The importance of level stratification for quantitative MR studies of lumbar intervertebral discs: a cross-sectional analysis in 101 healthy adults.

PURPOSE: To investigate whether quantitative T2-times depend on lumbar intervertebral disc (IVD) level. METHODS: The lumbar spine (Th12/L1-L5/S1) of 101 participants (53.5% female, 30.0[± 3.6]years, 173.5[± 9.6]cm and 69.9[± 13.4]kg), without history of back pain, was examined on a 3T scanner with sagittal T2-mapping. All IVDs were stratified according to Pfirrmann grade and lumbar level, with mean T2-time determined for the entire IVD volume and in five subregions of interests. RESULTS: Significant level-dependent T2-time differences were detected, both for the entire IVD volume and its subregions. For the entire IVD volume, Pfirrmann grade 2 IVDs displayed 9-18% higher T2-times in Th12/L1 IVDs compared to L2/L3-L5/S1 IVDs (0.001 > p < 0.004) and significantly different T2-times in L1/L2-L2/L3 IVDs compared to most of the IVDs in the lower lumbar spine. In Pfirrmann grades 1, 3 and 4 IVDs, no significant level-dependent T2-time differences were observed for the entire IVD. More pronounced results were observed when comparing IVD subregions, with significant level-dependent differences also within Pfirrmann grade 1 and grade 3 IVDs. For example, in posterior IVD subregions mean T2-time was 80-82% higher in Th12/L1 compared to L3/L4-L4/L5 Pfirrmann grade 1 IVDs (p < 0.05) and 10-14% higher in L5/S1 compared to L3/L4-L4/L5 Pfirrmann grade 3 IVDs (0.02 > p < 0.001). DISCUSSION: Significant level-dependent T2-time differences within several Pfirrmann grades, both for the entire IVD volume and for multiple IVD subregions, were shown in this large cohort study. The T2-time differences between levels existed in both non-degenerated and degenerated IVDs. These findings show the importance of stratifying for lumbar level when quantitative IVD studies are performed using T2-mapping. These slides can be retrieved under Electronic Supplementary Material.

Variability of T2-Relaxation Times of Healthy Lumbar Intervertebral Discs is More Homogeneous within an Individual Than across Healthy Individuals.

BACKGROUND AND PURPOSE: When one uses T2 relaxometry to classify lumbar intervertebral discs as degenerated, it is unclear whether the normative data should be based on other intervertebral discs from the same individual or from a pool of extraneous controls. This study aimed to explore the extent of intra- versus intersubject variation in the T2 times of healthy intervertebral discs. MATERIALS AND METHODS: Using prospectively acquired T2-relaxometry data from 606 intervertebral discs in 101 volunteers without back pain (47 men, 54 women) in a narrow age range (25-35 years), we calculated intra- and intersubject variation in T2 times of intervertebral discs graded by 2 neuroradiologists on the Pfirrmann scale. Intrasubject variation of intervertebral discs was assessed relative to other healthy intervertebral discs (Pfirrmann grade, ≤2) in the same individual. Multiple intersubject variability measures were calculated using healthy extraneous references ranging from a single randomly selected intervertebral disc to all healthy extraneous intervertebral discs, without and with segmental stratification. These variability measures were compared for healthy and degenerated (Pfirrmann grade ≥3) intervertebral discs. RESULTS: The mean T2 values of healthy (493/606, 81.3%) and degenerated intervertebral discs were 121.1 ± 22.5 ms and 91.5 ± 18.6 ms, respectively (P < .001). The mean intrasubject variability for healthy intervertebral discs was 9.8 ± 10.7 ms, lower than all intersubject variability measures (P < .001), and provided the most pronounced separation for healthy and degenerated intervertebral discs. Among intersubject variability measures, using all segment-matched healthy discs as references provided the lowest variability (P < .001). CONCLUSIONS: Normative measures based on the T2 times of healthy intervertebral discs from the same individual are likely to provide the most discriminating means of identifying degenerated intervertebral discs on the basis of T2 relaxometry.

