Occipital plagiocephaly: a critical review of the literature

1998 ◽  
Vol 89 (1) ◽  
pp. 24-30 ◽  
Author(s):  
Harold L. Rekate
Keyword(s):  
Diagnostic Criteria ◽  
Treatment Options ◽  
Surgical Techniques ◽  
Class Ii ◽  
Population Based ◽  
Class I ◽  
Weight Of Evidence ◽  
Class Iii ◽  
Content Type ◽  
Fine Print

Object. The literature on occipital plagiocephaly (OP) was critically reviewed to determine the feasibility of establishing treatment recommendations. Methods. Using standard computerized search techniques, medical literature databases containing peer-review articles dating from 1966 were queried for key words related to OP. The titles of all articles were scanned for relevance, and copies of potentially relevant articles published in English were reviewed. Articles in which treatment was discussed were categorized according to their weight of evidence as Class I (prospective randomized controlled trials), Class II (clinical studies in which data are collected prospectively or retrospective analyses based on clearly reliable data), and Class III (most studies based on retrospectively collected data) to evaluate their contribution to developing a consensus on the treatment of OP. Of the 4308 articles identified, all but 89 were excluded. Based on the review of these articles, the actual incidence of OP is unknown, and no population-based studies of its incidence or prevalence exist. The reported incidence of lambdoid craniosynostosis ranges from 3 to 20% with differences in diagnostic criteria accounting for the variability. With the possible exception of a lambdoid suture that is replaced by a dense ridge of bone, no other diagnostic criteria have been agreed on. There were no Class I studies and only one Class II study provided comparisons of outcomes in more than one treatment group with outcomes in an untreated group. Recommended treatment options included observation only, mechanical interventions, and a variety of surgical techniques. Conclusions. Controlled clinical trials are needed before any form of intervention can be recommended for the treatment of OP. If surgery, which is expensive and potentially dangerous, is to continue to play a role in the management of this condition, efforts should be made to determine if patients with untreated OP have suffered from lack of treatment.

Multiple subpial transections: outcome and complications in 20 patients who did not undergo resection

2002 ◽  
Vol 97 (1) ◽  
pp. 39-47 ◽  
Author(s):  
Johannes Schramm ◽  
Ales F. Aliashkevich ◽  
Thomas Grunwald
Keyword(s):  
Mr Imaging ◽  
Class Ii ◽  
Class I ◽  
Class Iii ◽  
Content Type ◽  
Surgical Methods ◽  
Over Time ◽  
Class Iv ◽  
Fine Print

Object. The authors describe patient characteristics, surgical methods, complications, and outcome over time in a cohort of patients who underwent multiple subpial transection (MST) without concomitant cortical resection. Methods. Twenty consecutive patients in whom drug-resistant epilepsy had been diagnosed a mean of 16 ± 9 years earlier (mean ± standard deviation [SD]) were treated with MST without cortical resection. The mean follow-up period was 49.3 ± 18.3 months (mean ± SD, median 58 months). At 12 months of follow up, two of the 20 patients were Engel Class I, one was Class II, six were Class III, and 11 were Class IV. At latest follow up, one patient was Engel Class I, one was Class II, seven were Class III, and 11 were Class IV. According to an alternative five-tiered classification system, two outcomes were excellent, seven were good, one was fair, nine were poor, and one was worse. Outcome was found to be better in patients with no lesions observed on magnetic resonance (MR) imaging, and worse in those with large MST areas. Outcome had a tendency to change (this occurred in 13 of 20 cases). Five patients (25%) improved and seven (35%) deteriorated in Engel outcome class, and in one (5%) both developments occurred over time. Most outcome class changes occurred before the end of the 2nd year (nine), and four were observed in the 5th year. There where seven transient neurological deficits and four surgical complications. There was no permanent significant morbidity, and there were no deaths. Conclusions. Forty-five percent of patients achieved a worthwhile improvement after pure MST, if Engel outcome Class III is deemed a worthwhile improvement. The alternative five-tiered classification resulted in 50% with worthwhile improvement (excellent, good, or fair outcome), 45% with poor, and 5% with worse outcome. Lesions that are detectable on MR imaging, and large MST areas are predictive of worse results. Significant intraoperative problems may arise, but this happens infrequently. There is a notable rate of transient morbidity but the rate of permanent morbidity is not significant.

