Clinical and technical factors in endoscopic skull base surgery associated with reconstructive success.

BACKGROUND: In this study, we identified key discrete clinical and technical factors that may correlate with primary reconstructive success in endoscopic skull base surgery (ESBS). METHODS: ESBS cases with intraoperative cerebrospinal fluid (CSF) leaks at four tertiary academic rhinology programs were retrospectively reviewed. Logistic regression identified factors associated with surgical outcomes by defect subsite (anterior cranial fossa [ACF], suprasellar [SS], purely sellar, posterior cranial fossa [PCF]). RESULTS: Of 706 patients (50.4% female), 61.9% had pituitary adenomas, 73.4% had sellar or SS defects, and 20.5% had high-flow intraoperative CSF leaks. The postoperative CSF leak rate was 7.8%. Larger defect size predicted ACF postoperative leaks; use of rigid reconstruction and older age protected against sellar postoperative leaks; and use of dural sealants compared to fibrin glue protected against PCF postoperative leaks. SS postoperative leaks occurred less frequently with the use of dural onlay. Body-mass index, intraoperative CSF leak flow rate, and the use of lumbar drain were not significantly associated with postoperative CSF leak. Meningitis was associated with larger tumors in ACF defects, nondissolvable nasal packing in SS defects, and high-flow intraoperative leaks in PCF defects. Sinus infections were more common in sellar defects with synthetic grafts and nondissolvable nasal packing. CONCLUSIONS: Depending on defect subsite, reconstructive success following ESBS may be influenced by factors, such as age, defect size, and the use of rigid reconstruction, dural onlay, and tissue sealants.

Neural mechanisms of the EEG alpha-BOLD anticorrelation.

An experimentally tested neural field theory of the corticothalamic system is used to model brain activity and resulting experimental EEG data, and to elucidate the neural mechanisms and physiological basis of alpha-BOLD anticorrelation observed in concurrent EEG and fMRI measurements. Several studies have proposed that the anticorrelation originates from a causal link between changes in the alpha power and BOLD signal. However, the results in this study reveal that fluctuations in alpha and BOLD power do not generate one another but instead respectively result from high- and low-frequency components of the same underlying cortical activity, and that they are inversely correlated via variations in the strengths of corticothalamic and intrathalamic feedback, thereby explaining their anticorrelation.

Effects of astrocytic dynamics on spatiotemporal hemodynamics: Modeling and enhanced data analysis.

The effects of astrocytic dynamics on the blood oxygen-level dependent (BOLD) response are modeled. The dynamics are represented via an astrocytic response function that approximates the effects of astrocytic activity, including delay between neural activity and hemodynamic response. The astrocytic response function is incorporated into a spatiotemporal hemodynamic model to predict the BOLD response measured using functional magnetic resonance imaging (fMRI). Adding astrocytic dynamics is shown to significantly improve the ability of the model to robustly reproduce the spatiotemporal properties of the experimental data such as characteristic frequency and time-to-peak. Moreover, the results are consistent across different astrocytic response functions, thus a simple impulsive form suffices to model the effective time delay of astrocytic responses. Finally, the results yield improved estimates of previously reported hemodynamic parameters, such as natural frequency and decay rate of the flow signal, which are consistent with experimentally verified physiological limits. The techniques developed in this study will contribute to improved analysis of BOLD-fMRI data.

Power spectrum of resting-state blood-oxygen-level-dependent signal.

Hemodynamic modeling is used to explore the origin, predict, and analyze the power spectrum of the resting-state blood-oxygen-level-dependent (BOLD) signal measured by functional magnetic resonance imaging (fMRI), which has been reported to have a power-law form, i.e., P(f)∝f^{-s}, where P(f) is the power, f is the frequency, and s>0 is the power-law exponent. However, current fMRI experimental paradigms have limited acquisition durations, affecting the spectral resolution of fMRI data at the low-frequency regime. Here, the claimed power-law spectrum is investigated by using a recent hemodynamic model to analytically derive the BOLD power spectrum, with parameters that are related to neurophysiology. The theoretical results show that, for all realistic parameter combinations, the BOLD power spectrum is flat at f≲0.01Hz, has a weak resonance originating from intrinsic oscillations of vasodilatory response, and becomes a power law for high frequencies, all of which is in agreement with an empirical data set that describes the spectrum of one subject and brain region. However, the results are contrary to studies reporting a pure power-law spectrum at f≲0.2Hz. The discrepancy is attributed largely to data averaging employed by current approaches that averages together important properties of the BOLD power spectrum, such as its resonance, that biases the spectrum to only show a power law. Data averaging also reduces the high-frequency power-law exponent relative to individual cases. Overall, this work demonstrates how the model can reproduce BOLD dynamics and further analyze its low-frequency behavior. Moreover, it also uses the model to explain the impact of procedures, such as data averaging, on the reported features of the BOLD power spectrum.

