Intracranial pressure during liver transplantation for fulminant hepatic failure.

During orthotopic liver transplantation (OLT) for fulminant hepatic failure (FHF), some patients develop cerebral injury secondary to intracranial hypertension. We monitored intracranial pressure (ICP) and cerebral perfusion pressure (CPP) before and during OLT in 12 FHF patients undergoing transplantation. All four patients who had normal ICP preoperatively maintained normal ICP/CPP throughout OLT. During OLT, four of the eight patients with pretransplant intracranial hypertension had six episodes of ICP increase. These episodes of intracranial hypertension occurred during failing liver dissection (n=3) and graft reperfusion (n=3). At the end of the anhepatic phase, the ICP was lower than the preoperative ICP in all patients, and was below 15 mmHg in all but one patient. These data suggest that in FHF patients who develop intracranial hypertension before OLT, dissection of the native liver and graft reperfusion are associated with a risk of brain injury resulting from intracranial hypertension and cerebral hypoperfusion.

Epidural methadone for analgesic management of patients with conservatively treated proximal femoral fractures.

Epidural methadone analgesia was initiated soon after admission to emergency room in elderly patients who sustained osteoporotic proximal femoral fracture and who were considered to be high surgical risks. The severe pain was significantly reduced, enabling early mobilization of the patients. The analgesia was discontinued only when nonnarcotic analgesia sufficed. The treatment lasted for about 3.5 weeks. One minor complication was observed during the treatment period. We concluded that patients who have femoral neck fracture who are at high risk for operation and have to be observed and stabilized before operation can be managed by continuous epidural methadone analgesia.

Functional consequences of expression of the neuron-specific, protein kinase C substrate RC3 (neurogranin) in Xenopus oocytes.

RC3 (neurogranin) is a neuron-specific substrate of protein kinase C (PKC) that accumulates predominantly in dendritic spines of forebrain neurons and undergoes long-term potentiation (LTP)-associated increases in PKC-phosphorylation in hippocampal slices. Here the hypothesis that RC3 functions by modulating the IP3/DAG second messenger pathway after its phosphorylation by DAG-activated PKC was tested by heterologous expression in Xenopus oocytes. Acetylcholine-evoked inward chloride (Cl-) currents, dependent on both IP3 release and intracellular calcium (Ca2+), were 2- to 3-fold higher in RC3-injected oocytes than in uninjected control oocytes. RC3-oocytes did not exhibit enhanced currents when preincubated with the protein kinase inhibitor H-7 or when a glycine residue was substituted for serine, the PKC phosphorylation site of RC3. Activation of endogenous oocyte PKC by phorbol esters generated inward Cl- currents in RC3 oocytes but not in control oocytes. RC3-dependent Cl- currents were also elicited by phorbol ester in Ca(2+)-free media. We propose that PKC-phosphorylated RC3 is capable of enhancing the mobilization of intracellular Ca2+ in Xenopus oocytes and, by inference, may play a role in Ca2+ homeostasis in dendrites of forebrain neurons.

Effects of 1,3-di-o-tolylguanidine (DTG), a sigma ligand, on local cerebral glucose utilization in rat brain.

The 2-deoxy-D-[1-14C]glucose ([14C]DG) method was used to examine the effects of the relatively selective sigma ligand 1,3-di-o-tolylguanidine (DTG) on cerebral metabolism in freely moving rats. Each animal received an i.p. injection of DTG (0.2, 1, or 5 mg/kg) or normal saline 20 min prior to the infusion of [14C]DG. DTG induced dose-dependent changes in local cerebral glucose utilization (LCGU) in several motor and limbic structures. Most structures showed increases in LCGU, with a maximum effect at 1 mg/kg. The most profound increases in LCGU were observed in brain regions that are rich in sigma receptors. These included cerebellar and related nuclei (interpositus, lateral and medial cerebellar n., vestibular n., olivary n.), ambiguus n., superior colliculus (superior layers), hippocampus (CA2, CA3, DG), n. basalis of Meynert interpeduncular n., and the substantia nigra pars compacta and pars reticulata. No significant decreases in glucose utilization were observed at any dose. Although the areas affected by DTG are similar to those previously reported for other sigma ligands, future studies employing a range of doses for additional selective sigma ligands must be carried out in order to confirm whether these changes in LCGU were sigma-mediated.

