An in vivo analysis of the dimensional changes of the neuroforamen after anterior cervical diskectomy and fusion: a radiologic investigation

Eighteen patients (11 men, 7 women; average age, 45.5 years) who underwent anterior cervical diskectomy and fusion (ACDF) for the treatment of radiculopathy had preoperative and immediate postoperative computed tomography (CT) scans to measure pre- and postoperative foraminal heights and foraminal areas, preoperative disk space height, and postoperative graft height. The mean foraminal height preoperatively was 0.851 cm; postoperatively, it was 1.01 cm, with a mean percentage increase of 20% (-8.8 to 56.8%). Mean preoperative foraminal area was 37.53 mm2, increasing to a mean of 49.04 mm2 postoperatively with a mean percentage increase of 33% (range, -1.5 to 76.9%). No significant correlations between graft height and change in maximal foraminal height or foraminal area or between changes in foraminal height or area and postoperative symptom relief were found. Although significant increases in foraminal dimensions were seen radiographically after ACDF, these increases were variable and not strongly related to graft height. In addition, the increases in foraminal dimensions were not related to the short-term clinical results of ACDF. This study fails to support the hypothesis that the reliable results of ACDF can be ascribed primarily to indirect decompression of the uncovertebral foramen by disk-space distraction.

Little knowledge and limited practice: emergency contraceptive pills, the public, and the obstetrician-gynecologist

OBJECTIVE

To assess Americans' knowledge and attitudes about emergency contraceptive pills and the knowledge, attitudes, and practices of obstetrician-gynecologists with respect to emergency contraceptive pills.

METHODS

A random sample of a national cross-section of 2002 Americans, age 18 and older, including 1000 women and 1002 men, was surveyed by telephone between October 12 and November 13, 1994. A nationally representative sample of 307 obstetrician-gynecologists, whose names were drawn from the American Medical Association Physicians' Masterfile, was surveyed by telephone between February 1 and March 21, 1995. Both Surveys addressed knowledge and attitudes about unplanned pregnancy and contraception options, including emergency contraception. Despite response rates of 50 and 77%, respectively, both unweighted samples closely mirror the populations from which they were drawn.

RESULTS

Americans are not well informed about emergency contraceptive pills. Only 36% of respondents indicated that they knew "anything could be done" within a few days after unprotected sex to prevent pregnancy. Fifty-five percent said they had "heard of" emergency contraceptive pills, and only 1% had ever used them. Ninety-nine percent of obstetrician-gynecologists reported being "familiar" with emergency contraceptive pills. Twenty-two percent were "somewhat familiar." Among those who said they were "very familiar" with the method (77%), the majority considered emergency contraceptive pills to be "very safe" (88%) and "very effective" (85%). Overall, 70% of obstetrician-gynecologists surveyed said they had prescribed emergency contraceptive pills within the last year, but on an infrequent basis; 77% of those who prescribed emergency contraceptive pills did so five or fewer times.

CONCLUSION

Public knowledge about the availability and use of emergency contraceptive pills is limited, as is the practice of prescribing the pills among obstetrician-gynecologists. Because patients rely on health care providers for information on birth control, health care providers can improve knowledge about the availability of emergency contraceptive pills among their patients.

The long-term follow-up of patients with Klippel-Feil syndrome and congenital scoliosis

STUDY DESIGN

This study evaluated the long-term results of Klippel-Feil syndrome in patients with congenital scoliosis.

OBJECTIVES

To determine the incidence of cervical and cervical-related symptoms of patients who have Klippel-Feil syndrome associated with congenital scoliosis.

SUMMARY OF BACKGROUND DATA

Many authors have described the association of Klippel-Feil syndrome and congenital scoliosis. In this population of patients, cervical lesions often are discovered incidentally. The significance of these lesions is unknown.

METHODS

Thirty-two patients with congenital scoliosis and Klippel-Feil syndrome were observed for more than 10 years. They were questioned specifically about cervical and cervical-related symptoms. All patients had sequential cervical radiographs and physical examinations.

