Lesion Volume in Relapsing Multiple Sclerosis is Associated with Perivascular Space Enlargement at the Level of the Basal Ganglia.

BACKGROUND AND PURPOSE: Perivascular spaces surround the blood vessels of the brain and are involved in neuroimmune functions and clearance of metabolites via the glymphatic system of the brain. Enlarged perivascular spaces could be a marker of dysfunction in these processes and, therefore, are highly relevant to monitoring disease activity in MS. This study aimed to compare the number of enlarged perivascular spaces in people with relapsing MS with MR imaging markers of inflammation and brain atrophy. MATERIALS AND METHODS: Fifty-nine patients (18 with clinically isolated syndrome, 22 with early and 19 with late relapsing-remitting MS) were scanned longitudinally (mean follow-up duration = 19.6 [SD, 0.5] months) using T2-weighted, T1-weighted, and FLAIR MR imaging. Two expert raters identified and counted enlarged perivascular spaces on T2-weighted MR images from 3 ROIs (the centrum semiovale, basal ganglia, and midbrain). Baseline and change with time in the number of enlarged perivascular spaces were correlated with demographics and lesion and brain volumes. RESULTS: Late relapsing-remitting MS had a greater average number of enlarged perivascular spaces at baseline at the level of the basal ganglia (72.3) compared with early relapsing-remitting MS (60.5) and clinically isolated syndrome (54.7) (F = 3.4, P = .042), and this finding correlated with lesion volume (R = 0.44, P = .0004) but not brain atrophy (R = -0.16). Enlarged perivascular spaces increased in number with time in all regions, and the rate of increase did not differ among clinical groups. CONCLUSIONS: Enlarged perivascular spaces at the level of the basal ganglia are associated with greater neuroinflammatory burden, and the rate of enlargement appears constant in patients with relapsing-remitting disease phenotypes.

Giardia Colonizes and Encysts in High-Density Foci in the Murine Small Intestine.

Giardia lamblia is a highly prevalent yet understudied protistan parasite causing significant diarrheal disease worldwide. Hosts ingest Giardia cysts from contaminated sources. In the gastrointestinal tract, cysts excyst to become motile trophozoites, colonizing and attaching to the gut epithelium. Trophozoites later differentiate into infectious cysts that are excreted and contaminate the environment. Due to the limited accessibility of the gut, the temporospatial dynamics of giardiasis in the host are largely inferred from laboratory culture and thus may not mirror Giardia physiology in the host. Here, we have developed bioluminescent imaging (BLI) to directly interrogate and quantify the in vivo temporospatial dynamics of Giardia infection, thereby providing an improved murine model to evaluate anti-Giardia drugs. Using BLI, we determined that parasites primarily colonize the proximal small intestine nonuniformly in high-density foci. By imaging encystation-specific bioreporters, we show that encystation initiates shortly after inoculation and continues throughout the duration of infection. Encystation also initiates in high-density foci in the proximal small intestine, and high density contributes to the initiation of encystation in laboratory culture. We suggest that these high-density in vivo foci of colonizing and encysting Giardia likely result in localized disruption to the epithelium. This more accurate visualization of giardiasis redefines the dynamics of the in vivo Giardia life cycle, paving the way for future mechanistic studies of density-dependent parasitic processes in the host. IMPORTANCEGiardia is a single-celled parasite causing significant diarrheal disease in several hundred million people worldwide. Due to limited access to the site of infection in the gastrointestinal tract, our understanding of the dynamics of Giardia infections in the host has remained limited and largely inferred from laboratory culture. To better understand Giardia physiology and colonization in the host, we developed imaging methods to quantify Giardia expressing bioluminescent physiological reporters in two relevant animal models. We discovered that parasites primarily colonize and encyst in the proximal small intestine in discrete, high-density foci. We also show that high parasite density contributes to encystation initiation.

Mammary transcriptome analysis of lactating dairy cows following administration of bovine growth hormone.

