Headache in intracerebral hematomas

OBJECTIVES: We sought to describe the frequency and location of headache in intracerebral hematoma (ICH) and to analyze its clinical and CT predictors by means of multivariate analysis. BACKGROUND: Headache is more common in intracerebral hemorrhage than in ischemic stroke, and its frequency varies with hematoma location, but the pathophysiologic mechanisms of headache associated with ICH are not fully known. METHODS: We examined a cohort of 289 patients with ICH during a 14-month period in a university hospital. Clinical, including the presence and location of headache, and CT features were collected by two neurologists. RESULTS: One hundred and sixty-five (57%) patients with ICH had a headache at the onset of their stroke. Headache was more common in cerebellar and lobar hemorrhages than in deep ones (thalamic, caudate, capsuloputaminal, brainstem). Headache was also more common in women, patients younger than 70 years, those who vomited, and those with meningeal signs, a Glasgow Coma Scale score < 10, a hematoma volume > 10 ml or CT evidence of intraventricular or subarachnoid bleeding, moderate to severe hydrocephalus, or transtentorial herniation or midline shift. In multiple logistic regression analysis, only meningeal signs (odds ratio [OR] = 2.3), cerebellar or lobar location (OR = 2.1), transtentorial herniation (OR = 1.8), and female gender (OR = 1.6) were significant predictors of headache at the onset of ICH. CONCLUSIONS: Hematoma location, meningeal signs, and gender are more predictive of headache than hematoma volume, suggesting that headache is more often related to the activation of an anatomically distributed system in susceptible individuals and to subarachnoid bleeding than to intracranial hypertension.     

Wünderlich syndrome caused by metastatic gastric sarcoma in the kidney. Report of a case

Two of the most important biochemical hepatic pathways in the liver are those that synthesize methionine and S-adenosylmethionine (SAM) through the methylation of homocysteine. This article reviews some recent findings in this laboratory, which demonstrate that ethanol feeding to rats impairs one of these pathways involving the enzyme methionine synthetase (MS), but by way of compensation increases the activity of the enzyme betaine:homocysteine methyl transferase (BHMT), which catalyzes the second pathway in methionine and SAM biosynthesis. It has been shown that despite the inhibition of MS, the enhanced BHMT pathway utilizes hepatic betaine pools to maintain levels of SAM. Subsequent to the above findings, it has been shown that minimal supplemental dietary betaine at the 0.5% level generates SAM twofold in control animals and fivefold in ethanol-fed rats. Concomitant with the betaine-generated SAM, ethanol-induced hepatic fatty infiltration was ameliorated. In view of the fact that SAM has already been used successfully in the treatment of human maladies, including liver dysfunction, betaine, shown to protect against the early stages of alcoholic liver injury as well as being a SAM generator, may become a promising therapeutic agent and a possible alternative to expensive SAM in the treatment of liver disease and other human maladies.     

Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging

The purpose of this study was to demonstrate that specialized magnetic resonance imaging provides an accurate assessment of lesions of the articular cartilage of the knee. Arthroscopy was used as the comparative standard. Eighty-eight patients who had an average age of thirty-eight years were evaluated with magnetic resonance imaging and subsequent arthroscopy because of a suspected meniscal or ligamentous injury. The magnetic resonance imaging was performed with a specialized sequence in the sagittal, coronal, and axial planes. Seven articular surfaces (the patellar facets, the trochlea, the femoral condyles, and the tibial plateaus) were graded prospectively on the magnetic resonance images by two independent readers with use of the 5-point classification system of Outerbridge, which was also used at arthroscopy. Six hundred and sixteen articular surfaces were assessed, and 248 lesions were identified at arthroscopy. Eighty-two surfaces had chondral softening; seventy-five, mild ulceration; fifty-three, deep ulceration, fibrillation, or a flap without exposure of subchondral bone; and thirty-eight, full-thickness wear. To simplify the statistical analysis, grades 0 and 1 were regarded as disease-negative status and grades 2, 3, and 4 were regarded as disease-positive status. When the grades that had been assigned by reader 1 were used for the analysis, magnetic resonance imaging had a sensitivity of 87 per cent (144 of 166), a specificity of 94 per cent (424 of 450), an accuracy of 92 per cent (568 of 616), a positive predictive value of 85 per cent (144 of 170), and a negative predictive value of 95 per cent (424 of 446) for the detection of a chondral lesion. Interobserver variability was minimum, as indicated by a weighted kappa statistic of 0.93 (almost perfect agreement). With use of this readily available modified magnetic resonance imaging sequence, it is possible to assess all articular surfaces of the knee accurately and thereby identify lesions that are amenable to arthroscopic treatment.     

