The clinical significance of the high-intensity zone on lumbar spine magnetic resonance imaging.

STUDY DESIGN: Prospective observational study of anular tears, diagnosed by a high-intensity zone within the anulus on lumbar spine magnetic resonance imaging, and correlation with the clinical features. OBJECTIVES: To assess the prevalence of high-intensity zones in patients who are investigated for back and leg pain and to determine whether there are clinical features that can be used for diagnosis of the presence of a high-intensity zone. SUMMARY OF BACKGROUND DATA: Results in previous studies have shown that the presence of a high-intensity zone is associated with reproduction of a patient's pain on stress discography. Neural compression on magnetic resonance imaging has been shown to be associated with back pain, but to date, no study has correlated the presence of a high-intensity zone with the clinical features. METHODS: The lumbar spine magnetic resonance images in 156 patients in whom back and leg pain were investigated were analyzed for the presence and appearances of high-intensity zones. The clinical features of those patients with a high-intensity zone but with no evidence of neural compression on magnetic resonance imaging were analyzed by t test and X2 test. RESULTS: A high-intensity zone occurred in patients at a prevalence of 45.5% and usually occurred posteriorly (77%) and posterolaterally (22%) within the anulus. There were no features within the history, functional disability questionnaire, or physical examination that aided in a clinical diagnosis of those patients with a high-intensity zone. CONCLUSIONS: A high-intensity zone is a common finding in patients in whom low back and leg pain are investigated, but the presence of a high-intensity zone does not define a group of patients with particular clinical features.

The therapeutic impact of lumbar spine MRI on patients with low back and leg pain.

UNLABELLED: The influence of lumbar spine magnetic resonance imaging (MRI) on the management of patients with low back and leg pain, with a clinical diagnosis of neural compression, has been investigated by a controlled prospective observational study. The clinical features of the patients at the time of request for MRI have been compared with the subsequent management in order to define the clinical indications for lumbar spine MRI. METHODS: Clinical history, physical examination findings and tests of functional and psychological disability were all recorded at the time of request for MRI. Following MRI, patients were assessed without knowledge of the MRI findings and a diagnosis and management plan recorded. Immediate access to the MRI report and hard copy films was then provided and a revised diagnosis and management plan made. The clinical features and MRI findings were compared with the subsequent management. RESULTS: Seventy-two patients were examined, 65 (90.3%) had leg pain as a predominant feature and abnormalities in neurological examination were found in 31 (43%). Twenty-three of 48 (47.9%) of patients with a pre MRI management plan of surgery were changed to conservative management following the MRI. The diagnosis altered in 50 % of cases with the largest change in diagnosis occurring in 13 patients where MRI did not confirm the clinical impression of nerve root compression. Seventeen patients with no abnormality of neurological testing were subsequently treated by surgery which included all 12 patients treated by spinal fusion. CONCLUSIONS: The major impact of MRI was to move patients towards conservative treatment. A variety of features in the history and physical examination as well as MRI findings are predictors for surgical treatment. The variety of diagnoses and surgical options available make it difficult to define clear clinical guidelines for the use of MRI.

Generation and characterization of a polyclonal antipeptide antibody to human glycodelin.

OBJECTIVE: To develop and characterize an antiglycodelin antibody using a 15-amino acid synthetic peptide as antigen, derived from the sequence of human glycodelin. DESIGN: We have developed a chicken antiglycodelin-derived peptide antibody and have characterized the antibody with the use of endometrial and ovarian cell lines. The antibody was also tested for its ability to detect glycodelin by ELISA assay, immunocytochemistry, and by Western blot. SETTING: Various cell lines, cell culture medium, and amniotic fluid were used in the experiments. PATIENT(S): Amniotic fluid was collected from pregnant patients in their first trimester of pregnancy. INTERVENTION(S): No intervention. MAIN OUTCOME MEASURE(S): Detection of glycodelin. RESULT(S): The cell lines RL95-2 (human endometrial carcinoma cells), OVCAR-3 (human ovarian adenocarcinoma cells), HeLa (human cervical epitheloid carcinoma cells), and EM42-D (human endometrial epithelial cells) reacted with the antibody, indicating the presence of glycodelin. A specific 45-kd protein representing glycodelin was detected by Western blot in the amniotic fluid. CONCLUSION(S): Antipeptide antibodies can be successfully used to detect and quantify the presence of glycodelin in cells and fluids.