The galactopoietic effect of growth hormone (GH) in lactating ruminants is well established; however the mechanisms that mediate these effects are not well understood. The first objective of this study was to determine the effect of GH on the synthesis of the major casein and whey proteins. The second objective was to identify the genes and pathways that may be involved in mediating the effect of GH on milk synthesis. A single subcutaneous injection of a commercially available slow release formulation of GH (Lactatropin®), or physiological saline solution (control) was administered to non-pregnant dairy cows (n=4/group) in mid-late lactation. Milk samples were collected for composition analysis and mammary lobulo-alveolar tissue was collected postmortem 6 days post injection. Gene expression profiles were evaluated using either a 22 000 bovine complementary DNA microarray or quantitative PCR (qPCR), and microarrays were validated by qPCR. The yield of all the major casein and whey proteins was increased 32% to 41% in GH-treated cows, with the exception of α-lactalbumin yield which was elevated by 70% relative to controls. Treatment with GH treatment tended to increase the concentration of α-lactalbumin but had no effect on the concentration of any of the major milk proteins. Messenger RNA (mRNA) abundance of the major whey and casein genes, with the exception of α-s2-casein, was increased in response to GH compared with controls, which is consistent with the positive effect of GH on milk production. Treatment with GH treatment influenced the mRNA abundance of genes involved in cell growth and proliferation, transcriptional and translational regulation, actin cytoskeleton signalling, lipid metabolism and cell death. This study has provided new insights into the cell signalling that may be involved in mediating the effect of GH on milk production in the mammary gland of lactating dairy cows.

Increased abundance of frost mRNA during recovery from cold stress is not essential for cold tolerance in adult Drosophila melanogaster.

Frost (Fst) is a candidate gene associated with the response to cold in Drosophila melanogaster because Fst mRNA accumulation increases during recovery from low temperature exposure. We investigated the contribution of Fst expression to chill-coma recovery time, acute cold tolerance and rapid cold hardening (RCH) in adult D. melanogaster by knocking down Fst mRNA expression using GAL4/UAS-mediated RNA interference. In this experiment, four UAS-Fst and one tubulin-GAL4 lines were used. We predicted that if Fst is essential for cold tolerance phenotypes, flies with low Fst mRNA levels should be less cold tolerant than flies with normal levels of cold-induced Fst mRNA. Cold-induced Fst abundance and recovery time from chill-coma were not negatively correlated in male or female flies. Survival of 2 h exposures to sub-zero temperatures in Fst knockdown lines was not lower than that in a control line. Moreover, a low temperature pretreatment increased survival of severe cold exposure in flies regardless of Fst abundance level during recovery from cold stress, suggesting that Fst expression is not essential for RCH. Thus, cold-induced Fst accumulation is not essential for cold tolerance measured as chill-coma recovery time, survival to acute cold stress and RCH response in adult D. melanogaster.

Surfer's myelopathy: a radiologic study of 23 cases.

BACKGROUND AND PURPOSE: Surfing is an uncommon cause of an acute nontraumatic myelopathy. This study describes the MR imaging characteristics and clinical correlates in 23 subjects with surfer's myelopathy. MATERIALS AND METHODS: This was a retrospective review of 23 cases of surfer's myelopathy from 2003-2012. Spinal cord MR imaging characteristics and neurologic examinations with the use of the American Spinal Injury Association scale were reviewed. Logistic regression was used to determine associations between MR imaging characteristics, American Spinal Injury Association scale, and clinical improvement. RESULTS: All subjects (19 male, 4 female; mean age, 26.3 ± 7.4 years) demonstrated "pencil-like," central T2-hyperintense signal abnormalities in the spinal cord extending from the midthoracic region to the conus with associated cord expansion and varying degrees of conus enlargement on spinal cord MR imaging within 24 hours of symptom onset. T1 signal was normal. Faint gadolinium enhancement was present in a minority. Although there was a strong correlation between initial American Spinal Injury Association score and clinical improvement (P = .0032), MR imaging characteristics were not associated with American Spinal Injury Association score or clinical improvement. CONCLUSIONS: Surfer's myelopathy should be considered in the radiographic differential diagnosis of a longitudinally extensive T2-hyperintense spinal cord lesion. MR imaging characteristics do not appear to be associated with severity on examination or clinical improvement.

Basal cold but not heat tolerance constrains plasticity among Drosophila species (Diptera: Drosophilidae).

