Neuropsychological course of voltage-gated potassium channel and glutamic acid decarboxylase antibody related limbic encephalitis.

BACKGROUND AND PURPOSE: Autoantibodies (abs) to glutamic acid decarboxylase (GAD) and to voltage-gated potassium channels (VGKC) induce distinct courses of limbic encephalitis, related to MRI findings, seizure outcome and cognition. METHODS: A detailed analysis of the cognitive course of the two forms is presented, spanning a median time interval of 28 months, including parameters of attention, learning and memory in 15 VGKC-ab-positive and 16 GAD-ab-positive patients. RESULTS: In both groups, the initially significantly impaired attention performance recovered to a putatively premorbid level. In VGKC patients the partially severely impaired learning and memory performance improved under treatment but remained subnormal at last follow-up. By contrast, GAD-ab-positive patients had initially less impaired learning and memory scores but did not show an improvement under treatment. CONCLUSIONS: The results provide evidence of distinct relations between inductive processes and cognitive outcome in VGKC-ab-positive and GAD-ab-positive subforms of limbic encephalitis, which possibly depend on differences in pathogenic molecular mechanisms and affected cerebral loci.

The sclerostin-neutralizing antibody AbD09097 recognizes an epitope adjacent to sclerostin's binding site for the Wnt co-receptor LRP6.

The glycoprotein sclerostin has been identified as a negative regulator of bone growth. It exerts its function by interacting with the Wnt co-receptor LRP5/6, blocks the binding of Wnt factors and thereby inhibits Wnt signalling. Neutralizing anti-sclerostin antibodies are able to restore Wnt activity and enhance bone growth thereby presenting a new osteoanabolic therapy approach for diseases such as osteoporosis. We have generated various Fab antibodies against human and murine sclerostin using a phage display set-up. Biochemical analyses have identified one Fab developed against murine sclerostin, AbD09097 that efficiently neutralizes sclerostin's Wnt inhibitory activity. In vitro interaction analysis using sclerostin variants revealed that this neutralizing Fab binds to sclerostin's flexible second loop, which has been shown to harbour the LRP5/6 binding motif. Affinity maturation was then applied to AbD09097, providing a set of improved neutralizing Fab antibodies which particularly bind human sclerostin with enhanced affinity. Determining the crystal structure of AbD09097 provides first insights into how this antibody might recognize and neutralize sclerostin. Together with the structure-function relationship derived from affinity maturation these new data will foster the rational design of new and highly efficient anti-sclerostin antibodies for the therapy of bone loss diseases such as osteoporosis.

Experimental assignment of the structure of the transition state for the association of barnase and barstar.

Association of a protein complex follows a two step reaction mechanism, with the first step being the formation of an encounter complex which evolves into the final complex. Here we present new experimental data for the association of the bacterial ribonuclease barnase and its polypeptide inhibitor barstar which shed light on the thermodynamics and structure of the transition state and preceding encounter complex of association at diminishing electrostatic attraction. We show that the activation entropy at the transition state is close to zero, with the activation enthalpy being equal to the free energy of binding. This observation was independent of the magnitude of the mutual electrostatic attraction, which were altered by mutagenesis or by addition of salt. The low activation entropy implies that the transition state is mostly solvated at all ionic strengths. The structure of the transition state was probed by measuring pairwise interaction energies using double-mutant-cycles. While at low ionic strength all proximal charge-pairs form contacts, at high salt only a subset of these interactions are maintained. More specifically, charge-charge interactions between partially buried residues are lost, while exposed charged residues maintain their ability to form specific interactions even at the highest salt concentration. Uncharged residues do not interact at any ionic strength. The results presented here suggest that the barnase-barstar binding sites are correctly aligned during the transition state even at diminishing electrostatic attraction, although specific short range interactions of uncharged residues are not yet formed. Furthermore, most of the interface desolvation (which contributes to the entropy of the system) has not yet occurred. This picture seems to be valid at low and high salt. However, at high salt, interactions of the activated complex are limited to a more restricted set of residues which are easier approached during diffusion, prior to final docking. This suggest that the steering region at high salt is more limited, albeit maintaining its specificity.

The role of Glu73 of barnase in catalysis and the binding of barstar.