Augmentation index in resistance to thyroid hormone (RTH).

OBJECTIVE: Resistance to thyroid hormone (RTH) is associated with a varied clinical presentation. The cardiac effects of RTH have been described but vascular function has yet to be fully evaluated in this condition. We have measured the arterial function of those with RTH to assess any vascular changes. DESIGN: An observational study. PATIENTS: Twelve RTH patients were recruited from the thyroid clinic (mean value +/- SD), age 40.8 +/- 18.7 years; BMI 27.2 +/- 4.2 kg/m(2) and compared with 12 healthy, euthyroid, age-matched controls (age 41.4 +/- 19.3; BMI 24.8 +/- 4.4 kg/m(2)) with no history of cardiovascular disease. No interventional measures were instituted. MEASUREMENTS: Arterial stiffness was measured using pulse wave analysis at the radial artery. Thyroid function, fasting lipids and glucose were also measured on the same occasion in both patients and controls. Results The corrected augmentation index, a surrogate marker of arterial stiffness was significantly higher in patients compared with controls (21.0% +/- 14.1%vs. 5.4% +/- 18.2%, P < 0.03). Low density lipoprotein cholesterol (LDL-cholesterol) levels were also significantly elevated in patients compared with controls (3.0 +/- 0.6 vs. 2.1 +/- 0.5 mmol/l; P < 0.002). CONCLUSION: RTH patients show evidence in this study of increased augmentation index consistent with an increase in arterial stiffness compared with euthyroid controls. They also demonstrate elevated LDL-cholesterol levels. Both these measures may lead to increased cardiovascular risk.

Effects of antihistamines on the lung vascular response to histamine in unanesthetized sheep. Diphenhydramine prevention of pulmonary edema and increased permeability.

To see whether antihistamines could prevent and reverse histamine-induced pulmonary edema and increased lung vascular permeability, we compared the effects of a 4-h intravenous infusion of 4 mug/kg per min histamine phosphate on pulmonary hemodynamics, lung lymph flow, lymph and plasma protein content, arterial blood gases, hematocrit, and lung water with the effects of an identical histamine infusion given during an infusion of diphenhydramine or metiamide on the same variables in unanesthetized sheep. Histamine caused lymph flow to increase from 6.0+/-0.5 to 27.0+/-5.5 (SEM) ml/h (P less than 0.05), lymph; plasma globulin concentration ratio to increase from 0.62+/-0.01 to 0.67+/-0.02 (P less than 0.05), left atrial pressure to fall from 1+/-1 to -3+/-1 cm H2O (P less than 0.05), and lung lymph clearance of eight protein fractions ranging from 36 to 96 A molecular radius to increase significantly. Histamine also caused increases in lung water, pulmonary vascular resistance, arterial PCO2, pH, and hematocrit, and decreases in cardiac output and arterial PO2. Diphenhydramine (3 mg/kg before histamine followed by 1.5 mg/kg per h intravenous infusion) completely prevented the histamine effect on hematocrit, lung lymph flow, lymph protein clearance, and lung water content, and reduced histamine effects on arterial blood gases and pH. 6 mg/kg diphenhydramine given at the peak histamine response caused lymph flow and lymph: plasma protein concentration ratios to fall. Metiamide (10 mg/kg per h) did not affect the histamine lymph response. We conclude that diphenhydramine can prevent histamine-induced pulmonary edema and can prevent and reverse increased lung vascular permeability caused by histamine, and that histamine effects on lung vascular permeability are H1 actions.

Less invasive stabilisation system plating for distal femoral fractures.

PURPOSE: To review the outcome of less invasive stabilisation system (LISS) plating for complex distal femoral fractures. METHODS: Records of 6 men and 11 women who underwent LISS plating for complex distal femoral fractures from September 2001 to August 2005 were reviewed. One patient who died 12 months after surgery due to a cardiac problem was excluded. The mean age of the remaining patients was 61 years and the mean follow-up period was 12 months. Four patients, 3 of whom had open fractures, had sustained high-energy trauma. According to the AO classification, 8 fractures were type 33A and 9 type 33C. RESULTS: The mean time to union was 17 weeks. Two patients with non-union underwent a second LISS plating and bone grafting, resulting in a satisfactory final outcome. Delayed radiographic union was observed in one patient, but clinically he was asymptomatic and mobile. The fracture finally united at 9 months. CONCLUSION: LISS plating is useful in treating complex distal femoral fractures, resulting in reduced blood loss and low infection rates, while achieving early mobility due to primary stability of the construct.