Thermal tolerance and its plasticity are important for understanding ectotherm responses to climate change. However, it is unclear whether plasticity is traded-off at the expense of basal thermal tolerance and whether plasticity is subject to phylogenetic constraints. Here, we investigated associations between basal thermal tolerance and acute plasticity thereof in laboratory-reared adult males of eighteen Drosophila species at low and high temperatures. We determined the high and low temperatures where 90% of flies are killed (ULT(90) and LLT(90) , respectively) and also the magnitude of plasticity of acute thermal pretreatments (i.e. rapid cold- and heat-hardening) using a standardized, species-specific approach for the induction of hardening responses. Regression analyses of survival variation were conducted in ordinary and phylogenetically informed approaches. Low-temperature pretreatments significantly improved LLT(90) in all species tested except for D. pseudoobscura, D. mojavensis and D. borealis. High-temperature pretreatment only significantly increased ULT(90) in D. melanogaster, D. simulans, D. pseudoobscura and D. persimilis. LLT(90) was negatively correlated with low-temperature plasticity even after phylogeny was accounted for. No correlations were found between ULT(90) and LLT(90) or between ULT(90) and rapid heat-hardening (RHH) in ordinary regression approaches. However, after phylogenetic adjustment, there was a positive correlation between ULT(90) and RHH. These results suggest a trade-off between basal low-temperature tolerance and acute low-temperature plasticity, but at high temperatures, increased basal tolerance was accompanied by increased plasticity. Furthermore, high- and low-temperature tolerances and their plasticity are clearly decoupled. These results are of broad significance to understanding how organisms respond to changes in habitat temperature and the degree to which they can adjust thermal sensitivity.

Valine partitioning and kinetics between the gastrointestinal tract and hind limbs in lambs with an adult Trichostrongylus colubriformis burden.

Intestinal parasitic infection increases the demand for AA because of increased protein synthesis in the intestine and increased luminal losses of AA, and these increased demands may be supported by increased mobilization of AA from the skeletal muscles. Two experiments were conducted to determine the effects of parasitic infection on valine kinetics within the gastrointestinal tract and hind limbs of lambs fed fresh forages. On d 1, lambs were given 6,000 stage-3 Trichostrongylus colubriformis larvae per day for 6 d (n = 6) or kept as parasite-free controls (n = 6) and fed fresh lucerne (Medicago sativa; Exp. 1) or fresh sulla (Hedysarum coronarium; Exp. 2). On d 48, valine kinetics within the mesenteric- (MDV) and portal-drained viscera (PDV) and hind limbs were obtained by carrying out concurrent infusions of para-amminohippuric acid into the mesenteric vein and indocyanin green into the abdominal aorta (for blood flow), and [3,4-(3)H]valine into the jugular vein and [1-(13)C]valine into the abomasum for 8 h (for kinetics). During the infusions, blood was collected from the mesenteric and portal veins and from the mesenteric artery and vena cava, and plasma was harvested. After the 8-h infusion, lambs were euthanized, ileal digesta were collected, and tissues were sampled from the intestine and muscle (biceps femoris). Tissues, digesta, and plasma were analyzed for valine concentration, specific radioactivity, and isotopic enrichment. In both experiments, intestinal worm burdens on d 48 were greater in parasitized lambs (P = 0.0001 and 0.003). In Exp. 1, parasitic infection increased (P = 0.03) the total valine irreversible loss rate (ILR) in the MDV and PDV. In Exp. 2, luminal ILR of valine in the MDV was reduced (P = 0.01); however, ILR of valine in the PDV was unaffected. Despite these changes within the MDV and PDV, parasitic infection did not affect the ILR of valine within the hind limbs, and valine transport rates were largely unchanged. We suggest that the increased mobilization of AA from the hind limbs that might have occurred in the early phase of inflammation was no longer required when the parasitic infection was established. The MDV and PDV data may indicate that the non-MDV parts of the PDV play an important role in this adaptation, which warrants further study.

Metabolic rate and oxidative stress in insects exposed to low temperature thermal fluctuations.

