Radiological evaluation before and after treatment with an osseointegrated bone-anchor following major limb amputation-a guide for radiologists

Osseointegrated implants have been developed to allow direct skeletal fixation of a prosthesis as an alternative to traditional socket-fitted prostheses for patients who have suffered from a major limb amputation. The implants contribute to improvements in functional outcome and quality of life and radiological evaluation plays a crucial role in pre- and post-operative assessment. This article acts as a guide for radiologists who may be tasked with providing the radiological information required by surgeons and prosthetists. We also look at the radiological appearances of complications that may arise in patients treated with an osseointegrated implant. Plain X-rays are used to screen patients who wish to undergo treatment. Limb-length X-rays are then used to measure the length of any residual bone, and comparisons can be made with the normal side (if present). From this, decisions about the likely size of the implant and the need for further amputation can be made. CT scans enable accurate assessment of the medullary cavity and cortical thickness. Post-operatively, plain X-rays form the mainstay of the routine monitoring of the bone-implant interface. Potential complications include infection, aseptic loosening, mechanical fracture of the implant and periprosthetic fracture. Infection and aseptic loosening can be seen as a lucency at the bone-implant interface which (if left untreated) can lead to loss of the implant. Implant and periprosthetic fractures are radiographically obvious. Radiologists involved in the care of patients undergoing treatment with an osseointegrated implant should become familiar with the imaging requirements so they can contribute to optimal patient outcomes.

Associations between cortical lesions, optic nerve damage, and disability at the onset of multiple sclerosis: insights into neurodegenerative processes

BACKGROUND

Multiple sclerosis cortical lesions are areas of demyelination and neuroaxonal loss. Retinal layer thickness, measured with optical coherence tomography (OCT), is an emerging biomarker of neuroaxonal loss. Studies have reported correlations between cortical lesions and retinal layer thinning in established multiple sclerosis, suggesting a shared pathophysiological process. Here, we assessed the correlation between cortical lesions and OCT metrics at the onset of multiple sclerosis, examining, for the first time, associations with physical or cognitive disability.

OBJECTIVE

To examine the relationship between cortical lesions, optic nerve and retinal layer thicknesses, and physical and cognitive disability at the first demyelinating event.

METHODS

Thirty-nine patients and 22 controls underwent 3T-MRI, optical coherence tomography, and clinical tests. We identified cortical lesions on phase-sensitive inversion recovery sequences, including occipital cortex lesions. We measured the estimated total intracranial volume and the white matter lesion volume. OCT metrics included peripapillary retinal nerve fibre layer (pRNFL), ganglion cell and inner plexiform layer (GCIPL) and inner nuclear layer (INL) thicknesses.

RESULTS

Higher total cortical and leukocortical lesion volumes correlated with thinner pRNFL (B = -0.0005, 95 % CI -0.0008 to -0.0001, p = 0.01; B = -0.0005, 95 % CI -0.0008 to -0.0001, p = 0.01, respectively). Leukocortical lesion number correlated with colour vision deficits (B = 0.58, 95 %CI 0.039 to 1,11, p = 0.036). Thinner GCIPL correlated with a higher Expanded Disability Status Scale (B = -0.06, 95 % CI -1.1 to -0.008, p = 0.026). MS diagnosis (n = 18) correlated with higher cortical and leukocortical lesion numbers (p = 0.004 and p = 0.003), thinner GCIPL (p = 0.029) and INL (p = 0.041).

CONCLUSION

The association between cortical lesions and axonal damage in the optic nerve reinforces the role of neurodegenerative processes in MS pathogenesis at onset.

Relapsing polychondritis in systemic sclerosis: A rare vasculitic mimic

Introduction:

Relapsing polychondritis is a rare, immune-mediated disease characterised by inflammation of cartilaginous structures. Auricular chondritis, sparing the fatty lobule, is the most typical feature, followed by nose and laryngotracheal involvement. Albeit rare, neurologic involvement is reported with relapsing polychondritis. Cranial nerve involvement is the most frequent neurologic manifestation and is probably due to an underlying vasculitic process. Approximately one-third of relapsing polychondritis patients can overlap with other systemic diseases, including other autoimmune connective tissue diseases, but association with systemic sclerosis has very rarely been described.

Case description:

A 63-year-old woman presented with acute new-onset severe dysphagia, accompanied by hoarseness and preceded by pain, swelling and erythema of the left pinna, unresponsive to antibiotics. She had a history of long-standing limited cutaneous systemic sclerosis. Cranial nerve examination revealed right-sided palatal palsy, and left vocal cord palsy was found on fibreoptic nasendoscopy. Magnetic resonance imaging of the head and neck showed bilateral enhancement of an extracranial segment of the glossopharyngeal and vagus nerves. Clinical features and imaging findings were consistent with relapsing polychondritis, which successfully responded to high-dose steroids.

