCK) are less efficacious at reducing meal size. The converse is true if individuals are above their normal weight, when they tend to eat smaller meals. The final section reviews how these signals are received and integrated by the CNS, as well as the neural circuits and transmitters involved.