Males Have Higher Rates of Peri-operative Mortality Following Surgery for Osteoporotic Vertebral Compression Fracture.

In this study, we evaluated the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF. We found no statistical association between surgical complications and patient sex. However, males exhibited higher rates of mortality and 30-day readmissions relative to females. INTRODUCTION: Osteoporotic vertebral compression fractures (OVCF) contribute substantially to the financial burden of the US healthcare system. As the size of the elderly population grows, the number of fractures attributed to osteoporosis is expected to increase. Studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications. The purpose of this study was to evaluate the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF. METHODS: A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients. Patients were grouped as male or female. Mortality within 30 days of surgery due to any cause, incidence of surgical complications, and 30-day readmission rates following surgery were tabulated. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR) with corresponding p values and 95% confidence intervals. RESULTS: In total, 1979 patients met inclusion and exclusion criteria. Mortality within the 30 days following surgery for OVCF was statistically greater in men than in women (OR = 1.58; p = 0.050). The 30-day readmission rate was also statistically higher in men (OR = 1.41; p = 0.017). Neither minor (OR = 0.90; p = 0.560) nor major (OR = 1.14; p = 0.569) complications were statistically correlated with sex. On average, men underwent surgery for OVCF at a younger age than women. CONCLUSIONS: Male patients undergoing surgery for OVCF have higher rates of peri-operative mortality and 30-day readmissions following surgery. Sex was not found to be associated with postoperative complications. LEVEL OF EVIDENCE: III.

The role of the Community Pharmacist in promoting vaccinations among general population according to the National Vaccination Plan 2017-2019: results from a survey in Sicily, Italy.

INTRODUCTION: The 2017-2019 Italian National Vaccination Plan promotes the improvement of knowledge and attitudes of healthcare workers about vaccine prevention, in order to spread a vaccination culture among general population. Similarly to the General Practitioner, the Pharmacist represents a fundamental forefront for both patients and healthy people, also in promoting vaccine acceptance. This research aims to analyze knowledge and attitudes about vaccines of Community Pharmacists and to evaluate the burden of vaccination counselling during their work activities. MATERIAL AND METHODS: A standardized, self-administered and previously validated questionnaire, including 5 sections and 28 items, was submitted to a sample of Community Pharmacists working in Western Sicily. The survey was carried out through an online questionnaire, that investigated socio-demographic data, knowledge and attitudes towards vaccination and the role of the Pharmacist as vaccination counselor during his work. RESULTS: A total of 120 Pharmacists were surveyed. 99.2% of them were definitely agreed with the Regional Vaccination Schedule. A large majority (n = 114, or 95%) were fully vaccinated and have vaccinated, or would vaccinate in future, their children. According to Community Pharmacists interviewed, at least 90% of clients asked for further explanations about vaccination, and the citizens' trust towards vaccination increased (30%) or remained stable (54.2%) over time in the last 5 years. Finally, as reported by interviewed Pharmacists, a correct counselling provided by General Practitioners (GPs) and Family Pediatricians was the main boost in increasing vaccination confidence, instead of mass-media and web misinformation that has led to skepticisms among general population. CONCLUSION: The study demonstrated the key role of the Community Pharmacist for their consumers in vaccination counselling. In future, a strong collaboration between Community Pharmacists and all the actors promoting vaccination themes (GPs, family Pediatricians, public health workers) will be essential, as well as a uniform and standardized University training on vaccination themes for all these categories.

The human invariant chain is the core protein of the human class II-associated proteoglycan.

The human class II-associated chondroitin sulfate proteoglycan (CSPG) was analyzed biochemically and immunologically to determine a possible relationship with the human invariant chain (gamma 1) and its related components. The CSPG was purified by a three-step procedure involving associative ion-exchange chromatography, immunoprecipitation, and dissociative ion-exchange chromatography. Treatment of the CSPG with chondroitinase revealed core proteins of Mr approximately 46,000, 38,000, and 28,000, with the 38,000 species most highly represented. Tryptic peptide analysis revealed identity of the peptides of the 38,000 Mr core protein and gamma 1, and of the 28,000 Mr species and p25. The CSPG and its core proteins were shown to react directly with the mouse anti-human invariant chain monoclonal antibody VIC-Y1 and a rabbit antiserum produced against a synthetic peptide corresponding to the C-terminal end of invariant chain. These results demonstrate that the invariant chain is the core protein of the class II-associated CSPG. In addition, virtually all the CSPG was shown to be present on the cell surface.

