Remission of Dowager's hump by manipulative correction of spinal alignment: a case report

Dowager's hump is described as excessive kyphotic curvature in the thoracic spine with a Cobb angle of more than 40 degrees. This case report presents a 61 years old female office clerk who experienced headaches and neck pain for 3 years that extended into her right shoulder and upper chest. She consulted her primary care physician two months before seeing the chiropractor when the neck pain worsened. A diagnosis of cervicalgia related to osteoarthritis was made based on cervical and thoracic X-ray findings. The patient received non-steroid anti-inflammatory drugs (celecoxib and etoricoxib) and stretching exercises at home. At the onset of chiropractic care, radiographs showed loss of cervical lordosis, narrowing at the C4-5, C5-C6, and C6-7 intervertebral disc space with marginal osteophytes. Based on these findings, a working diagnosis of cervicogenic headache was established. After treatment for 9 months, the patient showed improvement in symptoms and function from cervical curve radiographic change and dextro-convexity of the thoracic spine. Avoiding forward head flexion and maintaining correct posture in daily activities will be key mechanisms to prevent the reoccurrence of Dowager's hump. The improvement of symptoms following chiropractic therapy has been shown to correlate with radiographic markers of spinal realignment.

Improved long-term survival with coronary artery bypass graft surgery compared to percutaneous coronary intervention in diabetics with multivessel disease

Background

While randomized clinical trials have demonstrated the superiority of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in patients with diabetes and multivessel coronary artery disease (CAD), there remains a paucity of observational evidence comparing these two modalities.

Methods

Clinical and administrative databases for Canada's most populous province, Ontario, were linked to obtain records of all patients with angiographic evidence of multivessel CAD (defined as: 2-vessel and 3-vessel disease) treated with either isolated CABG or PCI from October 2008 to March 2017. Left main disease was excluded in the primary analysis. Baseline characteristics of patients undergoing CABG and PCI were compared and 1:1 propensity score matching was performed to account for baseline differences. 30-day mortality was compared in the matched groups. Late mortality and the composite of major cardiovascular and cerebrovascular events (MACCE, consisting of stroke, myocardial infarction (MI), repeat revascularization, and death) were compared between the matched groups using a stratified log rank test and Cox-proportional hazards model. The individual non-fatal components of MACCE were compared using the Fine-Gray model that accounted for death as a competing risk. A secondary analysis that included patients with left main disease was also performed for the outcome of late mortality. A sensitivity analysis that excluded patients with acute coronary syndrome was also conducted for late mortality.

Results

A total of 9,395 and 4,016 patients underwent CABG and PCI respectively. Prior to matching, CABG patients were younger (65.7 vs 68.5 years, p<0.001), more likely male (78% vs 73%, p<0.001) and with more severe CAD. Propensity score matching based on 24 baseline covariates yielded 3,782 well-balanced pairs. There was no difference in early mortality between CABG and PCI (2.3% vs 2.5%, p=0.65). The rate of all-cause mortality over 8-years was significantly higher with PCI compared to CABG (Figure- HR: 1.35, 95% CI: 1.23–1.50). The cumulative incidence of MI (HR 1.91, 95% CI: 1.66–2.20) and need for repeat revascularization (HR: 4.06, 95% CI: 3.54–4.66) were significantly higher with PCI over 8 years. There was no difference in late stroke between PCI and CABG (stroke (HR: 0.85, 95% CI: 0.68–1.07). Overall MACCE was higher in PCI compared to CABG (HR: 1.94, 95% CI: 1.80–2.09). In our secondary analysis that included patients with left main disease, findings were robust and late mortality remained higher with PCI compared to CABG (HR: 1.42, 95% CI: 1.30–1.54). In a sensitivity analysis where patients with acute coronary syndrome at the time of presentation were excluded, late mortality remained higher with PCI (HR: 1.30, 95% CI: 1.12–1.49) in 2,028 matched pairs.

Conclusions

In patients with multivessel CAD and diabetes we observed improved long-term mortality and freedom from MACCE at 8-years with CABG compared to PCI.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Canadian Institutes of Health Research

91Transcatheter valve-in-valve versus redo surgical aortic valve replacement for the management of failed biological prosthesis: early and late outcomes

Background

While the gold standard for the management of failed previous biological prosthesis was redo surgical aortic valve replacement (SAVR), valve-in-valve (ViV) transcatheter AVR (TAVR) has emerged as a less invasive option. Published studies comparing the two techniques have been small and limited to early outcomes. Herein, we compare early mortality, morbidity and late mortality between ViV TAVR and redo SAVR.