Barnase, a small extracellular ribonuclease from Bacillus amyloliquefaciens and its intracellular inhibitor barstar have co-evolved to bind tightly and rapidly. Barnase has also evolved to be catalytically active. The active site of barnase and its binding site for barstar use the same subset of amino acids. The exception is Glu73 (the general base in catalysis), which although located at the centre of the binding site, is separated by three ordered water molecules from barstar. We examined in this work the contribution of Glu73 to both catalysis and barstar binding. Truncation mutants of the general base (Glu73 --> Ala or Ser) retain a residual RNase activity of about 0.3% while mutants with larger hydrophobic replacements (Glu 73 --> Trp or Phe) have virtually no catalytic activity. This, and binding data of 3'-GMP with the different barnase mutants suggest that the loss in activity results from the elimination of the general base, which can be substituted to some extent by water or other polar side-chains in truncation mutants. All of the Glu73 mutations lead to a weakening of the free energy of complex formation with barstar by 1.4 to 3.0 kcal/mol (including Gln). This is surprising, since Glu73 does not interact directly with barstar and there is an electrostatic repulsion between Glu73 on barnase and the negatively charged binding surface of barstar. A newly developed method of constructing double mutant cycles between multiple mutations at the same site appears to pinpoint a favourable interaction between Glu73 and one of its nearest neighbours in barstar, Asp39. The coupling energy between those residues is presumably indirect: the carboxylate of Glu73 organizes neighbouring positively charged groups in barnase, Lys27, Arg83, and Arg87 to interact with Asp39 in barstar. This emphasizes that an apparent interaction between a pair of residues as measured with double mutant cycles is the sum of their direct and indirect interactions.

Thermodynamics of the interaction of barnase and barstar: changes in free energy versus changes in enthalpy on mutation.

We have studied the thermodynamics of the interaction between the ribonuclease barnase and its natural polypeptide inhibitor barstar. The contribution of specific residues and interactions within the barnase-barstar interface to the enthalpy of binding has been examined using isothermal titration calorimetry and protein engineering. The enthalpy of association of the wild-type proteins is -18.9 (+/-0.1) kcal/mol at pH 8 and at 25 degrees C. The enthalpy of binding remains favourable for 31 different combinations of mutations in the interface. The effects on the binding enthalpy upon replacing a side-chain involved in the interaction of barnase and barstar are, however, always unfavourable and in most cases larger than the effects on the free energy of binding. Interaction enthalpies calculated by double mutant cycle analysis are in some cases much larger than the interaction free energies. The interaction enthalpies for complexes between different barnase mutants with amino acid substitutions of the general base residue glutamic acid 73 and a barstar variant (D39A) vary by as much as 8.3 kcal/mol while the coupling free energies differ only by 1 kcal/mol. The use of enthalpies for the analysis of structure-activity relationships appears to be complicated by enthalpy-entropy compensation of weak intermolecular interactions. These tend to cancel out in measurements of free energy, which is thus the preferred quantity for simple analysis of interactions.

Immunoglobulin mutant library genetically screened for folding stability exploiting bacterial signal transduction.

A model repertoire of variants of immunoglobulin kappa variable domain REIv with different folding stabilities was generated by oligonucleotide-directed randomization of position 29, a key conserved residue of hypervariable loop 1. Fused to ToxR', the membrane-anchored cytoplasmic domain of the Vibrio cholerae ToxR transcription activator, different members of the library induce different levels of transcription from the ctx promoter in Escherichia coli. Differences in transcription activation correlate positively with folding stabilities of the corresponding REIv domains. Since conformationally stabilized REIv derivatives elicit a dark red colony phenotype on EMB-lactose indicator plates, this procedure constitutes a genetic screen for immunoglobulin folding stability.

Stimulus complexity dependent memory impairment and changes in motor performance after deletion of the neuronal gap junction protein connexin36 in mice.

Gap junction channels, composed of connexin (Cx) proteins, are conduits for intercellular communication and metabolic exchange in the central nervous system. Connexin36 (Cx36) is expressed in distinct subpopulations of neurons throughout the mammalian brain. Deletion of the Cx36 gene in the mouse affected power and frequency of gamma and sharp wave-ripple oscillations, putative correlates of memory engram inscription. Here, we present a behavioral analysis of Cx36-deficient mice. Activity patterns, exploratory- and anxiety-related responses were largely unaffected by elimination of Cx36, while sensorimotor capacities and learning and memory processes were impaired. Repeated testing on the rotarod suggested that the Cx36-deficient mice showed slower motor-coordination learning. After a retention interval of 24 h the Cx36-deficient mice showed habituation to an open-field, but failed to habituate to a more complex spatial environment (Y-maze). A more pronounced memory impairment was found when Cx36 knockout mice had to remember recently explored objects. Cx36-deficient mice were unable to recognize objects after short delays of 15 and 45 min. These data suggest that lack of Cx36 induces memory impairments that vary in dependence of the complexity of the stimuli presented. Our results suggest that neuronal gap junctions incorporating Cx36 play a role in learning and memory.