Pocket 4 of the HLA-DR(alpha,beta 1*0401) molecule is a major determinant of T cells recognition of peptide.

To investigate the functional roles of individual HLA-DR residues in T cell recognition, transfectants expressing wild-type or mutant DR(alpha,beta 1*0401) molecules with single amino acid substitutions at 14 polymorphic positions of the DR beta 1*0401 chain or 19 positions of the DR alpha chain were used as antigen-presenting cells for five T cell clones specific for the influenza hemagglutinin peptide, HA307-19. Of the six polymorphic positions in the DR beta floor that were examined, mutations at only two positions eliminated T cell recognition: positions 13 (four clones) and 28 (one clone). In contrast, individual mutations at DR beta positions 70, 71, 78, and 86 on the alpha helix eliminated recognition by each of the clones, and mutations at positions 74 and 67 eliminated recognition by four and two clones, respectively. Most of the DR alpha mutations had minimal or no effect on most of the clones, although one clone was very sensitive to changes in the DR alpha chain, with loss of recognition in response to 10 mutants. Mutants that abrogated recognition by all of the clones were assessed for peptide binding, and only the beta 86 mutation drastically decreased peptide binding. Single amino acid substitutions at polymorphic positions in the central part of the DR beta alpha helix disrupted T cell recognition much more frequently than substitutions in the floor, suggesting that DR beta residues on the alpha helix make relatively greater contributions than those in the floor to the ability of the DR(alpha,beta 1*0401) molecule to present HA307-19. The data indicate that DR beta residues 13, 70, 71, 74, and 78, which are located in pocket 4 of the peptide binding site in the crystal structure of the DR1 molecule, exert a major and disproportionate influence on the outcome of T cell recognition, compared with other polymorphic residues.

Antibody recognition of an immunogenic influenza hemagglutinin-human leukocyte antigen class II complex.

The A/Japan/57 influenza hemagglutin (HA) peptide HA 128-145, when bound by human histocompatibility leukocyte antigen-DRw11 cells, is recognized by the human CD4+ T cell clone V1. A rabbit antiserum has been raised against HA 128-145 which recognizes not only the free peptide, but also the HA 128-145/DRw11 complex on a solid matrix, in solution, or on the surface of viable cells. The detection of these complexes on viable cells was shown to be class II specific, DRw11 restricted, and commensurate with the level of DRw11 expression. The identity of DRw11 as the cell surface molecule binding HA 128-145 was confirmed by immunoprecipitation, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and tryptic peptide mapping. Using this antiserum HA 128-145/DRw11 complexes could be detected on the cell surface as soon as 30 min after the peptide was added, and increased up to 24 h. Dissociation kinetics showed these complexes were long-lived, with a half-life of approximately 14 h. This anti-HA peptide antiserum represents the first direct means of studying antigenic peptide-human leukocyte antigen class II complexes on the surface of living cells without the addition of a non-amino acid moiety to the peptide. The properties of this antiserum thus provide the potential to study naturally processed antigenic peptides as well as the mechanism of processing itself in a physiologically relevant system.

What gastroenterologists should know about direct oral anticoagulants.

Direct oral anticoagulants are being increasingly used in patients with non-valvular atrial fibrillation and venous thromboembolism, due to their improved efficacy/ safety ratio, a predictable anticoagulant effect without need for routine coagulation monitoring, and fewer food and drug interactions compared with vitamin K antagonists. Gastrointestinal bleeding remains a serious complication, whose management is challenging for gastroenterologists due to the lack of a standardized clinical approach. Clinical experience on periendoscopic management of these drugs is still limited and there is a paucity of clinical data supporting guidelines recommendations', and this ultimately turns out in different, unsubstantiated and potentially harmful practices of patient management. Present study will provide a thorough revision on the risk of GI bleeding for DOAC therapy and the identification of patient risk factors to individualize treatment. Moreover, the approach to management of DOACs in case of bleeding complications is discussed, and an algorithm of different strategies in presence or not of plasma level measurement is proposed. Finally the periendoscopic management for elective procedures will be reviewed, at the light of the guideline recommendations and new evidences from observational studies.

Validation of multisociety combined task force definitions of abnormal disk morphology.

