Neuronal activity regulates Matrin 3 abundance and function in a calcium-dependent manner through calpain-mediated cleavage and calmodulin binding

RNA-binding protein (RBP) dysfunction is a fundamental hallmark of amyotrophic lateral sclerosis (ALS) and related neuromuscular disorders. Abnormal neuronal excitability is also a conserved feature in ALS patients and disease models, yet little is known about how activity-dependent processes regulate RBP levels and functions. Mutations in the gene encoding the RBP Matrin 3 (MATR3) cause familial disease, and MATR3 pathology has also been observed in sporadic ALS, suggesting a key role for MATR3 in disease pathogenesis. Here, we show that glutamatergic activity drives MATR3 degradation through an NMDA receptor-, Ca2+-, and calpain-dependent mechanism. The most common pathogenic MATR3 mutation renders it resistant to calpain degradation, suggesting a link between activity-dependent MATR3 regulation and disease. We also demonstrate that Ca2+ regulates MATR3 through a nondegradative process involving the binding of Ca2+/calmodulin to MATR3 and inhibition of its RNA-binding ability. These findings indicate that neuronal activity impacts both the abundance and function of MATR3, underscoring the effect of activity on RBPs and providing a foundation for further study of Ca2+-coupled regulation of RBPs implicated in ALS and related neurological diseases.

Efficiency of exogenous zinc sulfate application reduced fruit drop and improved antioxidant activity of 'Kinnow' mandarin fruit

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Kinnow' mandarin (Citrus nobilis L.× Citrus deliciosa T.) is an important marketable fruit of the world. It is mainstay of citrus industry in Pakistan, having great export potential. But out of total production of the country only 10% of the produce meets the international quality standard for export. Pre-harvest fruit drop and poor fruit quality could be associated with various issues including the plant nutrition. Most of the farmers do not pay attention to the supply of micro nutrients which are already deficient in the soil. Furthermore, their mobility within plants is also a question. Zinc (Zn) is amongst those micronutrients which affect the quality and postharvest life of the fruit and its deficiency in Pakistani soils is already reported by many researchers. Therefore, this study was carried out to evaluate the influence of pre-harvest applications of zinc sulfate (ZnSO4; 0, 0.4%, 0.6% or 0.8%) on pre-harvest fruit drop, yield and fruit quality of 'Kinnow' mandarin at harvest. The treatments were applied during the month of October i.e. 4 months prior to harvest. The applied Zn sprays had significant effect on yield and quality of the "Kinnow" fruit. Amongst different foliar applications of ZnSO4applied four months before harvest, 0.6% ZnSO4 significantly reduced pre-harvest fruit drop (10.08%) as compared to untreated control trees (46.45%). Similarly, the maximum number of fruits harvested per tree (627), fruit weight (192.9 g), juice percentage (42.2%), total soluble solids (9.5 °Brix), ascorbic acid content (35.5 mg 100 g-1) and sugar contents (17.4) were also found significantly higher with 0.6% ZnSO4 treatment as compared to rest of treatments and control. Foliar application of 0.6% ZnSO4 also significantly improved total antioxidants (TAO) and total phenolic contents (TPC) in fruit. In conclusion, foliar spray of ZnSO4 (0.6%) four months prior to harvest reduced pre-harvest fruit drop, increase yield with improved quality of 'Kinnow' mandarin fruit.