Frequency of minor nervous dysfunction in school children.

A study was made on 88 third grade school children to determine the frequency of minor nervous dysfunction (MND) Touwen and Prechtl). The study consisted of a neurological and an motoscopic examination as well as a visuomotor performance test (Gleiss). The following results were obtained: 1. Suspected MND was found in 15.9% of the population. 2. Only two children had optimal performance according to Prechtl's optimality concept. 3. If the diagnosis MBD is made excluding the behavioral description as a diagnostic criterion, no significant statistical correlation was found with school marks or social class. 4. The specific character of Lempp's "frühkindliches exogenes Psychosyndrom" and the behavioral disturbances described seems to us to be questionable. We found such disturbances with our methods as frequently in children with disturbed organic brain function as in children from a low social class.

Delta 9-tetrahydrocannabinol alters cerebral metabolism in a biphasic, dose-dependent manner in rat brain.

delta 9-tetrahydrocannabinol (THC)-induced alterations in limbic and neocortical function are associated with deficiencies in short-term memory and recall. The 2-deoxy-D-glucose (2DG) autoradiographic method was used to examine the effect of acute THC administration (0, 0.2, 0.5, 2.0, 10.0 mg/kg) on regional brain metabolism in limbic and cortical brain regions of male rats. THC altered 2DG uptake in a biphasic, dose-dependent manner in most limbic and cortical structures, however most diencephalic and brainstem structures examined were unaffected. The 0.2 mg/kg THC dose significantly increased 2DG uptake relative to vehicle treatment in all cortical and selected limbic regions, whereas the 2.0 and 10.0 mg/kg THC doses decreased 2DG uptake in most of these regions. Certain limbic regions, particularly the hippocampus, are more sensitive to THC suggesting a selective regional action of the drug at lower doses. The incidence of enhanced metabolic activity in limbic and cortical regions is consistent with the occurrence of high density cannabinoid receptors in these regions.

Effect of 6-hydroxydopamine or repeated amphetamine treatment on mesencephalic mRNA levels for AMPA glutamate receptor subunits in the rat.

Expression of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) subunit mRNAs were assayed in the ventral mesencephalon of rats that received either a unilateral microinjection of the dopamine neurotoxin 6-hydroxydopamine (6-OHDA; Experiment 1) or repeated treatment with amphetamine (Experiment 2). GluR2 levels were decreased 1 and 3 days after the lesion, and GluR1 and GluR3 levels also showed a transient decrease at 1 day after the lesion. Repeated amphetamine treatment did not significantly alter GluR1-4 levels measured 30 min after the third or tenth amphetamine injection, even though locomotor sensitization was obtained. Thus, while the present results indicate that AMPA receptor subunits are associated with dopamine-containing cell bodies in the ventral mesencephalon, these transcripts may not be responsible for the development of amphetamine sensitization.

Functional studies of single-site variants in the calmodulin-binding domain of RC3/neurogranin in Xenopus oocytes.

Single-site variants in the calmodulin-binding domain of RC3/neurogranin were heterologously expressed in Xenopus oocytes to examine their effects on serotonin-evoked currents. RC3 variants serine36 -->alanine (Ser36-->Ala), serine36-->glycine (Ser36-->Gly), and phenylalanine37-->tryptophan (Phe37-->Trp), which bind calmodulin but are deficient in protein kinase C (PKC) phosphorylation, display serotonin-evoked Ca(2+)-dependent Cl- currents in oocytes similar to control oocytes. A serine36-->aspartate (Ser36-->Asp) variant, which does not bind calmodulin and mimics the PKC-phosphorylated state of RC3, significantly enhances serotonin-evoked currents in a manner similar to wild-type. The results suggest that RC3 not only regulates the availability of free calmodulin in a dendritic spine but also, when phosphorylated, independently stimulates G-protein coupled second messenger pathways that generate inositol 1,4,5-trisphosphate (IP3), diacylglycerol (DAG) and intracellular Ca2+.

Gain in mass density of bone following strenuous physical activity.