Methods

Clinical and administrative databases for Canada's most populous province, Ontario (>13 million patients), were linked to identify patients undergoing ViV and redo SAVR for a failed biological prosthesis. Baseline characteristics were compared and 1:1 propensity score matching (PSM) was performed to account for baseline differences. Standardized mean differences (SMD) were used to assess adequacy of PSM, whereby a SMD<0.10 indicated a good match. Early outcomes were compared in the matched groups using McNemar's test. In accordance to government privacy legislation, outcomes with <6 events, were presented as absolute risk difference (ARD) between ViV and Redo SAVR to prevent patient re-identification. Late mortality was compared between the matched groups using Kaplan-Meier survival curves and a Cox-proportional hazard model.

Results

Records of 558 patients undergoing intervention for a failed biological prosthesis between March 2008 to September 2017 in 11 Ontario institutions were reviewed (ViV = 214, redo SAVR = 344). Patients who underwent ViV were older (78.2±8.2 vs 69.1±11.4, p<0.001, SMD=0.92) and had more hypertension, diabetes, ischemic heart disease, atrial fibrillation, congestive heart failure compared to redo SAVR before PSM (SMD>0.20). Propensity matching on 24 variables yielded similar groups for comparison (n=133 pairs). Ages were similar between ViV and Redo SAVR (76.0±6.2 vs 76.0±8.7, SMD=0.003) along with all other comorbidities (SMD<0.1). 30-day mortality was significantly lower with ViV compared to Redo SAVR (ARD: −7.4%, 95% confidence interval (95% CI): −12.4%, −2.3%). The rate of permanent pacemaker implantation (ARD: −8.1%, 95% CI: −14.2%, −2.1%), blood transfusions (ARD: −62.2%, 95% CI: −75.2%, −49.1%) and length of stay (LOS) (mean difference: −7.8 days, 95% CI: −11.0, −4.6 days) were also lower with ViV. All-cause mortality at 5 years was similar between ViV and redo SAVR (Figure, p=0.19).

Figure 1

Conclusion

ViV TAVR was associated with lower early mortality, risk of permanent pacemaker implantation, any blood transfusion, and hospital LOS compared to redo SAVR in the largest PSM study to date. While there was no difference in late mortality at 5 years, additional studies with more subjects and longer follow-up are necessary. ViV TAVR may be the preferred approach for the treatment of failed biological prosthesis.

A phase I trial of PRN1008, a novel reversible covalent inhibitor of Bruton's tyrosine kinase, in healthy volunteers

AIM

To evaluate the safety, tolerability, and pharmacokinetics/pharmacodynamics of PRN1008, a novel Bruton's tyrosine kinase (BTK) inhibitor, in healthy volunteers, and thus determine the dose range for future clinical studies.

METHODS

This was a two-part randomized, placebo controlled study in healthy volunteers using a liquid formulation. Part I was a single ascending dose design with dose levels of 50-1200 mg (n = 6 active, two placebos per cohort); Part II was a multiple ascending dose design, with dose regimens ranging from 300 to 900 mg daily, either four times or twice daily for 10 days. Plasma pharmacokinetics, adverse events, vital signs, electrocardiograms and laboratory parameters were assessed. BTK occupancy in peripheral blood mononuclear cells was evaluated as a marker of target engagement.

RESULTS

PRN1008 was rapidly absorbed following oral administration, and was safe and well tolerated in all dose regimens evaluated in both single and multiple doses. PRN1008 demonstrated a large volume of distribution, and a half-life of approximately 3-4 h. BTK occupancy of >90% was observed within 4 h after dosing in both single and multiple dose regimens, and was closely linked to maximum plasma concentration. BTK occupancy decay was slow (-1.6% h^-1 ), and occupancy was sustained despite drug concentrations being undetectable. No severe or serious adverse events occurred, and the most common adverse events were gastrointestinal in nature.

CONCLUSIONS

PRN1008 was safe and well-tolerated following oral administration, and achieved high, sustained levels of BTK occupancy in peripheral blood mononuclear cells.

