Projected increase in total knee arthroplasty in the United States - an alternative projection model.

OBJECTIVE: The purpose of our study was to estimate the future incidence rate (IR) and volume of primary total knee arthroplasty (TKA) in the United States from 2015 to 2050 using a conservative projection model that assumes a maximum IR of procedures. Furthermore, our study compared these projections to a model assuming exponential growth, as done in previous studies, for illustrative purposes. METHODS: A population based epidemiological study was conducted using data from US National Inpatient Sample (NIS) and Census Bureau. Primary TKA procedures performed between 1993 and 2012 were identified. The IR, 95% confidence intervals (CI), or prediction intervals (PI) of TKA per 100,000 US citizens over the age of 40 years were calculated. The estimated IR was used as the outcome of a regression modelling with a logistic regression (i.e., conservative model) and Poisson regression equation (i.e., exponential growth model). RESULTS: Logistic regression modelling suggests the IR of TKA is expected to increase 69% by 2050 compared to 2012, from 429 (95%CI 374-453) procedures/100,000 in 2012 to 725 (95%PI 121-1041) in 2050. This translates into a 143% projected increase in TKA volume. Using the Poisson model, the IR in 2050 was projected to increase 565%, to 2854 (95%CI 2278-4004) procedures/100,000 IR, which is an 855% projected increase in volume compared to 2012. CONCLUSIONS: Even after using a conservative projection approach, the number of TKAs in the US, which already has the highest IR of knee arthroplasty in the world, is expected to increase 143% by 2050.

Mutations in the alpha-tubulin 67C gene specifically impair achiasmate segregation in Drosophila melanogaster.

Drosophila melanogaster oocytes heterozygous for mutations in the alpha-tubulin 67C gene (alphatub67C) display defects in centromere positioning during prometaphase of meiosis I. The centromeres do not migrate to the poleward edges of the chromatin mass, and the chromatin fails to stretch during spindle lengthening. These results suggest that the poleward forces acting at the kinetochore are compromised in the alphatub67C mutants. Genetic studies demonstrate that these mutations also strongly and specifically decrease the fidelity of achiasmate chromosome segregation. Proper centromere orientation, chromatin elongation, and faithful segregation can all be restored by a decrease in the amount of the Nod chromokinesin. These results suggest that the accurate segregation of achiasmate chromosomes requires the proper balancing of forces acting on the chromosomes during prometaphase.

Photoactivated gene expression for cell fate mapping and cell manipulation.

A long-standing goal of developmental biologists is to create developmental fate maps by tracking individual cells through development. Another objective is to perturb the behavior of selected cells and follow the ensuing effects. To this end, we have developed a technique that allows for spatial and temporal control of gene expression in single cells or patches of cells using light to induce gene expression. This technique relies on "caging" the activity of the potent transcriptional activator GAL4VP16 with a photolabile compound, which can be removed with a brief exposure to long-wavelength ultraviolet (UV) light. The caged GAL4VP16 is injected into early-stage embryos, which are aged to the desired point in development, and the cell(s) of interest are irradiated with a brief pulse of long-wavelength UV light. This method has been used extensively in Drosophila, Xenopus, and Zebrafish embryos. The methods for purifying, caging, injection, and photoactivation of the GAL4VP16 protein, and methods for the visualization of marked cells are described in detail.

Familial amyotrophic lateral sclerosis with a novel Leu126Ser mutation in the copper/zinc superoxide dismutase gene showing mild clinical features and lewy body-like hyaline inclusions.