BACKGROUND AND PURPOSE: The multisociety task force descriptively defined abnormal lumbar disk morphology. We aimed to use their definitions to provide a higher level of evidence for the validation of MR imaging in the evaluation of this pathology in patients who have undergone diskectomy by retrospectively classifying their preoperative MRI. MATERIALS AND METHODS: This retrospective, institutional review board-approved study included 54 of 86 consecutive patients (47 men; average age, 44 years) enrolled in an ongoing prospective trial of surgically treated lumbar disk herniation who had preoperative MRI and documented intraoperative classification of the abnormal disk as protrusion, extrusion, or sequestration by the treating surgeon. Preoperative MRI was classified by 2 blinded radiologists; discrepancies were resolved by a third reader. Statistical analysis of interobserver agreement and imaging compared with surgical findings was performed. RESULTS: The readers disagreed on only 1 of the 54 cases. The third reader resolved the disagreement. Eight protrusions and 46 extrusions were found on imaging, with no sequestrations. At surgery, there were 13 protrusions and 40 extrusions, with 2 of the extrusions also containing sequestrations; the remaining case had only sequestration. There were 16 discrepancies between imaging and surgery, resulting in 70% agreement. CONCLUSIONS: This study, which was intended to validate the multisociety combined task force definitions of abnormal disk morphology by using MR imaging with a surgical criterion standard, found 70% agreement between imaging diagnosis and surgical findings. Although reasonable, this finding highlights differences that often exist between intraoperative and preoperative imaging findings of lumbar disk herniation.

The molecules recognized by anti-MT2 alloantisera and anti-MT2-like (DRw52) monoclonal antibodies are different.

The human class II alloantigens include the HLA-DR, DQ, and MT determinants. Previous reports in the literature suggest that while the DQ determinants appear to be on a molecule separate from DR, the MT determinants are variably present on DR or DQ molecules. We have previously reported, using the homozygous DR5 cell line Swei, that the MT4 determinant defined by the allosera, MGH88B, was only on the DQw3 molecule, while MT2, defined by the functionally monospecific anti-MT2 alloantiserum MGH87B, was present on both the DR5 and DQw3 molecules. We now report using the monoclonal antibody ILR2 directed against an MT2-like determinant DRw52, that DRw52 is present on the DR molecules only. The MT2 determinant(s) recognized by the functionally monospecific alloantisera MGH87B appear to include the DRw52 determinant(s) recognized by the monoclonal antibody ILR2.

The HLA-class II-associated chondroitin sulfate proteoglycan expressed by class II positive T and monocyte-like cell lines is larger than that expressed by EBV-transformed B-lymphoblastoid cell lines.

The human class II-associated chondroitin sulfate proteoglycan (CSPG) was originally detected as an approximately 40-70 kd species from normal human tonsil cells and Epstein-Barr virus (EBV) transformed B-lymphoblastoid cell lines. The identification of the invariant chain as the core protein of the CSPG allowed us to directly assay for the CSPG on both class II positive and negative immunocompetent cells of other lineages. Our results indicate that the CSPG is present on the class II-positive monocyte-like cell line U937 and T-cell line HUT-102, but not on the class-II negative T-cell line CCRF/CEM. No class II positive cells were found that did not also express the CSPG. The expression of the CSPG on U937 cells is increased after stimulation with gamma-interferon and PMA, paralleling the previously described increase in class II and invariant chain expression. In addition, the CSPGs from U937, HUT-102, and Raji, all cell lines derived from human malignancies, migrate as an approximately 55-90 kd species, larger than the CSPG previously characterized. However, the core proteins of the CSPG from all cells studied appear as two bands of 38 and 28 kd, indicating the size difference in the CSPG is attributable to differences in the glycosaminoglycan chains.

A new polymorphic determinant on HLA-DQ molecules.

In man, the immune response genes are located within the HLA-D/DR region, and the gene products, the Ia antigens, are expressed on B lymphocytes, monocytes, and a percentage of null cells and activated T lymphocytes. We recently identified a human Ia antigen, K19, which appeared to be limited in its expression to B lymphocytes, and to be preferentially expressed on the more mature cells within this population. This work was facilitated by a monoclonal antibody. HK-19, which recognized a monomorphic determinant of this Ia molecule. We now report the characterization of a second monoclonal antibody, HK-13, which recognized the same molecule as HK-19, but only on cells from some individuals. The greater affinity of HK-13 allowed more complete characterization of the K19/K13 molecule. This characterization included cytofluorography, two-dimensional gel electrophoresis, tryptic peptide mapping, and partial N-terminal amino acid sequencing, and indicated that K19 and K13 were epitopes on HLA-DQ (DC) molecules. The pattern of reactivity of HK-13 on a panel of typing cells did not correlate with any of the known HLA-DQ polymorphic determinants. Thus, HK-13 is a new polymorphic determinant of the HLA-DQ series.

