MRRead-A Novel Approach to Training Residents in Magnetic Resonance Image Temporomandibular Joint Interpretation

PURPOSE

The purpose of our study was to create an online, web-based training module that would instruct a group of participants in the interpretation of a magnetic resonance image (MRI) of the temporomandibular joint (TMJ) scan in a logical, step-wise manner to locate and identify all relevant features of internal derangement. The investigator's hypothesis was that implementing the MRRead TMJ training module would improve the participants' competency in the interpretation of MRI TMJ scans.

METHODS

The investigators designed and implemented a single-group prospective cohort study. The study population was composed of oral and maxillofacial surgery interns, residents, and staff. Subjects eligible for study inclusion were oral and maxillofacial surgeons of any level, between 18 and 50 years of age, that completed the MRRead training module to completion. The primary outcome variable was the difference between the pretest and post-test scores of the participants, and the frequency of missing internal derangement findings before and after the course. Secondary outcomes of interest were subjective data gathered from the course, including participant feedback as well as subjective evaluation of the training module and perceived benefit, as well as the learner's self-reported confidence level in interpreting MRI TMJ scans on their own before and after completion of the course. Descriptive and bivariate statistics were used.

RESULTS

The study sample consisted of 68 subjects, aged 20 to 47 (M = 29.1) years. When comparing the results of the exams precourse and post course, the overall frequency of missed features of internal derangement decreased from 19.7 to 5.9, and the total score overall increased from 8.5 to 68.6%. Regarding secondary outcomes, the majority of participants indicated that they agree or strongly agree with a number of positive subjective questions asked. In addition, there was a statistically significant increase in the participants' comfort levels in the interpretation of MRI TMJ scans.

CONCLUSION

The results of this study confirm the hypothesis that completing the MRRead training module (www.MRRead.ca) improves competency and comfort among participants in the interpretation of MRI TMJ scans and their identification of features of internal derangement correctly.

Fin1-PP1 Helps Clear Spindle Assembly Checkpoint Protein Bub1 from Kinetochores in Anaphase

The spindle assembly checkpoint (SAC) monitors chromosome attachment defects, and the assembly of SAC proteins at kinetochores is essential for its activation, but the SAC disassembly process remains unknown. We found that deletion of a 14-3-3 protein, Bmh1, or hyperactivation of Cdc14 early anaphase release (FEAR) allows premature SAC silencing in budding yeast, which depends on a kinetochore protein Fin1 that forms a complex with protein phosphatase PP1. Previous works suggest that FEAR-dependent Fin1 dephosphorylation promotes Bmh1-Fin1 dissociation, which enables kinetochore recruitment of Fin1-PP1. We found persistent kinetochore association of SAC protein Bub1 in fin1Δ mutants after anaphase entry. Therefore, we revealed a mechanism that clears SAC proteins from kinetochores. After anaphase entry, FEAR activation promotes kinetochore enrichment of Fin1-PP1, resulting in SAC disassembly at kinetochores. This mechanism is required for efficient SAC silencing after SAC is challenged, and untimely Fin1-kinetochore association causes premature SAC silencing and chromosome missegregation.

Improving the diagnosis of LV non-compaction with cardiac magnetic resonance imaging

BACKGROUND

Current diagnostic criteria for left ventricular non-compaction (LVNC) poorly correlate with clinical outcomes. We aimed to develop a cardiac magnetic resonance (CMR) based semi-automated technique for quantification of non-compacted (NC) and compacted (C) masses and to ascertain their relationships to global and regional LV function.

METHODS

We analysed CMR data from 30 adults with isolated LVNC and 20 controls. NC and C masses were measured using relative signal intensities of myocardium and blood pool. Global and regional LVNC masses was calculated and correlated with both global and regional LV systolic function as well as occurrence of arrhythmia.

