Operative findings and surgical outcomes in patients undergoing Chiari 1 malformation decompression: relationship to the extent of tonsillar ectopia.

BACKGROUND: The diagnosis of Chiari 1 malformation is based on the extent of tonsillar ectopia. OBJECTIVE: To examine the relationship between the extent of tonsillar ectopia and the intra-operative findings and clinical outcome following Chiari decompression surgery. METHODS: Patients were divided into four groups depending on the position of the cerebellar tonsil (T): group 1: 0 < T < 3; group 2: 3 ≤ T ≤ 5; group 3: 5 < T ≤ 10; and group 4: T > 10. Intra-operative observations were recorded with regard to compression of the brain stem by posterior inferior cerebellar artery (pica), neuroma formation along the first cervical (C1), and accessory spinal nerves (XI), and pallor of the cerebellar tonsils. Brain stem auditory evoked potentials, (BAEP), were monitored in each case. One hundred sixty-eight patients accrued between 2009 and 2013 agreed to participate in an outcome study to determine the effectiveness of foramen magnum decompression. Findings across the four groups were compared using one-way ANOVA. Observed differences were further subjected to paired analysis. Intra-group comparisons were made using the paired t test. A P value less than 0.05 was considered statistically significant. RESULTS: There were 98 patients in group 1, 147 patients in group 2, 180 patients in group 3, and 63 patients in group 4. The mean extent of tonsillar ectopia was 0.4, 4.0, 7.1, and 14.3 mm in the four groups respectively. The prevalence of tonsillar pallor was greatest in group 4. Otherwise, there was no difference observed in the operative findings. A reduction of > 0.1 msec in the wave III-wave V latency of the BAEP was noted in all four groups with equal frequency. One hundred ten patients complied with at least 6 months follow-up. There was no difference in the prevalence of symptoms between the four groups at the time of initial evaluation and at 6 weeks and 6 months following surgery. There was a statistically significant reduction in the intensity of individual symptoms 6 months following surgery regardless of the extent of tonsil ectopia. CONCLUSION: Other than the finding of tonsillar pallor, there was no relationship between the extent of tonsillar ectopia and the intraoperative anatomical and physiological observations, nor was there any relationship to the likelihood of symptomatic improvement following surgery. These observations call into question the focus on the extent of tonsillar of ectopia in assessing the patient who presents with symptoms of the Chiari malformation.

Is there a relationship between the extent of tonsillar ectopia and the severity of the clinical Chiari syndrome?

BACKGROUND: Chiari 1 malformation is diagnosed if the cerebellar tonsils extend at least 5 mm below the opisthion-basion line. OBJECTIVE: To examine the correlation of the extent of tonsillar ectopia with the prevalence and severity of the symptoms associated with the Chiari malformation. METHODS: Patients (N = 428) were grouped according to the extent of tonsillar ectopia on the mid-sagittal MRI image (group 1, 0-< 3 mm; group 2, 3-5 mm; group 3, > 5 mm). Groups were compared regarding demographics, symptoms, neurological signs, pain score, and response to HADS and sf-36 questionnaires. Results were analyzed using one-way ANOVA, chi-square, and two sample Z test, and Student's t test for pairwise comparison, (statistical significance p < 0.05). A logistic regression analysis was performed to determine the relationship between tonsillar ectopia and the probability of a patient reporting any particular symptom. RESULTS: There were 97,148 and 183 patients in groups 1, 2, and 3 respectively. Groups did not differ with regard to antecedent trauma or female preponderance. Patients in group 1 were more symptomatic than those in groups 2 and 3 with regard to some symptoms, (p = 0.04-p = 0.000). Regression analysis confirmed an inverse relationship between the extent of tonsillar ectopia and the likelihood of many symptoms. The pain score was greatest in group 1, (p = 0.006). Prevalence of objective signs of myelopathy did not differ between groups except for Hoffmann sign which was more prevalent in group 1, (p = 0.034). HADS and sf-36 scores did not differ between groups. CONCLUSION: The severity of the symptoms associated with the Chiari malformation does not correlate directly with the extent of tonsillar ectopia. The extent of tonsillar ectopia should be re-evaluated as the threshold for diagnosis of Chiari 1 malformation.