RESULTS

Despite rather dramatic radiographic appearances, only seven (22%) of the 32 patients had cervical or cervical-related symptoms, with two patients requiring surgery for their cervical lesions. The extent of the deformities and the average number of cervical vertebrae fused and cervical fusion-patterns were statistically similar between the symptomatic and asymptomatic groups. Patients fused to the cervicothoracic junction for management of their deformities had a significantly increased incidence of cervical symptoms. Also, patients with congenital stenosis had a significantly greater incidence of upper extremity pain.

CONCLUSIONS

Only a small number of patients with Klippel-Feil syndrome and congenital scoliosis developed cervical symptoms. No fusion pattern that placed the patient at greater risk for developing symptoms could be identified. Factors that did lead to a greater incidence of cervical symptoms were fusion to the cervicothoracic junction and congenital cervical stenosis.

Short courses of ofloxacin for the treatment of enteric fever

Typhoid fever continues to be a major public health problem in tropical countries, exacerbated in recent years by the spread of multi-drug resistant strains of Salmonella typhi. Short treatment courses of fluoroquinolones are effective, and have the advantage of reduced cost and increased compliance, but the optimal length of treatment is unknown. In an open, randomized comparison, 107 adults with uncomplicated enteric fever (95 of whom had positive blood cultures for S. typhi and 5 for S. paratyphi) were treated with oral ofloxacin, 15 mg/kg/d for 2 d or 10 mg/kg/d for 3 d. Mean fever clearance times were the same in the 2 treatment groups (97 h). There were 7 treatment failures, one in the 2 d group and 6 in the 3 d group (P = 0.07). Three of the 5 patients infected with nalidixic acid resistant strains of S. typhi had treatment failures, compared with 4 of 90 with nalidixic acid sensitive isolates (P < 0.0001; relative risk 13.5, 95% confidence interval 4.1-43%). Treatment with ofloxacin for 2 or 3 d is equally effective in adults with uncomplicated enteric fever caused by nalidixic acid sensitive strains of S. typhi. The epidemiology and management of nalidixic acid resistent typhoid needs further investigation.

Musculoskeletal pain in cardiac ultrasonographers: results of a random survey

Myalgias and arthralgias are common among workers whose jobs require repetitive isometric maneuvers or malalignment of body position. However, few systematic studies have been performed to evaluate the frequency of these complaints among cardiac ultrasonographers. Therefore the purpose of this study was to determine the prevalence of musculoskeletal pain (MSP) among ultrasonographers and to identify risk factors related to their occurrence. Two hundred twenty ultrasonographers randomly chosen from a list of more than 1600 active members of the American Society of Echocardiography were mailed surveys consisting of 22 questions. Included were questions regarding height, age, years of experience, frequency and type of physical exercise, and job-related parameters such as a number of scans per day, scanning from right or left side of bed, number of hours, bed type, type of equipment, and manual or self-propelled machines. Respondents were asked whether they had had back, neck, or shoulder pain related to their profession and to describe treatment rendered and its effectiveness. One hundred thirteen (51%) of 220 ultrasonographers responded to the survey. Ninety (80%) of 113 respondents reported new pain that was not present before they began scanning, with 42 of this group (46%) requiring either physiotherapy (n = 17) or medication (n = 23). Treatment was believed to be helpful in 63% of cases. Factors found to have a positive relationship to MSP included ultrasonographer height less than 63 inches, performing 100 or more scans per month, average scan time of 25 minutes or more per patient, and use of manually propelled machines (each p < 0.05). Factors found to have no relationship to MSP included age, type of equipment, right or left scan position, physical conditioning, bed type, and time between patients. Musculoskeletal pain is prevalent among cardiac ultrasonographers, and may have specific work-related factors for its occurrence.