Development of a specific live-cell assay for native autophagic flux

Autophagy is an evolutionarily conserved pathway mediating the breakdown of cellular proteins and organelles. Emphasizing its pivotal nature, autophagy dysfunction contributes to many diseases; nevertheless, development of effective autophagy modulating drugs is hampered by fundamental deficiencies in available methods for measuring autophagic activity or flux. To overcome these limitations, we introduced the photoconvertible protein Dendra2 into the MAP1LC3B locus of human cells via CRISPR/Cas9 genome editing, enabling accurate and sensitive assessments of autophagy in living cells by optical pulse labeling. We used this assay to perform high-throughput drug screens of four chemical libraries comprising over 30,000 diverse compounds, identifying several clinically relevant drugs and novel autophagy modulators. A select series of candidate compounds also modulated autophagy flux in human motor neurons modified by CRISPR/Cas9 to express GFP-labeled LC3. Using automated microscopy, we tested the therapeutic potential of autophagy induction in several distinct neuronal models of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). In doing so, we found that autophagy induction exhibited discordant effects, improving survival in disease models involving the RNA binding protein TDP-43, while exacerbating toxicity in neurons expressing mutant forms of UBQLN2 and C9ORF72 associated with familial ALS/FTD. These studies confirm the utility of the Dendra2-LC3 assay, while illustrating the contradictory effects of autophagy induction in different ALS/FTD subtypes.

Cost estimation alongside a multi-regional, multi-country randomized trial of antenatal ultrasound in five low-and-middle-income countries

BACKGROUND

Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency.

METHODS

We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and hospital-based (facility) care for pregnant women, in general, with selective complication-related data collection in women participating in a large maternal health registry and clinical trial in five LMICs. We estimated average costs from a facility/health system perspective for outpatient and inpatient services. We converted all country-level currency cost estimates to 2015 United States dollars (USD). We compared average costs across countries for ANC visits, deliveries, higher-risk pregnancies, and complications, and conducted sensitivity analyses.

RESULTS

Our study included sites in five countries representing different regions. Overall, the relative cost of individual ANC and delivery-related healthcare use was consistent among countries, generally corresponding to country-specific income levels. ANC outpatient visit cost estimates per patient among countries ranged from 15 to 30 USD, based on average counts for visits with and without US. Estimates for antenatal screening US visits were more costly than non-US visits. Costs associated with higher-risk pregnancies were influenced by rates of hospital delivery by cesarean section (mean per person delivery cost estimate range: 25-65 USD).

CONCLUSIONS

Despite substantial differences among countries in infrastructures and health system capacity, there were similarities in resource allocation, delivery location, and country-level challenges. Overall, there was no clear suggestion that adding antenatal screening US would result in either major cost savings or major cost increases. However, antenatal screening US would have higher training and maintenance costs. Given the lack of clinical effectiveness evidence and greater resource constraints of LMICs, it is unlikely that introducing antenatal screening US would be economically efficient in these settings--on the demand side (i.e., patients) or supply side (i.e., healthcare providers).

TRIAL REGISTRATION

Trial number: NCT01990625 (First posted: November 21, 2013 on https://clinicaltrials.gov ).

Matrin 3 in neuromuscular disease: physiology and pathophysiology

RNA-binding proteins (RBPs) are essential factors required for the physiological function of neurons, muscle, and other tissue types. In keeping with this, a growing body of genetic, clinical, and pathological evidence indicates that RBP dysfunction and/or gene mutation leads to neurodegeneration and myopathy. Here, we summarize the current understanding of matrin 3 (MATR3), a poorly understood RBP implicated not only in ALS and frontotemporal dementia but also in distal myopathy. We begin by reviewing MATR3's functions, its regulation, and how it may be involved in both sporadic and familial neuromuscular disease. We also discuss insights gleaned from cellular and animal models of MATR3 pathogenesis, the links between MATR3 and other disease-associated RBPs, and the mechanisms underlying RBP-mediated disorders.

An Intramolecular Salt Bridge Linking TDP43 RNA Binding, Protein Stability, and TDP43-Dependent Neurodegeneration

The majority of individuals with amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) exhibit neuronal cytoplasmic inclusions rich in the RNA binding protein TDP43. Even so, the relation between the RNA binding properties of TDP43 and neurodegeneration remains obscure. Here, we show that engineered mutations disrupting a salt bridge between the RNA recognition motifs of TDP43 interfere with RNA binding and eliminate the recognition of native TDP43 substrates. The same mutations dramatically destabilize TDP43, alter its subcellular localization, and abrogate TDP43-dependent neuro-degeneration. Worms harboring homologous TDP-1 mutations phenocopy knockout strains, confirming the necessity of salt bridge residues for TDP43 function. Moreover, the accumulation of functional TDP43, but not RNA binding-deficient variants, disproportionately affects transcripts encoding ribo-some and oxidative phosphorylation components. These studies demonstrate the significance of the salt bridge in sustaining TDP43 stability and RNA binding properties, factors that are crucial for neurodegeneration arising from TDP43 deposition in ALS and FTD.