Fluctuating temperatures are a predominant feature of the natural environment but their effects on ectotherm physiology are not well-understood. The warm periods of fluctuating thermal regimes (FTRs) provide opportunities for repair leading to increased survival, but there are also indications of negative effects of warm exposure. In this study, we examined respiration and oxidative stress in adult Alphitobius diaperinus exposed to FTRs and to constant low temperatures. We hypothesized that cold exposure will cause oxidative stress and that FTRs would reduce the amount of chill injuries, via activation of the antioxidant system. We measured V˙CO2, activities of super oxide dismutase (SOD), amounts of total (GSHt) and oxidized glutathione (GSSG) during cold and warm periods of FTRs. Increased severity of cold exposure caused a decrease in the glutathione pool. SOD levels increased during the recovery period in the more severe FTR. The antioxidant response was sufficient to counter the reactive oxygen species production, as the GSH:GSSG ratio increased. We conclude that cold stress causes oxidative damage in these beetles, and that a warm recovery period activates the antioxidant system allowing repair of cold-induced damage, leading to the increased survival previously noted in beetles exposed to fluctuating versus constant temperatures.

Insulin regulation of amino-acid metabolism in the mammary gland of sheep in early lactation and fed fresh forage.

Insulin plays an important role in regulating the partitioning of nutrients to the mammary gland, particularly in lactating ruminants fed concentrate-based diets. There is evidence that the nutritional status of the animals might also affect their response to insulin. This is largely untested in early lactating ruminants fed fresh forage. To investigate nutritional effects on insulin response, 12 lactating sheep, housed indoors, were allocated to one of two treatment groups (hyperinsulinaemic euglycaemic clamp (HEC) or control) in a randomised block design and fed perennial ryegrass (Lolium perenne)/white clover (Trifolium repens) pasture. Mammary amino acid (AA) net uptake from plasma and utilisation for milk protein synthesis was measured during the 4th day of the HEC using arterio-venous concentration differences, and 1-13C-leucine was used to estimate whole body and mammary gland leucine kinetics. There was no change in feed intake, milk protein output and mammary blood flow during the HEC (P > 0.1). The HEC decreased (P < 0.1) the arterial concentrations of all essential AA (EAA) except histidine. The mammary net uptake of some EAA (isoleucine, leucine, methionine and phenylalanine) was reduced by the HEC (P < 0.1). Leucine oxidation in the mammary gland was not altered during the HEC (P > 0.1) but mammary protein synthesis was reduced by the HEC (P < 0.05). These results show that sheep mammary gland can adapt to changing AA precursor supply to maintain milk protein production during early lactation, when fed fresh forage. How this occurs remains unclear, and this area deserves further study.

Physiological variation and phenotypic plasticity: a response to 'Plasticity in arthropod cryotypes' by Hawes and Bale.

In a recent publication, Hawes and Bale provide an extended discussion of phenotypic plasticity in the context of low temperature responses of animals. They argue that phenotypic plasticity may be partitioned phylogenetically at several levels and go on to explore these levels, and cold hardiness strategies that they term cryotypes, which in their view constitute cryotypic plasticity. Here we argue that this attempt to partition plasticity is misleading, that the term 'genotypic plasticity' is potentially highly confusing and a misnomer for physiological variance, and that the term 'superplasticity' should not be used. We also show that a definition of strategies as cryotypes is not useful and that the hypothesis about the relationship between evolutionary derivation and extent of plasticity in freeze-avoiding vs freeze-tolerant species is not supported by current evidence.

Intestinal amino acid absorption in lambs fed fresh Lucerne ( Medicago sativa) during an established Trichostrongylus colubriformis infection.

The effects of an established Trichostrongylus colubriformis infection on amino acid (AA) absorption from the small intestine and their availability to other tissues were determined in lambs 48 days post infection. The lambs were fed fresh Lucerne (Medicago sativa; 800 g dry matter (DM)/day) and dosed with 6000 L3 T. colubriformis larvae for 6 days (n = 5) or kept as parasite free controls (n = 6). Faecal egg production was monitored every second day from day 22 to day 48. A nitrogen (N) balance was conducted on days 35 to 43 after infection, and digesta flow and AA concentration measurements were made on day 44. On day 48 after infection, blood was continuously collected from the mesenteric artery and vein, plasma harvested and AA concentrations measured. Faecal egg production peaked on the 26th day after infection (P < 0.001) and intestinal worm burdens on day 48 were greater (P < 0.001) in the infected lambs. Feed intake and liveweight gain were similar (P > 0.10) between control and infected lambs. Digestibility and flow of DM and N through the digestive tract were also unaffected (P > 0.10) by parasite infection. Despite a trend towards higher abomasal AA flux in the parasitised lambs (P < 0.10), apparent AA absorption from the small intestine and AA availability to other tissues were unaffected (P > 0.10) by infection. These results suggest that an established parasite infection had little effect on the intestinal absorption and availability of AA to other tissues in lambs fed fresh Lucerne.

