Effects of temperature on Anoplophora glabripennis (Coleoptera: Cerambycidae) larvae and pupae.

Developmental thresholds, degree-days for development, larval weights, and head capsule widths for each larval instar and the pupal stage of Anoplophora glabripennis (Motschulsky) (Coleoptera: Cerambycidae) were studied at eight constant temperatures (5, 10, 15, 20, 25, 30, 35, and 40°C) for two source populations (Ravenswood, Chicago, IL [IL], and Bayside, Queens, NY [NY]). The estimated lower threshold temperature for development of instars 1-5 and the pupal stage was near 10°C and was near 12°C for the higher instars. Developmental rate was less temperature sensitive for instars 5-9 compared with instars 1-4. Development for all but the first instar was inhibited at constant temperatures >30°C, and all instars failed to develop at 40°C. Although the two source populations had similar responses to temperature, IL larvae were heavier than those from NY. Temperature and its influence on larval weight had profound impacts on whether a larva proceeded to pupation. Based on the temperature effects detailed here, larval development and pupation should be possible in most of the continental United States where suitable hosts are available. These data can be used to develop a degree-day model to estimate beetle phenology; however, at least 2°C should be added to air temperatures to adjust for the mediation of temperature by the wood. These data provide a basis for predicting the potential geographical range of this species and for developing phenological models to predict the timing of immature stages, both of which are important for management programs.

Dalteparin as periprocedure anticoagulation for patients on warfarin and at high risk of thrombosis.

BACKGROUND: Patients taking warfarin and at high risk for thromboembolic complications have traditionally been hospitalized for two to three days to receive standard treatment with intravenous heparin both prior to and following procedures while their international normalized ratio (INR) is subtherapeutic. OBJECTIVE: To assess the feasibility of protocol implementation for outpatient anticoagulation with low-molecular-weight heparin to eliminate or reduce the length of hospital admission needed solely for anticoagulation. METHODS: Patients included were receiving warfarin for a prosthetic heart valve, mitral valve disease with atrial fibrillation, or recent episode of venous thromboembolism. Warfarin was discontinued four days prior to the procedure. Subcutaneous dalteparin 200 units/kg was given on the two mornings prior to the procedure and restarted 12-24 hours after the procedure until the INR was in the therapeutic range. Warfarin was reinitiated on the evening of surgery. RESULTS: Twenty-four patients underwent 26 procedures. There were two minor bleeding complications, and one patient experienced a transient ischemic attack. Patients received a median of five days of dalteparin. The INR returned to the therapeutic range on the median postoperative day 4. All patients avoided two days of hospitalization prior to the procedure (i.e., no patients needed to be admitted preoperatively for anticoagulation). A median of four days would have been required for the sole purpose of postoperative anticoagulation. CONCLUSIONS: Outpatient perioperative anticoagulation with dalteparin for high-risk patients requiring long-term oral anticoagulation appears feasible and warrants further study.

Vasculitis of the central nervous system.

Central nervous system (CNS) vasculitis occurs in a variety of clinical settings. Some exhibit a distinct age preference; others a tissue tropism. Most frequently encountered are giant cell arteritis (temporal arteritis) and vasculitis secondary to infections. The CNS may be involved in the systemic vasculitides, and neurologic abnormalities occasionally appear as a presenting manifestation of disease. Isolated angiitis of the CNS, a rare form of vasculitis restricted to the CNS, must be distinguished from other causes of CNS inflammation and from noninflammatory vascular disease. We are learning a great deal about the cellular mechanisms of vascular inflammation in the brain. Some manifestations of the clinical disease result from histologic features of the infiltrate and the size of affected vessel. However, the local consequences of inflammation such as increased coagulation and altered vasomotor tone, as well as the systemic consequences such as activation of the central noradrenergic systems, trigeminovascular system, and hypothalamic pituitary adrenal axis contribute to both pathogenesis of disease and recovery. Two central issues that confront us now are improving the accuracy of the diagnosis (including identifying any underlying infectious causes) and limiting the long-term damage both from disease and its therapies.

Alterations in hypothalamic-pituitary-adrenal function correlated with the onset of murine SLE in MRL +/+ and lpr/lpr mice.