RESULTS

LVNC patients had significantly higher end-systolic (ES) and end-diastolic (ED) NC:C ratios compared to controls (ES 0.21 [SD 0.09] vs. 0.12 [SD 0.02], p<0.001; ED 0.39 [SD 0.08] vs. 0.26 [SD 0.05], p<0.001). NC:C ratios correlated inversely with global ejection fraction, with a stronger correlation in ES vs. ED (r=-0.58, p<0.001 vs. r=-0.30, p=0.03). ES basal, mid and apical NC:C ratios also showed a significant inverse correlation with global LV ejection fraction (ES basal r=-0.29, p=0.04; mid-ventricular r=-0.50, p<0.001 and apical r=-0.71, p<0.001). Upon ROC testing, an ES NC:C ratio of 0.16 had a sensitivity of 70% and a specificity of 95% for detection of significant LVNC. Patients with sustained ventricular tachycardia had a significantly higher ES NC:C ratio (0.31 [SD 0.18] vs. 0.20 [SD 0.06], p=0.02).

CONCLUSIONS

The NC:C ratio derived from relative signal intensities of myocardium and blood pool improves the ability to detect clinically relevant NC compared to previous CMR techniques.

Coordination of chromatid separation and spindle elongation by antagonistic activities of mitotic and S-phase CDKs

Because cohesion prevents sister-chromatid separation and spindle elongation, cohesion dissolution may trigger these two events simultaneously. However, the relatively normal spindle elongation kinetics in yeast cohesin mutants indicates an additional mechanism for the temporal control of spindle elongation. Here we show evidence indicating that S-phase CDK (cyclin dependent kinase) negatively regulates spindle elongation. In contrast, mitotic CDK promotes spindle elongation by activating Cdc14 phosphatase, which reverses the protein phosphorylation imposed by S-phase CDK. Our data suggest that S-phase CDK negatively regulates spindle elongation partly through its phosphorylation of a spindle pole body (SPB) protein Spc110. We also show that hyperactive S-phase CDK compromises the microtubule localization of Stu2, a processive microtubule polymerase essential for spindle elongation. Strikingly, we found that hyperactive mitotic CDK induces uncoupled spindle elongation and sister-chromatid separation in securin mutants (pds1Δ), and we speculate that asynchronous chromosome segregation in pds1Δ cells contributes to this phenotype. Therefore, the tight temporal control of spindle elongation and cohesin cleavage assure orchestrated chromosome separation and spindle elongation.

Slk19 clusters kinetochores and facilitates chromosome bipolar attachment

Yeast kinetochore protein Slk19 is required for kinetochore clustering, and nocodazole exposure to slk19 mutant cells causes impaired kinetochore capture and delayed chromosome bipolar attachment after nocodazole washout.

In all eukaryotic cells, DNA is packaged into multiple chromosomes that are linked to microtubules through a large protein complex called a kinetochore. Previous data show that the kinetochores are clustered together during most of the cell cycle, but the mechanism and the biological significance of kinetochore clustering are unknown. As a kinetochore protein in budding yeast, the role of Slk19 in the stability of the anaphase spindle has been well studied, but its function in chromosome segregation has remained elusive. Here we show that Slk19 is required for kinetochore clustering when yeast cells are treated with the microtubule-depolymerizing agent nocodazole. We further find that slk19Δ mutant cells exhibit delayed kinetochore capture and chromosome bipolar attachment after the disruption of the kinetochore–microtubule interaction by nocodazole, which is likely attributed to defective kinetochore clustering. In addition, we show that Slk19 interacts with itself, suggesting that the dimerization of Slk19 may mediate the interaction between kinetochores for clustering. Therefore Slk19 likely acts as kinetochore glue that clusters kinetochores to facilitate efficient and faithful chromosome segregation.