Treatment of immune-mediated temporal lobe epilepsy with GAD antibodies.

PURPOSE: Temporal lobe epilepsy with antibodies (abs) against the glutamic acid decarboxylase 65 isoform (GAD-TLE) is known as an immune-mediated neurological syndrome. Here we evaluate the therapy response to various immunotherapies and epilepsy surgery in this syndrome. METHOD: All patients with GAD-TLE and follow-up data and stored serum and CSF samples, identified and treated at the Bonn centre from 2002 to 2010, were studied retrospectively. Seizure freedom for ≥1 year and reduction of ≥50%, i.e. therapy response, were assessed. GAD-ab titres and neuropsychological performances were documented prior and after individual interventions. RESULTS: Thirteen patients with GAD-TLE were identified with the following seizure responses: corticosteroids (5 responders out of 11 treated patients); i.v. immunoglobulins (1/5), apheresis therapy (1/8); and natalizumab (1/1), selective amygdala-hippocampectomy (2/3). None of the patients achieved sustained seizure freedom apart from one patient. This patient was on antiepileptic drug treatment after discontinuation of immunotherapy. CONCLUSION: The seizure response to immunotherapies in patients with GAD-TLE was poor. Corticosteroids were the most effective regarding seizure response. Especially the poor effects of apheresis therapies support the idea that GAD-abs are not directly pathogenic. None of three patients was seizure-free after temporal lobe surgery suggesting that GAD-TLE patients respond worse than others to this type of intervention. Our results reflect the chronic course of the disease with low likelihood for patients with GAD-TLE to attain long-term seizure freedom.

Aged endothelial nitric oxide synthase knockout mice exhibit higher mortality concomitant with impaired open-field habituation and alterations in forebrain neurotransmitter levels.

Endothelial nitric oxide synthase (eNOS) has been implicated in various brain and peripheral pathologies such as renal failure, heart failure or stroke. Consequently, the mortality rate of aged eNOS knockout mice (eNOS-/-) was higher than that of age-matched (18-22 months old) controls. Only seven of the original 14 eNOS-/- animals that participated in the study reached the age of 18 months or older, whereas no control mice died during this life span. In order to assess the behavioral and neurochemical consequences of chronic eNOS deficiency we examined whether the surviving aged eNOS-/- mice showed changes in terms of motor, emotional, exploratory and neurochemical parameters. Aged eNOS-/- mice showed reduced exploratory activity in the open-field with no habituation observable neither within sessions nor after repeated exposures. Pole test performance of eNOS-/- mice was comparable to controls. In the elevated plus-maze eNOS-/- mice did not differ from controls in terms of time spent in and entries into arms, but showed less locomotion on the open arms. The most prominent neurochemical alterations in the forebrains of aged eNOS-/- mice were: (a) increased acetylcholine levels in the neostriatum; (b) decreased noradrenaline concentrations in the ventral striatum; and (c) lower serotonin levels in the frontal cortex and ventral striatum. The present findings suggest that mice which survived chronic eNOS-deficiency into old age, show some behavioral and neurochemical phenotypes distinct from adult eNOS-/- mice.

Characterization of in vitro oxidized barstar.

The polypeptide inhibitor of the ribonuclease barnase, barstar, has two cysteine residues in positions 40 and 82. These have been proposed to form a disulfide bridge leading to an increase in stability without changing the inhibitory activity of the protein. Barstar and a mutant (E80A) were oxidized in vitro and the biochemical and physico-chemical properties of the oxidized monomers were analysed. The oxidized proteins show no inhibition of barnase using a plate assay and are significantly destabilized. CD spectra indicate a loss of secondary structure. The amino acid substitution E80 --> A stabilizes the oxidized barstar to about the same extent as it does the reduced protein, indicating, however, that the helical region which it is in is intact.

A phage-based system to select multiple protein-protein interactions simultaneously from combinatorial libraries.