scholarly journals Occipital plagiocephaly: a critical review of the literature

1997 ◽  
Vol 2 (2) ◽  
pp. E3 ◽  
Author(s):  
Harold L. Rekate
Keyword(s):  
Key Words ◽  
Diagnostic Criteria ◽  
Group Treatment ◽  
Critical Review ◽  
Treatment Options ◽  
Surgical Techniques ◽  
Class Ii ◽  
Class I ◽  
Review Of The Literature ◽  
Scientific Publications

The objective of this review was to determine what information is available on the incidence, pathophysiology, late complications, and treatment paradigms for occipital plagiocephaly based on a critical review of the literature obtained from recognized databases in peer-reviewed scientific publications. The content of this article is based on a critical review of the literature, and when discussing treatment options, classification of those articles with respect to the strength of the recommendations they contain. Using standard computerized search techniques, databases containing medical literature were queried for key words related to occipital plagiocephaly beginning in 1966. Key words used for this search were: lambdoid, craniosynostosis, cranial sutures, facial asymmetry, torticollis, and plagiocephaly. Titles of all articles were scanned for relevance. Copies of all potentially relevant articles published in the English language were obtained and received at least a cursory review. Several articles not captured by these methods were found to be important when referenced in the articles obtained. Articles discussing treatment were divided into Class I, Class II, and Class III data for the purpose of deciding on their applicability to the development of a potential consensus for the treatment of this controversial condition. Using the aforementioned key words, there were 4308 articles identified with potential relevance: scanning by title excluded all but 89. Of the 89, those with on-line abstracts were scanned, the remainder were obtained via interlibrary loan when needed for scanning of the article itself. The actual incidence of occipital plagiocephaly is unknown and there are no population-based studies of its incidence or prevalence. The reported incidence of lambdoid craniosynostosis ranges from 3 to 20% with the differences primarily due to differences in diagnostic criteria. With the possible exception of a lambdoid suture, which is replaced throughout its entire course by a dense ridge of bone, there are no other diagnostic criteria upon which there is agreement. There are no Class I and only one Class II studies in which a group of patients treated with one form of therapy is compared with another form of therapy or an untreated group. Treatment options that are recommended include observation only, mechanical treatments such as exercises, positioning, remodeling helmets, and a wide variety of surgical techniques. Very few reports accessed through the aforestated methodology report patients suffering any significant late effects of occipital plagiocephaly, although it may be morphometrically evident in as many as 14% of adults. Controlled clinical trials will be needed before any form of intervention can be generally recommended. If surgery, which is expensive and potentially dangerous, is to continue to play a role in the management of this condition, efforts should be made to ascertain from the general population which patients who have not been treated have suffered from this lack of treatment.

An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies

1999 ◽  
Vol 91 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Michael G. Fehlings ◽  
Charles H. Tator
Keyword(s):  
Clinical Studies ◽  
Class Ii ◽  
Decompressive Surgery ◽  
Evidence Based ◽  
Class Iii ◽  
Content Type ◽  
Cord Injury ◽  
Limited Class ◽  
Fine Print

Object. The authors conducted an evidence-based review of the literature to evaluate critically the rationale and indications for and the timing of decompressive surgery for the treatment of acute, nonpenetrating spinal cord injury (SCI). Methods. The experimental and clinical literature concerning the role of, and the biological rationale for, surgical decompression for acute SCI was reviewed. Clinical studies of nonoperative management of SCI were also examined for comparative purposes. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class III (retrospective studies). Examination of studies in which animal models of SCI were used consistently demonstrated a beneficial effect of early decompressive surgery, although it is difficult to apply these data directly to the clinical setting. The clinical studies provided suggestive (Class III and limited Class II) evidence that decompressive procedures improve neurological recovery after SCI. However, no clear consensus can be inferred from the literature as to the optimum timing for decompressive surgery. Many authors have advocated delayed treatment to avoid medical complications, although good evidence from recent Class II trials indicates that early decompressive surgery can be performed safely without causing added morbidity or mortality. Conclusions. There is biological evidence from experimental studies in animals that early decompressive surgery may improve neurological recovery after SCI, although the relevant interventional timing in humans remains unclear. To date, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for SCI can only be considered a practice option. Furthermore, analysis of the literature does not allow definite conclusions to be drawn regarding appropriate timing of intervention. Hence, there is a need to conduct well-designed experimental and clinical studies of the timing and neurological results of decompressive surgery for the treatment of acute SCI.