National audit of incontinence surgery in the United Kingdom

The aim of the study was to describe the experience, current trends and management of incontinence surgery for urodynamic stress incontinence (USI) in the United Kingdom. The study was a postal questionnaire survey that was sent to a cohort of surgeons known to be performing continence surgery. The subjects addressed included the considered role of the surgeon, the total number and type of operations performed in the last year, urodynamics and physiotherapy prior to incontinence surgery, operative complications, postoperative advice and follow-up (lengths and methods). The response rate was 54%. Large variations were found in all areas. The survey provides evidence of the number of incontinence operations performed, potentially important trends and differences in the practice and management of incontinence in the United Kingdom. This survey may be helpful in making guidelines and standards for audit at regional, local and individual levels as well as recommendations for strategies to enhance professional expertise in urogynaecology in the United Kingdom.

Tension-free vaginal tape (TVT) in the United Kingdom

Four hundred and twenty-six surgeons identified as performing TVT in the United Kingdom in the year ended 1 January 2002 were sent a postal questionnaire to identify the technique employed and the complications encountered. An 81% response rate was achieved. Over 7000 TVT operations were reported. Large numbers of surgeons perform a small number of operations each year. A variety of different surgical techniques and anaesthetics are used. Bladder perforations have been reported by 44% and de novo bladder overactivity by 37% of surgeons. Tape erosion is seen in 0.33%. Twenty-eight per cent of surgeons have seen voiding abnormalities that persist for more than 6 weeks. Fifty-seven per cent of surgeons perform short-term follow-up only. The operation is performed in a variety of different ways, by surgeons with variable experience and volumes of work. The different surgical techniques have not been evaluated prospectively and complications are seen more commonly than originally reported.

The multilayer regulation of the metaphase-to-anaphase transition

The fluctuating activity of the cyclin-dependent kinases (Cdks) is critical for the periodic phosphorylation of a given Cdk substrate. Previous studies have been focus on the positive role of Cdk-dependent protein phosphorylation in cell cycle progression. Recent studies indicate that, in budding yeast, highly active S-phase cyclin-associated Cdk not only promotes DNA synthesis but also inhibits the initiation of chromosome segregation. The FEAR (Cdc14 early anaphase release) pathway alleviates the negative effect of the S-phase cyclin on anaphase by promoting the dephosphorylation of S-phase cyclin-specific substrates, revealing a new layer of regulation in the metaphase-to-anaphase transition.

Applying HEDIS clinical measures to community health centers: a feasibility study

Since participation in managed care is critical for community health centers' (CHCs) survival, centers must demonstrate their good performance to purchasers (e.g., state Medicaid agencies) and health plans. Such measures also can contribute to quality improvement. Ideally, the effort would use measures and methods widely recognized in the managed care industry, logically the Health Plan Employer Data and Information Set (HEDIS). This article summarizes a feasibility study of applying HEDIS clinical measures to CHCs as providers. It finds that, with concerted, well-directed efforts, it will be possible to use clinical HEDIS measures in health centers.

Protein ProQ influences osmotic activation of compatible solute transporter ProP in Escherichia coli K-12

ProP is an osmoregulatory compatible solute transporter in Escherichia coli K-12. Mutation proQ220::Tn5 decreased the rate constant for and the extent of ProP activation by an osmotic upshift but did not alter proP transcription or the ProP protein level. Allele proQ220::Tn5 was isolated, and the proQ sequence was determined. Locus proQ is upstream from prc (tsp) at 41.2 centisomes on the genetic map. The proQ220::Tn5 and prc phenotypes were different, however. Gene proQ is predicted to encode a 232-amino-acid, basic, hydrophilic protein (molecular mass, 25,876 Da; calculated isoelectric point, 9.66; 32% D, E, R, or K; 54.5% polar amino acids). The insertion of PCR-amplified proQ into vector pBAD24 produced a plasmid containing the wild-type proQ open reading frame, the expression of which yielded a soluble protein with an apparent molecular mass of 30 kDa. Antibodies raised against the overexpressed ProQ protein detected cross-reactive material in proQ+ bacteria but not in proQ220::Tn5 bacteria. ProQ may be a structural element that influences the osmotic activation of ProP at a posttranslational level.