Selectively infective phage (SIP) can be used to identify protein-protein interactions. SIP was modified to facilitate the simultaneous selection of interacting protein pairs from large combinatorial libraries. An interference-resistant phage was constructed which non-covalently, but stably links the genetic information of an interacting pair, encoded separately on phage and phagemid vectors, by co-packaging into heteropolyphages. In a model system, the interaction between a SIP-selected peptide and the intracellular domain of the p75 neurotrophin receptor was detected in the presence of a 10(4)-fold excess of a non-interacting control pair (jun leucine zipper and p75 intracellular domain) via SIP hetero-polyphage transductants. To minimize the redundancy of transductants and to minimize possible ligand exchange generated in a solution-based SIP screening, a filter-based in situ infectivity screening was developed. The combination of the above techniques may provide a powerful system for rapid screening of very large sequence spaces.

Self-administration of neurokinin substance P into the ventromedial caudate-putamen in rats.

There is evidence that the neurokinin substance P plays a role in learning and reinforcement processes. Reinforcing effects of substance P were found upon injection into several parts of the brain. The aim of the present study was to gauge possible reinforcing effects of microinjections of substance P into the ventromedial caudate-putamen in rats. Two different behavioral paradigms were employed. In the first experiment a two-compartment choice procedure was used and the rats could trigger substance P injections (500 pg per 5 nl injection volume) into the ventromedial caudate-putamen by entering one distinctive compartment. During the injection period, substance P-injected animals spent significantly more time in the drug-paired compartment than vehicle-injected controls. In the second experiment, nose-poking through a hole in one wall of the cage was used as the operant. Rats that could self-administer substance P (100 pg per 5 nl injection volume) into the ventromedial caudate-putamen emitted a significantly higher rate of operant responding on the first day of testing and a significantly lower rate on the third day compared to vehicle-injected animals. The experiments provide evidence that the administration of substance P into the ventromedial part of the caudate-putamen can have positive reinforcing effects, but that repeated injections can have aversive properties. These effects are discussed, firstly, with regard to the possible mechanisms of intrastriatal substance P on striatonigral and striatopallidal output systems and, secondly, with respect to their possible relevance in the study of the basal forebrain reinforcement system.

Unaltered radial maze performance and brain acetylcholine of the endothelial nitric oxide synthase knockout mouse.

Proceeding from previous findings of a beneficial effect of endothelial nitric oxide synthase (eNOS) gene inactivation on negatively reinforced water maze performance, we asked whether this improvement in place learning capacities also holds for a positively reinforced radial maze task. Unlike its beneficial effects on the water maze task, eNOS gene inactivation did not facilitate radial maze performance. The acquisition performance over the days of place learning did not differ between eNOS knockout (eNOS-/-) and wild-type mice (eNOS+/+). eNOS-/- mice displayed a slight and eNOS+/+ mice a more severe working memory deficit in the place learning version of the radial maze compared to the genetic background C57BL/6 strain. Possible differential effects of eNOS inactivation, related to differences in reinforcement contingencies between the Morris water maze and radial maze tasks, behavioral strategy requirements, or to different emotional and physiological concomitants inherent in the two tasks are discussed. These task-unique characteristics might be differentially affected by the reported anxiogenic and hypertensional effects of eNOS gene inactivation. Post-mortem determination of acetylcholine concentrations in diverse brain structures revealed that acetylcholine and choline contents were not different between eNOS-/- and eNOS+/+ mice, but were increased in eNOS+/+ mice compared to C57BL/6 mice in the frontal cortex. Our findings demonstrate that phenotyping of learning and memory capacities should not rely on one learning task only, but should include tasks employing both negative and positive reinforcement contingencies in order to allow valid statements regarding differences in learning capacities between rodent strains.

High Helicobacter pylori eradication rate with a 1-week regimen containing ranitidine bismuth citrate.

BACKGROUND: High Helicobacter pylori eradication rates have consistently been reported with 2-week dual therapy regimens of ranitidine bismuth citrate plus clarithromycin. Ranitidine bismuth citrate with two antibiotics may provide an alternative 1-week eradication regimen. METHODS: This double-blind, randomized, parallel group, international, multicentre study compared ranitidine bismuth citrate 400 mg b.d. and clarithromycin 500 mg b.d. for 2 weeks (RC) with ranitidine bismuth citrate 400 mg b.d., clarithromycin 500 mg b.d. and metronidazole 400 mg b.d. for 1 week (RCM) for eradication of H. pylori in 350 patients with dyspepsia. RESULTS: Treatment with RC and RCM eradicated H. pylori (established by the combination of two negative results from two discrete 13C-UBTs at nominal weeks 4 and 12) from 89% (95% CI: 84-94) and 92% (95% CI: 88-97) of the observed population, and from 78% (95% CI: 72-84) and 80% (95% CI: 75-86) of the intention-to-treat population. When established only by one negative 13C-UBT result at least 28 days after the end of treatment, the respective intention-to-treat rates were 85% (95% CI: 79-90) and 88% (95% CI: 83-93). Both regimens were well-tolerated, only 6% of patients given RC and 4% given RCM discontinued treatment. Median plasma bismuth concentrations at the end of the second week of study were low, at 3.5 and 0.4 ng/ mL, respectively. CONCLUSIONS: Ranitidine bismuth citrate triple therapy for 1 week (RCM) and dual therapy for 2 weeks (RC) were equally effective for the eradication of H. pylori infection.