Lifestyle guidelines for managing adverse effects on bone health and body composition in men treated with androgen deprivation therapy for prostate cancer: an update.

BACKGROUND: Men treated with androgen deprivation therapy (ADT) for prostate cancer are prone to multiple treatment-induced adverse effects, particularly with regard to a deterioration in bone health and altered body composition including decreased lean tissue mass and increased fat mass. These alterations may partially explain the marked increased risk in osteoporosis, falls, fracture and cardiometabolic risk that has been observed in this population. METHODS: A review was conducted that assessed standard clinical guidelines for the management of ADT-induced adverse effects on bone health and body composition in men with prostate cancer. RESULTS: Currently, standard clinical guidelines exist for the management of various bone and metabolic ADT-induced adverse effects in men with prostate cancer. However, an evaluation of the effectiveness of these guidelines into routine practice revealed that men continued to experience increased central adiposity, and, unless pharmacotherapy was instituted, accelerated bone loss and worsening glycaemia occurred. CONCLUSIONS: This review discusses the current guidelines and some of the limitations, and proposes new recommendations based on emerging evidence regarding the efficacy of lifestyle interventions, particularly with regard to exercise and nutritional factors, to manage ADT-related adverse effects on bone health and body composition in men with prostate cancer.

Subclinical hypothyroidism, arterial stiffness, and myocardial reserve.

CONTEXT: Subclinical hypothyroidism (SCH) is associated with increased risk of cardiac disease; its impact on arterial function is less clear. OBJECTIVE: The objective of the study was the assessment of arterial and cardiac function. DESIGN: The study was a 6-month controlled observational study using pulse wave analysis and tissue Doppler dobutamine stress echocardiography. SETTING: The study was conducted at a thyroid clinic. PATIENTS: Nineteen female SCH patients with raised TSH, normal free T(4), and no cardiovascular disease [aged 49.2 +/- 3.8 yr; body mass index (BMI) 29.9 +/- 6.7 kg/m(2)] were recruited from the thyroid clinic, and 10 female controls (aged 50.2 +/- 3.4 yr; BMI 29.7 +/- 7.2 kg/m(2)) also participated in the study. INTERVENTIONS: Incremental doses of l-thyroxine were used. MAIN OUTCOME MEASURES: Indices of vascular stiffness and left ventricular echocardiographic function were measured. RESULTS: Baseline augmentation gradient was elevated in SCH, compared with controls [10.3 +/- 5.1 (sd) mm Hg vs. 8.0 +/- 4.2, P < 0.05]; when euthyroid (mean T(4) dose 114 mug/d), it fell to 8.8 +/- 5.3 mm Hg (P < 0.05). Heart rate-corrected augmentation index was 26.7 +/- 9.9 vs. 18.8 +/- 9.9% (P < 0.02), falling to 19.7 +/- 9.6% (P < 0.001) after treatment. Time of travel of the reflected wave was 139.3 +/- 11.7 msec, compared with 141.5 +/- 8.8 msec in controls (P < 0.05), increasing to 144.9 +/- 11.9 msec (P < 0.05). There were no differences in resting global, regional left ventricular function, or regional myocardial velocities during maximal dobutamine stress between SCH patients and controls, or in treated patients, compared with baseline. CONCLUSIONS: Arterial stiffness was increased in SCH and improved with l-thyroxine, which may be beneficial, whereas myocardial functional reserve was similar to controls and remained unaltered after treatment.

Evidence for a dihydropyridine-sensitive and conotoxin-insensitive release of noradrenaline and uptake of calcium in adrenal chromaffin cells.