Interleukin (IL)-6 and its soluble receptor induce TIMP-1 expression in synoviocytes and chondrocytes, and block IL-1-induced collagenolytic activity

To define the potential role of interleukin-6 (IL-6) and its soluble receptor alpha in cartilage metabolism, we analyzed their effects on tissue inhibitor of metalloproteases (TIMP) synthesis by synoviocytes and chondrocytes. TIMP-1 production by isolated human articular synovial fibroblasts and chondrocytes, stimulated by IL-6 and/or its soluble receptor, was first assayed by specific enzyme-linked immunosorbent assay; the slight stimulatory effect of IL-6 on TIMP-1 production by both types of cells was markedly amplified by the addition of soluble receptor, the maximal secretion being observed only at 96 h. TIMP-1 mRNA expression, determined by ribonuclease protection assay, was induced by IL-6 together with its soluble receptor, but TIMP-2 and -3 mRNAs were not affected by these factors. A specific neutralizing antibody abolished the effects of the soluble receptor. Finally, supernatant from synoviocytes stimulated by IL-6 plus its soluble receptor blocked almost completely the collagenolytic activity of supernatant from IL-1-induced synoviocytes. These observations indicate that IL-6 and its soluble receptor have a protective role in the metabolism of cartilage. Given the high levels of soluble receptor in synovial fluid and the marked induction of IL-6 by IL-1 or TNF-alpha, it is likely that IL-6 and its soluble receptor are critical in controlling the catabolic effects of pro-inflammatory cytokines.     

Markedly altered colchicine kinetics in a fatal intoxication: examination of contributing factors

1. Colchicine poisoning, which is relatively rare, is associated with significant morbidity and mortality. Whilst a new treatment modality, in the form of colchicine-specific Fab fragments is on the horizon, currently available therapy is largely supportive. 2. The elimination of colchicine occurs primarily by hepatic metabolism, following a first-order process, with significant enterohepatic circulation. Renal extraction is responsible for approximately 20% of colchicine elimination. 3. We report a case of colchicine intoxication, complicated by the presence of co-ingestants, in which serum colchicine concentrations remained quasi-constant over the 3 days of the patient's survival, consistent with marked alterations both in metabolism and excretion. The initial presentation was relatively benign but the subsequent course was one of severe colchicine poisoning, resulting in death. 4. Severe colchicine toxicity appears to have resulted in a vicious cycle of progressive organ dysfunction and impaired elimination. 5. Josamycin, one of the co-ingestants and an inhibitor of P-glycoprotein, the membrane pump responsible for multidrug resistance, may have played a significant role in impeding the cellular and biliary elimination of colchicine. Co-ingested opioid and anticholinergic compounds may have altered colchicine absorption and gastrointestinal transit. 6. This case serves as a reminder of the need for attention to co-ingested drugs, to early aggressive therapy, and if available, to consideration of immunotherapy.     

Extensive modifications for methionine enhancement in the beta-barrels do not alter the structural stability of the bean seed storage protein phaseolin

Common beans are widely utilized as a food source, yet are low in the essential amino acid methionine. As an initial step to overcome this defect the methionine content of the primary bean seed storage protein phaseolin was increased by replacing 20 evolutionarily variant hydrophobic residues with methionine and inserting short, methionine-rich sequences into turn and loop regions of the protein structure. Methionine enhancement ranged from 5 to 30 residues. An Escherichia coli expression system was developed to characterize the structural stability of the mutant proteins. Proteins of expected sizes were obtained for all constructs except for negative controls, which were rapidly degraded in E. coli. Thermal denaturation of the purified proteins demonstrated that both wild-type and mutant phaseolin proteins denatured reversibly at approximately 61 degrees C. In addition, urea denaturation experiments of the wild-type and a mutant protein (with 30 additional methionines) confirmed that the structural stability of the proteins was very similar. Remarkably, these results indicate that the phaseolin protein tolerates extensive modifications, including 20 substitutions and two loop inserts for methionine enhancement in the beta-barrel and loop structures, with extremely small effects on protein stability.     

Immersion technique for brain removal in perinatal autopsies

Perinatal autopsies present forensic patholgists with a variety of challenges, not the least of which involves the removal and examination of very small and sometimes fragile organs. Removal of the immature brain can be particularly troublesome. Even if great care is taken during brain removal, one is often left with no more than a semifluid amorphous mass of softened tissue by the time the brain is ready to be fixed in formalin. We describe a method of perinatal brain removal which helps to preserve brain shape and integrity. By removing the brain while the head (and body) is totally immersed in water, we find that the brain is easier to remove and less apt to destruction. Subsequent fixation in formalin results in well-preserved, intact specimens, allowing for optimal examination and sectioning.     

Purification, characterization, and spasmogenic activity of neurotensin from the toad Bufo marinus

Neurotensin (NT) was isolated from an extract of the intestine of the cane toad, Bufo marinus and its primary structure established as: pGlu-Ala-Ile-Val-Ser-Lys-Ala-Arg-Arg-Pro-Tyr-Ile-Leu. This amino acid sequence shows five substitutions (Leu2 --> Ala, Tyr3 --> Ile, Glu4 --> Val, Asn5 --> Ser, and Pro7 --> Ala) compared with bovine NT. Synthetic Bufo NT (pD2 = 8.05 +/- 0.28) was equipotent and equally effective as bovine NT (pD2 = 8.24 +/- 0.38) in producing spasmogenic contraction of isolated segments of toad small intestine. However, the maximum response produced by Bufo NT was only 35 +/- 2% of that produced by substance P. The potencies, but not the maximum responses, to Bufo and bovine NT were significantly (p < 0.05) attenuated by pre-treatment with atropine but neither parameter was significantly diminished by tetrodotoxin and indomethacin. The data suggest that the action of NT involves interaction with receptors on toad intestinal smooth muscle that recognize the C-terminal region of NT (residues 8-13) that has been fully conserved during evolution of tetrapods. Contractile activity is mediated, at least in part, by release of acetylcholine.