Flores et al. uncover essential roles for an intramolecular salt bridge in the function of TDP43, an RNA binding protein implicated in neurodegenerative diseases. Salt bridge interruption attenuates TDP43 RNA binding affinity and specificity, destabilizes the protein, and prevents TDP43-mediated neurotoxicity arising from misprocessing of ribosomal and mitochondrial transcripts.

DDX3X and specific initiation factors modulate FMR1 repeat-associated non-AUG-initiated translation

A CGG trinucleotide repeat expansion in the 5' UTR of FMR1 causes the neurodegenerative disorder Fragile X-associated tremor/ataxia syndrome (FXTAS). This repeat supports a non-canonical mode of protein synthesis known as repeat-associated, non-AUG (RAN) translation. The mechanism underlying RAN translation at CGG repeats remains unclear. To identify modifiers of RAN translation and potential therapeutic targets, we performed a candidate-based screen of eukaryotic initiation factors and RNA helicases in cell-based assays and a Drosophila melanogaster model of FXTAS. We identified multiple modifiers of toxicity and RAN translation from an expanded CGG repeat in the context of the FMR1 5'UTR. These include the DEAD-box RNA helicase belle/DDX3X, the helicase accessory factors EIF4B/4H, and the start codon selectivity factors EIF1 and EIF5. Disrupting belle/DDX3X selectively inhibited FMR1 RAN translation in Drosophila in vivo and cultured human cells, and mitigated repeat-induced toxicity in Drosophila and primary rodent neurons. These findings implicate RNA secondary structure and start codon fidelity as critical elements mediating FMR1 RAN translation and identify potential targets for treating repeat-associated neurodegeneration.

Matrin 3-dependent neurotoxicity is modified by nucleic acid binding and nucleocytoplasmic localization

Abnormalities in nucleic acid processing are associated with the development of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Mutations in Matrin 3 (MATR3), a poorly understood DNA- and RNA-binding protein, cause familial ALS/FTD, and MATR3 pathology is a feature of sporadic disease, suggesting that MATR3 dysfunction is integrally linked to ALS pathogenesis. Using a rat primary neuron model to assess MATR3-mediated toxicity, we noted that neurons were bidirectionally vulnerable to MATR3 levels, with pathogenic MATR3 mutants displaying enhanced toxicity. MATR3's zinc finger domains partially modulated toxicity, but elimination of its RNA recognition motifs had no effect on survival, instead facilitating its self-assembly into liquid-like droplets. In contrast to other RNA-binding proteins associated with ALS, cytoplasmic MATR3 redistribution mitigated neurodegeneration, suggesting that nuclear MATR3 mediates toxicity. Our findings offer a foundation for understanding MATR3-related neurodegeneration and how nucleic acid binding functions, localization, and pathogenic mutations drive sporadic and familial disease.