Flagellar waveform dynamics of freely swimming algal cells

We present quantitative measurements of time-dependent flagellar waveforms for freely swimming biflagellated algal cells, for both synchronous and asynchronous beating. We use the waveforms in conjunction with resistive force theory as well as a singularity method to predict a cell's time-dependent velocity for comparison with experiments. While net propulsion is thought to arise from asymmetry between the power and recovery strokes, we show that hydrodynamic interactions between the flagella and cell body on the return stroke make an important contribution to enhance net forward motion.

Compound odontoma causing airway obstruction of the newborn: a case report

A newborn presented with acute airway obstruction secondary to a compound odontoma of the hard palate/nasal floor. This is the first case recorded in the literature. We review the pathology of compound odontomas and discuss the management of this rare and interesting case.

Immunostaining patterns of myoepithelial cells in breast lesions: a comparison of CD10 and smooth muscle myosin heavy chain

BACKGROUND

Recent studies have reported CD10 expression in myoepithelial cells (MEC) of the breast, supporting its use as a marker to help distinguish invasive breast carcinoma (IC) from ductal carcinoma in situ (DCIS).

AIM

To compare the effectiveness of CD10 with smooth muscle myosin heavy chain (SMMHC) in the detection of MEC in benign and malignant breast lesions.

METHODS

Histological material from 25 patients with DCIS and 21 with IC were immunostained for CD10 and SMMHC. Staining was scored on a scale of 0 to 3+ (0, no staining; 3+, intense) and the staining distribution was documented as focal, partial, or circumferential.

RESULTS

Uniform, 3+ circumferential CD10 and SMMHC staining of MEC was seen in normal breast ducts and lobules, and in ducts and acini involved in sclerosing adenosis and apocrine metaplasia. In an analysis of total ducts involved by DCIS, 3+ circumferential staining was seen in 65 of 366 ducts (17.7%) stained for CD10 versus 190 of 396 ducts (48%) stained for SMMHC. MEC were not detected immunohistochemically in 116 of 366 ducts (31.7%) with anti-CD10 and 50 of 396 (12.7%) with anti-SMMHC. In contrast, all ICs were negative for both CD10 and SMMHC. Focal background staining of stromal myofibroblasts was seen with both CD10 and SMMHC, but CD10 showed a higher rate of non-specific staining of epithelial cells.

CONCLUSION

Although CD10 can aid in the distinction between IC and DCIS, SMMHC is a more sensitive and specific marker of MEC and shows less heterogeneity of immunostaining patterns.

Diagnostic value of liquid-based (Thinprep) preparations in nongynecologic cases

Most studies utilizing the liquid-based ThinPrep method for the preparation of nongynecological specimens report a diagnostic sensitivity and specificity of over 90%. ThinPrep-processed slides in 162 cases sent to us from outside laboratories were assessed for their diagnostic value. These included fine-needle aspiration (FNA) (128) and other nongynecological specimens (34), representing bronchopulmomary washings, body cavity fluids, and urine samples. Slides were examined independently for adequacy and diagnostic value. These results were compared with the final diagnosis rendered upon examination of the entire submitted cytologic specimens, including direct smears, cytospins, and cell blocks. Based on review of the ThinPrep-processed slides alone, diagnosis of malignancy or neoplasia was made in 54 of 86 cases (63%), while 18/86 (21%) were less than optimal and 14/86 (16%) were unsatisfactory. Pulmonary specimens, body cavity fluids, and urine were generally satisfactory, while thyroid and breast FNA were more often less than optimal or unsatisfactory. This limited study suggests that utilization of ThinPrep processing alone may have reduced diagnostic value in the fine-needle aspiration cases studied here.

Ultrasound-guided fine-needle aspiration biopsy of the thyroid: role of on-site assessment and multiple cytologic preparations

Several studies have shown that ultrasound guidance can serve as a valuable aid in improving the diagnostic yield of fine-needle aspiration (FNA) biopsy of thyroid nodules. In this study, we evaluated the combined impact of ultrasound-guidance, rapid on-site evaluation of FNA specimens, and different cytologic preparations (fresh and alcohol-fixed smears, Millipore filter) and staining methods (Diff-Quik and Papanicolaou stains) on the diagnostic yield of thyroid FNA. Ultrasound-guided FNA was performed on 282 patients (313 cases) between November 1997 and April 1999. The diagnostic categories included: benign (198 cases, 63.2%); indeterminate (42 cases, 13.4%); suspicious for follicular variant of papillary carcinoma (26 cases, 8.3%), malignant (32 cases, 10.1%); and nondiagnostic (15 cases, 5%). The nondiagnostic cases also included 6 cystic lesions without any solid component and 3 thyroid-bed aspirations. After excluding these, the nondiagnostic rate was only 2%. Histological follow-up was available in 77 (77/313) cases. The concordance rate between cytological and histological diagnosis was 100% in malignant, 67% in suspicious, and 56% in indeterminate cases. All cases with histologic follow-up were selected to evaluate the independent diagnostic efficacy of each aforementioned cytologic staining method. A definite diagnosis could be made solely on the basis of air-dried, Diff-Quik-stained preparations in 50 (65%), alcohol-fixed, Papanicolaou stained smears in 68 (88%), and Millipore filter preparations in 70 (91%) cases. We conclude that ultrasound-guided FNA combined with on-site evaluation and different cytologic preparations can significantly improve the diagnostic accuracy of thyroid FNA specimens.

