Predictors of decline in verbal fluency after frontal lobe epilepsy surgery.

Few studies have focused on language changes following frontal lobe epilepsy (FLE) surgery. The aim of the current study is to quantify the role of resection location and size in verbal fluency decline after FLE surgery and to examine its predictors. A retrospective chart review identified 36 adult patients who underwent FLE surgery. Verbal fluency was assessed using the Controlled Oral Word Association Test (COWAT). Nine (25%) of the patients had significant decline. Binary logistic regression incorporating side of resection and preoperative COWAT score significantly predicted decline and accounted for 25% of the variance. A trend was also noted for decliners to have higher postoperative seizure recurrence (p=0.067). There was no effect of size of resection. Patients undergoing FLE surgery are at risk of verbal fluency decline, especially if they have a high presurgical verbal fluency score, undergo a frontal lobe resection in the language dominant hemisphere, and have poor seizure outcome.

Guidance of magnetic resonance imaging and placement of skin-marker localization devices.

AIM: A variety of magnetic resonance imaging (MRI)-compatible skin-marker localization devices are available on the market. MRI protocols call for the liberal use of the skin markers over the specific site of symptoms or over any palpable mass. This study investigates the usefulness of patient-assisted placement of 1 000-mg fish oil capsules as skin markers over the area of maximum localized pain, signs, or symptoms and correlates this placement with any potential underlying neuropathology or potential pain generator. METHODS: One-hundred symptomatic patients undergoing MRI were assessed for focal or localized signs or symptoms. Under the direction of a physician and with guidance from the patient, the MRI technician placed a 1 000-mg fish-oil capsule over the area of maximum pain or signs and symptoms. Patients with poorly localized, diffuse symptoms or an area of maximal signs and symptoms outside the field of view of the MRI were not included in this study. All MRI exams were reviewed by clinical physicians and radiologists or neuroimaging physicians. RESULTS: In all 100 cases, the images show clearly visible MRI-compatible skin-surface markers that correlate with potential underlying neuropathology. CONCLUSION: Our results show that 1 000-mg fish-oil capsules can be used as MRI localization devices as a cost-effective alternative to more expensive commercially available devices.

Scoliosis in chickens: responsiveness of severity and incidence to dietary copper.

The severity and incidence of spinal lesions were manipulated in a line of chickens susceptible to scoliosis by varying their dietary intake of copper. A decrease in expression of the lesion was related to increased intake of copper. The change in expression, however, appeared to be related only indirectly to the defects in collagen cross-linking, maturation, and deposition known to be associated with dietary copper deficiency. Thus, a dietary constituent in the range of normal intakes may act as an environmental factor in the expression of scoliosis.

Estrogen receptor alpha signaling pathways differentially regulate gonadotropin subunit gene expression and serum follicle-stimulating hormone in the female mouse.

Estrogen, acting via estrogen receptor (ER)alpha, regulates serum gonadotropin levels and pituitary gonadotropin subunit expression. However, the cellular pathways mediating this regulation are unknown. ERalpha signals through classical estrogen response element (ERE)-dependent genomic as well as nonclassical ERE-independent genomic and nongenomic pathways. Using targeted mutagenesis in mice to disrupt ERalpha DNA binding activity, we previously demonstrated that ERE-independent signaling is sufficient to suppress serum LH levels. In this study, we examined the relative roles of ERE-dependent and -independent estrogen signaling in estrogen regulation of LH, FSH, prolactin, and activin/inhibin subunit gene expression, pituitary LH and FSH protein content, and serum FSH levels. ERE-independent signaling was not sufficient for estrogen to induce pituitary prolactin mRNA or suppress pituitary LHbeta mRNA, LH content, or serum FSH in estrogen-treated ovariectomized mice. However, ERE-independent signaling was sufficient to reduce pituitary glycoprotein hormone alpha-subunit, FSHbeta, and activin-betaB mRNA expression. Together with previous serum LH results, these findings suggest ERE-independent ERalpha signaling suppresses serum LH via reduced secretion, not synthesis. Additionally, ERE-dependent and ERE-independent ERalpha pathways may distinctly regulate steps involved in the synthesis and secretion of FSH.

