Biomedical subjects
Publications and source records attributed to C E Clarke.
A 69-year-old man developed severe neck and back pain with paraparesis which resolved within 2 h of onset. A CT myelogram demonstrated an extensive anterior extradural haematoma. This and several other cases from the literature suggest that patients with spontaneous spinal haematomas who rapidly recover from their neurological deficit do not require urgent surgical decompression.
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The detection of clonal rearrangements of the immunoglobulin heavy chain gene by the polymerase chain reaction provides a rapid method to differentiate monoclonal from polyclonal B-lymphocyte proliferations. It has been shown to be highly specific and so far, no false-positive results have been described. A case of a poorly differentiated colonic adenocarcinoma that showed a "false positive" clonal immunoglobulin heavy chain gene rearrangement by the polymerase chain reaction technique is reported. DNA contamination was unlikely because of the strict adherence to the laboratory polymerase chain reaction protocol and also the repeated demonstration of the same amplified band in a separate experiment using DNA extracted from another piece of tumor tissue. The apparent monoclonal immunoglobulin heavy chain gene rearrangement in the first polymerase chain reaction may be related to a combination of the paucity of lymphoid cells in the tissue sample and the presence within this small number of lymphocytes of a clonal reactive cell population. It is, therefore, important to correlate the routine microscopic and immunohistochemical findings in the interpretation of polymerase chain reaction results, especially when working with nonlymphoid tumors and lymphocyte-poor lesions.
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A computer database was established for the medical audit of admissions to the North Manchester General Hospital neurology unit. Over a six-month period, 277 patients completed 300 hospital stays. A higher proportion of patients were admitted from the North Manchester District compared with the peripheral districts served by the unit, suggesting that more neurology in these areas was performed by general physicians. This supports claims for an increase in the number of neurologists to improve the quality of service at district level. The introduction of a programmed investigation unit, closed at weekends, would allow financial savings since 60% of cases did not require a bed at the weekend. It would also allow more efficient pre-booking of investigations. The diagnostic yields from routine B12 and folate levels, syphilis serology, thyroid function tests, chest radiography and electrocardiography were low and should be replaced by more selective investigations. Savings might also be made by performing the 38% of myelograms restricted to the lumbar region in the out-patient department. The introduction of out-patient magnetic resonance imaging will make significant savings by obviating the need for many of the inpatient myelograms which were required in 55 patients. The simple and relatively inexpensive technology used in this study provided medical staff with valuable information on which to base changes in practice and evaluate their consequences.
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In a retrospective case note study of 86 patients with myasthenia gravis, 60 had an anti-acetylcholine receptor antibody assay performed by the regional immunology laboratory. Antibody was detected in 38% which compares with 66-93% in other series. Whilst the use of staphylococcal protein A to precipitate the antibody-receptor complex, rather than anti-human immunoglobulin, may be partly responsible for this low sensitivity, other methodological problems are likely to exist. It is suggested that this potentially critical assay becomes a subject for regular audit.
The selective dopaminergic antagonist ligands [3H]SCH 23390 and [3H]sulpiride were used to reveal autoradiographically dopamine D1 and D2 receptors, respectively, in brain sections from monkeys which had received unilateral intracarotid infusions of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), causing loss of dopamine-containing neurones of the substantia nigra pars compacta. The monkeys developed hemi-parkinsonian symptoms (tremor, bradykinesia) in limbs contralateral to the side of the toxin infusion. Administration of apomorphine (0.05-0.25 mg/kg) caused contralateral rotational behaviour, and reversal of the parkinsonian symptoms. Loss of forebrain dopaminergic terminals was assessed autoradiographically using [3H]mazindol to label dopamine uptake sites. A reduction in these sites of 97% (mean brain value) in the caudate nucleus, and 91% in the putamen, as compared with binding values from untreated control monkeys, was accompanied by a significant increase in the binding of [3H]sulpiride (D2) in these structures. In contrast, in the same animals there was no similar increase in [3H]SCH 23390 binding to D1 receptors in the denervated areas. These results suggest that in the parkinsonian brain, where the dopaminergic innervation of the caudate nucleus and putamen has been lost, D2 receptors may be more susceptible than D1 receptors to changes, revealed here as an increase in [3H]sulpiride binding sites.