BACKGROUND: Mutations in the SOD1 gene are responsible for approximately 25% of all familial amyotrophic lateral sclerosis (ALS) cases. However, the correlation between the clinical and pathological features and the various SOD1 gene mutations has not been well characterized. OBJECTIVES: To screen the SOD1 gene in search of potential mutations and to obtain clinical and pathological data for 2 Japanese families with ALS. DESIGN: Clinical histories and neurological findings, gross and microscopic pathological features, and DNA analysis of the SOD1 gene. RESULTS: The 2 families with ALS showed a novel missense mutation in the SOD1 gene, which was heterozygous for point mutation TTG to TCG, causing substitution of leucine for serine at codon 126 (Leu126Ser) in exon 5. Clinically, patients showed slower disease progression and lack of upper motor neuron signs. Neuropathologically, the autopsied patient showed the form of familial ALS with posterior column involvement, and the pontocerebellar tract and the dentate nuclei of the cerebellum were also involved. Furthermore, abundant Lewy body-like hyaline inclusions were observed in the affected motor and nonmotor neurons. CONCLUSIONS: Familial ALS with a novel Leu126Ser mutation in the SOD1 gene showed mild clinical features and lack of upper motor neuron signs. We believe that Leu126Ser might be associated with the clinical features and that the mutation site in the SOD1 gene and disease duration might be associated with the formation of Lewy body-like hyaline inclusions.

A case of chronic GM1 gangliosidosis presenting as dystonia: clinical and biochemical studies.

Clinical and biochemical studies are reported on a 32-year-old man with GM1 gangliosidosis who presented with a slowly progressive dystonia that began when he was aged 7 years and eventually became almost totally incapacitating at the age of 35. There was only mild intellectual deterioration, but myoclonus, seizures and macular cherry-red spots were never observed. Proton-density and T2-weighted MRI scans showed symmetrical hyperintense lesions of both putamina. No increase of GM1 ganglioside was found in plasma or cerebrospinal fluid, and the metabolism of GM1 ganglioside in cultured skin fibroblasts from the patient was also almost normal, although the residual activity of GM1 ganglioside beta-galactosidase activity was only 10% of normal. These findings suggest that impaired GM1 ganglioside metabolism is not present systemically as it is in the infantile and juvenile types of the disorder, but is mainly confined to the central nervous system in chronic GM1 gangliosidosis.

Free radicals, lipid peroxides and antioxidants in blood of patients with myotonic dystrophy.

We studied the levels of free radicals, lipid peroxides and antioxidants, as well as superoxide dismutase (SOD) activity in the blood of six patients with myotonic dystrophy (MyD) (mean age 52.8, SD 5.0 years) and seven controls (mean age 48.8, SD 6.3 years). Electron spin resonance was used to assess the free radicals by the spin-trapping method using 5,5-dimethyl-1-pyrroline-1-oxide. The levels of C centre radical (P < 0.05) and H radical (P < 0.05) in blood from the six MyD patients were significantly higher than those in the seven controls. The SOD activities in red blood cells and serum from the six MyD patients showed no significant difference from those in the seven controls. The serum lipid peroxide concentration was increased in five of the MyD patients and tended to increase further as the disease progressed. The serum vitamin E level was low in two patients and in the low normal range in three. Serum coenzyme Q10 was decreased in four patients. The serum selenium level was decreased in two patients and that of serum albumin was decreased in three. Therefore we conclude that increased levels of free radicals and lipid peroxides and decreased antioxidant levels play an important role in the pathogenesis of MyD.

Mitochondrial encephalomyopathy (MELAS): pathological study and successful therapy with coenzyme Q10 and idebenone.

Two patients with mitochondrial myopathy, encephalopathy, lactic acidosis and strokelike episodes (MELAS) in one family are reported. Pathological examination of case 1 showed ragged-red fibers, with 7% of the fibers being unstained by cytochrome c oxidase stain, peripheral nerve damage, multiple areas of softening in the cerebrum and midbrain, and spongy changes in the cerebrum, optic nerve and pons. Electron microscopic examination revealed abnormal accumulations of mitochondria in the skeletal muscle, smooth muscle and cardiac muscle. The activity of cytochrome c oxidase in the brain and liver showed a tendency to decrease. In case 2 (maternal aunt of case 1), muscular weakness and peripheral nerve damage improved by treatment with coenzyme Q10. By adding idebenone to the coenzyme Q10 therapy, the EEG and Wechsler's Adult Intelligence Scale (WAIS) improved. Furthermore, in the cerebral spinal fluid (CSF), the protein, lactate, and pyruvate decreased, and the monoamines and monoamine metabolites increased.