A group of 223 military recruits aged 18-21 years underwent strenuous physical training for a period of 14 weeks. The absolute bone density of the distal tibia in both lower limbs was measured before the training period and at its end. The density was determined by the Compton scattering technique, which has been developed in our laboratory; this method provides the bone mass of all bone constituents per unit volume. The distribution curve of the bone density in both tibiae shifted to higher values at the end of the training period. The mean bone density in the right and left tibia increased significantly by 7.5%. This study indicates that following an intensive physical exercise regime, a significant increase in the mass density of bone can be obtained in young adults within a short period.

The relative significance of trabecular and cortical bone density as a diagnostic index for osteoporosis.

The density of the distal radius in the non-dominant forearm was measured non-invasively by Compton spectrometry in 234 post-menopausal women. The density of the trabecular tissue was determined almost independently from that of cortical tissue by horizontal and vertical scanning of the bone. It was found that the lower the density of the trabecular bone, the greater the difference between the density of the cortical and trabecular bone. As osteoporosis progresses, trabecular bone density in the distal radius seems to decrease faster than that of compact bone. Hence the severity of the disease is best determined by measuring the density of trabecular bone.

Effect of intense physical activity on the bone-mineral content in the lower limbs of young adults.

The effect of intense physical training on the bone-mineral content of young adults who are unaccustomed to physical activity has not yet been established. In this study, 268 male recruits, eighteen to twenty-one years old, were evaluated before and after fourteen weeks of strenuous physical training. The bone-mineral content of both legs at the level of the distal third of the tibia in each individual was measured using single-beam photon absorptiometry. The subjects started their training with equal values for bone-mineral content in both legs. During the training period, the average bone-mineral content of the left leg increased by 11.1 per cent and that of the right leg, by 5.2 per cent. In the group of subjects who did not complete the training course, mainly because they incurred stress fractures, the increase in bone-mineral content was significantly less than the increase in those who completed the program. This study indicated that in young adults a high level of loading of bone results in either a stress fracture or a rapid increase in bone-mineral content.

Etiology of idiopathic scoliosis: current trends in research.

Current population studies characterize idiopathic scoliosis as a single-gene disorder that follows the patterns of mendelian genetics, including variable penetrance and heterogeneity. The role of melatonin and calmodulin in the development of idiopathic scoliosis is likely secondary, with indirect effects on growth mechanisms. Reported abnormalities of connective tissue, skeletal muscle, platelets, the spinal column, and the rib cage are all thought to be secondary to the deformity itself. Although no consistent neurological abnormalities have been identified in patients with idiopathic scoliosis, it is possible that a defect in processing by the central nervous system affects the growing spine. The true etiology of idiopathic scoliosis remains unknown; however, it appears to be multifactorial.

Negative bone scans in impending tibial stress fractures. A report of three cases.

Three highly motivated military recruits who presented with tibial pain on exertion are reported. Their initial bone scan assessments to rule out stress fracture were normal, and the recruits were returned to demanding training. One month later, because of persistent and increasing tibial pain, they were rescanned and focal activity representative of tibial stress fractures was found in each case. Until now it has been assumed that a negative bone scan ruled out a stress fracture unequivocally. Our reported cases show that bone pain may in fact precede scintigraphic evidence of a stress fracture. Persistent and increasing bone pain during demanding physical activity, even in the presence of a prior normal bone scan, may represent stress fracture and repeat bone scan may be indicated.

Stress fractures and tibial bone width. A risk factor.

A prospective study of 295 infantry recruits has shown that the mediolateral width of the tibia measured radiographically at each of three different levels in the bone had a statistically significant correlation with the total incidence of stress fractures as well as with those in the tibia alone or the femur alone. A narrow tibial width was shown to be a risk factor, but cortical thickness was not found to be significant.

Stress fractures in military recruits. A prospective study showing an unusually high incidence.

In a prospective study of 295 male Israeli military recruits a 31% incidence of stress fractures was found. Eighty per cent of the fractures were in the tibial or femoral shaft, while only 8% occurred in the tarsus and metatarsus. Sixty-nine per cent of the femoral stress fractures were asymptomatic, but only 8% of those in the tibia. Even asymptomatic stress fractures do, however, need to be treated. Possible explanations for the unusually high incidence of stress fractures in this study are discussed.

Acoustic emission from trabecular bone during mechanical testing: the effect of osteoporosis and osteoarthritis.