Collagen crosslinking and cartilage glycosaminoglycan composition in normal and scoliotic chickens.

The amounts of lysine-derived crosslinks in collagens from tendon, cartilage, intervertebral disc, and bone and changes in the composition of sternal cartilage glycosaminoglycans were estimated in two lines of chickens, a control-isogenic line and a line that develops scoliosis. In the scoliotic line, scoliosis first appears at 3-4 weeks and progressively increases in severity and incidence so that 90% of the birds express the lesion by week 10. We have reported previously that cartilage, tendon, and bone collagens from scoliotic birds are more soluble than corresponding collagens from normal birds. Herein, collagen crosslinking and altered proteoglycan metabolism are examined as possible mechanisms for the differences in collagen solubility. At 1 week of age there were fewer reducible crosslinking amino acids (hydroxylysinonorleucine, dihydroxylysinonorleucine, and lysinonorleucine) in collagens from sternal cartilage and tendon in the scoliotic line than in the isogenic line. However, by week 3 and at weeks 5 or 7 values were similar in both groups. The amounts of hydroxypyridinium in vertebral bone and intervertebral disc collagen were also similar in both groups of birds. Consequently, differences in collagen crosslinking do not appear to be a persistent developmental defect underlying the expression of scoliosis in the model. However, differences were observed in cartilage proteoglycans and glycosaminoglycans from the scoliotic line that were not present in cartilage from the isogenic line. The average molecular weight of the uronide-containing glycosaminoglycans was 30% less in the scoliotic line than in the isogenic line, i.e., 12,000 compared to 18,000. The size distribution of cartilage proteoglycans from the scoliotic line also differed from that of proteoglycans from the isogenic line.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolation and characterization of fibronectin from bovine aqueous humor.

Aqueous humor collected from freshly enucleated bovine eyes was passed over a gelatin affinity column, and bound material was eluted with 4M urea. When fractionated by sodium dodecyl sulfate electrophoresis, the eluted material co-migrated with human plasma fibronectin and protein standards of approximately 220,000 daltons. Amino acid analyses demonstrated a composition similar to that of human plasma fibronectin and fibronectin synthesized by cultured cells. The concentration of fibronectin in aqueous humor is approximately 100 times less than in human plasma.

Androgen responsiveness of the pituitary gonadotrope cell line LbetaT2.

Androgens have a profound effect on the hypothalamic-pituitary axis by reducing the synthesis and release of the pituitary gonadotropin LH. The effect on LH is partly a consequence of a direct, steroid-dependent action on pituitary function. Although androgen action has been well studied in vivo, in vitro cell models of androgen action on pituitary gonadotropes have been scarce. Recently, an LH-expressing cell line, LbetaT2, was generated by tumorigenesis targeted to the LH-producing cells of the mouse pituitary. The purpose of these studies was to determine the presence of androgen receptor (AR) and establish its function in this cell line. RT-PCR analysis indicated that the LbetaT2 cell line expresses AR mRNA. Transient transfection assays, using the mouse mammary tumor virus (MMTV) promoter, showed that a functional AR is also present. Testosterone (TEST), dihydrotestosterone (DHT), 7alpha-methyl-19-nortestosterone (MENT), and fluoxymesterone (FLUOXY) increased reporter gene activity in the rank order of potencies MENT>DHT> TEST>FLUOXY. Additionally, activation of MMTV promoter activity by DHT in LbetaT2 cells was diminished by the AR antagonists casodex and 2-hydroxy-flutamide, indicating that the effects of DHT are mediated through AR. In summary, these studies showed that the LbetaT2 cell line is a useful model for the evaluation and molecular characterization of androgen action in pituitary gonadotropes.

MR evaluation of developmental venous anomalies: medullary venous anatomy of venous angiomas.