Biophysically based method to deconvolve spatiotemporal neurovascular signals from fMRI data.

BACKGROUND: Functional magnetic resonance imaging (fMRI) is commonly used to infer hemodynamic changes in the brain after increased neural activity, measuring the blood oxygen level-dependent (BOLD) signal. An important challenge in the analyses of fMRI data is to develop methods that can accurately deconvolve the BOLD signal to extract the driving neural activity and the underlying cerebrovascular effects. NEW METHOD: A biophysically based method is developed, which combines an extensively verified physiological hemodynamic model with a Wiener filter, to deconvolve the BOLD signal. RESULTS: The method is able to simultaneously obtain spatiotemporal images of underlying neurovascular signals, including neural activity, cerebral blood flow, cerebral blood volume, and deoxygenated hemoglobin concentration. The method is tested on simulated data and applied to various experimental data to demonstrate its stability, accuracy, and utility. COMPARISON WITH EXISTING METHODS: The resulting profiles of the deconvolved signals are consistent with measurements reported in the literature, obtained via multiple neuroimaging modalities. CONCLUSIONS: The method provides new testable predictions of the spatiotemporal relations of the deconvolved signals for future studies. This demonstrates the ability of the method to quantify and analyze the neurovascular mechanisms that underlie fMRI, thereby expanding its potential uses.

Response-mode decomposition of spatio-temporal haemodynamics.

The blood oxygen-level dependent (BOLD) response to a neural stimulus is analysed using the transfer function derived from a physiologically based poroelastic model of cortical tissue. The transfer function is decomposed into components that correspond to distinct poles, each related to a response mode with a natural frequency and dispersion relation; together these yield the total BOLD response. The properties of the decomposed components provide a deeper understanding of the nature of the BOLD response, via the components' frequency dependences, spatial and temporal power spectra, and resonances. The transfer function components are then used to separate the BOLD response to a localized impulse stimulus, termed the Green function or spatio-temporal haemodynamic response function, into component responses that are explicitly related to underlying physiological quantities. The analytical results also provide a quantitative tool to calculate the linear BOLD response to an arbitrary neural drive, which is faster to implement than direct Fourier transform methods. The results of this study can be used to interpret functional magnetic resonance imaging data in new ways based on physiology, to enhance deconvolution methods and to design experimental protocols that can selectively enhance or suppress particular responses, to probe specific physiological phenomena.

Epstein-Barr virus latent membrane protein 1 (LMP1) upregulates Id1 expression in nasopharyngeal epithelial cells.

Nasopharyngeal carcinoma is closely associated with Epstein-Barr virus (EBV) infection. The EBV-encoded LMP1 has cell transformation property. It suppresses cellular senescence and enhances cell survival in various cell types. Many of the downstream events of LMP1 expression are mediated through its ability to activate NF-kappaB. In this study, we report a novel function of LMP1 to induce Id1 expression in nasopharyngeal epithelial cells (NP69) and human embryonal kidney cells (HEK293). The Id1 is a basic helix-loop-helix (bHLH) protein and a negative transcriptional regulator of p16(INK4a). Expression of Id1 facilitates cellular immortalization and stimulates cell proliferation. With the combination of both specific chemical inhibitors and genetic inhibitors of cell signaling, we showed that induction of Id1 by LMP1 was dependent on its NF-kappaB activation domain at the carboxy-terminal region, CTAR1 and CTAR2. Induction of Id1 by LMP1 may facilitate clonal expansion of premalignant nasopharyngeal epithelial cells infected with EBV and may promote their malignant transformation.

Restoration of wild-type PTEN expression leads to apoptosis, induces differentiation, and reduces telomerase activity in human glioma cells.