Posterior atlantoaxial facet screw fixation in rheumatoid arthritis

1998 ◽  
Vol 89 (1) ◽  
pp. 8-12 ◽  
Author(s):  
Mohammed Aly Eleraky ◽  
Roberto Masferrer ◽  
Volker K. H. Sonntag
Keyword(s):  
Screw Fixation ◽  
Class Ii ◽  
Atlantoaxial Instability ◽  
Rigid Fixation ◽  
Class Iii ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Fine Print

Object. This retrospective review was conducted to determine the efficacy of transarticular screw fixation in a group of patients who were treated for rheumatoid atlantoaxial instability. Methods. Thirty-six patients (mean age 63 years) with rheumatoid atlantoaxial instability were treated with posterior atlantoaxial transarticular screw fixation supplemented with an interspinous C1–2 strut graft—cable construct to provide immediate three-point fixation to facilitate bone fusion. Previous attempts at fusions by using bone grafting with wire fixation at other institutions had failed in six of these patients. Six patients underwent transoral odontoid resections for removal of large irreducible pannus as a first-stage procedure, which was followed within 2 to 3 days by the posterior procedure. Postoperatively, 33 patients were placed in hard cervical collars and three required halo vests because of severe osteoporosis. Of eight patients categorized as Ranawat Class II preoperatively, all eight returned to normal after surgery; of eight patients in Ranawat Class III-A preoperatively, four improved to Class II and four remained unchanged. All 20 patients classified as Ranawat Class I preoperatively recovered completely. Pain decreased or resolved in all patients, and there were no complications related to instrumentation. At follow-up review (mean 2 years), 33 patients (92%) had solid bone fusions, and three (8%) had stable fibrous unions. Conclusions. Posterior atlantoaxial transarticular screw fixation provides a good surgical alternative for the management of patients with rheumatoid atlantoaxial instability. This technique provides immediate three-point rigid fixation of the C1–2 region, thus obviating the need for halo vest immobilization in most cases.

scholarly journals EPID-24. OBESITY IN MALES WITH MENINGIOMA: A U.S. POPULATION-BASED STUDY

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii83-ii83
Author(s):  
Maryam Shahin ◽  
Ali Rae ◽  
Christian Lopez Ramos ◽  
Jacob Bagley ◽  
Stephen Bowden ◽  
...  
Keyword(s):  
Class Ii ◽  
Population Based ◽  
Class I ◽  
Class Iii ◽  
Improvement Program ◽  
Steroid Synthesis ◽  
Class I Obesity ◽  
Significant Difference ◽  
Icd 10 ◽  
Male Patients

Abstract BACKGROUND The female predominance of meningiomas may reflect a hormonal influence on tumorigenesis. Obesity alters steroid synthesis and chronically exposes men to hyperestrogenemia. OBJECTIVE Identify differences in males undergoing craniotomy for meningioma compared to other tumors or aneurysms. METHODS The National Surgical Quality Improvement Program was retrospectively queried from 2013–2018 for cases of craniotomy for resection of meningioma, other tumor, and aneurysm by CPT code in male patients and confirmed with postoperative ICD-10 code. Height and weight data were used to create body mass index (BMI): underweight (< 18.5), normal (18.5 to< 25), overweight (25 to< 30), class I obesity (30 to< 35), class II obesity (35 to< 40), and class III obesity (40+). RESULTS We identified 2,458 males who underwent craniotomy for meningioma, 9,889 for other tumor, and 386 for aneurysm. Using multivariable logistic regression, age (OR 1.01 per year, 95% CI 1.01-1.01, p< 0.001), diabetes mellitus (OR 1.32, 95% CI 1.17–1.48, p< 0.001), and increasing BMI (overweight: OR 1.55, 95% CI 1.36–1.76, p< 0.001; class I: OR 2.00, 95% CI 1.75–2.30, p< 0.0001; class II: OR 2.05, 95% CI 1.24–1.76, p< 0.001; class III: OR 1.47, 95% CI 1.24–1.76, p< 0.0001) were significantly and independently associated with craniotomy for meningioma compared to other tumor or aneurysm. For other tumor, higher BMI was associated with lower likelihood (overweight: OR 0.70, 95% CI 0.62–0.79, p< 0.001; class I: OR 0.55, 95% CI 0.49–0.63, p< 0.001; class II: OR 0.52, 95% CI 0.44–0.62, p< 0.001; class III: OR 0.74, 95% CI 0.63–0.87, p< 0.001). For aneurysm, there was no significant difference (overweight p=0.70; class I p=0.65; class II p=0.76; class III p=0.57). CONCLUSIONS BMI independently predicts having craniotomy for meningioma when compared to other tumor or aneurysm amongst US male patients.