Gene transcription during exposure to, and recovery from, cold and desiccation stress in Drosophila melanogaster.

We exposed adult male Drosophila melanogaster to cold, desiccation or starvation, and examined expression of several genes during exposure and recovery. Frost was expressed during recovery from cold, and was up-regulated during desiccation. Desiccation and starvation (but not cold) elicited increased expression of the senescence-related gene smp-30. Desat2 decreased during recovery from desiccation, but not in response to starvation or cold. Hsp70 expression increased after 1 h of recovery from cold exposure, but was unchanged in response to desiccation or starvation stress, and Hsp23 levels did not respond to any of the stressors. We conclude that D. melanogaster's responses to cold and desiccation are quite different and that care must be taken to separate exposure and recovery when studying responses to environmental stress.

The life-cycle of Philornis downsi (Diptera: Muscidae) parasitizing Darwin's finches and its impacts on nestling survival.

The fly, Philornis downsi Dodge & Aitken, was first collected in 1964 on the Galápagos Islands and is now widespread across the archipelago. Virtually nothing is known about the behaviour and ecology of the fly as well as for the genus in general. Here, we describe all larval instars for the first time, and discuss infection intensity and impacts of parasitism on nestling survival of Darwin's finches. Adult P. downsi are non-parasitic free-living flies, whereas the larvae are obligate blood-feeding parasites on nestling birds. The larvae show a marked shift in their host site specificity--a novel finding for the genus Philornis: the first and early second larval instars live as agents of myiasis in finch nostrils and other tissues, while the older second and third instar larvae reside in the nest material and feed externally on the blood of nestlings, leading to blood losses in nestlings of 18-55%. Pupation occurs in the bottom layer of the nest. The combined effects of tissue damage by the endoparasitic instar larvae and anaemia by nest-dwelling haematophagous instar larvae account for the high nestling mortality (76%) due to Philornis parasitism. This represents the highest mortality by Philornis reported in the literature and emphasizes the extremely serious threat this parasite poses for the endemic passerine fauna of the Galápagos Islands.

Consequences of transferring three sorghum genes for secondary metabolite (cyanogenic glucoside) biosynthesis to grapevine hairy roots.

A multigenic trait (biosynthesis of the secondary metabolite, dhurrin cyanogenic glucoside) was engineered de novo in grapevine (Vitis vinifera L.). This follows a recent report of transfer of the same trait to Arabidopsis (Arabidopsis thaliana) using three genetic sequences from sorghum (Sorghum bicolor): two cytochrome P450-encoding cDNAs (CYP79A1 and CYP71E1) and a UDPG-glucosyltransferase-encoding cDNA (sbHMNGT). Here we describe the two-step process involving whole plant transformation followed by hairy root transformation, which was used to transfer the same three sorghum sequences to grapevine. Transgenic grapevine hairy root lines that accumulated transcript from none, one (sbHMNGT), two (CYP79A1 and CYP71E1) or all three transgenes were recovered and characterisation of these lines provided information about the requirements for dhurrin biosynthesis in grapevine. Only lines that accumulated transcripts from all three transgenes had significantly elevated cyanide potential (up to the equivalent of about 100 mg HCN kg(-1) fresh weight), and levels were highly variable. One dhurrin-positive line was tested and found to release cyanide upon maceration and can therefore be considered 'cyanogenic'. In in vitro dual co-culture of this cyanogenic hairy root line or an acyanogenic line with the specialist root-sucking, gall-forming, aphid-like insect, grapevine phylloxera (Daktulosphaira vitifoliae, Fitch), there was no evidence for protection of the cyanogenic plant tissue from infestation by the insect. Consistently high levels of dhurrin accumulation may be required for this to occur. The possibility that endogenous grapevine gene expression is modulated in response to engineered dhurrin biosynthesis was investigated using microarray analysis of 1225 grapevine ESTs, but differences in patterns of gene expression associated with dhurrin-positive and dhurrin-negative phenotypes were not identified.

Is screening for sexually transmitted infections in men who have sex with men who receive non-occupational HIV post-exposure prophylaxis worthwhile?