Administration of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in primates induced a parkinsonian syndrome that could be reversed by levodopa treatment. Animals quickly developed an apparent restlessness ("akathisia") of the lower limbs after as little as five doses. After 4-10 weeks of regular levodopa therapy, animals developed "peak dose" choreiform movements in the lower limbs that spread, with time, to involve the upper limbs and orofacial musculature. With further treatment (5-21 months), animals developed "peak dose" dystonia that variably involved the limbs and orofacial musculature. These conditions represent novel models of levodopa-induced chorea and dystonia in humans. They depend on the same underlying neuropathology and treatment regimen as their human counterparts. It is to be anticipated that these models of dyskinesia will be useful in determining the mechanisms underlying chorea and dystonia in humans and are ideally suited for experimental evaluation of new treatment strategies.
The neural mechanisms that mediate dystonia were investigated in a novel experimental primate model of dopamine agonist-induced dystonia. This condition was produced by long-term (15 months) dopamine agonist therapy of a macaque monkey that had been rendered hemiparkinsonian by unilateral infusion of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine into the right common carotid artery. The 2-deoxyglucose (2-DG) metabolic mapping technique was applied to the animal during the expression of active unilateral dystonia, and regional brain uptake of 2-DG was assessed autoradiographically. The results demonstrate that dystonia is associated with marked increases in 2-DG uptake in the constituent nuclei of the basal ganglia (caudate nucleus, putamen, medial and lateral segments of the globus pallidus) and in the subthalamic nucleus, but decreased uptake in the structures that receive output of the basal ganglia (ventral anterior/ventral lateral thalamic complex and lateral habenula). Based on these findings it is suggested that dystonia is characterized by increased activity in the putaminopallidal and pallidosubthalamic pathways, and decreased activity in the subthalamopallidal and pallidothalamic pathways.
A patient with an extensive spinal cord glioma is presented. The lumbar mass and cervical cavity associated with the tumour were demonstrated by myelography and computed tomography. Magnetic resonance imaging provided greater detail than these conventional imaging modalities without exposure to ionising radiation and was of considerable additional value in the planning of surgery.
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The right common carotid artery was surgically exposed under general anaesthesia in 6 cynomolgus monkeys and MPTP (0.5-2.2 mg/kg) directly infused. This produced a hemiparkinsonian syndrome in the contralateral limbs which responded to treatment with both levodopa and apomorphine. These drugs also precipitated dose-dependent contralateral rotation which reached a peak 2 weeks after MPTP infusion. A massive depletion of large, presumably dopaminergic cells was found from the ipsilateral substantia nigra pars compacta. Three animals receiving chronic therapy with apomorphine developed choreoathetoid movements of the limbs and the face contralateral to the infusion 2 weeks after the commencement of treatment. The severity of the dyskinesia gradually increased and after 4 weeks peak-dose hemiballistic movements were seen. Levodopa and the selective D-2 and D-1 dopamine agonists LY-171555 and SKF 38393 also reversed parkinsonian features and produced contralateral rotation and peak-dose dyskinesia. This unilateral model of parkinsonism in the primate will be of value in the elucidation of the mechanisms by which chronic levodopa or dopamine agonist therapy enhance involuntary movements in parkinsonism.