Synovial membrane cytokine profiles in reactive arthritis secondary to intravesical bacillus Calmette-Guérin therapy

We describe the cellular infiltrate and cytokine profile in sequential synovial membrane biopsies from a patient with acute followed by chronic synovitis after intravesical bacillus Calmette-Guérin (BCG) therapy for an in situ transitional cell carcinoma of the bladder. Histological and immunohistochemical analysis of 3 synovial biopsies were done sequentially over a 9 month period. The patient was HLA-B27 positive, but HLA-DR4 negative, and did not have the "shared epitope." Unlike other cases, this patient's arthritis did not respond initially to nonsteroidal antiinflammatory drugs and was exacerbated by corticosteroid therapy. The synovitis took a neutrophilic form, with marked synovial membrane content of interleukin 8 (IL-8) and tumor necrosis factor alpha (TNF-alpha). It subsequently developed into chronic lymphoplasmacytoid synovitis, similar to rheumatoid arthritis (RA), with decreased IL-8 but continuing IL-1 and TNF-alpha production in the synovial membrane. The synovitis resolved to a fibrotic synovium with residual thickening of the synovial lining layer and continued production of TNF-alpha. Thus, during the evolution of this arthritis, the synovial layer and continued production of TNF-alpha. Thus, during the evolution of this arthritis, the synovial membrane yielded a cellular infiltrate and cytokine content that had marked similarities with that seen in RA; however, the arthritis eventually remitted spontaneously.

Differential effects of polycationic protein on Cl- secretory and Na+ absorptive airways

Effects of cationic proteins on electrolyte transport depend on the specific channels and electrochemical driving forces expressed by epithelia. The bioelectric responses of canine tracheal and bronchial epithelia (CTE and CBE, respectively) to a polycationic protein, protamine, were therefore compared. CTE exhibited a brief transient inhibition of shortcircuit current (I(SC)) followed by a prolonged increase of 18 microA/cm2. The apical membrane transiently hyperpolarized and then depolarized by 11 mV. The increase in I(SC) was inhibited by bumetanide. Adenosine 3',5'-cyclic monophosphate, ionomycin, and thapsigargin attenuated the response whereas indomethacin or hypotonic solution had no effect, indicating that latent cystic fibrosis transmembrane regulator Cl- channels were activated. CBE preparations exhibited a 4-microA/cm2 decrease in I(SC), 2 mV hyperpolarization of the apical membrane, and an increase in fractional resistance of the apical membrane on exposure to protamine. These results were consistent with inhibition of the Na+ conductance in the apical membrane of CBE and confirmed that polycationic proteins exert differential effects on Cl- secretory and Na+ absorptive airways.

Pediatric seat belt injuries

Two cases are reported that reiterate the significance of pediatric seat belt usage. Detection of associated injuries is difficult and often delayed. The presence of intra-abdominal free fluid on CT without solid organ injury should indicate the need for surgical intervention. Diagnostic peritoneal lavage usage in pediatric seat belt trauma may need to be re-evaluated. These cases emphasize the above as well as important postinjury clinical changes necessary for earlier diagnosis. A newly designed youth seat belt is presented to help prevent these injuries.

Public knowledge and perceptions about unplanned pregnancy and contraception in three countries

A 1994-1995 survey of men and women aged 18-44 in the United States, Canada and the Netherlands revealed considerable differences in public knowledge and perceptions about unplanned pregnancy and contraception. The proportion who believe that unplanned pregnancy is a "very big problem" is 60% in the United States, 36% in Canada and 6% in the Netherlands. Americans are more likely than their Canadian or Dutch counterparts to cite societal problems as significant factors in the rate of unplanned pregnancy; higher proportions of Americans also cite the cost of contraceptives (52% vs. 46% of Canadians and 34% of Dutch men and women) and an inability to obtain methods (66%, 51% and 33%, respectively). In all three countries, adults are generally well informed about the relative effectiveness of commonly used contraceptives, but Americans are more skeptical about method safety and effectiveness. For example, 17% think the pill is "very safe," compared with 21% of Canadians and 40% of the Dutch; and whereas 64% of Americans consider the pill "very effective," 73% of Canadians and 90% of Dutch men and women give it this rating. Health care professionals are the most frequently cited source of contraceptive information, but only 51-63% of adults have ever discussed contraception with such a practitioner.