Superoxide dismutase and free radicals in sporadic amyotrophic lateral sclerosis: relationship to clinical data.

We studied the relationships between the superoxide dismutase (SOD) activity, free radical (FR) levels and clinical data in patients with sporadic amyotrophic lateral sclerosis (SALS). The SOD activities and blood FR levels of 16 patients with SALS (mean age 58.6 +/- 10.2 years), 11 with other neurological disease, including myotonic dystrophy (ND, mean age 53.5 +/- 9.1 years), and 15 normal control subjects (mean age 56.2 +/- 7.3 years) were measured. The mean levels of FR in blood from the patients with SALS and ND and the SOD activities in red blood cells (RBC) from those with ND were significantly higher than the corresponding control values. There was a positive correlation between the SOD activities in RBC and blood hydroxyl radical levels in the patients with ND, but neither the patients with SALS nor the controls showed such a correlation. The SALS patients without pyramidal signs showed slow disease progression and their mean RBC SOD activity was significantly higher than the corresponding control value. We compared the FR levels and SOD activities of 8 patients who needed a respirator within 40 months after the onset of SALS (SALS40, mean age 58.7 +/- 9.4 years), 3 who needed a respirator over 100 months after the onset of SALS (SALS100, mean age 58.3 +/- 15.9 years) and the controls. The mean blood FR levels of the SALS40 and SALS100 patients were significantly higher than the corresponding control values. The mean SOD activity in RBC from the SALS100 group was significantly higher than the SALS40 and control group values. Therefore, we concluded that elevated blood FR levels do not induce RBC SOD in SALS patients and that the disease progressed more rapidly in SALS patients with low than high RBS SOD activities.

A family of familial hypercholesterolemia with cerebral infarction and without coronary heart disease. An unusual case with corneal opacity, polyneuropathy and carpal tunnel syndrome in the family: therapy with probucol and tocopherol nicotinate.

A study is presented of a 48-year-old female patient and her three siblings with familial hypercholesterolemia. The family members had episodes of cerebral infarction and apparently had atherosclerosis of the internal carotid artery, but no coronary heart disease due to their almost normal level of cholesterol. The laboratory studies of the family members revealed the elevations of serum lipid peroxides, serum lipoprotein(a), leukotriene C4 in blood, the thromboxane B2/6-keto-prostaglandin F1 alpha ratio in plasma and serum hydroxyl radical. Therefore, it is suspected that these factors accelerating atherosclerotic process caused the cerebral infarction. The patient demonstrated corneal opacities, palpebral xanthomas, thickened Achilles tendons, polyneuropathy and the carpal tunnel syndrome. Laboratory studies revealed an elevation in the OKT4/8 ratio, monocyte dysfunction with respect to phagocytosis and chemotaxis, and the presence of the 46XX/45XO mosaic chromosome. Lipid deposits were observed in the Achilles tendon, the transverse carpal ligament, the Schwann's cells and axons of the sural nerve, and in the keratocytes and stroma of the cornea. Following the administration of tocopherol nicotinate and probucol, the patient's serum lipid peroxide normalized and there was improvement in her palpebral xanthomas, thickening of the Achilles tendons and polyneuropathy. We conclude that the lipid deposits in this patient were due to the abnormal oxidative metabolism of low-density lipoprotein and a disturbance of the scavenger pathway due to the monocyte dysfunction.