Conclusions:

This is a case of relapsing polychondritis mimicking progression of systemic sclerosis, showcasing its challenging features. It emphasises the importance of early diagnosis and prompt management with potential impact on the outcome, while highlighting the complex interplay between these two disease entities and vasculitic mechanisms, which may reflect the shared network of genetic predisposition across autoimmune rheumatic diseases.

Imaging features associated with H3 K27-altered and H3 G34-mutant gliomas: a narrative systematic review

Background

Advances in molecular diagnostics accomplished the discovery of two malignant glioma entities harboring alterations in the H3 histone: diffuse midline glioma, H3 K27-altered and diffuse hemispheric glioma, H3 G34-mutant. Radiogenomics research, which aims to correlate tumor imaging features with genotypes, has not comprehensively examined histone-altered gliomas (HAG). The aim of this research was to synthesize the current published data on imaging features associated with HAG.

Methods

A systematic search was performed in March 2022 using PubMed and the Cochrane Library, identifying studies on the imaging features associated with H3 K27-altered and/or H3 G34-mutant gliomas.

Results

Forty-seven studies fulfilled the inclusion criteria, the majority on H3 K27-altered gliomas. Just under half (21/47) were case reports or short series, the remainder being diagnostic accuracy studies. Despite heterogeneous methodology, some themes emerged. In particular, enhancement of H3 K27M-altered gliomas is variable and can be less than expected given their highly malignant behavior. Low apparent diffusion coefficient values have been suggested as a biomarker of H3 K27-alteration, but high values do not exclude this genotype. Promising correlations between high relative cerebral blood volume values and H3 K27-alteration require further validation. Limited data on H3 G34-mutant gliomas suggest some morphologic overlap with 1p/19q-codeleted oligodendrogliomas.

Conclusions

The existing data are limited, especially for H3 G34-mutant gliomas and artificial intelligence techniques. Current evidence indicates that imaging-based predictions of HAG are insufficient to replace histological assessment. In particular, H3 K27-altered gliomas should be considered when occurring in typical midline locations irrespective of enhancement characteristics.

Effect of pre-operative oral paracetamol on gastric residual volume and pH in young children in the context of a 1-hour clear fluid fast: a randomised controlled trial

High gastric residual volume and low pH are associated with increased mortality following pulmonary aspiration in animal studies. The use of pre-operative oral paracetamol has not been investigated in younger children and infants in the context of a prescriptive 1-h clear fluid fast aimed at reducing the risk of pulmonary aspiration while improving patient experience. Children aged 1 month up to a weight of 25 kg and scheduled for elective surgery were randomly allocated to receive a prescribed 3.6 ml.kg^-1 drink of water alone (water group) or 3 ml.kg^-1 water and oral Infant Calpol® syrup (24 mg.ml^-1 concentration, equivalent volume 0.6 ml.kg^-1 , paracetamol group) 1 h before the induction of anaesthesia. Following induction, a nasogastric tube was used to aspirate gastric contents and the volume and pH were recorded. Ninety-seven children, median (IQR [range]) age 24 (12-45 [1-96]) months and weight 12.4 (9.7-16.0 [2.9-27.0]) kg, were analysed. Median time from drink to induction was 54 (45-60 [21-113]) min. There was no significant difference in gastric residual volume (p = 1) or pH (p = 0.99) between the water and the paracetamol groups. Sub-group analysis revealed no significant difference in gastric residual volume or pH for 29 children who weighed < 10 kg compared with > 10 kg. Using a prescriptive fluid regime of 3 ml.kg^-1 of water, the addition of oral paracetamol syrup did not significantly alter gastric residual volume or pH in the context of a 1-h fast in infants and young children.

Accumulation of Brain Hypointense Foci on Susceptibility-Weighted Imaging in Childhood Ataxia Telangiectasia

BACKGROUND AND PURPOSE

SWI hypointense cerebral lesions have been reported in adults with the inherited cerebellar neurodegenerative disorder ataxia telangiectasia. This study aims to establish the prevalence, age-dependency, and spatial distribution of these lesions in children and young people with ataxia telangiectasia.

MATERIALS AND METHODS

Participants with classic ataxia telangiectasia and matched controls underwent SWI acquisition at 3T at 1 or 2 time points. SWI hypointense lesions were manually labeled according to the Microbleed Anatomical Rating Scale. Differences in prevalence of lesion number between groups with ataxia telangiectasia and without ataxia telangiectasia were tested with the Fisher exact test, and differences in age between participants with ataxia telangiectasia with and without lesions were tested using independent samples Mann-Whitney U test. The relationship between age and lesion number was modeled as an exponential function.