1. It has been suggested that neuronal voltage-sensitive calcium channels (VSCC) may be divided into dihydropyridine (DHP)-sensitive (L) and DHP-insensitive (N and T), and that both the L and the N type channels are attenuated by the peptide blocker omega-conotoxin. Here the effects of omega-conotoxin on release of noradrenaline and uptake of calcium in bovine adrenal chromaffin cells were investigated. 2. Release of noradrenaline in response to 25 mM K+, 65 mM K+, 10 nM bradykinin or 10 microM prostaglandin E1 was not affected by omega-conotoxin in the range 10 nM-1 microM. 3. 45Ca2+ uptake stimulated by high K+ and prostaglandin was attenuated by 1 microM nitrendipine and enhanced by 1 microM Bay K 8644; these calcium fluxes were not modified by 20 nM omega-conotoxin. 4. With superfused rat brain striatal slices in the same medium as the above cell studies, release of dopamine in response to 25 mM K+ was attenuated by 20 nM omega-conotoxin. 5. These results show that in these neurone-like cells, release may be effected by calcium influx through DHP-sensitive but omega-conotoxin-insensitive VSCC, a result inconsistent with the suggestion that omega-conotoxin blocks both L-type and N-type neuronal calcium channels.

Influence of phorbol esters, and diacylglycerol kinase and lipase inhibitors on noradrenaline release and phosphoinositide hydrolysis in chromaffin cells.

1. We have investigated the modification of catecholamine efflux and inositol phosphate formation in cultured adrenal chromaffin cells by tetradecanoyl phorbol acetate (TPA) and inhibitors of diacylglycerol kinase (R 59,022) and diacylglycerol lipase (RG 80267), the two principal pathways of diacylglycerol metabolism. 2. TPA (1 nM to 1 microM) elicited a slow, calcium-dependent, sustained release of noradrenaline, which was partially blocked by the dihydropyridine calcium channel blocker (-)-202,791 and potentiated by the channel enhancer (+)-202,791. 3. R 59,022 enhanced noradrenaline efflux at 30 and 50 microM, while the lipase inhibitor RG 80267 failed to elicit release. 4. Neither R 59,022 nor RG 80267 affected bradykinin- or histamine-stimulated release, but both drugs substantially attenuated nicotine- and high K(+)-stimulated release. 5. Pretreatment for 10 min with TPA (but not the relatively inactive 4-methoxy TPA) or the non-phorbol protein kinase C stimulator mezerein potently inhibited bradykinin- and histamine-stimulated accumulation of total [3H]-inositol phosphate; inhibition of [3H]-inositol phosphate formation was also seen with 24 h TPA treatment. 6. Neither R 59,022 nor RG 80267, separately or together, affected bradykinin-stimulated [3H]-inositol phosphate formation. 7. Thus while the mechanism exists for inhibition of formation of inositol phosphates by stimulation of protein kinase C, these studies failed to show that this mechanism is activated by agonists acting on phospholipase C linked receptors.

Stimulation of phosphatidic acid synthesis in bovine aortic endothelial cells in response to activation of P2-purinergic receptors.

In this study we used the bovine thoracic aorta endothelial cell line AG 4762 and primary bovine aortic endothelial cells to investigate the formation of phosphatidic acid (PA) in response to activation of P2-purinergic receptors. 2-Methylthio ATP (2MeSATP) stimulated the formation of [32P]-PA in bovine aortic endothelial cells labelled with 32P(i) for 2.5 hr. A comparison of the response to other ATP analogues suggests that this was mediated via a P2Y-purinergic receptor. Using various agonists at 30 microM there was a correlation between the formation of [32P]PA and of total inositol phosphates in the presence of lithium. The 2MeSATP-stimulated accumulation of [32P]PA showed an initial high rate, followed by a more sustained slower rate. The initial response was independent of extracellular calcium while the later response was dependent on calcium influx. The protein kinase C stimulator phorbol myristate acetate (PMA) produced only a very small enhancement of [32P]PA accumulation compared to 2MeSATP. The 2MeSATP stimulation of both inositol phosphates and [32P]PA was almost eliminated by the presence of PMA. Using cells prelabelled with [3H]methylcholine 2MeSATP produced only a small non-significant enhancement of [3H]choline formation; PMA by contrast formed a much larger amount of [3H]choline. There was no evidence of a change in [3H]phosphocholine. The dissociation between phospholipase D (PLD) activation and [32P]PA accumulation and the correlation between stimulation of [32P]PA accumulation and phospholipase C (PLC) activation all suggest that, using this protocol for labelling cells, the principle route of the stimulation of formation of [32P]PA is via the activation of PLC followed by metabolism of diacylglycerol (DAG) by DAG kinase. These results show that activation of P2Y-purinergic receptors on aortic endothelial cells leads to the formation of phosphatidic acid and that both PLD and PLC pathways are likely to contribute to this response.