PURPOSE: To present characteristic MR findings of developmental venous anomalies (DVAs) in terms of location of caput and draining veins, to correlate these findings with normal medullary venous anatomy, and to suggest an approach to the evaluation of DVAs by means of MR imaging. METHODS: We reviewed the contrast-enhanced MR examinations of 61 patients with DVA, which were selected from 4624 consecutive cranial MR examinations. Site of the DVA and size and direction of draining veins were recorded. RESULTS: Seventy-two DVAs with 78 draining veins were located: 18 were juxtacortical, 13 were subcortical, and 41 were periventricular or deep. Twenty-six of the DVA caputs were frontal, 16 were parietal, 13 were in the brachium pontis/dentate, seven were in the temporal lobe, three were in the cerebellar hemisphere, three were in the occipital lobe, three were in the basal ganglia, and one was in the pons. The draining veins were superficial in 29 cases and deep in 49. Of the 36 supratentorial deep draining veins, 16 were in the trigone/occipital horn, 11 were in the mid-body of the lateral ventricle, seven were in the frontal horn, and two were in the temporal horn. Among the 14 infratentorial deep draining veins, five were in the lateral recess of the fourth ventricle, four were anterior transpontine veins, three were lateral transpontine veins, and two were precentral cerebellar veins. CONCLUSION: The DVA caputs and their draining veins occurred in typical locations that could be predicted from the normal medullary venous anatomy, with the frontal, parietal, and brachium pontis/dentate being the most common locations. Drainage can occur in superficial cortical veins or sinuses or in deep ventricular veins or in both, no matter where the caput is located. Whether drainage was superficial or deep could not be predicted on the basis of the site of the DVA caput. Contrast-enhanced T1-weighted MR images showed the DVAs best, but diagnosis could be made from T2-weighted MR images.

Variational image segmentation using boundary functions.

A general variational framework for image approximation and segmentation is introduced. By using a continuous "line-process" to represent edge boundaries, it is possible to formulate a variational theory of image segmentation and approximation in which the boundary function has a simple explicit form in terms of the approximation function. At the same time, this variational framework is general enough to include the most commonly used objective functions. Application is made to Mumford-Shah type functionals as well as those considered by Geman and others. Employing arbitrary Lp norms to measure smoothness and approximation allows the user to alternate between a least squares approach and one based on total variation, depending on the needs of a particular image. Since the optimal boundary function that minimizes the associated objective functional for a given approximation function can be found explicitly, the objective functional can be expressed in a reduced form that depends only on the approximating function. From this a partial differential equation (PDE) descent method, aimed at minimizing the objective functional, is derived. The method is fast and produces excellent results as illustrated by a number of real and synthetic image problems.

Peer group image enhancement.

Peer group image processing identifies a "peer group" for each pixel and then replaces the pixel intensity with the average over the peer group. Two parameters provide direct control over which image features are selectively enhanced: area (number of pixels in the feature) and window diameter (window size needed to enclose the feature). A discussion is given of how these parameters determine which features in the image are smoothed or preserved. We show that the Fisher discriminant can be used to automatically adjust the peer group averaging (PGA) parameters at each point in the image. This local parameter selection allows smoothing over uniform regions while preserving features like corners and edges. This adaptive procedure extends to multilevel and color forms of PGA. Comparisons are made with a variety of standard filtering techniques and an analysis is given of computational complexity and convergence issues.

An efficient color representation for image retrieval.

A compact color descriptor and an efficient indexing method for this descriptor are presented. The target application is similarity retrieval in large image databases using color. Colors in a given region are clustered into a small number of representative colors. The feature descriptor consists of the representative colors and their percentages in the region. A similarity measure similar to the quadratic color histogram distance measure is defined for this descriptor. The representative colors can be indexed in the three-dimensional (3-D) color space thus avoiding the high-dimensional indexing problems associated with the traditional color histogram. For similarity retrieval, each representative color in the query image or region is used independently to find regions containing that color. The matches from all of the query colors are then combined to obtain the final retrievals. An efficient indexing scheme for fast retrieval is presented. Experimental results show that this compact descriptor is effective and compares favorably with the traditional color histogram in terms of overall computational complexity.

Precaution and safety in carbon dioxide laser surgery.