Abnormal mineralization of the Ts65Dn Down syndrome mouse appendicular skeleton begins during embryonic development in a Dyrk1a-independent manner

The relationship between gene dosage imbalance and phenotypes associated with Trisomy 21, including the etiology of abnormal bone phenotypes linked to Down syndrome (DS), is not well understood. The Ts65Dn mouse model for DS exhibits appendicular skeletal defects during adolescence and adulthood but the developmental and genetic origin of these phenotypes remains unclear. It is hypothesized that the postnatal Ts65Dn skeletal phenotype originates during embryonic development and results from an increased Dyrk1a gene copy number, a gene hypothesized to play a critical role in many DS phenotypes. Ts65Dn embryos exhibit a lower percent bone volume in the E17.5 femur when compared to euploid embryos. Concomitant with gene copy number, qPCR analysis revealed a  ~1.5 fold increase in Dyrk1a transcript levels in the Ts65Dn E17.5 embryonic femur as compared to euploid. Returning Dyrk1a copy number to euploid levels in Ts65Dn, Dyrk1a(+/-) embryos did not correct the trisomic skeletal phenotype but did return Dyrk1a gene transcript levels to normal. The size and protein expression patterns of the cartilage template during embryonic bone development appear to be unaffected at E14.5 and E17.5 in trisomic embryos. Taken together, these data suggest that the dosage imbalance of genes other than Dyrk1a is involved in the development of the prenatal bone phenotype in Ts65Dn embryos.

Nanofocusing optics for synchrotron radiation made from polycrystalline diamond

Diamond possesses many extreme properties that make it an ideal material for fabricating nanofocusing x-ray optics. Refractive lenses made from diamond are able to focus x-ray radiation with high efficiency but without compromising the brilliance of the beam. Electron-beam lithography and deep reactive-ion etching of silicon substrates have been used in a transfer-molding technique to fabricate diamond optics with vertical and smooth sidewalls. Latest generation compound refractive lenses have seen an improvement in the quality and uniformity of the optical structures, resulting in an increase in their focusing ability. Synchrotron beamline tests of two recent lens arrays, corresponding to two different diamond morphologies, are described. Focal line-widths down to 210 nm, using a nanocrystalline diamond lens array and a beam energy of E = 11 keV, and 230 nm, using a microcrystalline diamond lens at E = 15 keV, have been measured using the Diamond Light Source Ltd. B16 beamline. This focusing prowess is combined with relatively high transmission through the lenses compared with silicon refractive designs and other diffractive optics.

Teaching of major communicable diseases in Sudanese medical schools: a critical look

This descriptive, cross-sectional study of Sudanese medical schools aimed to describe and analyse the proportion of their curricula currently allocated for teaching of communicable diseases and to assess the teaching methods and student assessment tools. Qualitative and quantitative data were collected from heads of departments and students in 20 of the 27 medical faculties and from ministry of health staff at federal and state levels. Curriculum designs ranged from traditional to innovative, community-oriented programmes. Problems regarding student evaluations were identified. Major limitations included shortages of staff, reference materials and teaching aids. Poor knowledge of students about different aspects of diseases endemic in Sudan was found. Recommendations include curriculum development, staff recruitment and training, and improvement of teaching and training of students.

Changing spectrum of gallstone disease: an experience of 23 cases less than 10 years of age

BACKGROUND

An overall increase in the incidence of paediatric cholelithiasis forms the basis of this study, which aims to investigate the overall changing clinical pattern of cholelithiasis.

METHODS

This is a retrospective observational descriptive study including twenty three (23) patients with gallstones admitted and operated during June 2006-June 2008 in surgical department of a teaching hospital. All the patients with sonological evidence of gallstones, less than 10 years of age with history of acute or chronic abdominal symptoms are included in the study population. After admission all the subjects were investigated and finally operated by open approach (21 patients) during the same admission. The details of all the patients were recorded on a proforma and statistical analysis done on SPSS version 12.

RESULTS

Of the total study population, there were 19 (82.6%) males and 4 (17.39%) females with a mean age of 7 years and a range of 4-10 years. Ultrasound revealed gallstones in all the patients with a varying proportion of the walls of gallbladder. The commonest presentation was abdominal pain in the right upper quadrant, which was vague, and of mild to moderate intensity. In 21 (91.30%) patients, no specific underlying cause was found while two patients (8.6%) had haematological disorder as underlying cause for the gallstones.

CONCLUSION

This study indicates an alarming increase in the incidence of idiopathic gallstones in children less than 10 years of age with a distinct male predominance.