scholarly journals Treatment of metastatic spinal epidural disease: a review of the literature

2003 ◽  
Vol 15 (5) ◽  
pp. 1-9 ◽  
Author(s):  
Paul Klimo ◽  
John R. W. Kestle ◽  
Meic H. Schmidt
Keyword(s):  
Spinal Cord ◽  
Radiation Therapy ◽  
Metastatic Cancer ◽  
Treatment Options ◽  
Large Body ◽  
Surgical Techniques ◽  
Class Ii ◽  
Class I ◽  
Spinal Disease ◽  
Spinal Epidural

Object Spinal cord compression is one of the most dreaded complications of metastatic cancer. It can lead to a number of sequelae, including pain, spinal instability, neurological deficits, and a reduction in the patient's quality of life. Except in selected circumstances, treatment is palliative. Treatment options include surgery, radiation, and chemotherapy. The goal of this study was to summarize the existing data on the outcomes of various treatment methods for metastatic spinal epidural disease and to make appropriate recommendations for their use. Methods The authors used a search strategy that included an electronic database search, a manual search of journals, analysis of bibliographies in relevant review papers, and consultation with the senior author. There is good evidence, including Class I data, that steroid drugs constitute a beneficial adjunctive therapy in patients with myelopathy from epidural compression. Historically, conventional radiation therapy has been viewed as the first-line treatment because it has been shown to be as effective as a decompressive laminectomy, with a lower incidence of complications (Class II data). Nevertheless, in the last 20 years there has been remarkable progress in surgical techniques and technology. Currently, the goals of surgery are to achieve a circumferential decompression of the spinal cord, and to reconstruct and immediately stabilize the spinal column. Results in a large body of literature support the belief that surgery is better at retaining or regaining neurological function than radiation and that surgery is highly effective in relieving pain. Most of the data on the treatment of metastatic spinal disease are Class II or III, but the preliminary results of a well-designed, randomized controlled trial in which surgery is compared with standard radiation therapy represents the first Class I data. Conclusions As the number of treatment options for metastatic spinal disease has grown, it has become clear that effective implementation of these treatments can only be achieved by a multidisciplinary approach.

scholarly journals Environmental Cadmium Exposure and Dental Indices in Orthodontic Patients

Healthcare ◽  
2021 ◽  
Vol 9 (4) ◽  
pp. 413
Author(s):  
Hui-Ling Chen ◽  
Jason Chen-Chieh Fang ◽  
Chia-Jung Chang ◽  
Ti-Feng Wu ◽  
I-Kuan Wang ◽  
...  
Keyword(s):  
Cadmium Concentration ◽  
Class Ii ◽  
Cadmium Exposure ◽  
Class I ◽  
P Value ◽  
Tooth Decay ◽  
Class Iii ◽  
Orthodontic Patients ◽  
Urine Cadmium ◽  
The Mean