BACKGROUND/AIMS: Non-occupational HIV post-exposure prophylaxis (NPEP) is routinely prescribed after high risk sexual exposure. This provides an opportunity to screen and treat individuals at risk of concurrent sexually transmitted infections (STI). The aim of this study was to assess the efficacy of an STI screening programme in individuals receiving NPEP. METHODS: STI screens were offered to all individuals receiving NPEP from March 2001 to May 2004. Screen results were compared to type of sexual exposure and baseline patient characteristics. RESULTS: A total of 253 subjects were screened, representing 85% of the target population. All were men who have sex with men (MSM). Common exposure risks were receptive anal intercourse (RAI) in 61% and insertive anal intercourse (IAI) in 33%. 32 (13%) individuals had one or more STI. The most common STIs were rectal infections with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in 11 (4.5%) and six (2.5%) individuals, respectively. Subjects with rectal CT were significantly more likely to be co-infected with rectal NG (p<0.001). There was no association between the presence of a rectal STI and age or exposure risk. Only six (19%) individuals with an STI were symptomatic at screening. CONCLUSION: In this cohort of MSM receiving NPEP, high rates of concomitant STIs are observed highlighting the importance of STI screening in this setting.

Myocardial contractility in premature neonates with and without patent ductus arteriosus.

Controversy exists as to whether a hemodynamically significant left-to-right shunt due to a patent ductus arteriosus (PDA) affects ventricular contractility. Load-dependent indices such as ejection fraction and shortening fraction have traditionally been used to assess contractility, but the relationship between the rate-corrected velocity of fiber shortening (MVCFc) and wall stress may be more suitable, as it is a preload-independent, afterload-adjusted method of assessing ventricular contractility. Age-related differences have been established for these variables in normal adults and children and it has been recommended for use in the premature neonate. The study was performed to assess left ventricular contractility in premature neonates with a significant left-to-right shunt due to a PDA. Using echocardiography, we measured the relationship of MVCFc to stress at peak systole (SPS) in two groups of premature infants. Group 1 consisted of 15 controls (680-1495 g, 25-32 weeks' gestation), and Group 2 of 15 neonates with hemodynamically significant PDA (840-1635 g, 26-33 weeks' gestation). In both groups, MVCFc was linearly and inversely related to SPS ( p < 0.001). The regression equations were as follows: Group 1, MVCFc = -0.0153SPS + 1.70 ( R(2) = 0.68); and Group 2, MVCF = - 0.019SPS + 1.89 ( R(2) = 0.76). There was no significant difference in the relationship between the two groups, but their slopes were significantly steeper and had a higher Y-intercept than the relationship we previously reported for older children. This preliminary study establishes the normal MVCFc/SPS relationship in the premature neonate (25-33 weeks' gestation) and suggests that premature infants function at a higher resting contractile state than older children. A hemodynamically significant PDA has no effect on contractility. These data will be useful in assessing left ventricular contractility in premature neonates with other types of ventricular loading and noncardiac stress.

Early dialysis in a neonate with intrauterine lisinopril exposure.

In general, angiotensin converting enzyme (ACE) inhibitors should be discontinued in pregnancy, as they can induce an ACE fetopathy. For the treatment of the latter, early peritoneal dialysis is recommended for in utero exposure to captopril and enalapril, although the outcome is poor. Early peritoneal dialysis has not previously been reported for lisinopril induced multiorgan failure. A case is reported in which treatment was given on postnatal day 3. The patient recovered from oligoanuria to almost normal renal function, and heart, brain, and musculoskeletal injury was reversible. This is despite relatively poor clearance of the drug through peritoneal dialysis. Analysis of the pharmacokinetic data suggests that haemodialysis or haemofiltration would be more efficacious for removal of the drug, and these treatments should be performed if available.

Resection of the lesion in patients with hypothalamic hamartomas and catastrophic epilepsy.