Mesh versus non-mesh repair of ventral abdominal hernias

BACKGROUND

To investigate the relative effectiveness of mesh and suture repair of ventral abdominal hernias in terms of clinical outcome, quality of life and rate of recurrence in both the techniques.

METHODS

This is a retrospective descriptive analysis of 236 patients with mesh and non-mesh repair of primary ventral hernias performed between January 2000 to December 2004 at Surgery Department, Liaquat University of Medical and Health Sciences, Jamshoro. The record sheets of the patients were analyzed and data retrieved to compare the results of both techniques for short-term and long-term results. The data retrieved is statistically analyzed on SPSS version 11.

RESULTS

There were 43 (18.22%) males and 193 (81.77%) females with a mean age of 51.79 years and a range of 59 (81-22). Para-umbilical hernia was the commonest of ventral hernia and accounted for 49.8% (n=118) of the total study population followed by incisional hernia comprising 24% (n=57) of the total number. There was a significant difference in the recurrent rate at 3 years interval with 23/101 (22.77%) recurrences in suture-repaired subjects compared to 10/135 (7.40%) in mesh repair group. Chronic pain lasting up to 1-2 years was noted in 14 patients with suture repair. Wound infection is comparatively more common (8.14%) in mesh group. The other variables such as operative and postoperative complications, total hospital stay and quality of life is also discussed.

CONCLUSION

Mesh repair of ventral hernia is much superior to non-mesh suture repair in terms of recurrence and overall outcome.

Frequency of Campylobacter jejuni in diarrhoea/dysentery in children in Rawalpindi and Islamabad

OBJECTIVE

To determine the frequency of Campylobacter jejuni infection in children suffering from diarrhoea/dysentery in the Department of Microbiology, Army Medical College and Military Hospital, Rawalpindi, from 29 August 2002 to 29 November 2002.

METHODS

The study was carried out on one hundred stool samples of children up to the age of twelve years admitted with diarrhoea/dysentery in Military hospital, Rawalpindi. The samples were collected in clean polypropylene containers containing Cary Blair medium. These were transported to the Microbiology Department, Army Medical College, Rawalpindi within 1-2 hours. The samples were inoculated on Modified Preston (Oxoid) and Karmali media (Oxoid) beside other routine stool culture media. The cultures were incubated at 42 degrees C under microaerophilic conditions. The growth after 48 hours was provisionally identified by colonial morphology, oxidase test, Gram staining and motility. The organisms were identified to species level by hippurate hydrolysis, urease test, nitrate reduction, catalase test, H2S production and resistance to cephalothin.

RESULTS

Eighteen percent of samples yielded the growth of Campylobacter jejuni. Mean age of children with Campylobacter jejuni infection was 18 months with peak incidence from 12 to 21 months. Male female ratio was 1.7:1. All the children had loose motions. Seven out 18 (39%) had a combination of symptoms of loose motions, vomiting and pain abdomen. Those having fever with or without other complaints constituted 11 out of 18 (61.11%) i.e. more than 50% of all the children yielding C. jejuni had fever. About 90% of diarrhoeal stools had blood and fifty percent also had mucous. There was either history of chicken meat consumption or contact with cattle and pets in most of the cases and both in some of them.

CONCLUSION

Campylobacter jejuni is a frequent cause of diarrhoea/dysentery in children in our set up. In children it is often related to pets keeping and chicken meat consumption. In the remaining, untreated drinking water may be the source. Campylobacter jejuni frequently presents with blood and mucous in stools with sporadic cases presenting with watery diarrhoea.

Hepatitis B and C single and co-infection in chronic liver disease and their effect on the disease pattern

OBJECTIVE

To find the frequency of hepatitis B and C virus (HBV and HCV) infection and their coinfection in chronic liver disease and any differences in the clinical features of single and coinfections. METHODOLGY: All clinically recognisable adult CLD patients admitted to Military Hospital, Rawalpindi in years 1999-2000, were included in the study. Their history and clinical features were recorded. Seromarkers for HBV (HBsAg, anti-HBc) and HCV (anti-HCV) were done.