Effect of HIV counseling and testing on sexually transmitted diseases and condom use in an urban adolescent population

OBJECTIVE

To determine whether human immunodeficiency virus (HIV) counseling and testing has an effect on reducing subsequent risk behaviors in those tested, to evaluate stability in condom use over time, and to determine whether self-reported frequency of condom use relates to the incidence of sexually transmitted diseases (STDs).

DESIGN

Cohort study with 2-year follow-up.

SETTING

An urban adolescent-medicine clinic.

PARTICIPANTS

A random sample of 149 patients (118 female and 31 male adolescents) with a mean (+/- SD) age of 16.4 +/- 1.51 years were selected from a cohort of 500 patients at high risk for HIV infection. The patients had received a risk behavior questionnaire during pretest counseling for HIV testing. They were divided into 3 groups, identified by the letter F, S, or R, based on their self-report of frequency of condom use at enrollment: 24% used condoms frequently/always (F); 40%, sometimes (S); and 36%, rarely/never (R). One hundred twenty-six patients (85%) made return visits.

INTERVENTION

HIV counseling and testing.

MAIN OUTCOME MEASURES

Medical record documentation of STDs before and after HIV testing, and self-reported condom use frequency.

RESULTS

Before HIV testing, all 3 condom use groups had a similar frequency of STD visits per month. The number of STD visits per month did not decrease significantly in the posttest period for either the total group or each of the 3 subgroups. Also, most patients (F, 67%; S, 44%; R, 53%) in each of the 3 subgroups had shifted unfavorably to rarely/never (R) condom use within the month before their follow-up visit. Only 24% (8 patients) of those in the initial frequently/always (F) group reported continued frequent condom use.

CONCLUSIONS

As has been found in adult studies, single-dose interventions such as HIV counseling and testing did not seem to reduce HIV risk behaviors in our sample of high-risk adolescent patients. None of the 3 groups showed a significant decrease in STDs after HIV testing and counseling. Also, our adolescent patients reported widely varying condom use frequency over time, yet the incidence of STDs did not correlate with self-reported condom use.

Are adolescents accurate in self-report of frequencies of sexually transmitted diseases and pregnancies?

PURPOSE

Many surveys of adolescent behavior are dependent on self-reported data. We sought to assess the accuracy of adolescent self-report of sexually transmitted diseases (STDs) and pregnancies.

METHODS

We randomly selected 149 (118 females, 31 males) adolescents to participate in this accuracy study. Follow-up questionnaires were administered to the 126 patients (99 females, 27 males) who returned after enrollment. Patients were asked about STDs and pregnancies during the follow-up period which ranged from 6 months to 1 year. All patient charts were reviewed to validate post-testing history.

RESULTS

Return visits were made by 126 patients (84%). Fifty-one (40%) denied having had an STD at all during the follow-up period but were found to have had at least one STD. Another 11 (9%) admitted having had an STD but had multiple STDs in excess of what they reported. Only 46% of the patients provided accurate information on the follow-up questionnaire. Of the 99 girls who returned for follow-up, the inaccurate patients (10%) consisted of 9 who reported no visits for a pregnancy but had a pregnancy documented in their charts and 1 who underreported her number of pregnancies. Reliability analysis of the accuracy of STD and pregnancy self-report for our patients showed kappas ranging from 0.185 to 0.413 (slight and fair to moderate, respectively). Pearson correlation coefficients were 0.3107 and 0.4364 for STD and pregnancy, respectively.

CONCLUSIONS

Our patients' histories of visits for STDs and pregnancies are often not substantiated by review of their medical records. The reason for the inaccuracies in self-report of sexual behaviors is unclear. Further research in this area should be done. Physicians must confirm patient history concerning sexual practices through appropriate record review and medical evaluation.

Is sexual abuse in childhood or adolescence a predisposing factor for HIV infection during adolescence?