Direct determination of bisphenol A and nonylphenol in river water by column-switching semi-microcolumn liquid chromatography/electrospray mass spectrometry

A rapid and sensitive analytical method based on column-switching semi-microcolumn high-performance liquid chromatography (HPLC) with electrospray mass spectrometry was developed for determining trace levels of bisphenol A (2,2-bis(4-hydroxyphenyl)propane) and nonylphenol (4-nonylphenol) in river water. An aliquot of sample solution was directly injected into the precolumn packed with Capcellpak MF-Ph for sample cleanup and enrichment. The compounds of interest were then transferred to a C-18 analytical column for main separation through a change in flow path by a programmed switching valve. Bisphenol A, nonylphenol, and interfering substances were satisfactorily separated with a simple gradient elution complete within 35 min. Detection of their deprotonated molecules was conducted in negative ion mode. A reduced flow rate (100 &mgr;L/min) optimized for the narrow bore column was found advantageous in obtaining a high degree of sensitivity during electrospray detection. The influence of carrier additives on sensitivity was also examined. This method produced detection limits of 0.5 ng/mL for bisphenol A and 10 ng/mL for nonylphenol (signal-to-noise ratio 3). Calibration curves were observed in the range of 2.5-50 ng/mL (r(2) = 0.999) for bisphenol A and 50-500 ng/mL (r(2) = 0.998) for nonylphenol. Recoveries of the compounds from spiked distilled water and river water were 99.7-138.5% with a relative standard deviation (RSD) ranging from 2.2-9.7%. Copyright 1999 John Wiley & Sons, Ltd.

Accumulation of milky fluid: a late complication of cataract surgery.

We describe 3 patients who presented with an accumulation of homogeneous milky fluid in the capsular bag several years after continuous curvilinear capsulorhexis, phacoemulsification, and posterior chamber intraocular lens (IOL) implantation. In each case, the entire edge of the anterior capsule opening was tightly attached to the peripheral IOL optic. The milky fluid was present in the closed chamber between the IOL optic and the posterior capsule. The fluid was sampled in 2 patients, and its concentration of sodium hyaluronate was determined by high-performance liquid chromatography. The concentration of sodium hyaluronate resembled that in normal aqueous humor. In 1 case, the protein concentration was measured and found to be elevated. Electrophoresis showed that human serum albumin was the main protein constituent. While the outcome was favorable in all 3 patients, this delayed complication of cataract surgery merits further study to clarify its etiology and pathogenesis.

Cerebrospinal fluid corticotropin-releasing hormone in neurodegenerative diseases: reduction in spinocerebellar degeneration.

Levels of corticotropin-releasing hormone (CRH) in cerebrospinal fluid (CSF) were examined in patients with spinocerebellar degeneration (SCD) including olivopontocerebellar atrophy (OPCA), dentatorubropallidoluysian atrophy (DRPLA) and Friedreich's ataxia, Parkinson's disease (PD) and senile dementia of the Alzheimer type (SDAT), and normal aged subjects. CRH concentrations in CSF were significantly reduced in SCD compared to SDAT, PD and CSF and normal aged subjects. It is likely that degeneration not only of the cerebral cortex and the limbic system but also of the subcortical structures such as the brainstem and the cerebellum alters levels of CRH in CSF. Together with the recent anatomical and physiological evidence, the results suggest pathophysiological relevance of CRH for the cerebellar symptoms in SCD.

Stratum corneum lipid morphology and transepidermal water loss in normal skin and surfactant-induced scaly skin.

Stratum corneum lipid morphology was evaluated using attenuated total reflectance infrared spectroscopy (ATR-IR) in normal skin and surfactant-induced scaly skin to evaluate skin barrier function. To evaluate the degree of order of the intercellular lipid alkyl chain conformation, we measured the wavenumbers (frequency shifts) of the symmetrical and asymmetrical C-H stretching vibrations observed at approximately 2850 cm-1 and 2920 cm-1, respectively. There was a correlation between the wave-number and transepidermal water loss in normal skin. However, no difference was observed in surfactant-induced scaly skin from the baseline value in the wavenumbers of the C-H vibrations. These results suggest that in normal skin, lipid morphology plays an important role in the barrier function of the stratum corneum. However, the decline in barrier function in scaly skin is not due to conformational disorder of the lipid alkyl chain.

Spontaneous repair of superficial defects in articular cartilage in a fetal lamb model.