Cellular sites of enkephalin gene expression were investigated using the technique of in situ hybridization in the normal striatum and in the denervated striatum of monkeys depleted of dopamine by pretreatment with the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Animals received MPTP by either (a) intravenous injection to induce generalized parkinsonism, or (b) infusion into one carotid artery to induce unilateral parkinsonism. The animals which received systemic injections of MPTP were found to have an essentially total loss of nigral dopamine cells whereas the intracarotid MPTP treatment was found to destroy approximately 95% of the dopamine neurons in the ipsilateral substantia nigra. A double-stranded cDNA probe encoding the human preproenkephalin (PPE) gene was isotopically labelled with 35S and used to detect PPE mRNA within striatal tissue sections. Application of this radiolabelled cDNA probe to lightly fixed striatal sections from both groups of animals revealed an increase in expression of PPE mRNA within denervated striatal enkephalinergic neurons relative to control tissue. An increase in the number of detectable enkephalinergic mRNA-positive neurons relative to control tissue was also noted. These results suggest that the nigral dopaminergic neurons tonically inhibit PPE gene expression in the striatum.
The 2-deoxyglucose metabolic mapping technique has been used to investigate the neural mechanisms which underlie the symptoms of Parkinsonism in the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine primate model of Parkinson's disease. In six cynomolgus monkeys, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine was either (a) administered intravenously to induce generalized Parkinsonism, or (b) infused into one carotid artery to induce unilateral Parkinsonism. Post-mortem examination revealed profound cell loss from the substantia nigra, pars compacta either bilaterally or unilaterally in the two groups, respectively. In addition, there was pathological involvement of the ventral tegmental area and locus coeruleus in animals receiving intravenous 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. 2-Deoxyglucose autoradiography revealed widespread changes in 2-deoxyglucose uptake in the brains of parkinsonian animals when compared to controls. Most of these changes were in basal ganglia and related structures and were qualitatively similar in the two groups of experimental animals. Prominent increases in 2-deoxyglucose uptake were observed in the lateral segment of the globus pallidus (24-27%), the ventral anterior and ventral lateral nuclei of the thalamus (14-22%) and the nucleus tegmenti pedunculopontinus of the caudal midbrain (17-69%). A profound decrease (17-26%) in 2-deoxyglucose uptake was observed in the subthalamic nucleus. We propose these data to indicate that in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced Parkinsonism there is the following pattern of abnormal neuronal activity in basal ganglia circuitry: (i) increased activity in the projection from the putamen to the lateral segment of the globus pallidus; (ii) decreased activity in the projection from the putamen to the medial segment of the globus pallidus; (iii) decreased activity in the projection from the lateral segment of the globus pallidus to the subthalamic nucleus; (iv) increased activity in the projection from the subthalamic nucleus to the globus pallidus; and (v) increased activity in neurons of the medial segment of the globus pallidus projecting to the ventral anterior/ventral lateral thalamus and the pedunculopontine nucleus. These results are compared to the 2-deoxyglucose uptake findings in previous studies from this laboratory in hemiballism and hemichorea in the monkey. The central importance of the subthalamic nucleus in all three conditions is proposed, and supportive evidence for the excitatory nature of subthalamic efferent fibres is adduced.
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Three monkeys received a chronic intravenous course of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) so as to produce a permanent parkinsonian syndrome. One primate was electively commenced on chronic levodopa therapy 6 weeks after the cessation of MPTP treatment. Four months following the termination of MPTP administration, the response to oral doses of the novel D-2 dopamine agonist (+)-4-propyl-9-hydroxynaphthoxazine (PHNO) was assessed in all animals using a clinical rating scale and automatic activity counters. PHNO was found to be a highly potent antiparkinsonian agent, completely reversing the symptoms of parkinsonism in a dose-dependent manner. Peak-dose dyskinesia was noted in 2 MPTP-treated animals during trials with PHNO, but was more severe in the animal receiving chronic levodopa therapy. Response fluctuations such as 'end-of-dose' deterioration and the 'on-off' phenomenon were common to all 3 parkinsonian animals following PHNO. The anti-parkinsonian effect and frequency of treatment-induced side-effects appeared to be similar with PHNO and levodopa. These results confirm the efficacy of PHNO as an anti-parkinsonian drug and link the production of dyskinesia with the D-2 dopamine receptor.