BACKGROUND: Patients with hypothalamic hamartomas (HH) often have severe refractory epilepsy, incapacitating behavioral abnormalities, and cognitive decline. Attempts to control the seizure disorder by resection of apparently epileptogenic mesial temporal or other cortical structures have failed consistently. OBJECTIVE: To report a series of 13 patients in whom the hamartoma itself was resected. METHODS: All patients underwent preoperative evaluation between ages 2 and 33 years and had subtotal or complete resection of the hamartoma. Follow-up ranged from 1 to 5.5 years (mean: 2.8 y). RESULTS: Preoperatively, all patients had variable combinations of gelastic, complex partial, and generalized seizures. Eight had drop attacks. In addition, all had marked behavior abnormalities and cognitive impairment. Postoperatively, two patients are completely seizure-free and 11 are either seizure-free or have achieved a greater than 90% reduction of drop attacks and generalized tonic-clonic seizures. However, minor gelastic, complex partial, and atypical absence seizures have persisted in 11 patients, although at significantly reduced rates. In addition, there has been a dramatic improvement in behavior and cognition. Three patients had an anterior thalamic and one a capsular infarct, which left only minimal long-term deficits. Exact location of the lesion in relation to the interpeduncular fossa and the walls of the third ventricle correlated with extent of excision, seizure control, and complication rate. CONCLUSION: Resection can alleviate both the seizures and the behavioral and cognitive abnormalities of hypothalamic hamartomas, but complications are frequent.

Acquired right ventricular outflow tract obstruction in the recipient twin in twin-twin transfusion syndrome.

OBJECTIVES: The goal of this study was to determine the prevalence and evolution of acquired right ventricular outflow tract obstruction (RVOTO) in the recipient twin in twin-twin transfusion syndrome (TTTS). BACKGROUND: Twin-twin transfusion syndrome complicates 4% to 26% of diamniotic monochorionic twin gestations and is associated with high fetal morbidity and mortality. Cardiac dysfunction and biventricular hypertrophy may develop in the recipient twin with the potential for RVOTO. METHODS: This was a retrospective review of a two-center experience of TTTS to describe the prevalence and evolution of acquired RVOTO in the recipient twin. Right ventricular outflow tract obstruction was diagnosed or excluded by fetal or postnatal echocardiography or clinical assessment. RESULTS: Of 73 twin pregnancies with TTTS identified between 1994 to 1998, a total of seven (9.6%) were complicated by RVOTO in the recipient twin: two subvalvar/muscular, four valvar and one combined. Of 44 pregnancies with fetal echo, six had in utero RVOTO with antegrade flow diagnosed at gestational ages ranging from 19 to 27 weeks. In utero progression occurred in four cases over a period of four to eight weeks, with the development of RVOT atresia by delivery. Postnatal progression of RVOTO occurred in two cases, one of which required pulmonary balloon valvuloplasty at age two years. Postnatal regression of subvalvar RVOTO occurred in two cases in early infancy. Death related directly or indirectly to the RVOTO occurred in all four patients who developed complete RVOT obliteration. CONCLUSIONS: Right ventricular outflow tract obstruction may occur in the recipient twin of at least 9% of pregnancies complicated by TTTS. Right ventricular outflow tract obstruction progression is common in utero and may worsen neonatal outcome.

Patent foramen ovale and brain microembolization during scoliosis surgery in adolescents.

STUDY DESIGN: A case series is reported. OBJECTIVE: To improve understanding of the potential mechanisms associated with cerebral microemboli during scoliosis surgery in adolescents. SUMMARY OF BACKGROUND DATA: Paradoxical cerebral fat microembolization during scoliosis surgery has been associated with right-to-left shunting through an undetected patent foramen ovale. The prevalence of this cardiac defect in the adult population may be as high as 15% to 25%. Although the clinical relevance of this embolic phenomenon during scoliosis surgery has not been investigated, a few reports have documented its fatal consequences. It has been suspected in some patients with postoperative reduced visual function, particularly after complex instrumented fusions. METHODS: Bilateral transcranial Doppler (2 MHz) was used to monitor cerebral microemboli in the right and left middle cerebral arteries during spinal instrumentation and fusion in four patients. Additionally, transthoracic or transesophageal echocardiography incorporating pulse and color Doppler (3.5-5 MHz) and a contrast test was used in these patients to detect atrial shunts. RESULTS: Intraoperative transcranial Doppler monitoring detected high rates of cerebral microemboli associated with the presence of an atrial communication in two adolescents. In two additional patients with no detected brain microembolization, echocardiographic examination indicated the absence of an atrial shunt. CONCLUSION: The study findings suggest that unrecognized atrial communications in adolescents undergoing scoliosis surgery contribute to higher rates of Doppler-detected cerebral microemboli than those found in adolescents without this congenital defect.