A fetal lamb model was developed to investigate the capacity of fetal articular cartilage for repair after the creation of a superficial defect. Superficial defects, 100 micrometers deep, were made in the articular cartilage of the trochlear groove in the distal aspect of the femur in eighteen fetal lambs that were halfway through the 145-day gestational period; the contralateral limb was used as a sham control. The wounds were allowed to heal in utero for three, seven, fourteen, twenty-one, or twenty-eight days. Seven days after the injury, the defects were filled with a hypocellular matrix, which stained lightly with safranin O. At twenty-eight days, the staining of the matrix was similar to that of the sham controls and the chondrocyte density and the architectural arrangement of the cell layers had been restored. An inflammatory response was not elicited, and no fibrous scar tissue was observed.

Total hip replacement for patients who have ankylosing spondylitis. The importance of the formation of heterotopic bone and of the durability of fixation of cemented components.

Fifty-three total hip replacements were performed in thirty-one patients who had ankylosing spondylitis. After an average period of follow-up of 6.3 years, cemented conventional hip prostheses proved to be very durable in this young population (average age, forty-three years). Only one primary conventional hip prosthesis was revised for aseptic loosening, seventeen years after implantation. Clinically important heterotopic bone (Classes III and IV of Brooker et al.) developed in 11 per cent of the patients, all of whom had had a previous operation on the hip, postoperative infection, or complete ankylosis preoperatively. If a patient has clinically important heterotopic bone after one operation on the hip, and an arthroplasty of the contralateral hip or reoperation on the same hip is to be done, prophylactic treatment should be considered for prevention of formation of heterotopic bone.

Autonomic nervous disorder in motor neuron disease: a study of advanced stage patients.

Autonomic functions were studied in 10 respiratory-support patients with motor neuron disease (MND) at its most advanced stage by means of hemodynamic function tests. The mean duration of disease was 83.4 months (SD 28.0, range 50-140 months). All the patients in this study had lost their ability to breathe spontaneously and were ventilated by respirator. Hemodynamic function tests were performed in 8 out of 10 patients. These patients showed exaggerated sympathetic vasomotor reflexes, increased reflex hypertension and tachycardia in response to the cold pressor test and increased response to administration of adrenaline. However, the responses to both the Aschner eyeball pressure test and injection of atropine were normal, indicating normal parasympathetic nervous system function. Plasma and urine levels of norepinephrine, epinephrine and their metabolites were almost normal in all 10 patients, as were serum dopamine-beta-hydroxylase levels. In patients with the most advanced stage of MND, hyperfunction of the adrenergic sympathetic nervous system was observed, and this was considered to be a symptom characteristic of MND.

Evaluation of the ventilation-perfusion ratio in lung diseases by simultaneous anterior and posterior image acquisition.

Ventilation and perfusion images were acquired during tidal breathing using 81mKr gas and 99mTc-MAA. Anterior and posterior functional images of V/Q and Q/V were simultaneously acquired in 34 subjects with various lung diseases and 6 healthy controls. Superimposed anterior and posterior images were constructed and histograms of the frequency distribution for ventilation, perfusion, and the V/Q ratio were displayed for both lungs as well as for the left and right lungs individually. Blood gas analysis and general lung function tests were also performed on the day before scintigraphy. A correlation between marked uneven distribution of V/Q and A-aDO2 was found. When the proportion of counts at V/Q < 0.67 and/or V/Q > 1.50 in the V/Q counts histogram was compared with A-aDO2, there was a significant positive correlation for anterior images (r = 0.684, p < 0.05), posterior images (r = 0.654, p < 0.05) and superimposed images (r = 0.696, p < 0.05). Superimposed images therefore showed the highest correlation. There was no correlation between the results of lung function testing and A-aDO2. Coronal SPECT images were also obtained in 15 patients and compared with the superimposed anterior and posterior planar images. There was a good correlation (r = 0.888, p < 0.001) between both the imaging methods regarding the marked uneven distribution of V/Q. Simultaneous anterior and posterior planar image acquisition reduces the examining time, is simple, and is noninvasive. The present results also suggest that it is useful for quantitative evaluation of the ventilation-perfusion ratio.