The introduction of the carbon dioxide laser--(in 1972) by Strong and Jako as a surgical tool for removal of laryngeal papilloma--heralded a new period of surgical refinement and precision in otolaryngology and also led to adjustment and precautions in operating room setup and in the administration of anesthetics. This article recounts 8 years of experience in carbon dioxide laser surgery on 3500 head and neck patients. Techniques and precautions of administering anesthetics for laser surgery are presented. The management of a laser-ignited burn is also discussed.

The use of modified divinylbenzene-polystyrene resins in the separation of fermentation products. A case study utilizing amino acids and a dipeptide.

The adsorption of phenylalanine, aspartic acid, asparagine and aspartame from phosphate-buffered aqueous solutions with modified divinyl-benzene-polystyrene resins has been investigated using high pressure liquid chromatography (HPLC). The pH studied was 2.8, the temperature range was 293-313 K and the ionic strength was maintained at 1.0 mol dm-3. Over the range of variables investigated, the adsorption isotherms are linear and may be characterized by temperature and pH-dependent apparent adsorption equilibrium constants, characteristic of the resin-adsorbate system. By studying the dependence on temperature of this adsorption constant, heats of adsorption and entropy of adsorption have been estimated. In terms of the heat liberated on adsorption, the amino acids and a dipeptide can be ranked thus: aspartame > phenylalanine > aspartic acid > asparagine.

The development of the Australian Basic Intensive Care Knowledge Test.

The Basic knowledge Assessment Tool (BKAT), a test developed in the United States, has been presented as a valid and reliable test of basic knowledge for critical care nursing. However, it was necessary to determine the BKAT's validity and reliability in the Australian intensive care (IC) context. The Delphi technique, utilising a panel of eleven experts, was used to determine the content validity of the BKAT. The Delphi process resulted in the development of a test with 105 questions. These questions consist of 49 original BKAT questions, 25 original BKAT questions slightly modified, 3 original BKAT questions with major modifications and 28 new questions. A criterion group design was used to establish the modified test's reliability and decision validity. Item analysis was undertaken using item difficulty and item discrimination indexes. The modified test was completed by 14 registered nurses with no IC experience, 18 registered nurses with intermediate IC experience and 25 registered nurses qualified as intensive care specialists. The mean score (and standard deviation) for the test for each of the respective groups was 41(9), 69(9) and 86(7). These results were significantly different (p < 0001). The reliability was established with a Cronbach Alpha coefficient of .96. The modified test is a reliable and valid measure of IC basic knowledge and can be used as a valuable adjunct in the assessment of IC orientation programs.

Study to validate the outcome goal, competencies and educational objectives for use in intensive care orientation programs.

Intensive care orientation programs have become an accepted component of intensive care education. To date, however, there have been no Australian-based standards defining the appropriate level of competence to be attained upon completion of orientation. The aim of this study was to validate a set of aims, competencies and educational objectives that could form the basis of intensive care orientation and which would ensure an outcome standard of safe and effective practice. An initial document containing a statement of the desired outcome goal, six competency statements and 182 educational objectives was developed through a review of the orientation programs developed by the investigators. The Delphi technique was used to gain consensus among 13 nurses recognised for their expertise in intensive care education. The expert group rated the acceptability of each of the study items and provided suggestions for objectives to be included. An approval rating of 80 per cent was required to retain each of the study items, with the document refined through three Delphi rounds. The final document contains a validated statement of outcome goal, competencies and educational objectives for intensive care orientation programs.

Dense arrays of micro-needles for recording and electrical stimulation of neural activity in acute brain slices.

OBJECTIVE: This paper describes the design, microfabrication, electrical characterization and biological evaluation of a high-density micro-needle array. The array records from and electrically stimulates individual neurons simultaneously in acute slices of brain tissue. APPROACH: Acute slices, arguably the closest in-vitro model of the brain, have a damaged surface layer. Since electrophysiological recording methods rely heavily on electrode-cell proximity, this layer significantly attenuates the signal amplitude making the use of traditional planar electrodes unsuitable. To penetrate into the tissue, bypassing the tissue surface, and to record and stimulate neural activity in the healthy interior volume of the slice, an array of 61 micro-needles was fabricated. MAIN RESULTS: This device is shown to record extracellular action potentials from individual neurons in acute cortical slices with a signal to noise ratio of up to ∼15:1. Electrical stimulation of individual neurons is achieved with stimulation thresholds of 1.1-2.9 µA. SIGNIFICANCE: The novelty of this system is the combination of close needle spacing (60 µm), needle heights of up to 250 µm and small (5-10 µm diameter) electrodes allowing the recording of single unit activity. The array is coupled to a custom-designed readout system forming a powerful electrophysiological tool that permits two-way electrode-cell communication with populations of neurons in acute brain slices.