Systemic lupus erythematosus (SLE) is a spontaneously occurring, chronic autoimmune disease that can manifest neuropsychiatric abnormalities. The pathways mediating these central changes are not known; however, neuroendocrine alterations associated with inflammation may play a role. Predisposition to and progression of autoimmune disease has been associated with altered hypothalamic-pituitary-adrenal (HPA) function and inflammation has been reported to alter hypothalamic regulation of HPA responses. We investigated whether disease progression in a murine model of systemic lupus erythematosus (MRL +/+. MRL lpr/lpr) resulted in altered expression of HPA regulatory peptides at the level of the hypothalamus and how these alterations related to circulating levels of corticosterone, corticosterone binding globulin, and autoantibody titers. We report that as MRL +/+ and MRL lpr/lpr mice age and circulating levels of autoantibodies increase, there is a decrease in hypothalamic CRH mRNA expression and finally an increase in AVP mRNA expression. We also report that associated with increased autoantibody levels, disease progression, and altered hypothalamic peptide expression there is an increase in circulating levels of corticosterone and a trend for levels of corticosterone binding globulin to decrease. Our data complement previous observations of altered peptidergic regulation of the HPA axis and increased HPA activity during chronic inflammation in exogenously induced rodent models of chronic inflammation and indicate that similar processes may occur in spontaneous murine models of SLE.

The vasculitides.

Vascular inflammation stands at the center of innumerable physiological and pathological processes. Dissecting the mechanisms of successful vascular injury and repair, investigators provide information for scientists and clinicians. The neurologist benefits from studies across several disciplines. Details of the cellular functions in the infiltrates of temporal arteries impart a basis for rational therapy. The interactions of herpes virus with vessels wall remind us of the affinity of numerous infectious agents for the vasculature. Several animal models are enabling us to explore the genetic links in autoimmunity. Although clinical studies may not yet provide us with answers for accurate diagnosis and treatment of many of our patients, data from this year will keep our interest high.

Relaxation training inhibits fear and arousal during in vivo exposure to phobia-cue stimuli.

Twenty carefully selected snake phobics were exposed to a caged snake for eight trials via a conveyor apparatus. During the first and eighth trials the subjects brought the snake toward themselves as closely as tolerable; records were kept of the end-of-trial distances remaining between the subject and the snake. For the six intervening trials the experimenter placed the snake a standard distance away; records were kept of the subjects' heart rates and skin-conductance levels before and during the exposures, and of their self-reported fear intensities after the exposures. Half of the subjects had received six sessions of progressive relaxation training before the exposures occurred. The results for subjects who had received relaxation training versus subjects who had not received relaxation training showed clearly that the training served to attenuate arousal and fear in the context of in vivo exposure. The results showed also that relaxation worked by lowering arousal throughout the course of exposure, not by hastening or facilitating arousal decrement during exposure. Some implications of the results are discussed.

Central nervous system vasculitis.

Central nervous system vasculitis occurs in a variety of clinical settings. Some exhibit a distinct age preference; others a tissue tropism. Most frequently encountered are giant cell arteritis (temporal arteritis) and vasculitis secondary to infections. The central nervous system may be involved in the antineutrophil cytoplasmic antibody-associated systemic vasculitides and occasionally neurologic abnormalities appear as a presenting manifestation of disease. Isolated angiitis of the central nervous system, a rare form of vasculitis that is restricted to the central nervous system, must be distinguished from other causes of central nervous system inflammation and from noninflammatory vascular disease. We are learning a great deal about the cellular mechanisms of vascular inflammation in general. Some manifestations of the clinical disease result from histologic features of the infiltrate and the size of affected vessel. However, the local consequences of inflammation, such as increased coagulation and altered vasomotor tone, as well as the systemic consequences, such as activation of the central noradrenergic systems, trigeminovascular system, and hypothalamic pituitary adrenal axis, contribute both to pathogenesis of disease and to recovery.

Inflammatory disease as chronic stress.