Background. Previous studies have shown that environmental cadmium exposure could disrupt salivary gland function and is associated with dental caries and reduced bone density. Therefore, this cross-sectional study attempted to determine whether tooth decay with tooth loss following cadmium exposure is associated with some dental or skeletal traits such as malocclusions, sagittal skeletal pattern, and tooth decay. Methods. Between August 2019 and June 2020, 60 orthodontic patients with no history of previous orthodontics, functional appliances, or surgical treatment were examined. The patients were stratified into two groups according to their urine cadmium concentrations: high (>1.06 µg/g creatinine, n = 28) or low (<1.06 µg/g creatinine, n = 32). Results. The patients were 25.07 ± 4.33 years old, and most were female (female/male: 51/9 or 85%). The skeletal relationship was mainly Class I (48.3%), followed by Class II (35.0%) and Class III (16.7%). Class I molar relationships were found in 46.7% of these patients, Class II molar relationships were found in 15%, and Class III molar relationships were found in 38.3%. The mean decayed, missing, and filled surface (DMFS) score was 8.05 ± 5.54, including 2.03 ± 3.11 for the decayed index, 0.58 ± 1.17 for the missing index, and 5.52 ± 3.92 for the filled index. The mean index of complexity outcome and need (ICON) score was 53.35 ± 9.01. The facial patterns of these patients were within the average low margin (26.65 ± 5.53 for Frankfort–mandibular plane angle (FMA)). There were no significant differences in the above-mentioned dental indices between patients with high urine cadmium concentrations and those with low urine cadmium concentrations. Patients were further stratified into low (<27, n = 34), average (27–34, n = 23), and high (>34, n = 3) FMA groups. There were no statistically significant differences in the urine cadmium concentration among the three groups. Nevertheless, a marginally significant p-value of 0.05 for urine cadmium concentration was noted between patients with low FMA and patients with high FMA. Conclusion. This analysis found no association between environmental cadmium exposure and dental indices in our orthodontic patients.

Long-term hearing preservation after surgery for vestibular schwannoma

2005 ◽  
Vol 102 (1) ◽  
pp. 6-9 ◽  
Author(s):  
Simone A. Betchen ◽  
Jane Walsh ◽  
Kalmon D. Post
Keyword(s):  
Hearing Preservation ◽  
Magnetic Resonance Images ◽  
Class I ◽  
Repeated Testing ◽  
Content Type ◽  
Factors Influencing ◽  
Long Term Preservation ◽  
Fine Print

Object. Vestibular schwannomas (VSs) are now amenable to resection with excellent hearing preservation rates. It remains unclear whether immediately postoperative hearing is a durable result and will not diminish over time. The aim of this study was to determine the rate of long-term preservation of functional hearing following surgery for a VS and to examine factors influencing hearing preservation. Methods. All patients eligible for hearing preservation (Gardner—Robertson Class I or II) who had undergone resection of a VS by a single surgeon were reviewed retrospectively. Follow-up audiograms and magnetic resonance images were obtained. Of 142 patients deemed eligible for hearing preservation surgery, 38 had immediate postoperative hearing confirmed by an audiogram. In these patients with preserved hearing, the audiographic results demonstrated functional hearing in 30 (85.7%) of 35 patients who underwent repeated testing at a mean follow-up time of 7 years. Delayed hearing loss occurred in five (14.3%) of the 35 patients and did not correlate significantly with the size of the tumor. Hearing improved one Gardner—Robertson class postoperatively in three (7.9%) of the 38 patients. Conclusions. Long-term functional hearing was maintained in 85.7% of patients when it was preserved immediately postoperatively and the result was independent of tumor size. The results of this study emphasize that long-term preservation of functional hearing is a realistic goal following VS surgery and should be attempted in all patients in whom preoperative hearing is determined to be Gardner—Robertson Class I or II.

scholarly journals A convenient method of preparation of high-activity urease from Canavalia ensiformis by covalent chromatography and an investigation of its thiol groups with 2,2'-dipyridyl disulphide as a thiol titrant and reactivity probe

1976 ◽  
Vol 159 (2) ◽  
pp. 245-257 ◽  
Author(s):  
R Norris ◽  
K Brocklehurst
Keyword(s):  
Convenient Method ◽  
Specific Activity ◽  
Class Ii ◽  
High Reactivity ◽  
Class I ◽  
Thiol Groups ◽  
Class Iii ◽  
Active Centre ◽  
Class Ib ◽  
Covalent Chromatography