RESULTS

Analyzable SWI datasets from 17 participants with ataxia telangiectasia (with median age at first scan of 12.4 years; range, 4.6-20.2 years; 8 [47%] were female) and 22 matched healthy controls showed prevalence of SWI hypointense lesions in 41% of participants with ataxia telangiectasia and 0% in controls (P = .001, Fisher exact test). Lesions were exclusively supratentorial and predominantly lobar. Participants with ataxia telangiectasia with SWI hypointense lesions were older than those without (median age 5.2 years versus 9.3 years, U = 10.5, P = .014). An exponential curve described the relationship between age and lesion number (R ² = 0.67).

CONCLUSIONS

SWI hypointense lesions are common in children and young people with ataxia telangiectasia, accumulating from 12 years of age onward. In contrast to cerebellar-dominant neurodegeneration in ataxia telangiectasia, SWI hypointense lesions were exclusively supratentorial. Further investigation is needed to establish the clinical relevance of these imaging-detected lesions.

Rigid vs articulating instrumentation for task completion in single-port surgery

BACKGROUND

Single-port access surgery (SPA) may provide benefits but there is a steep learning curve. We compare traditional in-line instruments with articulating instruments.

METHODS

Fundamentals of laparoscopic surgery peg transfer task was performed using a 3-port approach or SPA device. Standard rigid instrumentation was compared with articulating instrumentation.

RESULTS

Twenty surgeons completed all tasks. Average time using a conventional approach was shorter than SPA (144 ± 54 vs 198 ± 74 seconds, P < .001). Articulating instruments required longer procedural time than rigid instrumentation (201 ± 66 vs 141 ± 58 seconds, P < .001). In the conventional model, task time was lower with rigid instruments than with articulating instruments (108 vs 179 seconds, P < .001). Task time in the SPA model was lower with rigid instruments (173 vs 223 seconds, P =.013).

CONCLUSIONS

All tasks required longer time to complete in SPA when compared with a conventional approach. Articulating instruments have an increased benefit in SPA surgery.

Fluorescent cholangiography in laparoscopic cholecystectomy: the initial Canadian experience

BACKGROUND

Bile duct injury remains a worrisome complication of laparoscopic cholecystectomy. Indocyanine Green (ICG) fluorescent cholangiography (FC) is a new approach that facilitates real-time intraoperative identification of biliary anatomy. This technology is hoped to improve the safety of dissection within Calot's triangle.

METHOD

Demographics, intraoperative details, and subjective surgeon data were recorded for elective cholecystectomy cases involving ICG. Goals were to identify rates of bile duct identification, and assess the perceived benefit of the device.

RESULTS

ICG was used in 12 biliary cases in Canada. Visualization rates of the cystic and common bile ducts were 100% and 83%, respectively. Also, 83% of surgeons felt that FC incorporated smoothly into the operation. No complications have been related to the technology.

CONCLUSIONS

FC allows noninvasive real-time visualization of the extrahepatic biliary tree. This novel technique has received positive feedback in its initial Canadian use and will likely be a durable adjunct for minimally invasive surgery.

Long-term benefits and adverse effects of intermittent versus daily glucocorticoids in boys with Duchenne muscular dystrophy

OBJECTIVE

To assess the current use of glucocorticoids (GCs) in Duchenne muscular dystrophy in the UK, and compare the benefits and the adverse events of daily versus intermittent prednisolone regimens.

DESIGN

A prospective longitudinal observational study across 17 neuromuscular centres in the UK of 360 boys aged 3-15 years with confirmed Duchenne muscular dystrophy who were treated with daily or intermittent (10 days on/10 days off) prednisolone for a mean duration of treatment of 4 years.

RESULTS

The median loss of ambulation was 12 years in intermittent and 14.5 years in daily treatment; the HR for intermittent treatment was 1.57 (95% CI 0.87 to 2.82). A fitted multilevel model comparing the intermittent and daily regiments for the NorthStar Ambulatory Assessment demonstrated a divergence after 7 years of age, with boys on an intermittent regimen declining faster (p<0.001). Moderate to severe side effects were more commonly reported and observed in the daily regimen, including Cushingoid features, adverse behavioural events and hypertension. Body mass index mean z score was higher in the daily regimen (1.99, 95% CI 1.79 to 2.19) than in the intermittent regimen (1.51, 95% CI 1.27 to 1.75). Height restriction was more severe in the daily regimen (mean z score -1.77, 95% CI -1.79 to -2.19) than in the intermittent regimen (mean z score -0.70, 95% CI -0.90 to -0.49).