RESULTS

A total of 97 (52 male, 45 female) patients were included in the study. Mean age was 51.6 years (range 16-75 years). Cirrhosis was present in 74.2%, chronic hepatitis (Ch Hep) in 18.6% and hepatocellular carcinoma (HCC) in 7.2%. Among the 74.1% patients with cirrhosis 28.5% were HBsAg positive, 55.5% anti-HBc positive and 68.1% anti HCV positive. In the chronic hepatitis cases 27.8% were HBsAg positive, 23.6% anti-HBc positive and 61.1% anti HCV positive. Among the patients of HCC 59.7% were HBsAg positive, 71.4% anti-HBc positive and 42% anti HCV positive. Regarding coinfection 7.2% were anti-HCV and HBsAg positive while 35.1% were anti-HCV and anti-HBc positive.

CONCLUSION

Ninety percent of patients with CLD had evidence of HBV, HCV or coinfection. Disease was more severe in patients with coinfection. Anti-HBc was found to be a sensitive indicator of past HBV.

Prospective randomized study of N-acetylcysteine, fenoldopam, and saline for prevention of radiocontrast-induced nephropathy

The objective of this study was to compare the efficacy of N-acetylcysteine (NAC), fenoldopam, and saline in preventing radiocontrast-induced nephropathy (RCIN) in high-risk patients undergoing cardiovascular procedures. We prospectively enrolled 123 patients who were scheduled for cardiovascular procedures and had a baseline creatinine > 1.6 mg/dl or creatinine clearance of < 60 ml/min. Patients were randomly assigned to receive either saline (0.45% normal saline at 1 cc/kg) for 12 hr before and 12 hr after the procedure, or fenoldopam (0.1 microg/kg/min) plus saline for 4 hr prior and 4 hr after the procedure, or NAC orally (600 mg) plus saline every 12 hr for 24 hr prior and 24 hr after the procedure. All the patients received low-osmolality nonionic contrast. RCIN was defined as an increase in creatinine level > 0.5 mg/dl after 48 hr. The incidence of RCIN was 17.7% in the NAC group, 15.3% in the saline group, and 15.7% in the fenoldopam group (P = 0.919). Of the 20 patients who developed RCIN, 2 required dialysis. Serum creatinine decreased after 48 hr (vs. baseline) in 38% patients in the NAC group, 18% in the fenoldopam group, and 15% in the saline group. In patients with chronic renal insufficiency, NAC or fenoldopam offered no additional benefit over hydration with saline in preventing RCIN.

[Laboratory methods of predicting primary and recurrent nephrolithiasis]

Concentrations of Na, K, Ca ions, oxalic and uric acids, total Ca, P as well as urease activity, the ability to form crystals, speed of crystallization, crystal chemical composition, pH stability were evaluated in the urine from 40 urolithiasis patients and 40 patients with recurrent nephroliths. It was found that fast or moderate crystallization, high urease activity and ability to form crystals, unstable urine pH indicate a high risk of both primary and recurrent nephrolith formation.

Mine blast injuries: ocular and social aspects

BACKGROUND/AIMS

Landmines have long been used in conventional warfare. These are antipersonnel mines which continue to injure people long after a ceasefire without differentiating between friend or foe, soldier or civilian, women or children. This study focuses on Afghan non-combatants engaged in mine clearing operations in Afghanistan in the aftermath of the Russo-Afghan war. The patterns and types of injuries seen are described and experiences in their management, ways, and means to prevent them, and recommendations for the rehabilitation of the affected individuals are given.

