Summary and recommendations for future research

A novel triblock copolymer of epsilon-caprolactone (CL) and ethylene oxide (E), CL6E90CL6, intended for use in implantable drug-delivery systems, has been subjected to gamma irradiation, in the solid state and in aqueous solution, under different controlled environmental conditions, to assess its stability to a radiation sterilization process. When copolymer matrices were irradiated with doses of irradiation up to 72 kGy in the presence of oxygen, negligible changes were observed in the molar mass, molecular mobility (assessed by pulsed nuclear magnetic resonance spectroscopy) and thermal properties. However, irradiation of matrices in the absence of oxygen (anoxia) induced the formation of cross-links, as indicated by a reduction in the molecular mobility of the copolymer, but without affecting its molar mass and thermal properties. Gamma irradiation of aqueous solutions of CL6E90CL6 in the presence of oxygen induced random polymer chain scission, as evidenced by a reduction in the molar mass, and the formation of a distribution of copolymer chain lengths in solution. Nuclear magnetic resonance relaxation studies showed that irradiation of solutions of CL6E90CL6 at concentrations greater than 4% w/v under anoxic conditions with doses of 54 kGy produced polymer gels with a network structure. These differences in the effects of gamma irradiation on the physicochemical properties of CL6E90CL6 might be germane to the method selected for sterilization of the polymer before its use in implantable drug-delivery systems.     

Crystal structures of a marginally active thymidylate synthase mutant, Arg 126-->Glu

Thymidylate synthase (TS) is a long-standing target for anticancer drugs and is of interest for its rich mechanistic features. The enzyme catalyzes the conversion of dUMP to dTMP using the co-enzyme methylenetetrahydrofolate, and is perhaps the best studied of enzymes that catalyze carbon-carbon bond formation. Arg 126 is found in all TSs but forms only 1 of 13 hydrogen bonds to dUMP during catalysis, and just one of seven to the phosphate group alone. Despite this, when Arg 126 of TS from Escherichia coli was changed to glutamate (R126E), the resulting protein had kcat reduced 2000-fold and Km reduced 600-fold. The crystal structure of R126E was determined under two conditions--in the absence of bound ligand (2.4 A resolution), and with dUMP and the antifolate CB3717 (2.2 A resolution). The first crystals, which did not contain dUMP despite its presence in the crystallization drop, displayed Glu 126 in a position to sterically and electrostatically interfere with binding of the dUMP phosphate. The second crystals contained both dUMP and CB3717 in the active site, but Glu 126 formed three hydrogen bonds to nearby residues (two through water) and was in a position that partially overlapped with the normal phosphate binding site, resulting in a approximately 1 A shift in the phosphate group. Interestingly, the protein displayed the typical ligand-induced conformational change, and the covalent bond to Cys 146 was present in one of the protein's two active sites.     

Endoscopic study of the small intestine with push enteroscopy. A prospective study

OBJECTIVE: To evaluate whether push enteroscopy of the small bowel (PES), undertaken after extensive previous investigations in suspected intestinal bleeding from an uncertain site, chronic diarrhoea or lymphoma of the small intestine, contributes to the diagnosis, and to ascertain the results of PES and its clinical significance. PATIENTS AND METHODS: 56 consecutive patients (29 men, 27 women; mean age 63 years) were investigated prospectively. The main indications for PES were the search for the source of intestinal bleeding in 79% of patients (group A), chronic diarrhoea or tropical sprue in 16% (group B) and search for tumour of lymphoma in 5% (group C). PES was always performed in fasting patients under sedation/analgesia using a video PES, which contrary to catheter enteroscopy provides a channel for intervention. RESULTS: In group A 27% of patients were found to have lesions, in particular angiodysplasias, or (in once case) leiomyoma. Half of these patients were successfully treated endoscopically without later surgical intervention being required (mean follow-up of six months). In the other half operation became necessary, either because the disease itself indicated it or the bleeding persisted, the source being in the more distant small intestine and thus not accessible to endoscopic intervention: only 50% of the length of the small intestine proved to be within reach of the instrument. No abnormalities were discovered in patients of groups B and C. CONCLUSION: In cases of gastrointestinal bleeding from an uncertain source PES should be performed first, because in many cases it may obviate surgical intervention. But PES seems to contribute little of diagnostic value in other indications.     