PTEN is a candidate tumor suppressor gene identified on human chromosome 10q23.3 that is frequently mutated or deleted in 30% to 44% of glioblastomas. Transient expression study of PTEN in glioma cells indicates that PTEN plays an important role in cellular proliferation, tumorigenicity, cell migration, and focal adhesions. In this study, we examined the biological consequences on U87MG glioma cells after stable gene transfer of wild-type PTEN. Cells stably expressing wild-type PTEN protein were found to have suppressed proliferation, as determined by cell counting and Ki-67 staining, as well as inhibited anchorage-independent growth. The PTEN-expressing cells also showed higher expression of glial fibrillary acidic protein and changed morphologically from spindle-shaped to elongated cell bodies with multiple slender processes, suggesting that these cells have undergone differentiation. In addition, telomerase activity decreased more than 10-fold in PTEN-expressing cells when compared with control cells. More importantly, apoptosis was detected in about 5% of PTEN-expressing cells, representing a 17-fold (p < 0.01) increase over the control cells. Taken together, these results suggest that PTEN plays an important role in regulation of cell homeostasis by maintaining a balance between proliferation, differentiation, and apoptosis.

Molecular analysis of microdissected de novo glioblastomas and paired astrocytic tumors.

Glioblastoma multiforme (GBM) often displays morphological heterogeneity in that low-grade (LG) area with well-differentiated cells are commonly found adjacent to high-grade (HG) area with poorly-differentiated cells. This heterogeneity may cause difficulty in obtaining representative tumor samples. Nevertheless, the genetic composition of these cells has only been occasionally examined. In the present study, we examined 29 de novo glioblastomas in which distinct LG and HG areas of sufficient volumes could be identified. These areas were microdissected from paraffin-embedded tissues and analyzed for genetic alterations: p53 mutations and immunohistochemistry; allelic losses at 17p13.1, 9p21, and 10q23-25; and amplification of the epidermal growth factor receptor (EGFR) gene and immunohistochemistry. We also examined 14 paired astrocytic tumors, in which a primary Grade II astrocytoma progressed over a period of time to a Grade III or Grade IV tumor. Our findings showed that the LG areas of the de novo glioblastomas exhibited numerous genetic aberrations, the proportion of which was increased in the HG areas. Genetic abnormalities seen in the LG areas were conserved in the HG areas suggesting that these morphologically different cellular subsets were derived from a common transformed clone. Also, the LG areas were genetically different from Grade II astrocytomas of the paired tumor group, in spite of their morphological similarity. In particular, the LG areas had more deletions on 10q23-25 (75% vs 20%, p = 0.04), but fewer p53 mutations (24% vs 71%, p = 0.003) and less p53 protein labeling (45% vs 79%, p = 0.04). These differences suggest that LG and HG areas in de novo glioblastoma are genetically closer to each other compared with paired low- and high-grade tumors that have progressed over time. Moreover, only a small proportion (17%) of our de novo glioblastomas exhibited EGFR amplification while a high proportion (62%) showed either p53 mutations or allelic loss of 17p13.1. We speculate that some de novo GBMs with copious LG areas may constitute a separate group with rapid progression from Grade II astrocytomas.

Concurrent hypermethylation of multiple genes is associated with grade of oligodendroglial tumors.

Current evidence suggests that epigenetic changes play an important role in the evolution of human cancers. In this study, we evaluated whether hypermethylation of CpG islands at the gene promotor regions of several tumor-related genes is involved in the carcinogenesis of oligodendroglial tumors. We examined the methylation status of 11 genes in a series of 43 oligodendroglial tumors (19 oligodendrogliomas, 13 anaplastic oligodendrogliomas, 9 oligoastrocytomas, and 2 anaplastic oligoastrocytomas) by methylation-specific polymerase chain reaction. Our results showed that hypermethylation of CpG islands was detectable in 8 of 11 genes studied and 74% of tumors were hypermethylated in at least 1 gene. Promotor hypermethylations were detected in O6-methylguanine-DNA methyltransferase (MGMT), RB1, estrogen receptor, p73, p16INK4a, death-associated protein kinase, p15INK4b, and p14ARF at 60%, 34%, 30%, 16%, 12%, 10%, 7%, and 2%, respectively. No hypermethylation was detected in the promotors of glutathione-S-transferase P1, von Hippel-Lindau or the DNA mismatch repair (hMLH1) genes. Statistical analysis revealed that concordant hypermethylation of at least 2 genes, p16INK4a and p15INK4b were significantly associated with anaplastic oligodendroglial tumors, and hypermethylation of MGMT was significantly associated with loss of chromosome 19q and with combined loss of chromosomes 1p and 19q. More importantly, several candidate tumor suppressor genes such as p16INK4a, p15INK4b, and p73 that were previously reported as unmutated in oligodendroglial tumors were found to be hypermethylated in their CpG islands. Taken together, we conclude that hypermethylation of CpG islands is a common epigenetic event that is associated with the development of oligodendroglial tumors.