CONCLUSIONS

Our study provides a framework for providing information to patients with Duchenne muscular dystrophy and their families when introducing GC therapy. The study also highlights the importance of collecting longitudinal natural history data on patients treated according to standardised protocols, and clearly identifies the benefits and the side-effect profile of two treatment regimens, which will help with informed choices and implementation of targeted surveillance.

A multi-institutional perspective of complication rates for elective nonreconstructive breast surgery: an analysis of NSQIP data from 2006 to 2010

BACKGROUND

As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications.

OBJECTIVE

The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery.

METHODS

Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications.

RESULTS

Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%).

CONCLUSIONS

Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

SEPN1-related myopathies: clinical course in a large cohort of patients

OBJECTIVE

To assess the clinical course and genotype-phenotype correlations in patients with selenoprotein-related myopathy (SEPN1-RM) due to selenoprotein N1 gene (SEPN1) mutations for a retrospective cross-sectional study.

METHODS

Forty-one patients aged 1-60 years were included. Clinical data including scoliosis, respiratory function, and growth measurements were collected by case note review.

RESULTS

Mean age at onset was 2.7 years, ranging from birth to the second decade of life. All but 2 remained independently ambulant: one lost ambulation at age 5 years and another in his late 50s. The mean age of starting nocturnal noninvasive ventilation (NIV) was 13.9 years. One child required full-time NIV at the age of 1 year while in 2 cases NIV was started at 33 years. Two patients died from respiratory failure at the age of 10 and 22 years, respectively. The mean age at scoliosis onset was 10 years, in most cases preceded by rigidity of the spine. Fourteen patients had successful spinal surgery (mean age 13.9 years). Twenty-one were underweight; however, overt feeding difficulties were not a feature.

CONCLUSIONS

This study describes the largest population affected by SEPN1-RM reported so far. Our findings show that the spectrum of severity is wider than previously reported. Respiratory insufficiency generally develops by 14 years but may occur as early as in infancy or not until the fourth decade. Motor abilities remain essentially static over time even in patients with early presentation. Most adult patients remain ambulant and fully employed.

Expression and cellular localization of human hyaluronidase-2 in articular chondrocytes and cultured cell lines

OBJECTIVE

There is debate whether hyaluronan (HA) can be enzymatically degraded within the extracellular matrix of cartilage and other tissues or whether its catabolism occurs strictly within the lysosomal compartment of chondrocytes and other cell types. Previous studies have suggested that one of the lysosomal hyaluronidases (hyaluronidase-2) can be expressed as a functionally-active glycosyl phosphatidylinositol-linked protein at the surface of mammalian cells. If this form of hyaluronidase expression occurs in chondrocytes, this could represent a possible mechanism for extracellular HA cleavage. Thus, which hyaluronidases are expressed and where was the objective of this study.

METHODS

mRNA for hyaluronidases was quantified by reverse transcription-polymerase chain reaction (RT-PCR) and enzymatic activity by HA zymograms. Recombinant forms of hyaluronidase-2 were generated and expressed in model cell lines. A peptide-specific polyclonal antiserum was prepared to localize endogenous human hyaluronidase-2 in human articular chondrocytes.

RESULTS

Hyaluronidase-2 is the principal mRNA transcript expressed by primary human articular chondrocytes as well as various model cell lines. Recombinant hyaluronidase-2, containing N-terminal or C-terminal epitope tags, was strictly localized intracellularly and not released by treatment with a phosphatidylinositol-specific phospholipase. Endogenous hyaluronidase-2 expressed by human chondrocytes as well as HeLa cells could only be detected following detergent permeabilization of the plasma membranes.

CONCLUSIONS

These data suggest that on chondrocytes and other cell types examined, hyaluronidase-2 is not present or functional at the external plasma membrane. Thus, local turnover of HA is dependent on receptor-mediated endocytosis and delivery to low pH intracellular organelles for its complete degradation.

Dietary Echinacea purpurea during murine pregnancy: effect on maternal hemopoiesis and fetal growth

BACKGROUND

The medicinal benefits of Echinacea sp. plants in several disease conditions, including insect bites, respiratory ailments, and even cancer and AIDS, have been touted for decades. Echinacea sp.-based phytoceuticals are among the top selling herbals in the Western marketplace today. However, evidence is very scant concerning the effects of using Echinacea species herbals during pregnancy. While available data indicates that fetal malformations do not occur during pregnancy in humans consuming this herb, there are no formal studies aimed at assessing the possibility that consuming Echinacea herbals may promote spontaneous abortions, thereby reducing the number of live births upon which to assess the presence or absence of malformations.

OBJECTIVES

We undertook a study in which pregnant mice were fed daily Echinacea purpurea from pregnancy onset until gestational days 10, 11, 12, 13, and 14.

METHODS

Maternal spleen and bone marrow were taken for enumeration of cells in each of five separate hemopoietic lineages/organ, and fetal status was recorded.