Evaluation of Tl-201 SPECT for monitoring the treatment of pulmonary and mediastinal tumors.

Tl-201 single photon emission computed tomography (SPECT) was performed in 88 patients with pulmonary or mediastinal tumors in order to evaluate its usefulness for the detection of disease and for the assessment of the effect of treatment. We also examined mediastinal and hilar lymph node metastasis from lung cancer. Tl-201 SPECT showed abnormal accumulation on delayed images in all lung cancer patients with tumor diameters more than 12 mm. In the 14 operated lung cancer patients, mediastinal and hilar lymph node metastases with diameters of more than 15 mm were imaged, but one with a diameter of 9 mm was missed. The retention index (RI) was 27.52 +/- 31.58 in malignant tumors and -13.67 +/- 8.15 in benign tumors (p < 0.05). The RI was significantly lower after treatment than before treatment. The interval until tumor recurrence or reactivation tended to be longer in patients who showed a significant decrease in the RI after therapy. These findings suggest the usefulness of the RI as an index of therapeutic efficacy.

Evaluation of uptake and release of technetium-99m MIBI SPECT of pulmonary and mediastinal lesions.

We evaluated the uptake and release of Tc-99m MIBI in 7 benign and 30 malignant pulmonary and mediastinal lesions. Of the 37 patients, 13 underwent surgery; malignant involvement was examined in 21 mediastinal lymph nodes. Tl-201 SPECT was also performed in 10 patients. Tc-99m MIBI SPECT studies were performed on transverse SPECT images acquired 30 minutes and 3 hours after intravenous injection of 600 MBq of Tc-99m MIBI with three gamma camera detectors (GCA-9300A). Regions of interest were set in the area of abnormal uptake of Tc-99m MIBI and in an area of normal tissue in the contralateral lung. The uptake ratio of the lesion in the contralateral normal lung was obtained on the early image (early ratio; ER) as well as the delayed image (delayed ratio; DR). The benign lesions showed significantly lower ER (1.6 +/- 0.3) and DR (1.4 +/- 0.4) than the malignant lesions (1.9 +/- 0.5 and 1.8 +/- 0.5, respectively; both p < 0.05). There was no significant difference in the retention index (RI), calculated as RI = (DR-ER)/ER x 100. The DR obtained with Tl-201 SPECT images was significantly higher than that obtained with Tc-99m MIBI SPECT (p < 0.05). For the detection of mediastinal lymph node metastases, the early images showed sensitivity, specificity, and accuracy of 85.7%, 100%, and 95.2%, respectively, for the delayed images these values were 85.7%, 92.9%, and 90.5%, respectively. These results suggest that the uptake ratio of Tc-99m MIBI is a useful index in assessing benign or malignant pulmonary and mediastinal lesions.

In vitro uptake and release of TI-201 and Tc-99m MIBI in cultured tumor cells and effect of anticancer drug.

201Tl is useful in the diagnosis of tumor malignancy determined by the grade of washout rate to normal tissue, especially in lung tumors and thyroid tumors. 99mTc-MIBI, a tracer of myocardial blood flow, is also a tumor tracer. We examined whether the growth of tumor cells is related to the uptake and release of these tracers in cultured tumor cells. Cultured tumor cells (HeLa cells and squamous cell carcinomas derived from human lung cancer) were incubated for 60 min with 10 kBq of either tracer for the kinetic study of cellular uptake. They were additionally incubated for 90 min with cold medium for the kinetic study of cellular release. These cells cultured with various concentrations of actinomycin D (ACD) or CDDP were used to examine the correlation between the cellular growth and kinetics of these tracers. The cellular release of 201Tl increased relative to the concentration of added ACD or CDDP in both cell types. In contrast, the cellular release of 99mTc-MIBI was not changed by the addition of ACD in HeLa cells. In conclusion, 201Tl showed a slower washout rate in high-growth tumor cells than in low-growth tumor cells; thus, it could act as an indicator of tumor malignancy by assessing its washout rate.