Trefoil factor expression in normal and diseased human salivary glands.

Trefoil factors are wound-healing peptides important in protection and healing of the human gastrointestinal tract. Their potential for therapy of gastrointestinal ulcers has been established. This study investigated the hypothesis that trefoil factors are also present in human salivary gland. Tissues from surgical biopsy specimens were collected fresh into ice and stored in liquid nitrogen. Breast, stomach, and colon constituted positive controls. Trefoil factor mRNAs were detected by reverse transcription polymerase chain reaction (RT-PCR) or by in situ hybridization (ISH) with formalin-fixed, paraffin-embedded sections. Amplified DNA fragments were ligated into pGEM-T Easy vector and used to transform competent Escherichia coli JM109, allowing sequencing to confirm identity of cloned fragments. Generation of amplifiable cDNA was confirmed using primers specific to the ubiquitously expressed abl gene. By RT-PCR, TFF1 (pS2) mRNA was detected in 14 of 15 glands, TFF3 (hITF) mRNA in 13, and TFF2 (hSP) in only 1 gland. ISH of 15 glands (7 of which had been studied by RT-PCR) showed the same pattern of expression and indicated that TFF1 mRNA was usually expressed at low levels by a few mucous cells, whereas TFF3 was produced abundantly by most mucous cells. There was no difference in patterns of expression comparing parotid, submandibular, and minor mucous glands. Nor was there an obvious relationship between trefoil factor expression and pathology, but those glands not expressing TFF1 or TFF3 had evidence of chronic inflammation or atrophy. Trefoil factors are likely to be important in healing, predisposition to, and therapy of, oral diseases.

Stiffness measurements to assess healing during leg lengthening. A preliminary report.

We describe a technique for measuring the stiffness of regenerate bone after leg lengthening. This allows early identification of slow healing by reference to normal patterns. We determined the time of removal of the fixator from clinical and radiological information independent of the stiffness result. In a series of 30 leg lengthenings there were no refractures when the tibial stiffness had reached 15 Nm/degree or the femoral stiffness 20 Nm/degree. Three refractures occurred at lower stiffness values. The technique is simple to perform, will allow a reduction in plain radiography and is recommended for routine postoperative management.

Fracture stiffness in callotasis determined by dual-energy X-ray absorptiometry scanning.

Assessing healing after distraction limb lengthening is essential to manage patients undergoing callotasis for leg lengthening or bone transport. Direct measurement of fracture stiffness can assess healing but the equipment may not be available. In addition, it requires removal of the fixator, which may be complicated for ring fixators. The present study investigates whether an equivalent measure of healing can be based on the mineral density pattern from dual-energy X-ray absorptiometry (DXA) scans. Nine consecutive patients undergoing callotasis were studied. Bending stiffness of the distraction segment was measured and DXA scans were performed regularly starting 6 weeks after completing distraction. In all, 23 simultaneous readings of bending stiffness and DXA scans were obtained. All density patterns showed a distinct minimum value of bone mineral density. We found a high and significant correlation between fracture bending stiffness and the square of the total mineral content at the location of minimum bone density (r2 = 0.77, P < 0.001). We conclude that DXA scans can be used reliably and effectively to determine fracture bending stiffness, valuable for determining both time of frame removal and delay in union.