Potentiation of antitumor activity of irinotecan by chemically modified oligonucleotides.

Co-administration of synthetic chemically modified oligonucleotides with irinotecan, a selective topoisomerase I inhibitor, provided a significant enhancement in the antitumor activity of irinotecan. The enhancement of antitumor activity of irinotecan with co-administration of chemically modified oligonucleotides was observed in several tumor models--pancreatic cancer (Panc-1), colon cancer (HCT-116) and melanoma (A375). Inhibition of tumor growth in all three models required the co-administration of irinotecan and chemically modified oligonucleotides, but was independent of the nucleotide sequence of the oligonucleotides. The potentiation of antitumor activity was dependent on the dose of irinotecan and chemically modified oligonucleotides administered. The enhancement of antitumor activity of irinotecan was also observed by co-administration of a phosphorothioate oligonucleotide, however, to a lesser extent than did chemically modified oligonucleotides, suggesting that metabolic stability of the oligonucleotide contributes to the enhancement of antitumor activity seen with irinotecan. The co-administration of dextran sulfate sodium with irinotecan showed insignificant potentiation of antitumor activity of irinotecan, suggesting that the enhancement of antitumor activity of irinotecan observed was not a result of polyanionic characteristic of oligonucleotides. Co-administration of irinotecan and chemically modified oligonucleotides did not result in increased toxicity in the tumor models studied. Potentiation of antitumor activity of irinotecan observed with co-administration of oligonucleotides suggests that the oligonucleotides affect the pharmacokinetics and/or metabolism of irinotecan. The use of chemically modified oligonucleotides together with irinotecan may increase the therapeutic index of irinotecan in cancer patients and continued development of such agents should be considered.

Nerve growth factor modulates the expression of muscarinic cholinergic receptor messenger RNA in telencephalic neuronal cultures from newborn rat brain.

The effect of nerve growth factor (NGF) on muscarinic receptor subtypes was investigated in a primary culture of telencephalic neurons prepared from neonatal rats. The treatment with 100 ng/ml of NGF significantly enhanced choline acetyltransferase (ChAT) activity and intracellular acetylcholine (ACh) content during cultivation. The same treatment induced an early transient increase of the number of muscarinic cholinergic receptors (mAChR), as measured by [3H]quinuclidinyl benzilate binding to cell homogenate, that was followed by a dramatic decrease of the receptor density from the 9th day of culture. Atropine completely prevented the decrease of the maximal number of muscarinic recognition sites induced by NGF. Prolonged exposure of telencephalic neurons to NGF also induced a significant reduction of the relative content of the messenger RNA (mRNA) encoding m1 and m3 receptors, while the m4 transcript was increased by the treatment. We suggest that the prolonged stimulation of cholinergic neurons by NGF induces a downregulation of m1 and m3 mAChR and their mRNAs on the postsynaptic site, while it increases the synthesis of the functionally distinct m4 receptor subtype, which might be presynaptically localized on cholinergic neurons. The transient increase of the receptor number that occurs at the first days of culture was not paralleled by changes in the relative content of mAChR mRNAs and might be associated with the trophic activity of NGF on cholinergic synapses during early development.

Postoperative synergistic gangrene after spinal fusion.

STUDY DESIGN: A case of synergistic necrotizing gangrenous fasciitis after spinal surgery is reported. OBJECTIVES: To describe this unusual complication, explain the rationale of treatment, and increase awareness of this serious postoperative complication. SUMMARY OF BACKGROUND DATA: Although several cases of postoperative synergistic necrotizing fasciitis have been reported, there are no previously reported cases of this condition after spinal surgery. METHODS: A rapidly progressive necrotizing spinal wound infection after fusion for degenerative disc disease was treated in a 39-year-old man. RESULTS: The infection was successfully treated with serial debridements, appropriate antibiotics, and hyperbaric wound oxygenation. CONCLUSIONS: The authors suggest adherence to the fundamental principles of treatment including radical surgical debridement and appropriate antibiosis for necrotizing gangrene after spinal surgery. In evaluation of aggressive spinal wound infections, diagnosis of synergistic necrotizing fasciitis should be kept in mind. Although hyperbaric wound oxygenation was implemented as an adjunct and appeared to aid in controlling the infection, its effect on outcome is not clear.