A nonradioactive method of in situ hybridization that uses riboprobes and paraffin-embedded tissue and its combination with immunohistochemistry

Current research into cytokine production in tissue sections relies on the detection of cytokine proteins using a variety of immunohistochemical methods. The disadvantages of this technique are that precise localization to a particular cell is difficult and it is uncertain whether the cells detected by this method are the origin or target of the cytokine or rather have nonspecifically absorbed the secreted cytokine. This question can be clarified using in situ hybridization, but current techniques are insensitive, poorly localizing, or time consuming. Biotin-labeled riboprobes were generated from cDNA fragments sandwiched between two RNA polymerase promoters (SP6 and T7 RNA polymerases) using a commercial riboprobe generation kit containing biotin-labeled UTP. The in situ hybridization technique was used to demonstrate cytokine mRNA in a range of tissues containing an inflammatory infiltrate and with a range of cytokine probes. This technique of in situ hybridization was combined with immunohistochemistry using an immunoalkaline phosphatase technique to show the powerful combination of these two techniques. The biotin-labeled riboprobes were sensitive enough to detect a range of cytokine mRNAs in a variety of tissue sections. The technique can be completed over a 24-h period and produces a stable color product that can be stored for long periods and can be quantitated using image analysis techniques. This technique was performed on paraffin-embedded tissue as well as cryosections and allowed for the detection of mRNA in archival tissue. It was also successfully combined with immunohistochemical techniques to determine simultaneously the localization of a cytokine product in particular cell lineages. A nonradioactive method for in situ hybridization using biotin-labeled riboprobes is described; it is capable of detecting mRNA products from a range of genes in a variety of tissue samples. An amplification step in the method enhances the sensitivity to a level that approaches that of radioactive methods, while maintaining the speed, safety, and simplicity of an immunoperoxidase detection system. The ability to use paraffin-embedded tissue with this method allows for improved tissue architecture and examination of archival tissue. These features should ensure greater use of in situ hybridization techniques in future research studies.

Synovial membrane inflammation and cytokine production in patients with early osteoarthritis

OBJECTIVE

To establish the presence of inflammation in and cytokine production by synovial membranes from patients with various stages of early osteoarthritis (OA), with knee pain, normal knee radiographs, and arthroscopic evidence of chondral damage.

METHODS

Synovial membrane samples were obtained from the knees of 63 patients at the time of arthroscopy for unexplained knee pain or at the time of joint replacement surgery. Evaluations of synovial membrane variables including thickness of lining layer, vascularity, and inflammatory cell infiltrate were by a blinded observer. In a subset of 20 patients, production of interleukin 1 alpha (IL-1 alpha), interleukin 1 beta (IL-1 beta), tumor necrosis factor alpha (TNF-alpha), and IL-1 receptor antagonist (IL-1ra) at the mRNA and protein levels was determined using in situ hybridization with biotin labeled ribo-probes and immunohistochemistry.

RESULTS

There was evidence of thickening of the lining layer, increased vascularity, and inflammatory cell infiltration in synovial membranes from patients with all grades of OA, with the most marked changes seen in synovial tissue from patients with advanced grades of OA. Similarly, production of IL-1 alpha, IL-1 beta, and TNF-alpha was present in synovial membranes from all patients with OA, irrespective of the degree of articular cartilage damage. There was a trend to decreased levels of IL-1ra in synovial membranes from patients with OA that did not attain statistical significance. Similarly, there was a decrease in the ratio of IL-1ra to IL-1 alpha and beta with increasing grades of OA.

CONCLUSION

Chronic inflammatory changes with production of proinflammatory cytokines are a feature of synovial membranes from patients with early OA, with the most severe changes seen in patients at the time of joint replacement surgery resembling those seen in rheumatoid arthritis. This low grade synovitis results in the production of cytokines that may contribute to the pathogenesis of OA.