It is now established that communication between the CNS and the immune system is bidirectional, that endocrine factors can alter immune function and that immune responses can alter both endocrine and CNS responses. In many respects CNS and endocrine responses to acute inflammation are similar to the changes associated with acute stress exposure. In contrast, during chronic inflammation associated with adjuvant induced arthritis (AA), although circulating levels of corticosterone are increased, the peptidergic regulation of the hypothalamus is different from that seen during acute stress. As the disease progresses, a paradoxical reduction occurs in CRH mRNA in the paraventricular nucleus (PVN), whereas PVN AVP mRNA increases. These data suggest that there is increased expression of AVP mRNA within the CRH cells of the PVN with an increased emphasis on AVP regulation of HPA output. Additionally, HPA function is altered during chronic inflammation such that responses to psychological stress (i.e. restraint) are significantly dampened, while responses to further inflammatory challenges are maintained. These data suggest that alterations in PVN peptide colocalization may be important in regulating the progression of peripheral inflammatory responses and that the effects of inflammation on the hypothalamus alter stress-responsive systems. In addition to the AA model, we have similarly observed alterations in PVN peptide mRNA expression with disease onset in the murine MRL lpr/lpr and MRL +/+ model of SLE. Disease onset in murine SLE is spontaneous and does not rely on exogenous application of adjuvant; however, decreased levels of CRH in the PVN were observed from early disease onset in this animal model. It is suggested that alterations in CRH regulation in response to either acute or chronic inflammation may contribute as etiological factors to both psychiatric (i.e. neuropsychiatric SLE) and stress-related disease.

Identification and cloning of a brain autoantigen in neuro-behavioral SLE.

In murine models of SLE, particular patterns of abnormalities of social interaction and memory collectively known as neurobehavioral dysfunction (NBD) correlate with the occurrence of brain reactive autoantibodies. Study of the immunopathogenic effects of these antibodies has been limited by the absence of isolated autoantibodies and antigens. In order to identify the molecular targets, we isolated autoantibodies highly specific for brain plasma membranes from MRL/lpr mice. After immunoscreening a brain expression library with these brain specific autoantibodies, we identified a single cDNA clone of unique sequence and relevant anatomic distribution. Transcript for this cDNA is wide spread among mammalian species but appears to be present only in the brain. Addition features, suggesting this cDNA is pertinent for further study include (1) the expressed protein, called lupus brain antigen 1, reacts with the screening immunoglobulins as well as immunoglobulins from other strains of murine neuro-SLE not used to screen the library, but not with immunoglobulins from normal mice, (2) the transcript distribution within the brain is similar to immunochemical localization of binding of the spontaneous autoantibodies and (3) the localization of transcript within the brain, in the hippocampus, hypothalamus an cingulate gyrus, corresponds to anticipated anatomical regions of clinical dysfunction. Further, the transcript is a large, potentially structural molecule of unique sequence. Antibodies to this molecule may mediate changes in behavior either by direct interactions with the cognate antigen or by indirect influences through neuro-endocrine axes.

Avoiding state intervention in not-for-profit/for-profit affiliations.

States attorneys general recently have intervened in transactions involving not-for-profit organizations that wish to convert to or transfer assets to for-profit status. These interventions are significant for two reasons: first, they reflect a tendency amount state attorneys general to involve states in the governance of not-for-profit healthcare organizations, and second, they demonstrate that attorneys general are paying renewed attention to the legal obligation of such organizations to provide a community health benefit, which imposes a charitable trust on not-for-profit healthcare organizations and the fiduciary duties of care and loyalty to that charitable trust on the organizations' officers and directors. To avoid state intervention in such transactions, officers and directors of not-for-profit organizations need to understand the circumstances under which attorneys general justify such intervention, which include the undervaluation of the organization's charitable assets; lack of a private letter ruling from the IRS; failure to adequately consider alternatives to the transaction; conflicts with the best interest of the organization; and inadequate responses to the attorney general's requests for information.

Clinical course and hemodynamic observations after supraannular mitral valve replacement in infants and children.