Placebo-controlled trial of lubiprostone for constipation associated with Parkinson disease.

OBJECTIVE: To evaluate the efficacy and tolerability of lubiprostone (Amitiza) for constipation in Parkinson disease (PD) in a double-blind, randomized, controlled study. METHODS: Patients with PD and clinically meaningful constipation (constipation rating scale score > 10 [range: 0-28]) were recruited from 2 academic movement disorder centers to participate in the study. After enrollment, patients were initially followed for 2 weeks and then were randomly assigned 1:1 to lubiprostone, and the dose was titrated up to 48 µg/day. They returned 4 weeks later for a final assessment. Data included stool diaries and global impressions (co-primary endpoints), demographics, Unified Parkinson's Disease Rating Scale scores, constipation scale scores, visual analog scale (VAS) scores, a stool diary, and adverse events. RESULTS: Fifty-four subjects (39 male, mean age 67.0 ± 10.1 years, and mean duration of PD 8.3 ± 5.4 years) were randomly assigned to lubiprostone or placebo. One patient in the drug group discontinued the study because of logistics, and one patient in the placebo group discontinued the study because of lack of efficacy. A marked or very marked clinical global improvement was reported by 16 of 25 (64.0%) subjects receiving drug vs 5 of 27 (18.5%) subjects receiving placebo (p = 0.001). The constipation rating scale (p < 0.05), VAS (p = 0.001), and stools per day in the diary (p < 0.001) all improved with drug compared with placebo. Adverse events with drug were mild, most commonly intermittent loose stools. CONCLUSION: In this randomized controlled trial, lubiprostone seemed to be well tolerated and effective for the short-term treatment of constipation in PD.

Magnetic resonance angiography of the circle of Willis in patients with symptomatic intracranial neuropathology: medicare LCD L25367(R4).

Patients with symptomatic intracranial neuropathology such as atherosclerotic occlusive disease or unruptured aneurysms face high risks for morbidity and mortality. Magnetic resonance angiography of the circle of Willis is an important tool used to detect and diagnose intracranial neuropathology; however, recent changes to the Medicare local coverage determinations for this procedure threaten to compromise the physician's ability to deliver this current standard of care. Physicians can assume an important role in advocating for this lifesaving procedure on behalf of this vulnerable patient population.

Urine drug testing in the treatment of chronic noncancer pain in a Kentucky private neuroscience practice: the potential effect of Medicare benefit changes in Kentucky.

BACKGROUND: Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose. STUDY DESIGN: A retrospective review of urine drug testing services. OBJECTIVE: To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits. METHODS: An audit of services provided during 2007 was conducted using computer software. OUTCOME MEASURES: Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care. RESULTS: Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured. LIMITATIONS: Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care. CONCLUSION: In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician's toolbox, the physician's ability to accurately diagnose and treat these patients could be impaired.

Importance of urine drug testing in the treatment of chronic noncancer pain: implications of recent medicare policy changes in kentucky.

BACKGROUND: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. OBJECTIVE: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. DISCUSSION: Practitioners are confronted with the ethical and legal dilemma of being called to adequately treat chronic pain in a culture with a high prevalence of prescription drug abuse. Yet the symptoms of drug abuse are nonspecific and therefore of limited value to the practitioner in determining patient compliance to drug treatment regimens. In contrast, urine drug testing has a reliable history, both in and out of medicine, as an independent sign of drug misuse. This sign can be used to aid in the diagnosis and treatment of drug misuse and underlying addictions to improve patient outcomes. CONCLUSION: Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse.