Targeted multifidus muscle activation reduces fibrosis of multifidus muscle following intervertebral disc injury.

PURPOSE: Aerobic exercise produces beneficial outcomes in patients with low back pain and partially attenuates the fibrotic changes to the multifidus in a model of intervertebral disc (IVD) degeneration. More targeted exercise might be required to fully attenuate these fibrotic alterations. This study aimed to investigate whether activation of the multifidus induced by neurostimulation could reduce fibrosis of the multifidus in a model of IVD degeneration in sheep. METHODS: IVD degeneration was induced in 18 merino sheep via a partial thickness unilateral annulus fibrosus lesion to the L1/2 and L3/4 IVDs. All sheep received an implantable neurostimulation device that provides stimulation of the L2 medial branch of the dorsal ramus. Three months after surgery, the animals were assigned to Injury or Activated groups. Activated animals received neurostimulation and the Injury group received no stimulation. Six months after surgery, the multifidus was harvested at L2 and L4. Van Gieson's, Sirius Red and immunofluorescence staining for Collagen-I and -III and quantitative PCR was used to examine fibrosis. Muscle harvested from a previous study without IVD injury was used as a control. RESULTS: Neurostimulation of the multifidus attenuated IVD degeneration dependent increases in the connective tissue, including Collagen-I but not Collagen-III, compared to the Injury group at L4. No measures of the multifidus muscle at L2, which received no stimulation, differed between the Injury and Activated groups. CONCLUSIONS: These data reveal that targeted activation of the multifidus muscle attenuates IVD degeneration dependent fibrotic alterations to the multifidus.

Corallina and Ellisolandia (Corallinales, Rhodophyta) photophysiology over daylight tidal emersion: interactions with irradiance, temperature and carbonate chemistry.

The photophysiology of three geniculate coralline algal species (Corallina officinalis, C. caespitosa and Ellisolandia elongata) was determined in intertidal rock pools in the south-west UK at Combe Martin (51°12'31N 4°2'19W) and Heybrook Bay (50°31'66N 4°11'41W), at the start, middle and end of summer (September 1 and 2) and winter (February 9 and 10) daylight tidal emersion periods, in relation to prevailing irradiance, temperature and carbonate chemistry conditions. Algal photophysiology was assessed from rapid light curves performed using pulse amplitude modulation fluorometry. Corallina and Ellisolandia experienced significant fluctuations in irradiance, temperature and carbonate chemistry over seasonal and tidal cycles. Rock pool carbonate chemistry was predictable (R2 = 0.82, P < 0.0001) by photodose (summed irradiance) plus water temperature, but not significantly related to photophysiology. In contrast, Corallina and Ellisolandia relative maximum electron transfer rate showed a significant negative relationship (R2 = 0.65, P < 0.0001) with irradiance plus water temperature. At a seasonal resolution, photoacclimation to maximize both light harvesting during winter months and photoprotection during summer months was observed for all species. Dynamic photoinhibition was apparent over both summer and winter tidal emersion, in relation to irradiance fluctuations. More effective photoinhibition was apparent during summer months, with greater sensitivity to irradiance and slower recovery in Fv/Fm, observed during winter. With sustained high irradiance over tidal emersion, the establishment of high pH/low inorganic carbon conditions may impact photochemistry. This study represents the first assessment of C. officinalis, C. caespitosa and E. elongata photophysiology underpinned by clear species concepts and highlights their ability to adapt to the dramatically fluctuating conditions experienced in intertidal rock pools.

Vascular endothelial growth factor and platelet derived growth factor modulates the glial response to a cortical stab injury.

Traumatic injury to the brain initiates an increase in astrocyte and microglial infiltration as part of an inflammatory response to injury. Increased astrogliosis around the injury impedes regeneration of axons through the injury, while activated microglia release inflammatory mediators. The persistent inflammatory response can lead to local progressive cell death. Modulating the astrocyte and microglial response to traumatic injury therefore has potential therapeutic benefit in brain repair. We examine the modulatory effect of a single bolus of vascular endothelial growth factor (VEGF) and platelet derived growth factor (PDGF) in combination on astrocytes and microglia to acute cerebral injury. A combination of VEGF and PDGF (20 pg) was injected into the striatum of adult male Sprague-Dawley rats. The effects of treatment were assessed by quantitative immunofluorescence microscopy analyzing astrocytes and microglia across the stab injury over time. Treatment delayed the onset of astrogliosis in the centre and edge of the stab injury up to day 5; however, increased astrogliosis at areas remote to the stab injury up to day 5 was observed. A persistent astrocytic response was observed in the centre and edge of the stab injury up to day 60. Treatment altered microglia cell morphology and numbers across the stab injury, with a decrease in ramified microglia, but an increase in activated and phagocytic microglia up to day 5 after stab injury. The increased microglial response from 10 until day 60 was comprised of the ramified morphology. Thus, VEGF and PDGF applied at the same time as a stab injury to the brain initially delayed the inflammatory response up to day 5 but evoked a persistent astrogliosis and microglial response up to 60 days.

Low cost polymer intramedullary nails for fracture fixation: a biomechanical study in a porcine femur model.

INTRODUCTION: Whilst intramedullary nailing is a commonly accepted technique for lower limb fracture fixation, the cost of nails can be prohibitive in hospitals in developing nations. In these institutions bone cement has found many off label applications, that whilst are effective do not meet manufacturers guidelines. The aim of this study was to examine the biomechanics of one such application, fracture fixation using a bone cement intramedullary nail. MATERIALS AND METHODS: Five porcine femurs underwent a mid-shaft osteotomy and were fixed using a nail made from antibiotic simplex bone cement. The torsional and flexural stiffness and shear modulus of these constructs were compared to five intact porcine femurs. RESULTS: The bone cement intramedullary nail was able to achieve relative stability in both torsion, with a mean shear modulus of 0.17 GPa and in flexion with a mean flexural stiffness of 358 N/mm. This corresponds to 47 and 22% of the respective measurements in the intact femurs. The mean ultimate flexural strength of fracture/nail constructs was 936 +/- 350 N, which is 20% of the ultimate flexural strength of an intact porcine femur (4,820 +/- 698 N). CONCLUSION: Intramedullary nails made from bone cement were able to provide sufficient promise in this situation to warrant further investigation for their applicability as a low cost alternative for use in developing countries.

Plasma levels of endothelin-1 after a pulmonary embolism of bone marrow fat.

BACKGROUND: During orthopedic surgery, embolization of bone marrow fat can lead to potentially fatal, intra-operative cardiovascular deterioration. Vasoactive mediators may also be released from the bone marrow and contribute to these changes. Increased plasma levels of endothelin-1 (ET-1) have been observed after pulmonary air and thrombo-embolism. The role of ET-1 in the development of acute cardiovascular deterioration as a result of bone marrow fat embolization during vertebroplasty was therefore investigated. METHODS: Bone cement was injected into three lumbar vertebrae of six sheep in order to force bone marrow fat into the circulation. Invasive blood pressures and heart rate were recorded continuously until 60 min after the last injection. Cardiac output, arterial and mixed venous blood gas parameters and plasma ET-1 concentrations were measured at selected time points. Post-mortem, lung biopsies were taken for analysis of intravascular fat. RESULTS: Cement injections resulted in a sudden (within 1 min) and severe increase in pulmonary arterial pressure (>100%). Plasma concentrations of ET-1 started to increase after the second injection, but no significant changes were observed. Intravascular fat and bone marrow cells were present in all lung lobes. CONCLUSION: Cement injections into vertebral bodies elicited fat embolism resulting in subsequent cardiovascular changes that were characterized by an increase in pulmonary arterial pressure. Cardiovascular complications as a result of bone marrow fat embolism should thus be considered in patients undergoing vertebroplasty. No significant changes in ET-1 plasma values were observed. Thus, ET-1 did not contribute to the acute cardiovascular changes after fat embolism.

Cardiovascular changes after pulmonary cement embolism: an experimental study in sheep.

BACKGROUND AND PURPOSE: Most cement leaks during vertebroplasty are asymptomatic, but pulmonary cement embolism has been reported to cause cardiovascular disturbances and even death. Adding hydroxyapatite (HA) to polymethylmethacrylate (PMMA) cement to reduce the quantity of barium may aggravate cardiovascular deterioration in the event of cement embolism by activating coagulation. Thus, we investigated the cardiovascular changes after pulmonary cement embolism of PMMA with and without HA. MATERIALS AND METHODS: In 13 sheep, cement (2.0 mL) was injected into the pulmonary trunk. Two different cements were used: 1) standard PMMA and 2) PMMA with 10% HA (PMMA & HA). Arterial, central venous and pulmonary arterial pressures, heart rate, and cardiac output were monitored continuously until 60 minutes after the injection. Blood gases and coagulation parameters (antithrombin, D-dimer) were measured before and after injection. RESULTS: Mean pulmonary arterial pressure had increased by approximately 9% (PMMA) and 14% (PMMA & HA) 1 minute after injection and stayed elevated. There were no significant differences between the groups. No evidence of thromboembolism was detected. CONCLUSION: Cement embolism did not result in clinically significant pulmonary arterial hypertension. Adding HA to PMMA cement did not cause more severe cardiovascular changes.

CT-based classification of long spinal allograft fusion.

Anterior column reconstruction of the thoracolumbar spine by structural allograft has an increased potential for biological fusion when compared to synthetic reconstructive options. Estimation of cortical union and trabecular in-growth is, however, traditionally based on plain radiography, a technique lacking in sensitivity. A new assessment method of bony union using high-speed spiral CT imaging is proposed which reflects the gradually increasing biological stability of the construct. Grade I (complete fusion) implies cortical union of the allograft and central trabecular continuity. Grade II (partial fusion) implies cortical union of the structural allograft with partial trabecular incorporation. Grade III (unipolar pseudarthrosis) denotes superior or inferior cortical non-union of the central allograft with partial trabecular discontinuity centrally and Grade IV (bipolar pseudarthrosis) suggests both superior and inferior cortical non-union with a complete lack of central trabecular continuity. Twenty-five patients underwent anterior spinal reconstruction for a single level burst fracture between T4 and L5. At a minimum of two years follow up the subjects underwent high-speed spiral CT scanning through the reconstructed region of the thoracolumbar spine. The classification showed satisfactory interobserver (kappa score = 0.91) and intraobserver (kappa score = 0.95) reliability. The use of high-speed CT imaging in the assessment of structural allograft union may allow a more accurate assessment of union. The classification system presented allows a reproducible categorization of allograft incorporation with implications for treatment.

Bonding cyanoacrylates and ultraviolet-curing adhesives.

This guide to the correct adhesives to use for bonding medical plastics reviews recent technological advances and the benefits they offer. Material and design considerations are also examined.

Magnetic resonance elastography of the lung: technical feasibility.

Magnetic resonance elastography (MRE) is a phase-contrast technique that can spatially map shear stiffness within tissue-like materials. To date, however, MRE of the lung has been too technically challenging-primarily because of signal-to-noise ratio (SNR) limitations and phase instability. We describe an approach in which shear wave propagation is not encoded into the phase of the MR signal of a material, but rather from the signal arising from a polarized noble gas encapsulated within. To determine the feasibility of the approach, three experiments were performed. First, to establish whether shear wave propagation within lung parenchyma can be visualized with phase-contrast MR techniques, MRE was performed on excised porcine lungs inflated with room air. Second, a phantom consisting of open-cell foam filled with thermally polarized (3)He gas was imaged with MRE to determine whether shear wave propagation can be encoded by the gas. Third, preliminary evidence of the feasibility of MRE in vivo was obtained by using a longitudinal driver on the chest of a normal volunteer to generate shear waves in the lung. The results suggest that MRE in combination with hyperpolarized noble gases is potentially useful for noninvasively assessing the regional elastic properties of lung parenchyma, and merits further investigation.

The Resource Mothers Study of Maternal Phenylketonuria: preliminary findings.

Women with phenylketonuria (PKU) must follow a strict low-phenylalanine diet during pregnancy in order to protect the fetus from the deleterious effects of high maternal blood phenylalanine. The Resource Mothers Study of Maternal PKU was undertaken to determine whether a home visitation programme was effective in helping women with PKU attain blood phenylalanine control earlier during pregnancy. Resource Mothers were trained to provide social support and practical assistance to women with PKU during pregnancy. Eight metabolic clinics in the United States participated in the study. Women with PKU who were planning pregnancy or already pregnant were enrolled in the study and were treated with a low-phenylalanine diet aimed at controlling blood phenylalanine to 120-360 micromol/L. They were randomly assigned to receive the services of a Resource Mother (RM group) or to a control group. Fifty women were enrolled, and accounted for 44 pregnancies which resulted in 28 live births, and 6 spontaneous abortions. Ten women are currently pregnant and another 6 have not become pregnant. Fifty-six percent of enrolled women began the diet prior to becoming pregnant. Fifty-three percent of women in the Resource Mother group were in metabolic control by 10 weeks gestation as compared to 39% in the control group. In addition, women who began diet after pregnancy and had a Resource Mother attained metabolic control earlier (mean gestational age of 22.4 weeks in the RM group vs 29.8 weeks in the control group). There was no difference in birth measurement z -scores of offspring born to women in the RM group compared to controls. All but 4 women rated themselves as feeling worse about the diet at the end of pregnancy than at the beginning, and few women in either group remained on diet after delivery.

Noninvasive linear accelerator radiosurgery as the primary treatment for trigeminal neuralgia.

The application of a dedicated linear accelerator (DLINAC) as a noninvasive surgical treatment for trigeminal neuralgia has not yet been demonstrated. This work evaluates the outcome and indications of 22 patients submitted to DLINAC radiosurgery as a primary treatment for essential trigeminal neuralgia. At last follow-up evaluation, 21 patients (95.5%) had sustained significant pain relief. DLINAC radiosurgery is safe and effective as a primary noninvasive surgical treatment for selected patients with essential trigeminal neuralgia.

Complete fundoplication has similar long-term results in patients with and without esophageal body dysmotility.

BACKGROUND: Partial fundoplication is advocated for the treatment of gastroesophageal reflux disease in patients with poor esophageal body function. We hypothesized that a complete floppy wrap may be just as safe in patients with poor esophageal motility. METHODS: A retrospective, case-control study was performed on patients who underwent a complete fundoplication and had poor esophageal motility. Study patients were matched with controls with normal esophageal body pressures according to sex, age, and duration of reflux symptoms. Patients were followed up and interviewed using a modified symptom and life quality questionnaire. RESULTS: Twenty-two patients and 22 matched controls underwent a complete fundoplication. The mean esophageal body pressure was 42.1 and 87.5 mmHg in the study and control groups, respectively (p <0.05). Average time to resolution of dysphagia was 10.1 weeks in the study group and 12 weeks in the control group. All patients but 1 (control) graded their life quality improvement as good to excellent. CONCLUSION: Our data suggest that a 360 degrees fundoplication has similar long-term results regardless of esophageal body motility. We suggest that a partial fundoplication may be reserved for patients with severe esophageal body dysfunction. The role of manometry in the preoperative workup should be reassesed: it may be mandatory only in patients with preoperative dysphagia or when achalasia is suspected.

Inhibitory effect of white wine on gastric myoelectrical activity and the role of vagal tone.

Although extensively investigated throughout the gastrointestinal tract, the influence of alcohol on gastric motility is still unclear. Our aim was to investigate the effect of wine on gastric myoelectrical activity and vagal activity. Ten healthy subjects were studied in two sessions with the electrogastrogram (EGG) for 30 min at baseline, 30 min after ingesting the test liquid [white wine (12.5% alcohol) or matched juice], and 60 min after a standard test meal. Spectral analysis was performed to compute EGG parameters and their postprandial changes. The vagal activity was assessed based on spectral analysis of the heart rate variability (HRV) signal derived from the ECG recording. White wine preload significantly diminished the postprandial increase in EGG dominant power compared to juice preload (1.16 +/- 1.57 vs 5.48 +/- 1.01 dB, P < 0.001). A significant decrease in vagal activity was observed after wine (23.40 +/- 4.30 vs 17.43 +/- 3.40%, P < 0.005), which remained unchanged after the test meal (23.40 +/- 4.30 vs 16.77 +/- 4.40%, P < 0.05). This decrease was not noted in the juice session. A correlation was established between changes after wine consumption in EGG dominant power and in the percentage of the vagal activity (r = 0.89, P < 0.05). In conclusion, white wine preload inhibits the postprandial EGG dominant power, suggesting a possible inhibition of postprandial gastric contractions. This effect may be associated with diminished vagal activity.

A practical guide to adhesive bonding.

Choosing the best adhesive method can be an exacting design task. This is especially true when joining dissimilar materials and when bonding certain plastics. All too often the adhesive is not fully considered at the design stage, which leads to problems during production. This guide discusses the key elements of the bonding process and provides advice when things do not go right.

Quadriceps load aggravates and roofplasty mitigates active impingement of anterior cruciate ligament grafts against the intercondylar roof.

Because of the complications of impingement of anterior cruciate ligament grafts on the intercondylar roof and because current surgical procedures locate the tibial tunnel such that impingement is avoided during passive but not active extension, the objectives of this study were to determine if (a) active extension precipitates and aggravates roof impingement, and (b) a roofplasty mitigates the effects of impingement. The tibial translation, flexion angle defining the onset of roof impingement, graft-roof contact pressure, and graft tension were measured for six cadaveric specimens. In each specimen, two tibial tunnel positions were studied: one customized for the slope of the intercondylar roof, and the other translated 6 mm anteriorly from the customized position. For a quadriceps load of 1,500 N, the flexion angle defining the onset of impingement, the peak contact pressure, and the graft tension increased significantly for both tunnel positions. The increases occurred because of the anterior tibial translation caused by the active load. Although a roofplasty decreased the onset of the angle of impingement, the graft tension remained unaffected. Thus, to mitigate the effect of impingement during active rehabilitative knee extension exercises, the position of the tibial tunnel must be customized to the angle of the intercondylar roof and a roofplasty must be performed. The extent of bone removed must be customized as well and can be determined by removing bone from the intercondylar roof in excess of that required to freely pass a rod, the same diameter of the graft, through the tibial tunnel into the intercondylar notch with the knee in full passive extension.

Contact pressure and tension in anterior cruciate ligament grafts subjected to roof impingement during passive extension.

Contact between an anterior cruciate ligament graft and the intercondylar roof has been termed roof impingement. Grafts with impingement sustain permanent damage, and if the injury is extensive enough, then the graft may fail, causing recurrent instability. This study evaluated two mechanical factors that could be responsible for the graft injury associated with roof impingement: an increase in graft tension or elevated pressures between the graft and the roof, or both. An anterior cruciate ligament reconstruction was performed using an Achilles tendon graft in five fresh-frozen cadaveric knees. Using a six-degree-of-freedom load application system, the anterior displacement of the knee with the native anterior cruciate ligament was restored in the reconstructed knee at a flexion angle of 30 degrees and with an anterior force of 200 N applied. Pressure between the graft and intercondylar roof, graft tension, and flexion angle were measured during passive knee extension for three tibial tunnel placements (anterior, center, and posterior). Intercondylar roof impingement increased the contact pressure between the graft and the roof but had no significant effect on graft tension. Therefore, during passive knee extension, the contact pressure between the anterior cruciate ligament graft and the intercondylar roof is a more likely cause of graft damage than increased graft tension.

Consulting skills training and medical students' interviewing efficiency.

In more traditional medical education, medical students took a patient's medical history by asking a series of sequenced, routine questions, covering presenting medical problem(s); medical history; social and personal history; systems review; and physical examination. Following this process, the student then attempted to derive the patient's medical problems. This inductive problem-solving paradigm may not assist students to prepare for their future interviewing needs, given doctors use a hypothetico-deductive, problem-solving approach when interviewing patients and numerous researchers have developed specialized communication skills training programmes designed to enhance students' interviewing skills. Students given specific consulting skills training have tended to show significantly greater interpersonal effectiveness and improved interview behaviours compared with students who experience traditional patient clerking training. These improvements in interviewing tend to persist over the period of students' medical training. The aim of the present study was to determine whether specialized communication skills training helped students elicit greater quantity and quality of information from patients and if so, whether such information assisted students in improving their diagnostic skills. Videotaped history-taking interviews conducted by students trained in communication skills and untrained (control) students were rated for their interview efficiency. A comparison of ratings given by experimentally naive, independent observers revealed that trained students were more efficient, but took no longer than their control group counterparts to elicit fuller, more relevant information. However, the student groups did not differ in the accuracy or scope of their medical diagnoses. It is argued that students' lack of medical knowledge in this early phase of their clinical training militated against their being able to use their interviewing competence to derive more potentially accurate medical diagnoses.

Low prevalence of primary biliary cirrhosis in Victoria, Australia. Melbourne Liver Group.

A prevalence study of primary biliary cirrhosis was carried out in the state of Victoria, Australia, by means of a mail survey of specialist physicians and a review of hospital records. Eighty four cases were identified, giving a prevalence of 19.1 per million population (95% confidence limits (CI) 15.3, 23.7), which is among the lowest in published reports. The prevalence in the Australian born, at risk population (women over the age of 24) was 51 per million (95% CI 37.5, 67.9). Both these figures are considerably lower than those in populations of similar age distribution in the UK and northern Europe. Since most Victorians are descended from British or European settlers, the low prevalence of primary biliary cirrhosis in this study supports the hypothesis that local environmental factors may be important in the pathogenesis of this disease.