RESULTS

The data indicate that the significant, pregnancy-induced elevation in splenic lymphocytes and nucleated erythroid cells was all but eliminated in those females which consumed E. purpurea daily throughout their pregnancy. Moreover, consuming E. purpurea during pregnancy reduced the number of viable fetuses.

CONCLUSIONS

The data may be extrapolated to suggest that in humans, abstention from consuming Echinacea products during the early/mid stages of pregnancy, may be prudent.

Congenital trigeminal anaesthesia

Two patients with congenital trigeminal nerve anaesthesia are described. The first (male, aged 14 years) had an isolated unilateral loss of sensation in all three divisions of the trigeminal nerve with no other abnormalities. The second patient (male, aged 3 years 6 months) had bilateral loss of sensation in all three divisions of the trigeminal nerve, associated with other neurological abnormalities. No explanation for their abnormalities was found. The Rosenberg classification of congenital trigeminal anaesthesia is discussed with reference to these patients and also with reference to the developmental biology of the trigeminal nerve.

The radiolysis and radioracemization of amino acids on clays

L-Leucine and its hydrochloride salt have been deposited on the clay minerals kaolin and bentonite, and the amino acid/clay preparations have been irradiated in a 3000 Ci60Co gamma-ray source for radiation dosages that achieved 2-89% radiolysis of the leucine. The undecomposed leucine was thereupon recovered and both percent radiolysis and percent radioracemization were determined. Similar studies were made using solid L-leucine and its hydrochloride, and L-leucine in 0.1 M aqueous solution. It has been found that radiolysis and radio-racemization in these and the previously studied leucine systems follow pseudo-first-order rate laws, and the corresponding specific rate constants are evaluated and compared. Leucine and its hydrochloride salt proved to be the most stable to both radiolysis and radioracemization, followed by leucine and its HCl salt on kaolin, followed by leucine and its HCl salt on bentonite, with leucine (and its HCl and Na salts) in aqueous solution being least stable to both radiolysis and (except for the HCl salt) radioracemization. Implications of these observations as regards the Vester-Ulbricht mechanism for the origin of optical activity are discussed.

Neonatal cerebral ischaemia with elevated maternal and infant anticardiolipin antibodies

A baby girl born by elective lower segment caesarean section was found to have left-sided focal seizures at 48 hours after birth. Her mother had previously had a neonatal death at 26 weeks' gestation and another child born at 32 weeks' gestation had a congenital right hemiplegia with a left middle cerebral artery infarct on CT scan. The mother had raised anticardiolipin IgG antibodies at the time of delivery of her second child, with no thrombotic symptoms. Therefore, during this pregnancy, she had been treated with low molecular weight heparin and aspirin. The baby's mother had raised IgG and IgM anticardiolipin antibodies and the baby had IgG anticardiolipin antibodies at the upper range of normal 4 days after delivery. The seizures were controlled with phenobarbitone and phenytoin. CT and MRI scans showed evidence of cerebral ischaemia. A repeat MRI scan at 4 months of age was normal, anticonvulsants were discontinued, and her latest neurological examination at 5 months was normal.

Antisense inhibition of chondrocyte CD44 expression leading to cartilage chondrolysis

OBJECTIVE

To better define critical functions of the hyaluronan receptor CD44 in cartilage.

METHODS

Articular chondrocytes and cartilage tissue slices were treated with CD44 sequence-specific antisense phosphorothioate oligonucleotides. CD44 expression was probed by immunofluorescence microscopy, enzyme-linked immunosorbent assay, and Western blotting.

RESULTS

Antisense oligonucleotides demonstrated a dose- and time-dependent inhibition of CD44 protein expression; negative controls showed no effect. Similar to osteoarthritic cartilage, antisense-treated cartilage slices displayed a near-total loss of stainable proteoglycan-rich matrix.

CONCLUSION

CD44 expression is needed for maintenance of cartilage homeostasis.

Renal cryosurgery: experimental evaluation of treatment parameters

OBJECTIVES

Cryosurgery represents a minimally invasive alternative for the management of small or equivocal lesions of the kidney. We evaluated the relationship between ultrasonographic appearance and intrarenal temperatures and the effect of renal artery occlusion on the efficacy of the freezing process in a canine model.

METHODS

Ten animals were treated with intraparenchymal cryoablative therapy with (n = 5) or without (n = 5) renal artery occlusion using a rapid freeze technique. Intrarenal temperatures were measured 1.0 cm away from the cryoprobe at various times during the freezing process. The distance from the cryoprobe to the ice ball as monitored by ultrasonography was also determined. The contralateral kidney was removed to facilitate studies of renal function and all animals were killed on day 28 for autopsy and histopathologic examination.

RESULTS

A target temperature of less than -20 degrees C was achieved 3.1 mm behind the ice ball in all animals tested. The ice ball stabilized at a radius of 16 mm with prolonged treatment, suggesting that multiple probes will be required to treat renal lesions greater than 2.5 cm in diameter. Renal artery occlusion did not significantly alter the freezing process and provided no practical advantage. Renal function remained stable (final serum creatinine level 1.5 mg/dL or less) in all but 1 animal in which an obstructive stricture of the ureteropelvic junction developed. Effective tissue ablation was confirmed at the treatment site in all instances.

CONCLUSIONS

Renal cryoablative therapy is a nephron-sparing modality that can be delivered in a safe, efficacious, and reproducible manner. The treatment parameters defined in this study should allow for intelligent patient selection and rational administration of renal cryotherapy.

Purification, characterization, and amino acid sequence determination of acanthins, potent inhibitors of platelet aggregation from Acanthophis antarcticus (common death adder) venom

Venom of Acanthophis antarcticus, a common death adder, exhibits potent antiplatelet effects. By a combination of gel-filtration, cation-exchange, and reversed-phase chromatographic methods, two inhibitors of platelet aggregation, named acanthin I and II, were purified to homogeneity as assessed by capillary electrophoresis and electrospray mass spectrometry. These isoforms exhibit the most potent antiplatelet activity known thus far, with IC50 values of 7 nM for acanthin I and 4 nM for acanthin II in human whole blood when collagen was used as an agonist, whereas with ADP the IC50 values were 10 and 12 nM, respectively. Acanthin I and II are basic proteins with pIs of 10.2 +/- 0.1 and 10.4 +/- 0.1 and molecular weights of 12,844.58 +/- 0.61 and 12,895.63 +/- 0.48, respectively, as determined by electrospray mass spectrometry. They exhibit phospholipase enzyme activity, and acanthin I and II hydrolyzed 51. 57 +/- 1.30 and 46.85 +/- 2.90 micromol of phosphatidylcholine/min/mg, respectively. The complete amino acid sequences of acanthin I and II showed that they have a high homology with each other and with other elapids' phospholipase A2 neurotoxin, especially pseudexin A.

The relation between pump flow rate and pulsatility on cerebral hemodynamics during pediatric cardiopulmonary bypass

OBJECTIVES

Neurologic impairment, at least partly ischemic in origin, has been reported in up to 25% of infants undergoing cardiopulmonary bypass, with or without circulatory arrest. Controversy continues about the effect of pump flow, pulsatile or nonpulsatile, on the brain and in particular on cerebral blood flow. This study examines the relationship between pump flow rate and cerebral hemodynamics during pulsatile and nonpulsatile cardiopulmonary bypass.

METHOD

Near-infrared spectroscopy was used to determine cerebral blood flow and cerebral blood volume (measured as concentration change) in a randomized crossover study. Pulsatile and nonpulsatile flow were used for six 5-minute intervals at each of three different pump flow rates (0.6, 1.2, and 2.4 L x m2 x min(-1)) in 40 patients, median age 2 months (range 2 weeks to 20 years 5 months). The relations between pulsatile flow, pump flow rate, cerebral blood flow, hemoglobin concentration change (cerebral blood volume), mean arterial pressure, arterial carbon dioxide tension, and hematocrit value were prospectively examined by means of multivariate analysis.

RESULTS

Cerebral blood flow decreased 36% per L x m(-2) x min(-1) decrease in pump flow rate and was associated with changes in mean arterial pressure but did not differ according to pulsatility. Change in hemoglobin concentration was unrelated to changes in pulsatility of pump flow.

CONCLUSION

Cerebral blood flow is related to pump flow rate. Pulsatile flow delivered with a Stöckert pump does not increase cerebral blood flow or alter hemoglobin concentration during cardiopulmonary bypass in children.

The relation between arterial oxygen tension and cerebral blood flow during cardiopulmonary bypass

OBJECTIVES

Neurological impairment occurs in up to 25% of infants undergoing cardiopulmonary bypass with or without circulatory arrest. Potential causes include alterations in cerebral blood flow, hypoxia and embolisation. During cardiopulmonary bypass, arterial oxygen tension is maintained at levels which under normal conditions cause cerebral vasoconstriction; this is a potential mechanism for ischaemia. The aim of this study was to explore the relation between arterial oxygen tension and cerebral blood flow during cardiopulmonary bypass.

METHODS

Near infrared spectroscopy was used to explore the relation between arterial oxygen tension and cerebral blood flow in 14 patients (median age 8 months; range 1 month to 10 years 11 months). The relations between arterial oxygen tension, arterial carbon dioxide tension, temperature, haematocrit, pump flow rate, mean arterial pressure and cerebral blood flow, were examined using multivariate analysis.