Technique for the harvesting of human cadaveric spines.

STUDY DESIGN: One hundred twelve fresh cadaveric spines were harvested using a newly described technique. OBJECTIVES: To develop and describe a technique for the expeditious excision of intact human cadaveric spines for biomechanical testing, to educate the dissector on the health and safety issues involved in harvesting spinal specimens, and to review the present recommendations for storage and preservation of spinal segments. SUMMARY OF THE BACKGROUND DATA: As the need for biomechanical spinal research continues to expand, the demand for fresh human cadaveric vertebral specimens increases. Previous techniques for harvesting are simplistic and sparse. This technique offers a reliable and expeditious method for procurement of spinal vertebral segments of any size. METHODS: Human cadaveric spines were harvested using an adaptation of previous posterior spinal approaches. Techniques for sectioning each vertebral region were developed. Detailed description of these techniques was meticulously documented. The procured spinal segments have been used for multiple biomechanical investigations. RESULTS: The technique has been used successfully in more than 100 spinal harvests. Approximate time required is 30 minutes. The harvested segments have been reliable biomechanical specimens in many published studies. CONCLUSIONS: A new technique for the rapid extraction of human cadaveric spines has been developed. Dissectors may benefit from the recommendations offered for sectioning of each region.

Occipital screw pullout strength. A biomechanical investigation of occipital morphology.

STUDY DESIGN: A three-group design with consistent pullout strength measures. OBJECTIVES: To determine pullout strength of three fixation types (unicortical screws, bicortical screws, wires) and to investigate their correlation with respect to occipital morphology. SUMMARY OF BACKGROUND DATA: A secured, multidirectional occipitocervical fusion requires internal fixation. Devices secured at occipital protuberance were suggested to offer the greatest pullout strength because of this region's thickness. METHODS: Twelve fresh human cadaveric occiputs were sketched with a grid delineating 21 fixation sites. Each site was drilled and hand-tapped. Four specimens were instrumented with unicortical screws on one side of the midline and bicortical screws on the other. Another four were instrumented with bicortical screws and wires, and the remaining four were instrumented with unicortical screws and wires. Two points on each specimen were secured with identical fixation to examine side-to-side symmetry. An MTS materials testing apparatus (MTS Systems Corporation, Eden Prairie, MN) was used to displace the fixators. Pullout strengths at different anatomic locations were recorded. RESULTS: The greatest pullout strength was at the occipital protuberance for all fixation types. The bicortical pullout strength was 50% greater than unicortical. The wire pullout strength was not significantly different from that of the unicortical screw (P > 0.05). Seventy-eight percent of wires broke at 1100 N. Unicortical pullout strength at occipital protuberance was comparable with that of the bicortical screw at other locations. CONCLUSIONS: Unicortical screw fixation at occipital protuberance offers acceptable pullout strength without the potential complications of bicortical screws or wire fixation.

Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder.

Using a dynamic biomechanical model of malunion of the shoulder, we have determined the change in deltoid force required for abduction with various combinations of superior and posterior displacement of fractures of the greater tuberosity of the humerus. We tested eight fresh human cadaver shoulders in a dynamic shoulder-testing apparatus during cycles of glenohumeral abduction from 0 degrees to 90 degrees. The greater tuberosities were osteotomised and stabilised to represent malunion with combinations of superior and posterior displacements of 1 cm and less. The peak force was measured for each displacement in each specimen and statistically compared with values of no displacement using a repeated-measures analysis of variance. The abduction force was significantly increased by 16% (p = 0.006) and 27% (p = 0.0001) by superior displacements of 0.5 cm and 1 cm, respectively, while combined superior and posterior displacement of 1 cm gave an increase in force of 29% (p = 0.001). While treatment criteria for acceptable residual displacement of the greater tuberosity are widely used, there is little information on the direct biomechanical effects of displacement on shoulder mechanics. Although the results of conservative treatment are influenced by a number of factors, including associated injuries, rehabilitation and the pre-existing function of the shoulder, our data suggest that small amounts of residual displacement may alter the balance of forces required to elevate the arm at the glenohumeral joint.

Nonarticular proximal tibia fractures: treatment options and decision making.