Inhibition of neuronal process outgrowth and neuronal specific gene activation by the Brn-3b transcription factor

The differentiation of the ND7 neuronal cell line to a nondividing phenotype bearing numerous neurite processes is accompanied by a dramatic increase in the levels of the activating POU family transcription factor Brn-3a and a corresponding fall in the levels of the closely related inhibitory factor Brn-3b. We have previously shown that the artificial overexpression of Brn-3a in these cells can induce neurite outgrowth and the activation of genes encoding synaptic vesicle proteins in the absence of a differentiation-inducing stimulus. Here we show that overexpression of Brn-3b can reduce process outgrowth and synaptic vesicle gene expression following exposure to a stimulus which would normally induce differentiation. These inhibitory effects are abolished by altering a single amino acid in the POU homeodomain of Brn-3b to its equivalent in Brn-3a. The converse mutation in Brn-3a allows it to inhibit process outgrowth in response to a differentiation-inducing stimulus. Hence a single amino acid difference results in these closely related factors having opposite effects and allows the balance between them to regulate differentiation.

Systemic liberation of interleukin-8 in the perioperative phase of liver transplantation

Serum levels of interleukin-8 (IL-8) were investigated in the perioperative phase of liver transplantation (LTx) in order to help determine whether this cytokine might serve as a parameter for preservation injury. In a study of 45 patients undergoing LTx, systemic IL-8 was estimated at the end of the anhepatic phase, at 30, 60, and 120 min after reperfusion of the graft, and 24 h and 7 days after LTx. A maximum mean concentration of 665 +/- 135 pg/ml was seen 60 min after LTx. The minimum was found on the 1st postoperative day (POD 1): 328 +/- 33 pg/ml. Significant changes were found between 60 min and PODs 1 and 7, as well as between 120 min and POD 1. Differences in cold ischemia time were not found to be significant. We conclude that monitoring of systemic IL-8 levels is not useful in the development of new liver preservation concepts.

The Brn-3a transcription factor induces neuronal process outgrowth and the coordinate expression of genes encoding synaptic proteins

The Brn-3a POU family transcription factor is expressed only in posmitotic neurons in the central nervous system and identifies the first differentiated neurons to appear in the midbrain, hindbrain, and spinal cord during development. This factor is also induced when undifferentiated proliferating ND7 cells cease dividing and differentiate to a mature neuronal-like phenotype bearing numerous neurite processes. We show that overexpression of Brn-3a in undifferentiated ND7 cells induces a mature neuronal phenotype characterized by process outgrowth and the induction of genes encoding synaptic proteins, although the cells continue to proliferate. In contrast, the closely related factors Brn-3b and Brn-3c do not have this effect. Although the N-terminal activation domain of Brn-3a is required for maximum induction of neurite outgrowth and gene expression, these effects are primarily dependent on the DNA binding POU domain, which also acts as an activation domain. Overexpression of the isolated POU domain of Brn-3a is sufficient to induce neurite outgrowth, while the ability of full-length Brn-3a to do so is abolished by mutating a single amino acid in the Brn-3a POU homeodomain to its equivalent in Brn-3b. Thus, Brn-3a appears to play a critical role in the specification of the mature neuronal phenotype, acting by stimulating the expression of genes whose products are required for process outgrowth and synapse formation.

Hormone replacement therapy: a review of the risk versus benefit--Part II

As the large ¿baby-boom¿ cohort of women enters the period of menopause, much attention is being focused on the potential public health benefits of hormone replacement therapy (HRT) and its relative safety. Increasingly, economic models derived from these studies define populations of women most likely to benefit from this treatment. This paper will review the clinical efficacy and safety of HRT and examine published pharmacoeconomic studies evaluating the use of HRT for post-menopausal women. Ultimately, the cost effectiveness of HRT is dependent on the extent of the cardioprotective effect of estrogen and estrogen-progestin combination therapy. Part II of this article describes the pharmacologic evidence that serves as a basis for evaluating HRT.