1. A convenient method of preparation of jack-bean urease (EC3.5.1.5) involving covalent chromatography by thiol-disulphide interchange is described. 2. Urease thus prepared has specific activity comparable with the highest value yet reported (44.5 ± 1.47 kat/kg, Km = 3.32 ± 0.05 mM; kcat. = 2.15 × 104 ± 0.05 × 104s-1 at pH7.0 and 38°C). 3. Titration of the urease thiol groups with 2,2'-dipyridyl disulphide (2-Py-S-S-2-Py) and application of the method of Tsou Chen-Lu [(1962) Sci. Sin.11, 1535-1558] suggests that the urease molecule (assumed to have mol.wt. 483000 and ε280 = 2.84 × 105 litre·mol-1-cm-1) contains 24 inessential thiol groups of relatively high reactivity (class-I), six ‘essential’ thiol groups of low reactivity (class-II) and 54 buried thiol groups (class-III) which are exposed in 6M-guanidinium chloride. 4. The reaction of the class-I thiol groups with 2-Py-S-S-2-Py was studied in the pH range 6-11 at 25°C(I = 0.1 mol/l) by stopped-flow spectrophotometry, and the analogous reaction of the class-II thiol groups by conventional spectrophotometry. 5. The class-I thiol groups consist of at least two sub-classes whose reactions with 2-Py-S-S-2-Py are characterized by (a) pKa = 9.1, k = 1.56 × 104M-1·s-1 and (b) pKa = 8.1, k = 8.05 × 102M-1·s-1 respectively. The reaction of the class-II thiol groups is characterized by pKa = 9.15 and k = 1.60 × 102M-1·s-1. 6. At pH values 7-8 the class-I thiol groups consist of approx. 50% class-Ia groups and 50% class-Ib groups. The ratio class Ia/class Ib decreases as the pH is raised according to a pKa value ≥ approx. 9.5, and at high pH the class-I thiol groups consist of at most 25% class-Ia groups and at least 75% class-Ib groups. 7. The reactivity of the class-II thiol groups towards 2-Py-S-S-2-Py is insensitive to the nature of the group used to block the class-I thiols. 8. All the ‘essential’ thiol groups in urease appear to be eeactive only as uncomplicated thiolate ions. The implications of this for the active-centre chemistry of urease relative to that of the thiol proteinases are discussed.

Regulation of mouse CYP1A1 gene expression by dioxin: requirement of two cis-acting elements during induction

1989 ◽  
Vol 9 (6) ◽  
pp. 2378-2386
Author(s):  
L A Neuhold ◽  
Y Shirayoshi ◽  
K Ozato ◽  
J E Jones ◽  
D W Nebert
Keyword(s):  
Gene Expression ◽  
Simian Virus 40 ◽  
Class Ii ◽  
Simian Virus ◽  
Class I ◽  
Ah Receptor ◽  
Class Iii ◽  
Cis Acting ◽  
Cyp1a1 Gene ◽  
Sv40 Dna

The mouse cytochrome P1450 (CYP1A1) gene is responsible for the metabolism of numerous carcinogens and toxic chemicals. Induction by the environmental contaminant tetrachlorodibenzo-p-dioxin (TCDD) requires a functional aromatic hydrocarbon (Ah) receptor. We examined the 5'-flanking region of the CYP1A1 gene in mouse hepatoma Hepa-1 wild-type cells and a mutant line having a defect in chromatin binding of the TCDD-receptor complex. We identified two cis-acting elements (distal, -1071 to -901 region; proximal, -245 to -50 region) required for constitutive and TCDD-inducible CYP1A1 gene expression. Three classes of DNA-protein complexes binding to the distal element were identified: class I, found only in the presence of TCDD and a functional Ah receptor, that was heat labile and not competed against by simian virus 40 (SV40) early promoter DNA; class II, consisting of at least three constitutive complexes that were heat stable and bound to SV40 DNA; and class III, composed of at least three constitutive complexes that were thermolabile and were not competed against by SV40 DNA. Essential contacts for these proteins were centered at -993 to -990 for the class I complex, -987, -986, or both for the class II complexes, and -938 to -927 for the class III complexes. The proximal element was absolutely essential for both constitutive and TCDD-inducible CYP1A1 gene expression, and at least two constitutive complexes bound to this region. These data are consistent with the proximal element that binds proteins being necessary but not sufficient for inducible gene expression; interaction of these proteins with those at the distal element was found to be required for full CYP1A1 induction by TCDD.

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