Detection of chromosomal imbalances in growth hormone-secreting pituitary tumors by comparative genomic hybridization.

Although recent molecular investigations have identified a number of genetic alterations that are associated with the development of pituitary adenomas, the exact pathogenesis mechanism of these tumors remains largely unknown. In this study, we used a genome-wide survey to detect specific genetic changes within the genome of pituitary adenomas. A series of 10 growth hormone-secreting adenomas were analyzed for their genetic imbalances on all 22 autosomes by comparative genomic hybridization (CGH). Chromosomal imbalances were detected in 8 GH-secreting adenomas, whereas 2 tumors had no detectable genetic abnormalities. Chromosome gains were more frequent than losses. Overrepresentation of whole or parts of chromosomes were detected in 5/10 (50%) in 19, 3/10 (30%) in each of 5, 9, and 22q, 2/10 (20%) in 17p12-q21, whereas DNA loss were 3/10 (30%) in 13q and 2/10 (20%) in 18. No detectable gain or loss of genetic material was observed in chromosomes 7, 8, 10, 12, 15, and 20. The findings of overrepresentation of chromosomes 5q, 9p, 17q and DNA loss of chromosome 18 were consistent with those detected in nonfunctioning adenomas (Daniely M, Aviram A, Adams EF, et al:J Clin Endocrinol Metab 83:1801-1805, 1998) suggesting that the development of pituitary tumors, at least in somatotroph and nonfunctioning adenomas, may share common pathway. Frequent amplifications in chromosomes 19 and 22q imply that candidate genes residing in these chromosomal regions may be involved in the pathogenesis of GH-secreting adenomas.

Genetic alterations in pediatric high-grade astrocytomas.

High-grade astrocytomas are tumors that are uncommon in children. Relatively few studies have been performed on their molecular properties and so it is not certain whether they follow different genetic pathways from those described in adult diffuse astrocytomas. In this study, we evaluated 24 pediatric high-grade astrocytomas (11 anaplastic astrocytomas and 13 glioblastomas) all of which were sporadic and primary. We studied mutations of p53, phosphatase and tensin homolog (PTEN), loss of heterozygosity (LOH) of chromosomes 17p13, 9p21 and 10q23-25, amplification of epidermal growth factor receptor (EGFR), and overexpression of EGFR and p53 protein. In addition, we searched for microsatellite instability (MSI) by using MSI sensitive and specific microsatellite markers. p53 mutations were found in 38% (9/24) of the high-grade astrocytomas and all brain stem tumors except 2 (71%, 5/7) had p53 mutations. PTEN mutations were found in 8% (2/24) of high-grade astrocytomas. However, no EGFR amplification was found in any of them. LOH was found at 17p13.1 in 50% (3/6 informative tumors), 9p21 in 83% (5/6 informative tumors), and 10q23-25 in 78% (7/9 informative tumors). Four tumors showed MSI, and 2 of them that showed widespread MSI were regarded as tumors with replication error (RER+) phenotype. All 4 tumors with MSI showed concurrent LOH of 9p21 and 10q23-25. Combining gene alterations, LOH, MSI, and gene mutations, inactivation of both alleles of PTEN and p53 was found in 57% (4/7 informative tumors) and 50% (3/6 informative tumors) of the cases respectively. We conclude that development of pediatric high-grade astrocytomas may follow pathways different from the primary or secondary paradigm of adult glioblastomas. In a subset of these tumors, genomic instability was also implicated.

Comparative genomic hybridization detects losses of chromosomes 22 and 16 as the most common recurrent genetic alterations in primary ependymomas.

In this study, we used comparative genomic hybridization to provide an overview of chromosomal imbalances in a series of 20 adult and 8 childhood ependymomas. All tumors displayed multiple genomic imbalances. Loss of genetic material was observed in chromosomes 22q (71%), 16 (57%), 17 (46%), 6 (39%), 19q (32%), 20q (32%), and 1p (29%), with the overlapped deletion regions determined at 16p13.1-13.3, 16q22-q24, 19q13.1-13.4, 20q13.1-13.2 and 1p36.1-36.3. Gain of DNA was commonly detected on chromosomes 5q (46%), 12q (39%), 7q (36%), 9q (36%), and 4q (32%), with overlapped regions of gain mapped to 5q21-22, 12q15-24.1, 7q11.2-31.2, 9q12-32, and 4q23-28, respectively. These findings suggest a greater degree of genomic imbalance in ependymomas than has been recognized previously and highlight chromosomal loci likely to contain oncogenes or tumor suppressor genes that may contribute to the molecular pathogenesis of this tumor. Our study also confirmed previous findings on frequent losses of 17 and 22q in ependymomas and further identified chromosome 16 loss as a common recurrent genetic aberration in ependymomas.