Modulation of cerebral somatosensory evoked potentials arising from tibial and sural nerve stimulation during rhythmic active and passive movements of the human lower limb

The magnitudes of cerebral somatosensory evoked potentials (SEPs), following stimulation of cutaneous or muscle afferents in the upper limb, are reduced during active and passive movements of the fingers. The generalizability of such a movement effect was tested for lower limb events. We measured SEP magnitudes following activation of cutaneous (sural) and mixed (tibial) nerves during the flexion phase of active and passive rhythmic movements of the human lower limb. In eight volunteers, 150 SEPs per condition were recorded from Cz' referenced to Fpz'. Compared to stationary controls, both active and passive movements significantly depressed the early SEP components (P1-N1) [mean values, to 12.8%, 9.9% respectively for tibial nerve and to 29.6%, 25.6% for sural nerve stimulation, p < 0.05]. The attenuation was still observed when only one leg was moved and with stimulation at an earlier point in the flexion phase of movement. Visual fixation did not significantly affect P1-N1 amplitudes, compared to eyes closed. As previously shown, soleus H reflexes with stable M waves were significantly depressed during the movements (p < 0.05). The general construct may be that centripetal flow initiated from somatosensory receptors during limb movement leads to modulation of both spinal and cortical responses following large diameter cutaneous or muscle afferent activation.     

Necrotizing fasciitis of the face

Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection with high morbidity and mortality rates. Its occurrence in the head and neck region is uncommon, the majority of reported cases being limited to involvement of the neck, usually from infections of dental or pharyngeal origin. Involvement of the face from NF is rare; only 35 such cases have been reported in the literature since 1960. It is not only associated with a high mortality but can also result in severe disfigurement of the face, posing challenging reconstructive problems. Successful management of facial NF requires early diagnosis, prompt institution of broad spectrum antibiotics, aggressive surgical debridement to control the infection, and reconstruction of the resultant soft tissue defects. This report describes four additional cases of facial necrotizing fasciitis. One of the four patients died as a result of sepsis and multi-organ system failure. Two of the three surviving patients had significant facial disfigurement. A comprehensive review of the facial NF cases reported in the literature is also provided. Based on our experience with facial NF and the results of all previous case reports, the clinical manifestations, pathogenesis, and management of this disease are discussed.     

Minimally invasive mitral valve repair using transthoracic aortic occlusion

This report describes a minimally invasive mitral valve repair done through a limited (6-cm) thoracic incision. The patient was supported by peripheral extracorporeal perfusion with cardiac arrest established using a new transthoracic aortic cross-clamp and antegrade blood cardioplegia. The patient was discharged on postoperative day 3 with minimal pain. This less invasive approach to mitral valve surgery may offer combined advantages to patients by increasing comfort, expediting recovery, and decreasing surgical costs by using modified traditional methods compared with specialized intraaortic occlusive balloons.     

Coronary arteries: retrospective cardiac gating technique to reduce cardiac motion artifact at spiral CT

Coronary artery calcification is a marker of atherosclerosis. Detection and quantification has previously been accomplished with electron-beam computed tomography (CT). Use of spiral CT for this application has been limited by cardiac motion. The authors evaluated a retrospective cardiac-gated postprocessing technique that necessitates no modification of scanner hardware or software. At spiral CT in 26 patients, motion artifact was reduced, coronary arteries were consistently visualized, and quantification of calcification could be performed in those patients with prominent deposits. Coronary artery calcification screening can therefore be offered in sites that have access to only spiral CT.     

Strategy for development of a pre-erythrocytic Plasmodium falciparum DNA vaccine for human use

Data generated in the Plasmodium yoelii rodent model indicated that plasmid DNA vaccines encoding the P.yoelii circumsporozoite protein (PyCSP) or 17 kDa hepatocyte erythrocyte protein (PyHEP17) were potent inducers of protective CD8+ T cell responses directed against infected hepatocytes. Immunization with a mixture of these plasmids circumvented the genetic restriction of protective immunity and induced additive protection. A third DNA vaccine encoding the P. yoelii sporozoite surface protein 2 (PySSP2) also induced protection. The P. falciparum genes encoding the homologues of these three protective P. yoelii antigens as well as another P. falciparum gene encoding a protein that is expressed in infected hepatocytes have been chosen for the development of a human vaccine. The optimal plasmid constructs for human use will be selected on the basis of immunogenicity data generated in mice and nonhuman primates. We anticipate that optimization of multi-gene P. falciparum DNA vaccines designed to protect against malaria by inducing CD8+ T cells that target infected hepatocytes will require extensive clinical trials during the coming years.