This study examines the relation between the nature of acoustic emission signals emitted from cancellous bone under compression and the mechanical properties of the tissue. The examined bone specimens were taken from 12 normal, 31 osteoporotic and six osteoarthritic femoral heads. The mechanical behaviour of the osteoporotic bone specimens was found to be significantly different from that of the normal specimens both in the pre-yield and post-yield ranges. In the osteoarthritic bones only the elastic behaviour was significantly different. The rates of acoustic events before yield and beyond it were found to be significantly higher both in the osteoporotic and osteoarthritic bone specimens. The average peak amplitude of the signals was also significantly higher in the diseased bones. Stepwise regression analysis showed that a combination of the acoustic emission parameters could significantly predict some mechanical properties of the bone. The energy absorbed during compression and the ultimate compressive stress of the specimens could be estimated from the rate of pre-yield acoustic events, the average amplitude of the signals and the rate of post-yield events. However, the explanation power of the acoustic emission parameters was only moderate. The nature of acoustic emission signals was thus demonstrated to be a potential tool for assessing bone quality.

Physical and psychosocial benefits of modified judo practice for blind, mentally retarded children: a pilot study.

A modified form of judo training was practiced by a class of 7 blind, mentally retarded children with associated neuropsychiatric disturbances. The biweekly training program lasted for 6 months. Analysis indicated improvements in physical fitness, motor skills, and psychosocial attitude. The authors concluded that a modified form of judo can be used as a therapeutic, educational, and recreational tool for multiply handicapped children.

Clinical efficacy of lumbar and lumbosacral fusion using the Boucher facet screw fixation technique.

The clinical outcome of posterolateral lumbar and lumbosacral fusions with facet screw fixation using the Boucher technique is reviewed retrospectively. The Boucher technique uses AO cortical screws that traverse the facet joint at an angle from the superior lamina, in a medial to lateral direction, to enter the respective inferior pedicle. The procedure was performed on 57 consecutive patients who had a degenerative disk disease. The pre-operative diagnosis was based on a physical examination and radiographs with myelography performed when deemed necessary. Surgery had been indicated and performed on patients with unresolved pain after 6 months of conservative therapy; radiographic signs of disk space narrowing, facet arthrosis, degenerative spondylolisthesis or instability on flexion and extension views. No prior history of spinal surgery, no involvement in any litigation or Workers Compensation process, and no detected psychiatric disturbances were also inclusion criteria for this study. Eighteen consecutive male and 39 consecutive female patients were included in the study. The average age at the time of surgery was 41.8 years. The mean active clinical follow-up (office visits) time was 5.06 months with the minimum follow-up time of 3 months. Two years after their surgery, all the patients were asked to fill out a questionnaire from which their progress was evaluated. All questionnaires were completed and returned. Postoperatively, patients were placed in either a lumbosacral corset, short rigid lumbosacral molded polypropylene brace or body cast. Overall clinical results for single level fusions showed that 91.2% of patients (31 of 34) had excellent results and 8.8% (3 of 34) had poor results. Of the multiple level fusions, 86.4% of patients (19 of 22) had excellent or good results and 9.1% (2 of 22) had poor results. Post-operative complications included only three wound infections at the iliac crest donor site. This study demonstrates that facet screw fixation using the Boucher technique has advantages. The technique not only is easy to implement by placing a small screw through a facet joint and it's respective pedicle, but produces excellent clinical results that are comparable to the other more bulky spinal instrumentation systems.

Avascular necrosis of the femoral head following intertrochanteric fracture.

Two cases are reported of avascular necrosis of the femoral head occurring as a late complication of an intertrochanteric fracture. The cases are presented to emphasize the importance of including this condition in the differential diagnosis of any late clinical deterioration following such an injury.

The logic of imaging in spine surgery.

Spinal imaging has rapidly evolved into a complex diagnostic field requiring specialized expertise. While many imaging modalities reveal portions of a topographic map of the spine necessary for surgery, only magnetic resonance imaging emerges as the imaging modality of widest and most efficacious first choice. With the increasing high-technology sophistication of modern imaging modalities, the spine surgeon must become completely conversant with the radiologic data produced by these imaging techniques. The authors present a logical approach to spinal imaging--an algorithm--based on etiologic classification and aimed at conserving medical resources and developing an optimal diagnostic pathway for spine injury and disease. Spine surgeons are urged to incorporate the interpretative insights of radiologists into the diagnostic process.