Evidence for anatomical specificity for the reinforcing effects of SP in the nucleus basalis magnocellularis.

Previous studies have shown that substance P (SP) exerts reinforcing effects following injection into the region of the nucleus basalis magnocellularis (NBM) in rats. The aim of the present study was to further characterize this effect by examining its anatomical specificity. Reinforcing effects of SP were assessed following unilateral microinjection into the NBM or into the nearby rostral part of the ventral pallidum (VP), using conditioned place preference as an index for reinforcement. Intracranial injection of SP was performed through small diameter glass micropipettes which allowed precise delivery of SP in minute quantities. A single microinjection of SP (0.2 and 1 ng) into the NBM produced a conditioned place preference, whereas injection of SP into the rostral VP failed to alter the preference behavior. The results confirm that SP has reinforcing effects when administered into the NBM and provide evidence that these effects are brain-site specific.

Comparison of intra-accumbens injection of histamine with histamine H1-receptor antagonist chlorpheniramine in effects on reinforcement and memory parameters.

Histaminergic neurons are located exclusively in the tuberomammillary nuclei (TM) of the hypothalamus from where they project to many regions of the brain including the basal ganglia. Earlier experiments led to the hypothesis that neuronal histamine (HA), particularly in relation to the H1 receptor, has an inhibitory role in learning and reward-related processes. Based on this premise, the objective of the present study was to compare HA with the H1-receptor antagonist d-chlorpheniramine (CPR) in effects on reinforcement and memory parameters after injection into different subregions of the rat nucleus accumbens (NAcc). In the first experiment, mnemoactive effects of CPR (0.1-10 microg) were assessed after injection into the caudal or rostral part of the NAcc with the one-trial uphill avoidance task as a measure of learning. The data show that intra-NAcc injection of CPR (10 microg) facilitated retention of the task, when the compound was administered immediately after training. This effect was evident only when CPR was administered into the caudal-shell but not into the rostral pole of the NAcc providing evidence for anatomical specificity of the intra-NAcc induced promotion of memory. In the second experiment, possible mnemonic and reinforcing effects of HA (0.001-1 microg) were gauged after injection of the amine into the caudal NAcc, using post-trial application in the uphill avoidance task to assess effects on learning and place preference as an index of reinforcing properties. The data show that caudal-NAcc injection of HA (0.1 microg) improved retention of the avoidance task and produced place preference indicative of a reinforcing action. The finding that intra-NAcc injection of HA can facilitate learning and has reinforcing effects is at variance with the proposed inhibitory nature of neuronal HA in reward-related processes. Thus, the disinhibition of reinforcement and facilitation of learning found earlier after partial destruction of TM-intrinsic neurons might not necessarily be related to a lesion-induced reduction of the HAergic tone. The observation that CPR has behavioral effects quite similar to HA suggests that the mnemoactive and reinforcing action of this compound might involve pharmacodynamic aspects beyond its antagonistic activity at H1-receptive sites.

Facilitation of learning following injection of the chondroitin sulfate proteoglycan biglycan into the vicinity of the nucleus basalis magnocellularis.