This exploratory study was conducted to determine whether sexual abuse might be a risk factor or marker for other risk factors for Human Immunodeficiency Virus (HIV) infection. Twenty-five HIV-positive adolescents were assessed for a variety of possible risk factors for HIV infection, including prior history of sexual abuse. Fifteen (60%) had a history of sexual abuse. A history of sexual abuse may be a risk factor for HIV infection directly, or it may be associated with or predispose one to other risk factors. The latter mechanism may be related to the long-term negative outcomes of some individuals with a history of sexual abuse. These may include same-sex sexual experiences as an adolescent, re-victimization with additional episodes of abuse, multiple consensual sexual partners, and drug and/or alcohol abuse. Preventive interventions aimed at reducing the risk of HIV infection must take a history of sexual abuse into account. Patients with such a history deserve intensive psychological counseling to help prevent adverse behavioral outcomes that can result in HIV infection.

Tonsillectomy and adenoidectomy in patients with Down syndrome

Tonsillectomy and adenoidectomy in patients with Down syndrome usually relieves symptoms of upper airway obstruction due to adenotonsillar hypertrophy. A retrospective review of 16 patients with Down syndrome who underwent a tonsillectomy and adenoidectomy was conducted to define early postoperative morbidity, and to evaluate the results of the procedure. Fifteen of 16 patients had upper airway obstruction manifest by adenotonsillar hypertrophy. One had adenoid hypertrophy only. Tonsillectomy and adenoidectomy (13), adenoidectomy (1), tonsillectomy (1), and UP3/adenoidectomy (1) were performed on these patients. Four patients (25%) required observation in an intensive care setting the first night. An average hospital stay of 2.1 days was noted with a range of 0 to 7 days. Significant postoperative apnea was common, and oxygen was used in over 60% of patients. Symptoms were resolved in 69% of patients at last follow up. In conclusion, tonsillectomy and adenoidectomy can be a useful procedure for children with Down syndrome and obstructive sleep apnea, however overnight hospitalization for observation and treatment of persistent apnea is appropriate.

The incontinent woman: 2

The second article in this two-part series deals with the diagnosis and treatment of urinary incontinence in women. This encompasses genuine stress incontinence, detrusor instability and sensory urgency. These can be effectively treated with careful understanding of the patient's symptomatology and objective diagnosis.

Can't keep that old barium meal down

I am one of a large group of nurses who would like to dispute the comments made in J Hendrickse's letter, Old barium meals are hard to swallow (September 22).

The incontinent woman: 1

Urinary incontinence is a common condition; however, symptoms often bear no relation to the ultimate diagnosis apart from uncomplicated stress incontinence. Objective investigation is recommended to establish an accurate diagnosis leading to effective treatment.

How does rHuEPO effect D/P creatinine ratios?

Initially starting CAPD patients on EPO was concerning after hearing reports of hemodialysis patients stating that they "may need more dialysis". The rationale given was that with a higher hematocrit the percentage of plasma in whole blood would decrease, leading to an increase of red cell mass. This decreased plasma volume and increased viscosity would lead to a slower blood flow ultimately resulting in less efficient dialysis. Assessing CAPD patients' peritoneal efficiency was the next step. We obtained pre and post-EPO PETs and evaluated. The initial results showed that D/P creatinine ratios were dropping as our Hcts increased, and ultrafiltration results projected an improvement. What remained unanswered was what took place over extended periods of time on EPO therapy. We examined twelve patients over a period of 27 months. Each patient received 4 exchanges per day using 1500 to 2500 volume. PET tests were performed on each patient prestudy, and at months three, six, and 25-27. Initially each patient received EPO 4000 units, 3/week, SQ. EPO easily increased and maintained our patients' hematocrits within 12 weeks after starting the study. D/P creatinine ratios initially dropped but as our study continued there was a return of D/P creatinine ratios to 6% greater than baseline. One report suggests that EPO may have a direct vasoconstricting effects on blood vessels caused by the stimulation of calcium toward the cell. Vasoconstriction of the vessels would lead to a decrease in exchangeable surface area resulting in a decreased D/P creatinine ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Trophoblastic differentiation in a malignant mixed mesodermal tumor of the ovary

Trophoblastic differentiation in an extragonadal carcinoma is a rare and unusual phenomenon which has been observed in the carcinomas of stomach, bronchus, esophagus, ovary, liver, urinary bladder, endometrium, and, rarely, in the sarcomas. To our knowledge, this phenomenon has not been observed previously in a mixed mesodermal sarcoma (MMS), and the present communication is to record such a case of MMS of ovary with this phenomenon.