RESULTS

There was no relation between cerebral blood flow and arterial oxygen tension, but a highly significant relation was observed between cerebral blood flow and pump flow rate, with cerebral blood flow decreasing 4.2-fold per L.m-2.min-1 decrease of pump flow rate.

CONCLUSION

There was no relation between arterial oxygen tension and cerebral blood flow during cardiopulmonary bypass, but low pump flow rate may lead to reduced cerebral blood flow.

Stöckert roller pump generated pulsatile flow: cerebral metabolic changes in adult cardiopulmonary bypass

There is evidence that during cardiopulmonary bypass (CPB), pulsatile pump flow improves cerebral metabolism. This was a study to explore the effect of pulsatile versus nonpulsatile perfusion on cerebral lactate, pyruvate, glucose and beta-hydroxybutyrate using a Stöckert roller pump. We found no significant differences between the arterial-venous (A-V) differences of lactate, glucose and beta-hydroxybutyrate (p > 0.05). When the upward trend of A-V pyruvate was accounted for, there was again no difference (p = 0.2). Arterial lactate:pyruvate ratios were not significantly different between pulsatile and nonpulsatile pump flow (p > 0.05). Venous lactate:pyruvate ratios were significantly higher during pulsatile bypass, but when the downward trend was accounted for, the differences between pulsatile and nonpulsatile values were no longer significant (p = 0.4). Therefore, the metabolic changes were not significant. There was no significant difference in systemic vascular resistance (SVR) during pulsatile and nonpulsatile flow (p = 0.4). Pulsatile flow delivered by the Stöckert roller pump appears to have no metabolic or SVR advantages in adults undergoing CPB.

Increased expression of CD44 in bovine articular chondrocytes by catabolic cellular mediators

Bovine articular chondrocytes cultured in alginate beads were used to study the effect of catabolic cellular mediators on CD44 expression. Treatment with either the 29-kDa fragment of fibronectin or interleukin-1 alpha results in a time- and dose-dependent inhibition of proteoglycan synthesis as well as a stimulation in the expression of CD44 mRNA level as determined by semi-quantitative polymerase chain reaction following reverse transcription. No noticeable effect at 6 h was observed. By 24 h, the major CD44 product (CD44H) from fibronectin fragment-treated cultures showed an 8-fold increase; CD44H from interleukin-1 alpha-treated cultures showed a 6-fold increase as compared to control cultures. In addition, a minor band, determined to be an isoform of CD44, was also shown to be up-regulated by both mediators. Stimulation of CD44 mRNA via interleukin-1 was also evident by in situ hybridization studies of bovine as well as human articular cartilage in organ culture. The increased in CD44 mRNA is matched by an increase at the protein level as determined by Western blot analysis. The Western blot reveals a doublet protein band at 80-90 kDa that corresponds to the molecular mass of CD44H. Cultures incubated with fibronectin fragments for 24 h had an 8.0-fold increase in CD44, while a 6.6-fold was observed for interleukin-1 alpha. Fluorescein-conjugated hyaluronan binding and internalization studies indicate that the increase in CD44 protein, induced by interleukin-1 alpha, closely correlates with an increase in functional hyaluronan receptors present at the chondrocyte cell surface. Taken together these results indicate that conditions that up-regulate chondrocyte catabolism also up-regulate the expression of CD44, a cell surface hyaluronan receptor involved in hyaluronan endocytosis.

Interstitial deletion of chromosome 10q23: a new case and review

A new case of a deletion of 10q23 is described. Only two other deletions involving this region have been previously noted. A review of clinical features of these three children did not show a distinct pattern of dysmorphic features. Other interstitial deletions of 10q are listed.

Inhibition of human leukocyte elastase by N-substituted peptides containing alpha,alpha-difluorostatone residues at P1