The measurement of lumbar proprioception in individuals with and without low back pain.

STUDY DESIGN: A clinical trial comparing a back pain group with a pain-free group. OBJECTIVES: To investigate whether proprioceptive deficits existed in a group of individuals reporting low back pain. SUMMARY OF BACKGROUND DATA: Little work has so far been conducted on the measurement of proprioception in the spine. Those studies that have been carried out, however, have failed to identify proprioceptive deficits in individuals with back pain. Previous work on peripheral joints has revealed that proprioception is affected with muscular or joint injury or degeneration. METHODS: Forty individuals took part in the study, 20 with back pain and 20 with no pain. Participants were required to reproduce a predetermined target position, in standing and four-point kneeling, 10 times in 30 seconds. A computer screen was used to provide visual feedback on position. A mean deviation from the target position was obtained for each individual. A measurement of left elbow position sense was conducted in five individuals from each group to establish differences in short-term motor memory between the groups. RESULTS: There were no differences between the subject groups in terms of short-term motor memory (P > 0.05). A two-way analysis of variance between subject groups and position to identify differences in accuracy (deviation from the target) found that there were differences between subject groups in either position (P < 0.05). There was no significant difference in accuracy between the positions used (P > 0.05). CONCLUSIONS: Differences in proprioception do exist between individuals with back pain and those free from back pain. Further research needs to be undertaken on proprioceptive exercise programs and their effect on back pain.

Intratester and intertester reproducibility of the lumbar motion monitor as a measure of range, velocity and acceleration of the thoracolumbar spine.

OBJECTIVE: The purpose of this study was to examine the intra- and intertester reproducibility of the Lumbar Motion Monitor (LMM) as a measure of thoracolumbar range of motion (RoM), velocity and acceleration. DESIGN: The study was a clinical trial using asymptomatic subjects. BACKGROUND: The LMM is a promising device from a clinical and research perspective, though the reproducibility of it's measurements has yet to be fully determined on subjects under free motion conditions. METHODS: For intratester reproducibility, 15 subjects were required to move as far and as fast as they could in 8 s through flexion, side flexion, and rotation. They were tested on three occasions with 48 h separating tests. For intertester reproducibility, 10 subjects were tested by two examiners, and were required to move as far and as fast as they could in 8 s. RESULTS: Intratester reproducibility coefficients ranged between 0.82 and 0.87 for RoM, 0.61 and 0.87 for velocity, and 0.46 and 0.72 for acceleration. Rotation had the poorest reproducibility in each instance. Intertester reproducibility ranged between 0.93 and 0.98. CONCLUSIONS: The reproducibility of the LMM is suitably high for RoM and velocity for the device to be used for evaluation in a clinical and research setting.

Paradoxical puborectalis contraction is a feature of constipation in patients with multiple sclerosis.

OBJECTIVE: To study the disturbed anorectal physiology associated with constipation in multiple sclerosis. METHODS: Anorectal function in 10 patients with clinically definite multiple sclerosis and constipation has been compared with 10 normal persons and 11 patients with idiopathic constipation, without multiple sclerosis. RESULTS: All 10 constipated patients with multiple sclerosis had difficulty evacuating barium paste during defaecography. In four of these there was complete failure of puborectalis relaxation when straining to defaecate, and in another four there was incomplete puborectalis relaxation. There was no evidence of lower motor neuron involvement of pelvic floor muscles in the multiple sclerosis group. CONCLUSIONS: Paradoxical puborectalis contraction is common in patients with multiple sclerosis in whom constipation is a symptom. This may be a feature of the disturbed voluntary sphincter control mechanism, analogous to detrusor sphincter dyssnergia in the bladder.