Heterogeneous responses of aquaporin-4 in oedema formation in a replicated severe traumatic brain injury model in rats.

Aquaporin-4 (AQP4) is the most abundant water channel in the rat brain. In this study, the distribution pattern and mRNA expression levels of AQP4 were examined in a severe traumatic brain injury model by immunohistochemistry and reverse transcription-polymerase chain reaction. Oedema formation and blood-brain barrier (BBB) integrity were assessed by wet-dry weight measurements and immunostaining of endogenous IgG respectively. In the oedematous contusional cortex with impaired BBB integrity, negative immunostaining of AQP4 and down-regulation of its mRNA level were identified (P<0.05) at 1 day post-injury, while in other oedematous regions of the injured brain where BBB was intact, there was no significant change in the AQP4 expression level. This heterogeneous pattern of AQP4 responses can be interpreted as follows: focal brain injury (such as a contusion) with impaired BBB resulting in vasogenic oedema is associated with reduction of AQP4 expression, whereas, in cytotoxic oedema, associated with diffuse brain injury with intact BBB, changes in AQP4 expression are not significant. This study provides basic information for investigating new treatments for traumatic brain oedema.

Detection of chromosomal imbalances in central neurocytomas by using comparative genomic hybridization.

OBJECT: Central neurocytomas are rare neuronal tumors commonly found in the intraventricular regions. Little is known about the tumorigenesis of these neoplasms. The aim of this study was to provide an overview of genetic imbalances in central neurocytomas. METHODS: In this study, comparative genomic hybridization was used to identify DNA sequence copy number changes (losses and gains) in a series of 10 central neurocytomas. Tumor DNA and normal reference DNA were differentially labeled and allowed to cohybridize to normal metaphase chromosomes. After hybridization and fluorescent staining of the bound DNA, regions of gain or of loss of DNA sequences were detected as changes in the tumor/normal fluorescence intensity ratio along the target metaphase chromosomes. A gain of DNA sequence was detected in chromosomes 2p, 10q, and 18q. A protooncogene, Bcl2, which maps to 18q21, was evaluated by immunohistochemical analysis to determine its role in the formation of central neurocytomas. CONCLUSIONS: In this study the authors identified recurrent genetic changes on chromosomes 2p, 10q, and 18q in central neurocytomas and highlighted chromosomal regions for additional mapping and cloning of candidate genes that are important in the development of central neurocytomas.

Analysis of loss of heterozygosity on chromosomes 10q, 11, and 16 in medulloblastomas.

OBJECT: The loss of genetic material from specific chromosome loci is a common feature in the oncogenesis of tumors and is often indicative of the presence of important tumor suppressor genes at these loci. Recent molecular genetic analyses have demonstrated frequent loss of chromosomes 10q, 11, and 16 in medulloblastomas. The aim of this study was to localize the targeted deletion regions on the three aforementioned chromosomes in medulloblastomas. METHODS: Loss of heterozygosity (LOH) was examined on chromosomes 10q, 11, and 16 in a series of 22 primary and two recurrent medulloblastomas by using polymerase chain reaction-based microsatellite analysis. The DNA extracted from the tumors and corresponding normal blood samples were amplified independently in the presence of radioactively labeled microsatellite primers, resolved by denaturing gel electrophoresis and processed for autoradiography. The DNA obtained from control blood samples that displayed allelic heterozygosity at a given microsatellite locus were considered informative. Loss of heterozygosity was inferred when the allelic signal intensity of the tumor sample was reduced by at least 40%, relative to that of the constitutional control. The LOH analysis demonstrated that deletions of chromosomes 10q, 11p, and 16q are recurrent genetic events in the development of medulloblastomas. Three subchromosomal regions of loss have been identified and are localized to the deleted in malignant brain tumors 1 [DMBT1] gene site on chromosomes 10q25, 11p13-11p15.1, and 16q24.1-24.3. CONCLUSIONS: These results indicate that DMBT1 is closely associated with the oncogenesis of medulloblastomas and highlight regions of loss on chromosomes 11p and 16q for further fine mapping and cloning of candidate tumor suppressor genes that are important for the genesis of medulloblastoma.