Nonarticular proximal-third fractures account for 5% to 11% of tibial shaft injuries and occur as a result of a variety of mechanisms. Treatment is more challenging than for more distal fractures, and the rates of compartment syndrome and arterial injury are higher, especially for displaced fractures. Closed management often leads to varus malunion, especially when the fibula is intact. Closed treatment should therefore be reserved for nondisplaced or minimally displaced fractures with little soft-tissue injury. Plating of the proximal tibia has become a less popular alternative because of the high incidence of infection and fixation failure. However, judicious use of lateral plates as an adjunct to medial external fixation in comminuted fractures can be effective. External fixation remains the most versatile method. It is indicated for fractures with short proximal fragments and in cases of extensive soft-tissue injury that would preclude use of other surgical techniques. Temporary joint-spanning external fixation has a role in the initial management of certain fracture patterns, particularly when accompanied by severe soft-tissue injury. Although intramedullary nailing can lead to valgus malunion in a sizable percentage of patients with this injury, it can be useful for stabilizing fractures with proximal fragments longer than 5 to 6 cm. Placing the entry portal more proximal and lateral, locking in extension, and using specific techniques, such as blocking screws, can improve alignment after nailing. Use of an algorithm that takes into account the severity of soft-tissue injury, the length of the fracture fragment, and the degree of fracture stability allows effective decision making among current treatment techniques.

In vivo activation of murine peritoneal macrophages by Nocardia water soluble mitogen (NWSM).

In vitro NWSM has been shown to be a B cell mitogen and a polyclonal activator. Although NWSM has been also shown to be adjuvant active in vivo, motogenicity and polyclonal activation are not observed when this fraction has been administered to mice. In contrast, the experiments reported here demonstrate that after in vivo administration several effects of NWSM on mouse peritoneal macrophages can be observed: NWSM was able to induce an important increase in the ability of peritoneal macrophages to inhibit in vitro growth of tumor cells, to increase their phagocytic activity and to enhance their ability to induce an immune response, following the incubation with an antigen NWSM was able to stimulate phagocytic activity of macrophages of C3H/He Orl. mice (LPS-resistant strain). Those findings suggest that the adjuvant activity of NWSM in vivo can be related to its capacity to activate macrophages.

Metastatic spinal tumors.

Metastatic spinal tumors are the most common type of malignant lesions of the spine. Prompt diagnosis and identification of the primary malignancy is crucial to overall treatment. Numerous factors affect outcome including the nature of the primary cancer, the number of lesions, the presence of distant nonskeletal metastases, and the presence and/or severity of spinal cord compression. Initial management consists of chemotherapy, external beam radiotherapy, and external orthoses. Surgical intervention must be carefully considered in each case. Patients expected to live longer than 12 weeks should be considered as candidates for surgery. Indications for surgery include intractable pain, spinal cord compression, and the need for stabilization of impending pathological fractures. Whereas various surgical approaches have been advocated, anterior-approach surgery is the most accepted procedure for spinal cord decompression. Posterior approaches have also been used with success, but they require longer-length fusion. To obtain a stable fixation, the placement of instrumentation, in conjunction with judicious use of polymethylmethacrylate augmentation, is crucial. Preoperative embolization should be considered in patients with extremely vascular tumors such as renal cell carcinoma. Vertebroplasty, a newly described procedure in which the metastatic spinal lesions are treated via a percutaneous approach, may be indicated in selected cases of intractable pain caused by non- or minimally fractured vertebrae.

Prenatal care use in nonmetropolitan and metropolitan America: racial/ethnic differences.

Pregnant women in nonmetropolitan communities are believed to use prenatal care services at lower rates than are metropolitan residents due to higher levels of poverty, lower levels of insurance coverage, and declining numbers of local hospitals and physicians. Yet scarce data exist on actual patterns of prenatal care use in nonmetropolitan areas. This study provides national estimates of prenatal care use among African American, White, and Hispanic women who delivered in 1988 in non-metropolitan and metropolitan areas of the United States. This study finds that nonmetropolitan residents are no more likely than metropolitan residents to go without care, to enter care late, or to make fewer visits. Nonmetropolitan residents are more likely to receive "inadequate" prenatal care as measured by the Kotelchuck Adequacy of Prenatal Care Utilization Index, with Hispanic residents having the highest rates of inadequate care. These findings are consistent with recent state-level reports, and they suggest the need to target prenatal care policies for populations in greatest need.