Experimental design affects social behavior outcomes in adult zebrafish developmentally exposed to lead.

Lead (Pb(2+)) affects neuronal and endocrine systems that influence social interactions. By providing potential hiding locations, spatial heterogeneity may affect Pb(2+)-induced behavioral outcomes. Therefore, a test chamber was designed into which a refuge could be inserted. The refuge allowed test subjects to escape from the mirror image that stimulated agonistic interactions. Behaviors with a mirror were compared with baseline activity patterns without a mirror. Adult (12-month old) male and female zebrafish, exposed to Pb(2+) (0-10 µM) as embryos (2-24 hours post fertilization), were tested individually for 5 min in each chamber design within 2 h of feeding. Behaviors were evaluated for % time in mirror zone, distance traveled (=activity level), and attacks on the mirror image. When there was no refuge, significant concentration-dependent increases occurred in male % time in mirror zone, activity level, and number of attacks. Increases in these variables were less pronounced in females. When there was a refuge, there were significant differences for males only in activity level and attacks at the higher developmental exposure concentrations; % time in mirror zone followed a similar pattern and level as without refuge. Females displayed Pb(2+)-induced behavioral changes only for attacks on mirror. Since the presence of refuges that is, environmental enrichment, reduced Pb(2+)-induced agonistic behavior in both sexes, experimental spatial design can be considered an important factor when interpreting behavioral outcomes.

Developmental lead exposure causes startle response deficits in zebrafish.

Lead (Pb(2+)) exposure continues to be an important concern for fish populations. Research is required to assess the long-term behavioral effects of low-level concentrations of Pb(2+) and the physiological mechanisms that control those behaviors. Newly fertilized zebrafish embryos (<2h post fertilization; hpf) were exposed to one of three concentrations of lead (as PbCl(2)): 0, 10, or 30 nM until 24 hpf. (1) Response to a mechanosensory stimulus: Individual larvae (168 hpf) were tested for response to a directional, mechanical stimulus. The tap frequency was adjusted to either 1 or 4 taps/s. Startle response was recorded at 1000 fps. Larvae responded in a concentration-dependent pattern for latency to reaction, maximum turn velocity, time to reach V(max) and escape time. With increasing exposure concentrations, a larger number of larvae failed to respond to even the initial tap and, for those that did respond, ceased responding earlier than control larvae. These differences were more pronounced at a frequency of 4 taps/s. (2) Response to a visual stimulus: Fish, exposed as embryos (2-24 hpf) to Pb(2+) (0-10 µM) were tested as adults under low light conditions (≈ 60 µW/m(2)) for visual responses to a rotating black bar. Visual responses were significantly degraded at Pb(2+) concentrations of 30 nM. These data suggest that zebrafish are viable models for short- and long-term sensorimotor deficits induced by acute, low-level developmental Pb(2+) exposures.

The type of responder T-cell has a significant impact in a human in vitro suppression assay.

BACKGROUND: In type 1 diabetes (T1D), a prototypic autoimmune disease, effector T cells destroy beta cells. Normally, CD4(+)CD25(+high), or natural regulatory T cells (Tregs), counter this assault. In autoimmunity, the failure to suppress CD4(+)CD25(low) T cells is important for disease development. However, both Treg dysfunction and hyperactive responder T-cell proliferation contribute to disease. METHODS/PRINCIPAL FINDINGS: We investigated human CD4(+)CD25(low) T cells and compared them to CD4(+)CD25(-) T cells in otherwise equivalent in vitro proliferative conditions. We then asked whether these differences in suppression are exacerbated in T1D. In both single and co-culture with Tregs, the CD4(+)CD25(low) T cells divided more rapidly than CD4(+)CD25(-) T cells, which manifests as increased proliferation/reduced suppression. Time-course experiments showed that this difference could be explained by higher IL-2 production from CD4+CD25(low) compared to CD4+CD25- T cells. There was also a significant increase in CD4+CD25(low) T-cell proliferation compared to CD4+CD25- T cells during suppression assays from RO T1D and at-risk subjects (n = 28, p = 0.015 and p = 0.024 respectively). CONCLUSIONS/SIGNIFICANCE: The in vitro dual suppression assays proposed here could highlight the impaired sensitivity of certain responder T cells to the suppressive effect of Tregs in human autoimmune diseases.

Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: mini-open versus all-arthroscopic.

BACKGROUND: The objective of this study was to determine mean cost and operative time differences between mini-open and all-arthroscopic rotator cuff repair techniques at surgical centers of low, intermediate, and high annual rotator cuff repair volume. METHODS: The 2006 New York State Ambulatory Surgery Database (NY-SASD) was utilized. It represents 100% of all outpatient procedures performed in hospital-affiliated and freestanding surgical centers, containing 10,658,923 patients for 2006 alone. Only patients who had an arthroscopic acromioplasty and either open or arthroscopic rotator cuff repair were included, leaving 5,224 patients for the study. These were divided into 2 groups: the mini-open group (1,334) and the all-arthroscopic group (3,890). Surgical center volume data were divided into 3 groups: low volume (<75 rotator cuff repairs per year), intermediate volume (75-199 rotator cuff repairs per year), and high volume (200+ rotator cuff repairs per year). RESULTS: Patient age and gender were normally distributed within the 2 groups with no significant differences between them (P = .82 and P = .31, respectively). Operative time was significantly shorter in the mini-open group (103 minutes) compared to the all-arthroscopic group (113 minutes), P < .00001. Surgical charges were also significantly less in the mini-open group ($7,841) compared to the all-arthroscopic group ($8,985), P < .00001. Regardless of the repair method, high volume surgical centers were significantly more expensive when compared to low and intermediate volume centers, P < .00001. CONCLUSION: The mini-open rotator cuff repair technique requires significantly less operative time and is significantly less expensive than the all-arthroscopic repair. Regardless of the repair technique, high volume surgical centers cost significantly more than low and intermediate volume surgical centers.

Developmental selenomethionine and methylmercury exposures affect zebrafish learning.

Methylmercury (MeHg) is a ubiquitous environmental pollutant and has been shown to affect learning in vertebrates following relatively low exposures. Zebrafish were used to model long-term learning deficits after developmental MeHg exposure. Selenomethionine (SeMet) co-exposure was used to evaluate its role in neuroprotection. Embryos were exposed from 2 to 24h post fertilization to (1) MeHg without SeMet, (2) SeMet without MeHg and (3) in combination of MeHg and SeMet. In case (1), the levels of MeHg were 0.00, 0.01, 0.03, 0.06, 0.10, and 0.30 microM. In case (2), the levels of SeMet were 0.00. 0.03, 0.06, 0.10, and 0.30 microM. In case (3), co-exposure levels of (MeHg, SeMet) were (0.03, 0.03), (0.03, 0.06), (0.03, 0.10), (0.03, 0.30), (0.10, 0.03), (0.10, 0.06), (0.10, 0.10), and (0.10, 0.30) microM. Learning functions were tested in individual adults, 4 months after developmental exposure using a spatial alternation paradigm with food delivery on alternating sides of the aquarium. Low levels of MeHg (<0.1 microM) exposure delayed learning in treated fish; fish exposed to higher MeHg levels were unable to learn the task; SeMet co-exposure did not prevent this deficit. These data are consistent with findings in laboratory rodents. The dorsal and lateral telencephalon are the primary brain regions in fish involved in spatial learning and memory. Adult telencephalon cell body density decreased significantly at all MeHg exposures >0.01 microM MeHg. SeMet co-exposure ameliorated but did not prevent changes in telencephalon cell body density. In summary, MeHg affected both learning and brain structure, but SeMet only partially reversed the latter.