METHODS

It is a retrospective and analytical study of 84 patients aged 19-56 years who sustained mine blast injuries during mine clearing operations in Afghanistan from November 1992 to January 1996. The study was carried out at a military hospital with tertiary care facilities. The patients were divided into three groups on the basis of their injuries. Group 1 required only general surgical attention, group 2 sustained only ocular injuries, while group 3 had combined ocular and general injuries. Patients in groups 2 and 3 were treated in two phases. The first phase aimed at immediate restoration of the anatomy, while restoration of function wherever possible was done in subsequent surgical procedures in the second phase.

RESULTS

It was observed that 51 out of 84 patients (60.7%) had sustained ocular trauma of a variable degree as a result of the blasts. The mean age of the victims was 29 years and they were all male. A total of 91 eyes of 51 patients (89.2%) had been damaged. Bilaterality of damage was seen in 40 (78.4%) patients. Most, 34 (37.3%), eyes became totally blind (NPL). Only a few escaped with injury mild enough not to impair vision. Foreign bodies, small and multiple, were found in the majority of eyes; most, however, were found in the anterior segment, and posterior segment injuries were proportionally less.

CONCLUSIONS

The prevalence of blindness caused by mine blast injuries is quite high. The resulting psychosocial trauma to the patients and their families is tremendous and has not been adequately highlighted. These injuries are a great drain on the country's resources. Enforcement of preventive measures and the use of protective gear and sophisticated equipment by the mine clearing personnel would prove to be far more economical in terms of human life as well as medical and economic resources. There is also need for greater attention towards the establishment of support groups and rehabilitation programmes for these individuals.

MR imaging of the type II lunate bone: frequency, extent, and associated findings

OBJECTIVE

Type II lunate bones have an "extra" facet that articulates with the hamate bone, which frequently leads to arthritis. Because the only prior studies, to our knowledge, on this common and clinically significant variant involved dissection of cadavers, we performed an MR imaging study of the type II lunate.

MATERIALS AND METHODS

We retrospectively reviewed MR images obtained at 1.5 T of 186 wrists for frequency of type II lunates, size of the extra facet, amount of hamatolunate apposition, and presence of hamate subchondral edema. Of the 186 wrists, 28 also had correlation with findings on wrist arthroscopy.

RESULTS

One hundred seven wrists (57.5%) had type II lunates with an average extra facet size of 4.6 mm (range, 1.2-12.0 mm). Apposition (articulation) of the extra lunate facet with the hamate averaged 77.4% (range, 0-100%). Hamate edema was seen in only nine wrists (4.8%), all of which had type II lunates. Arthroscopic evidence of focal hamate chondromalacia and MR imaging evidence of marrow edema were seen in six of these nine wrists; marrow edema was seen only in wrists with frank cartilage changes on arthroscopy.

CONCLUSION

An extra facet (type II lunate) was seen in approximately half of 186 wrists. On MR imaging, type II lunates usually have an innocuous appearance. A large percentage of patients with type II lunates also have chondromalacia, which often is occult on MR imaging. When visible, such chondromalacia is the cause of marrow edema similar to that seen in patients with carpal fractures.

Quality improvement issues in Brazil

BACKGROUND

In 1988 a new constitution in Brazil brought the creation of a national health system, the Unified Health System (Sistema Unico de Saúde; SUS).

A GROWING INTEREST IN QUALITY

Accountability is not yet a strong feature of the health system, even though the Ministry of Health has made efforts to encourage the federal district and 26 states to participate in some quality-of-care projects. Initiatives include certification by the International Standards Organization (ISO; Geneva); consulting services, especially in managerial processes; total quality management; patient satisfaction; and development of new technologies to increase efficiency.

ISSUES AND CONCLUSIONS

Physicians' oft-repeated claim that they know all it takes to offer patients high-quality care makes it difficult to enlist their help in quality programs in general and in establishing protocols and guidelines in particular. State licenses are a prerequisite for hospitals, but this is not always enforced; the local health authority may be relieved that hospital care is at least being provided. Similarly, the government may find it important that the population has access to health services, even if the service is not considered adequate. Government can encourage quality initiatives and assess and disseminate the findings.