Home-based paediatric records and communication in St. Lucia.

PIP: The usefulness of a home based pediatric record is examined in the home, child health clinics and hospital as a means of communicating health information. Such a record, the Child Health Passport (CHP) was successfully introduced into St. Lucia in 1976-77 and issued to all children under 5 years of age in order to facilitate communication between health workers and also between health workers and their patients. Data to be recorded on the CHP included weight (with a weight for age chart imprinted on the CHP), name and address, immunizations, and significant hospital problems and treatment. The card also had a pocket for messages and appointment schedules. Surveys on the use and condition of the card were taken at health centers, Casualty Department (Emergency Room) of the main hospital on the island, and the pediatric ward of the hospital; in addition, individual health workers were interviewed on the card's effectiveness and their feelings about its use. Results show the CHP highly accepted by the public with 86.1% to 93.6% of children being in possession of it. However, there was a progressive decrease in the presence of the card in the district doctor's clinic (69%), Casualty Department (57.2%), and hospital ward (39%). The main problem appears to be the need for the involvement of the doctor in using this record in hospital and in the district clinic. Parents and primary health care workers are shown to be conscientious in using the home based records and recommentation is made to extend use of the CHP to at least the antenatal and chronic disease areas, and possibly to the area of all clinical information at primary and secondary levels in the Caribbean. Charts detail the content of the CHP, and reasons it is preferable to the clinic record from different health worker's points of view.^ieng

Prophylactic radiotherapy against heterotopic ossification following internal fixation of acetabular fractures: a comparative estimate of risk.

OBJECTIVE: Radiotherapy (RT) is effective in preventing heterotopic ossification (HO) around acetabular fractures requiring surgical reconstruction. We audited outcomes and estimated risks from RT prophylaxis, and alternatives of indometacin or no prophylaxis. METHODS: 34 patients underwent reconstruction of acetabular fractures through a posterior approach, followed by a 8-Gy single fraction. The mean age was 44 years. The mean time from surgery to RT was 1.1 days. The major RT risk is radiation-induced fatal cancer. The International Commission on Radiological Protection (ICRP) method was used to estimate risk, and compared with a method (Trott and Kemprad) specifically for estimating RT risk for benign disease. These were compared with risks associated with indometacin and no prophylaxis. RESULTS: 28 patients (82%) developed no HO; 6 developed Brooker Class I; and none developed Class II-IV HO. The ICRP method suggests a risk of fatal cancer in the range of 1 in 1000 to 1 in 10,000; the Trott and Kemprad method suggests 1 in 3000. For younger patients, this may rise to 1 in 2000; and for elderly patients, it may fall to 1 in 6000. The risk of death from gastric bleeding or perforation from indometacin is 1 in 180 to 1 in 900 in older patients. Without prophylaxis risk of death from reoperation to remove HO is 1 in 4000 to 1 in 30,000. CONCLUSION: These results are encouraging, consistent with much larger series and endorse our multidisciplinary management. Risk estimates can be used in discussion with patients. ADVANCES IN KNOWLEDGE: The risk from RT prophylaxis is small, it is safer than indometacin and substantially overlaps with the range for no prophylaxis.

Detection of a noble gas molecular ion, 36ArH+, in the Crab Nebula.

Noble gas molecules have not hitherto been detected in space. From spectra obtained with the Herschel Space Observatory, we report the detection of emission in the 617.5- and 1234.6-gigahertz J = 1-0 and 2-1 rotational lines of (36)ArH(+) at several positions in the Crab Nebula, a supernova remnant known to contain both molecular hydrogen and regions of enhanced ionized argon emission. Argon-36 is believed to have originated from explosive nucleosynthesis in massive stars during core-collapse supernova events. Its detection in the Crab Nebula, the product of such a supernova event, confirms this expectation. The likely excitation mechanism for the observed (36)ArH(+) emission lines is electron collisions in partially ionized regions with electron densities of a few hundred per centimeter cubed.