Repeated measures of cognitive processing efficiency in adolescent athletes: implications for monitoring recovery from concussion

OBJECTIVE

The objective of this study was to determine whether an adolescent athlete, in the absence of concussion, would be expected to show an improvement in cognitive function during the course of a high school football season.

BACKGROUND

At least 60,000 American high school football players suffer cerebral concussion every year, and symptoms may persist for 4 or more years in as many as 24%.

METHOD

34 members of a cohort of healthy athletes, aged 13-18, were administered a computerized neuropsychologic test battery from the Automated Neuropsychological Assessment Metrics (ANAM) before and after the 1997 high school football season, with a mean interval of 16.1 (range 12.3-20.4) weeks between tests. Preseason and postseason scores on eight tests were compared, with significance determined by paired t-test. For those tests in which an improvement was noted, one-way analysis of variance and Wilcoxon tests were used with both preseason and postseason data to determine if there was a measurable difference in cognitive processing efficiency between older and younger subjects.

RESULTS

Improvements in processing efficiency (p < 0.001) were noted on tests designed to measure visual scanning and sustained attention (CDS), immediate recall (CDI), and short-term memory (CDD). Older subjects generally performed better on each of these tests, though the difference was significant in only one case (postseason CDI, 17-18 year olds vs. 13-14 year olds, Wilcoxon, p = 0.043).

CONCLUSIONS

Our findings suggest that ANAM is sensitive to differences and improvements in cognitive function during a 4 month interval in adolescence. They also suggest that using "return to baseline" cognitive function as the criterion for evidence of recovery from concussion may be insufficient, especially when the baseline measurement was obtained 4 or more months prior to the date of "full recovery."

An alpha-helical minimal binding domain within the H3 domain of syntaxin is required for SNAP-25 binding

The interaction between the proteins syntaxin 1A and SNAP-25 is a key step in synaptic vesicle docking and fusion. To define the SNAP-25 binding domain on syntaxin, we have prepared peptides that span the syntaxin H3 domain (residues 191-266), the region previously shown to be important for binding to SNAP-25, and then determined the affinities of these peptides for binding to SNAP-25. A minimal binding domain was identified within a region of 32 amino acids (residues 189-220). Its affinity for SNAP-25 is substantially enhanced by C-terminal extension (residues 221-266). Circular dichroism revealed the presence of substantial alpha-helicity in the H3 domain and in the 32-mer minimal binding domain, but not in H3 peptides that do not bind to SNAP-25. At temperatures that denature the alpha-helix of the minimal binding domain peptide, SNAP-25 binding is lost. Selected mutations in evolutionarily conserved residues of the amphiphilic alpha-helix within the minimal binding domain (e.g., residues 205 and 209) greatly reduce the affinity for SNAP-25 but have no major effect on secondary structure, suggesting that these residues may interact directly with SNAP-25. The H3 domain peptide and the minimal binding domain peptide inhibit norepinephrine release from PC12 cells. These results suggest that specific amino acid residues in the H3 domain, positioned by the underlying alpha-helical structure, are important for its binding to SNAP-25 and support the notion that this interaction is important for presynaptic vesicular exocytosis.

Schizophrenia: gender and familial risk

The morbid risks for schizophrenia and any nonaffective psychosis in the first degree relatives of male and female schizophrenic probands were compared utilizing Cox proportional hazards models. The schizophrenic probands (275 male; 106 female) were drawn from a larger sample of hospitalized patients obtained by systematically screening all psychiatric admissions to 15 facilities over a six-year period. Proband diagnoses (DSM-III) were based on a direct assessment of the patient and a review of medical records. The family history method was used to obtain information about the first degree relatives of the probands. Cox proportional hazards models were adjusted for duration of illness of the proband and gender of the relatives. First degree relatives of female probands had significantly higher morbid risks for schizophrenia and nonaffective psychosis than relatives of male probands. The differential risk for schizophrenia in the relatives of male and female probands demonstrated in this study, as well as others, suggests that males and females may be at different risk for subtypes of the disorder.