Management of pregnancy in mothers with spina bifida

Pregnancy complicated because of maternal spina bifida remains uncommon. With more aggressive surgical management in the 1960s these patients are now in adulthood and achieving pregnancies. In this series all four patients were delivered by caesarean section. As most patients have undergone extensive urological surgery great care is required at operation to avoid trauma to the urinary tract.

Analysis of the pattern of urine loss in women with incontinence as measured by weighing perineal pads

Three hundred and thirty-five women with urinary incontinence underwent a pad-weighing test for quantifying urine loss. Each one wore a series of pre-weighed sanitary towels for a total of 1 h. The pads were weighed again after use. The test results gave information about the severity of the incontinence which was not easy to obtain either from patient interview or from clinical examination. The type of activity was the main factor determining urine loss, although patients with detrusor instability lost more on average than the others. Voiding during the test period did not appear to influence the overall test results. Reproducibility of the test has been studied in 50 patients.

Cytotoxicity and mutagenicity of aflatoxin dichloride in normal and repair deficient diploid human fibroblasts

The cytotoxic and mutagenic effect of aflatoxin B1-dichloride (AFB1-Cl2), a direct-acting carcinogen which is a model for the proposed ultimate reactive metabolite of AFB1 (the 2,3-epoxide), was compared in normal, repair-proficient, diploid human fibroblasts and in complementation Group A xeroderma pigmentosum cells (XP12BE) which are virtually incapable of excision repair of DNA damage induced by ultraviolet radiation, the 7,8-diol-9,10-epoxide of benzo[alpha]pyrene, and several reactive aromatic amide derivatives. The XP cells were significantly more sensitive than normal to the cytotoxic and mutagenic effects of AFB1-Cl2, not only as a function of concentration administered but also of the number of AFB1-Cl2 residues initially bound to DNA. Cytotoxicity was determined from survival of colony-forming ability; resistance to 6-thioguanine was the genetic marker used for mutagenicity. We compared the rate of loss of AFB1-Cl2-DNA adducts from cells treated and held in the non-dividing state (confluent) over several days, as well as their ability to recover from the potentially mutagenic and/or cytotoxic effects of the agent. AFB1-Cl2 residues were lost from both strains of cells and both exhibited a gradual increase in survival. However, the rate of loss of adducts from the DNA in the normal cells was more rapid than in XP cells and they exhibited recovery from higher doses of AFB1-Cl2 than XP cells. The major primary DNA adduct formed in the human cells and in isolated DNA was a chemically unstable guanine derivative which could undergo a change in structure with time posttreatment to form a more stable secondary adduct. The cytotoxic effect of AFB1-Cl2 was highly correlated with the presence of either of these guanine adducts. Evidence suggests that the primary adduct is an N7-guanine adduct. The kinetics of the loss of this guanine and its transformation into the more stable secondary adduct resembled that reported recently for the major primary DNA adduct formed by the reaction of AFB1 at the N-7 position of guanine in the DNA of normal and XP cells and its transformation into the putative AFB1-ring opened triamino pyrimidyl structure.

A comparison of drop-plate and pour-plate methods for bacterial population counts of poultry anaphage (dehydrated caged layer excreta)

Pour-plate and drop-plate methods for bacterial population country of poultry anaphage (dehydrated caged layer excreta) were compared and were not found to be significantly different.

Gastric mucosal lacerations from blunt trauma to the abdomen

A 17-year old, Caucasian male, high school student sustained gastric mucosal lacerations from blunt trauma to the abdomen during a football game with associated severe upper gastrointestinal bleeding. The lacerations were diagnosed by endoscopy and treated conservatively with uneventful, rapid and complete recovery.