OBJECTIVES: We report the clinical course and unique hemodynamic findings after placement of a supraannular mitral valve prosthesis. BACKGROUND: Children with symptomatic mitral valve disease whose annulus is too small for the smallest prosthesis are difficult to manage. One option is valve replacement with a prosthesis positioned entirely within the left atrium (LA). METHODS: We reviewed 17 patients (median age 10 months) with symptomatic mitral valve disease who underwent placement of a supraannular valve prosthesis between 1980 and 1994. RESULTS: The actuarial survival rates were 88% at 1 month and 71%, 62% and 53% at 1, 2 and 10 years, respectively. Preoperative hemodynamic data (mean +/- SD)) compared with those after placement of the supraannular mitral prosthesis were as follows: "a" wave to left ventricular end-diastolic pressure gradient 17 +/- 5 versus 4 +/- 4 mm Hg (p = 0.003), mean LA pressure 25 +/- 6 versus 20 +/- 6 mm Hg (p = 0.07), "a" wave 30 +/- 6 versus 19 +/- 5 mm Hg (p = 0.006), "v" wave 28 +/- 5 versus 30 +/- 9 mm Hg (p = 0.31), mean pulmonary artery pressure 54 +/- 19 versus 42 +/- 15 mm Hg (p = 0.07) and left ventricular end-diastolic pressure 14 +/- 5 versus 16 +/- 4 mm Hg (p = 0.12). CONCLUSIONS: Supraannular mitral valve replacement provides relief of mitral stenosis or mitral regurgitation. However, LA to left ventricular early diastolic gradients with large atrial "v" waves contribute to elevated mean LA pressures in the absence of prosthetic valve obstruction or regurgitation. As a result of this unexpected finding, associated left heart obstructive lesions and pulmonary and left ventricular end-diastolic hypertension, the outlook remains poor.

Psychometric properties and factor structure of the Wechsler Memory Scale-Revised in a sample of persons with intractable epilepsy.

The Wechsler Memory Scale-Revised (WMS-R) is used routinely as a presurgical assessment of memory for clients considering elective resection of the temporal lobe and/or hippocampus for the relief of intractable temporal lobe epilepsy. This research investigated the psychometric properties of the WMS-R in a population of people with epilepsy. The sample consisted of 181 patients with a diagnosis of epilepsy who underwent a complete neuropsychological examination as a routine part of their investigation. The results confirm that the WMS-R has acceptable levels of reliability as measured by internal consistency. A factor analysis revealed a consistent three-factor structure: Visual Memory, Verbal Memory, and Attention/ Concentration factors. Multiple regression analysis, however, indicated that the Visual Memory index was susceptible to a number of influences, throwing into question whether it is a pure measure of nonverbal memory functioning.

Non-epileptic attack disorder: a psychological perspective.

Due to the serious medical consequences in failing to recognize non-epileptic attack disorder (NEAD), and the frequency with which neurologists come into contact with such patients, clearly NEAD constitutes a major concern for clinicians in the field of epilepsy. This article presents the psychological characteristics of 185 patients with NEAD. Psychological factors that were identified as being important in the understanding of the development and maintenance of NEAD included: anxiety or stress; physical abuse; significant bereavement; family dysfunctioning; relationship problems; depression; sexual abuse. An absence of relevant psychological factors was found in only 5% of patients. From patients' descriptions of their attacks, it appears that many symptoms are related to anxiety. Our findings are largely supported by previous studies and their relevance to effective management and treatment of NEAD patients is discussed.

Validation of the Wechsler Memory Scale-Revised in a sample of people with intractable temporal lobe epilepsy.

PURPOSE: The Wechsler Memory Scale-Revised (WMS-R) is used routinely for presurgical assessment of memory for patients considering elective resection of the temporal lobe and/or hippocampus for the relief of intractable temporal lobe epilepsy (TLE). We investigated the validity of the WMS-R in a population of people with TLE. METHODS: The sample consisted of 138 patients with a diagnosis of TLE in which the epileptogenic focus was clearly and exclusively lateralized to either the right or left hemisphere. They underwent a complete neuropsychological examination as a routine part of their investigation for epilepsy surgery. Psychometric scores included in this study were: Wechsler Adult Intelligence Scale-Revised (WAIS-R) I.Q. scores, National Adult Reading Test Revised (NART-R) predicted-I.Q. scores, and WMS-R Memory Index and subtest scores. RESULTS: Multiple univariate analyses were performed. The group with left temporal focus had significantly lower Verbal Memory Index, Logical memory (both immediate and delayed), and Digit Span scores. Visual/Verbal discrepancy scores incorrectly identified most patients with right temporal focus. Analyses of a total group of people with epilepsy (i.e., mixed temporal, frontal, occipital and unknown foci) as compared with the normative sample indicated that the patient group scored significantly lower across all memory index scores and most memory subtests. CONCLUSIONS: Our results confirm that the WMS-R is capable of lateralizing to left hemispheric impairment but is more problematic in the assessment of right hemispheric impairment. The Visual/Verbal Memory Index discrepancy has questionable validity. People with epilepsy performed less well on the WMS-R than did the normative sample. The need for reliable and valid nonverbal tests of memory is therefore warranted.