The impact of continuing education on patient outcomes in the elderly hip fracture population.

As the health care system is oriented to provide service with finite dollars, nursing educators are being asked to demonstrate how continuing education for staff improves patient outcomes. The purpose of this study was to evaluate the impact of an orthopedic-geriatric continuing education program for nurses on the elderly patient who had sustained a hip fracture. A significant difference was found between the control and experimental unit patients with respect to time to first ambulation and length of stay on the orthopedic unit.

Defecography in multiple sclerosis patients with severe constipation.

PURPOSE: To evaluate defecography in assessment of anorectal function in patients with multiple sclerosis (MS) who have intractable constipation. MATERIALS AND METHODS: Eleven patients with MS and constipation (10 women, one man) underwent defecography. A total of 130 mL of barium, liquid (20 mL) and paste, was introduced into the rectum. A dab of barium marked the external anal orifice, and, in the women, a tampon soaked with contrast medium marked the vagina. Video radiographic images and supplemental 100-mm static camera images were obtained. RESULTS: During defecation, six patients had no puborectalis muscle effacement, four patients had partial effacement, and one patient had complete effacement. No rectal emptying occurred in five patients, and emptying was incomplete in the rest. Three patients developed an intussusception, and two developed a posterolateral pouch. CONCLUSION: Defecography readily demonstrates rectal outlet obstruction and the failure of the puborectalis and anal sphincter muscles to relax. These are frequent findings in MS patients with intractable constipation.

Serological reactions to Brucella species in British pigs.

Until and including 1987 diagnostically significant serological titres to swine brucellosis had occurred in the serum agglutination test (SAT) or the complement fixation test (CFT), ie, > or = 100 iu or > or = 20 icftu, respectively, almost every year since reliable records began, but usually only about 0.05 per cent in the SAT and 0.005 per cent in the CFT. Brucella suis was never isolated by cultural examination. In 1988 the level of CFT reactions > or = 20 icftu rose to 0.42 per cent (1.04 per cent in the last quarter of the year) but the SAT reactions remained relatively unchanged. In 1989 the levels of both CFT and SAT reactions increased further with CFT reactions again predominating. Analyses of the serological reaction patterns in individual herds suggested that infection with brucella or some other organism capable of causing serological cross-reactions had become widespread in Great Britain, although signs of disease typical of swine brucellosis had not been observed. Some herds had reactions which persisted for many months whereas others showed them for only a short time. In early 1990 Yersinia enterocolitica serogroup O:9 was isolated from some pigs purchased from one of the reactor herds and this organism is probably responsible for the increased numbers of seroreactions. It had not previously been found in pigs in Great Britain.

Dilatation of the prostatic urethra with 35 mm balloon.

A series of 54 men, 25 with acute urinary retention and 29 with cytometrically proven bladder outflow obstruction (BOO), underwent dilatation of the prostatic urethra using a 35 mm fixed diameter, low compliance balloon. In 42 patients this was performed under cystoscopic guidance and in 12 patients under fluoroscopic control. Three months following dilatation, 13/27 patients (48%) with BOO who returned for review were rendered unobstructed and 19/27 (70%) were symptomatically improved. By 6 months only 3 remained unobstructed but 15 remained symptomatically improved. Nine months after dilatation 14 patients retained symptomatic improvement but only 2 remained unobstructed. Of the 25 patients treated for acute retention only 6 voided spontaneously, 1 of these relapsing into retention at 2 months and another at 4 months. No patient was rendered unobstructed but 2 patients (who declined prostatectomy) noted an improvement in their obstructive symptoms at both 3 and 6 months. No patient developed retrograde ejaculation following dilatation. Balloon dilatation to 35 mm has no role in acute urinary retention but may have a role in younger men with BOO who wish to avoid prostatectomy and the risk of retrograde ejaculation. In these patients careful follow-up is required.