Risk factors in schizophrenia. Season of birth, gender, and familial risk

The risk for schizophrenia among first-degree relatives of schizophrenic probands obtained from an epidemiological sample using family history methods was examined to determine whether month of birth of the proband was associated with familial risk. The results of this study of the first-degree relatives of 106 female schizophrenics and 275 male schizophrenics suggested that the relatives of probands born in the months February to May had the highest risk, although the association between month of birth and familial risk among the male probands was present only for those relatives who had onset of schizophrenia before the age of 30.

Psychiatric morbidity in the relatives of patients with DSM-III schizophreniform disorder: comparisons with the relatives of schizophrenic and bipolar disorder patients

Risks for psychiatric disorders (RDC) among first degree relatives of DSM-III schizophreniform, bipolar, and schizophrenic probands obtained from an epidemiologic sample using family history methods were examined. The relatives of the schizophreniform probands differed from the relatives of the schizophrenic and bipolar probands. The relatives of schizophreniform probands had significantly higher rates of affective illnesses (with the exception of bipolar illness) than the relatives of schizophrenic probands, and they had a significantly higher rate of psychotic affective disorders than the relatives of the bipolar probands.

Depressive mood, the single-parent home, and adolescent cigarette smoking

The association between depressive mood and cigarette smoking among adolescents was examined within a multivariate model. Subjects were 205 eleventh graders (123 boys and 82 girls) enrolled in a Northeast metropolitan public high school for science-oriented students. Logistic regression analysis showed an independent relation of depressive mood, friends' smoking behavior, and living in a single-parent home with cigarette smoking. Depression scores correlated with the number of cigarettes smoked. These associations suggest that depressive mood and stress may contribute to the onset of smoking.

Schizophrenia: age at onset, gender and familial risk

In a family history study of 366 schizophrenic probands and their 1851 first-degree relatives, we found a relationship between age at onset of psychosis in the male probands and the risk for schizophrenia in their relatives. The relatives of male schizophrenic probands whose onset of psychosis occurred when they were younger than 17 years of age had an increased risk of schizophrenia when compared with the relatives of male probands with an age at onset greater than 17. We did not find an association between age at onset of psychosis in the female probands and familial risk. Cox proportional hazards models permitted us to examine the relationship between age at onset of psychosis in the probands and familial risk while controlling for possible confounding effects.

Induction of ornithine decarboxylase activity by growth and differentiation factors in FRTL-5 cells

Induction of ornithine decarboxylase has been correlated with the onset of cellular proliferation and cAMP production. Whether the resulting increases in polyamine levels are essential mediators of growth and/or differentiation or are merely incidental remains controversial. We have used FRTL-5 thyroid cells in culture to study the effects of three growth factors on ornithine decarboxylase activity. These factors [TSH, bovine calf serum, and 12-O-tetradecanoylphorbol-13-acetate (TPA)] are thought to act through different intracellular pathways. TSH stimulates cAMP production in thyroid cells, calf serum acts through ill-defined pathways to stimulate growth, and TPA is known to activate protein kinase C. Bovine calf serum and TSH acted synergistically to induce ornithine decarboxylase activity. Activity was maximal when the phosphodiesterase inhibitor, methyl isobutyl xanthine, was included. Individually, neither serum nor TSH was a potent stimulator of the enzyme. Ornithine decarboxylase mRNA was apparent on Northern blots as a doublet following one hour of exposure to these agents. TPA did not stimulate ornithine decarboxylase activity and had an inhibitory effect on enzyme induction by TSH and serum. Difluoromethylornithine, a specific inhibitor of ornithine decarboxylase, inhibited growth induced by both TPA and TSH in putrescine-free medium. This effect was not apparent in medium containing 10(-5) M putrescine. The data indicate that, although intracellular levels of cyclic AMP regulate ornithine decarboxylase activity, a component in serum is necessary for significant induction of this enzyme. Factors stimulating growth by non-cyclic AMP-dependent pathways may act without apparently stimulating this enzyme, although polyamines appear to be essential for their growth stimulatory effects.