Identification of novel regions of allelic loss in ependymomas by high-resolution allelotyping with 384 microsatellite markers.

OBJECT: Ependymomas are rare glial neoplasms; little is known about the molecular pathogenesis of this tumor entity. In a previous study the authors found multiple genomic imbalances in ependymomas resected in 20 adults and eight children, including loss of chromosomes 1p, 6, 16, 17, 19q, 20q, and 22q, as well as gain of chromosomes 4q, 5q, 7q, 9q, and 12q on comparative genomic hybridization. The aim of this study was to map in more detail the commonly affected regions in ependymomas. METHODS: A comprehensive allelotype analysis of 16 ependymomas was conducted using 384 microsatellite markers that span the 22 autosomes. Based on this high-resolution loss of heterozygosity analysis, multiple overlapping deletion regions were identified as follows: 6q25.2-27, 16p12-13.1, 16q22.3-24.1, 17q22-24, 19q12-13.2, 20q13.2-13.3, and 22q13.1-13.3. CONCLUSIONS: These data confirmed previous reports that loss of chromosomes 17 and 22 were common in ependymomas. Moreover, the authors were able to identify loss of chromosomes 13, 16, 19, and 20 as novel findings in ependymomas. It is believed that potential tumor suppressor genes that reside in these commonly deleted regions may contribute to the molecular tumorigenesis of ependymomas.

Poems syndrome.

A 40 year old Chinese woman presented with anasarca and later developed features of POEMS syndrome. These are peripheral neuropathy (P), organomegaly (O), endocrine dysfunction (E), monoclonal gammopathy (M), and skin changes (S) which are usually associated with plasma cell dyscrasia. In our patient, monoclonal gammopathy was not detected on immunofixation electrophoresis and was revealed only after analysis of kappa/lambda light chain ratio of the raised serum IgA immunoglobulin. Needle liver biopsy of her grossly enlarged liver showed marked accumulation of glycogen and presence of giant mitochondria in the hepatocytes, a feature not previously reported.

Marmoset (Callithrix jacchus jacchus) spatial memory in a foraging task: win-stay versus win-shift strategies.

The spatial memory of common marmosets (Callithrix jacchus jacchus) was explored in 3 experiments with a simulated foraging task. In Experiment 1, individual monkeys foraged among 8 baited food sites. They appeared to use spatial memory to accurately avoid revisiting previously depleted sites. There was no difference in accuracy between the adult monkeys and a juvenile monkey tested on the same task. In Experiment 2, a win-stay paradigm was used. The adult monkey subject very accurately remembered locations that had previously contained food. The monkey tended to visit adjacent correct sites when retrieving food and thus minimized the total distance travelled. In Experiment 3, a win-shift paradigm was used with 2 adult monkeys. Although both monkeys performed at above-chance levels of accuracy on the win-shift task, they made many errors. These results suggest that marmosets may prefer tasks that require a win-stay strategy.

A retrospective study of community-acquired pneumonia in Hong Kong with special reference to the choice of antibiotics.

The records of patients admitted to the Prince of Wales Hospital with a presumptive diagnosis of pneumonia over a one-year period were reviewed retrospectively. Forty-four patients fulfilled our diagnostic criteria for community-acquired pneumonia and were included in the survey. The initial choice of antibiotics was reasonably uniform: a penicillin in 75%; erythromycin in 9% and other antibiotics in 16%. Lack of clinical improvement resulted in a change of antibiotics in 15 patients (34%). Overall 23 patients (52%) responded to a penicillin, 12 patients (27%) responded to erythromycin, and 8 patients (18%) responded to other antibiotics. This suggests that the majority of the causative organisms were sensitive to penicillin, but a significant number of patients required drugs which were effective against 'atypical' and gram negative organisms. One elderly patient, who also suffered from severe chronic airflow obstruction, died after a grand mal seizure which might have been partly related to theophylline toxicity (Mortality 2%). The investigations performed confirmed or strongly suggested the identity of the causative organism in only 9 patients (21%), and had little or no influence in therapeutic decisions. Although empirical antibiotic treatment was reasonably successful, frequent changes were required, and the lack of firm data on the aetiology indicates that a detailed prospective study is needed.