The aim of this study was to examine the effects of biglycan, a small chondroitin sulfate proteoglycan with neurotrophic activity, on memory and reinforcement upon unilateral injection into the region of the nucleus basalis magnocellularis (NBM). In experiment 1, rats with chronically implanted cannulas were injected with biglycan and tested on the uphill avoidance task, which involves punishment of a high-probability turning response on a tilted platform (negative geotaxis). Immediately after the training trial, that is, after a tail-shock was administered upon performing the response, rats received one microinjection (0.5 microliter) of substance P (SP) in a reference dosage of 0.74 pmol or biglycan (doses ranging from 1.3 to 1300.0 nmol) into the NBM region. When tested 24 h later, rats treated with SP (0.74 pmol) or biglycan (2.1 and 2.6 nmol) had significantly longer uphill latencies than vehicle (PBS) controls, indicative of superior learning of the avoidance response. In experiment 2, a test for possible proactive effects of post-trial biglycan on performance during the retention trial was performed. Furthermore, the uphill avoidance task was combined with a conditioned place preference task to assess possible reinforcing effects of biglycan. Rats were injected with either 2.6 or 130.0 nmol biglycan immediately after the training trial of the uphill task. One control group received 2.6 nmol biglycan 5 h after the trial, a second group was sham-operated. Additional groups were included which received biglycan (2.6 or 130.0 nmol), SP (0.74 pmol) or PBS after the training trial but no tail-shock.(ABSTRACT TRUNCATED AT 250 WORDS)

The histamine H1-antagonist chlorpheniramine facilitates learning in aged rats.

The effect of the histamine H1-receptor antagonist chlorpheniramine on inhibitory avoidance conditioning was investigated in 31-month-old rats, using a one-trial step-through avoidance task. Immediately after the learning trial, old rats were injected intraperitoneally with 5 or 10 mg/kg d-chlorpheniramine. Control groups included vehicle-injected old and adult (4-month-old) rats and a group of aged animals given an injection of 10 mg/kg chlorpheniramine 5 h after the training trial. When tested 24 h after training, aged rats receiving 10 mg/kg chlorpheniramine exhibited longer step-through latencies than vehicle-treated old controls, indicative of superior learning of the task. The hypermnestic effects of 10 mg/kg chlorpheniramine were no longer evident when injection was performed 5 h, rather than immediately after the learning trial, ruling out enduring proactive effects of the treatment on test performance. Furthermore, vehicle-treated old rats showed poorer inhibitory avoidance performance than vehicle-treated adult controls. Thus, the improvement in performance after the 10 mg/kg dose of chlorpheniramine can be interpreted in terms of a compensation of performance deficits in the old rats.

Studies of the protein synthesis system in the brain cortex during global ischemia and reperfusion.

Previous studies have demonstrated that brain protein synthesis declines after global ischemia and reperfusion. To investigate the role of the translation system in this phenomenon, we examined the ability of partially purified ribosomes, ribosome-bound mRNA and translation cofactors derived from the transiently ischemic cerebral cortex to synthesize protein in vitro. Samples were prepared from canines subjected to 20-min cardiac arrest and after 2 or 8 h of post-resuscitation intensive care. There was no significant decrease in the rate of in vitro protein synthesis as a consequence of either ischemia or reperfusion. Northern hybridization of ribosome-bound RNA revealed a discrete band of mRNA for brain-specific creatine kinase (ck-bb) that was consistent in presence and intensity in all groups. However, mRNA for heat shock 70 protein (hsp-70) was observed only during reperfusion and markedly increased between 2 and 8 h reperfusion. Thus, we conclude that (1) the transcription system is intact during reperfusion and hsp-70 mRNA is made and translocated to the ribosomes during reperfusion, (2) mRNA for ck-bb is not displaced from ribosomes by the appearance of hsp-70 during reperfusion and (3) isolated ribosomes maintain their ability to translate in vitro during the first 8 h of reperfusion after global brain ischemia. Therefore, the early reduction in protein synthesis observed in vivo during post-ischemic brain reperfusion is not due to an intrinsic dysfunction of the ribosomes.

Improved results in acute appendicitis care following areawide review.

The Wisconsin Professional Review Organization compared acute appendectomies being performed in 1981 to those done in 1978 in 32 Wisconsin hospitals. In both years approximately 75 percent of primary appendectomies were in patients 5 to 30 years of age, one-fourth were in patients 15 to 19 years of age, and the majority were in males. Incidence of normal appendices dropped from 16.1 percent in 1978 to 11.4 percent in 1981 (p less than 0.005). The number of patients with normal appendices who did not meet symptom criteria dropped from 37.3 percent to 9.5 percent (p less than 0.05). Incidence of normal appendices was highest in small hospitals. Severity and ruptures or perforations increased, but not significantly. Postoperative complications and mortality decreased. Average length of stay decreased overall, but increased for patients with complications and ruptures or perforations. These data suggest that areawide reviews assure quality and help contain costs. Physician self-regulation using areawide studies may produce desirable change.