Symptoms versus flow rates versus urodynamics in the selection of patients for prostatectomy.

Many prostatectomies are performed on the basis of symptoms alone; 39% of patients referred by their family doctors and 23% of patients who were on waiting lists for prostatectomy of other hospitals, but who had not undergone any urodynamic investigations, were found to be unobstructed on urodynamic criteria. A screening peak urinary flow rate of 12 ml/s or less was associated with urodynamic evidence of obstruction in 95% of cases; 35% of patients with symptoms of outflow obstruction and a flow rate greater than 12 ml/s were also found to be obstructed. One year post-operatively, 84% of patients who were selected for surgery on combined symptomatic and urodynamic criteria were pleased symptomatically with their result. The failure of detrusor instability to resolve following prostatectomy was associated with symptomatic failure of treatment. Residual obstruction was demonstrated in 5 patients who had undergone prostatectomy and were asymptomatic at this time. This study illustrates that objective measures are necessary in the assessment of patients prior to prostatectomy in order to select only patients who are obstructed. The importance of a screening flow rate is emphasised. All patients who underwent surgery had cystometric evidence of obstruction but the symptomatic results of surgery were no better than the results in patients who had been assessed according to non-urodynamic selection criteria. We have thus failed to identify a need for routine cystometry in the pre-operative assessment of these patients. Cystometry does, however, have a role in assessing patients with pre-operative flow rates greater than 12 ml/s and in those who remain symptomatic following prostatectomy.

Bladder outflow tract obstruction and urinary retention from benign prostatic hypertrophy treated by balloon dilatation.

Forty-eight men with urodynamically proven bladder outflow tract obstruction (BOO) and 19 with retention secondary to benign prostatic hypertrophy were treated by balloon dilatation of the prostate as out-patients; 31 were dilated with 20 mm and 36 with 25 mm balloons. Of the 48 men with BOO, 37 had repeat cystometrograms at intervals ranging from 3 to 11 months after dilatation and 33 (89%) remained obstructed by urodynamic criteria. Of 6 who only had a peak flow rate assessment, 5 had a flow less than 12 ml/s. Of the 19 patients in retention only 3 were able to void and all are obstructed. Symptoms of hesitancy, poor stream, frequency and nocturia were improved in less than 50% of patients. No reliable correlation was found between objective response and balloon size, length of time of dilatation, prostate size or morphology, detrusor pressure or stability, or post-dilatation urethrogram appearances. Balloon dilatation to 25 mm is not adequate therapy for bladder outflow tract obstruction or urinary retention from prostatic hypertrophy.

Lectin agglutination of thermophilic Campylobacter species.

Agglutination tests with lectins indicated differences in the surface composition of strains of the thermophilic (optimum temperature 42 degrees C) Campylobacter species C. coli, C. faecalis, C. hyointestinalis, C. jejuni and C. laridis. All strains examined were agglutinated by the protein-reactive agglutinins of Mangifera indica (mango) and Persea americana (avocado) and a large proportion was also agglutinated by the carbohydrate-reactive lectins of Canavalia ensiformis (Jack bean) and Triticum vulgaris (wheat germ). Reactions with other lectins varied widely between strains, even of the same species and serotype. Lectin agglutination may be useful as a supplementary procedure for characterizing individual Campylobacter isolates for epidemiological purposes.

Enzyme-linked immunosorbent assay for antibodies to Campylobacter fetus in bovine vaginal mucus.

An enzyme-linked immunosorbent assay (ELISA) was used to detect antibodies to Campylobacter fetus subspecies venerealis in bovine vaginal mucus. The results of testing 168 samples from experimentally infected, field cases and control cows showed that the ELISA was more sensitive than the vaginal mucus agglutination test and also detected antibodies in earlier stages of infection.