A series of tripeptides which contain alpha,alpha-difluorostatone residues at P1-P1' and span the S3-S1' subsites have been shown to be potent inhibitors of human leukocyte elastase (HLE). The tripeptides described contain the nonproteinogenic achiral residue N-(2,3-dihydro-1H-inden-2-yl)glycine at the P2-position. This redidue has previously been shown in the case of HLE to be a good bioisosteric replacement for L-proline. Of the peptides prepared, those which contain the alpha,alpha-difluoromethylene keton derivative of L-valine (difluorostatone) are the preferred residue at the P1-primary specificity position. Substitution at P1 by the corresponding alpha,alpha-difluoromethylene ketones of L-leucine and L-phenylalanine gives inactive compounds. Of the tripeptides described the most potent in vitro compound is ethyl N-[N-CBZ-L-valyl-N-(2,3-dihydro-1H-inden-2-yl)glycyl]- 4(S)-amino-2,2-difluoro-3-oxo-5-methylhexanoate (17B) (IC50 = 0.635 microM). It is presumed that the inhibitor 17b interacts with the S3-S1' binding regions of HLE. Additionally extended binding inhibitors were prepared which interact with the S3-S3' binding subsites of HLE. In order to effect interaction with the S1'-S3' subsites of HLE, the leaving group side of cleaved peptides, spacers based upon Gly-Gly, and those linked via the N epsilon of L-lysine were utilized. One of the most potent extended compounds (P3-P3') in vitro is methyl N6-[4(S)-[[N-[N-CBZ-L-valyl-N- (2,3-dihydro-1H-inden-2-yl)glycyl]amino]-2,2-difluoro-3-oxo-5- methylhexanoyl]-2(S)-(acetylamino)-6-aminohexanoate (24b) (IC50 = 0.057 microM). The described in vitro active inhibitors were also evaluated in hamsters in an elastase-induced pulmonary hemorrhage (EPH) model. In this model, intratracheal (it.) administration of 22c, 5 min prior to HLE challenge (10 micrograms, it.) effectively inhibited hemorrhage (94.6%) in a dose-dependent manner. The described alpha,alpha-difluoromethylene ketone inhibitors are assumed to act as transition-state analogs. The inhibition process presumably acts via hemiketal formation with the active site Ser195 of HLE, and is facilitated by the strongly electron withdrawing effect of the alpha,alpha-difluoromethylene functionality.

Intrachromosomal insertion of chromosome 7

A direct intrachromosome insertion of chromosome 7 is described, and previous reports of intrachromosomal insertions are listed. All others were ascertained through a phenotypically abnormal proband. Ours is the first presenting with multiple pregnancy losses. Since the risk of chromosomally abnormal liveborns is appreciable, prenatal diagnosis should be made available to known carriers of chromosome insertions.

Instantaneous axis of rotation as a function of the three columns of the spine

A knowledge of the rotatory motion of the vertebral bodies is needed to understand the normal biomechanical behavior of the spine. The aims of this investigation were 1) to define the instantaneous axis of rotation of the lumbar spine in rotation; and 2) to study the effect of the loss of the anulus, facet joints, and ligamentous structures on the location of the instantaneous axis of rotation. The instantaneous axis of rotation was found in 10 human cadaver thoracolumbar spines by the method of Reuleaux from superimposed serial photographs. Long-segment specimens were tested to minimize the effect of the imposed axis of the testing device. The instantaneous axis of rotation was consistently posterior to the anulus in the intact spine. With isolated destruction of the columns of the spine, the instantaneous axis of rotation migrated to the remaining intact structures. Anterior releases enhance derotation by removing the primary rotatory stabilizer. Ultimate control of a rotatory deformity or instability lies in the recognition that the anterior structures have a mechanical advantage in resisting torsion.

Inhibition of human leukocyte elastase (HLE) by N-substituted peptidyl trifluoromethyl ketones

A series of tripeptides possessing trifluoromethyl or aryl ketone residues at P1 were prepared and evaluated both in vitro and in vivo as potential inhibitors of human leukocyte elastase (HLE). Tripeptides containing non naturally occurring N-substituted glycine residues at the P2-position have been demonstrated to be potent in vitro inhibitors of HLE, with IC50 values in the submicromolar range. Sterically demanding substituents on the P2-nitrogen have no detrimental effect on in vitro potency. The inhibition process presumably acts via hemiketal formation with the active site Ser195 of HLE, and is facilitated by the strongly electron withdrawing trifluoromethyl functionality. Deletion of the amino acid at the P3-subsite region affords inactive compounds. Valine is the preferred residue at the P1-position, whereas the corresponding glycine, alanine, alpha,alpha-dimethylglycine, or phenylalanine analogues are all inactive. The compounds described herein all confer a high degree of in vitro specificity when tested against representative cysteine, aspartyl, metallo, and other serine proteases. One of the most potent in vitro inhibitors is (3RS)-N-[4-[[[(4-chlorophenyl)sulfonyl]amino]carbonyl]phenyl] oxomethyl]-L-valyl-N-(2,3-dihydro-1H-inden-2-yl)glycine N-[3-(1,1,1-trifluoro-4-methyl-2-oxopentyl)]amide (20i; BI-RA-260) (IC50 = 0.084 microM). Compound 20i was also tested in hamsters in an elastase-induced pulmonary hemorrhage (EPH) model. In this model, intratracheal (it.) administration of 20i, 5 min prior to HLE challenge, effectively inhibited hemorrhage in a dose-dependent manner with an ED50 of 4.8 micrograms. The inhibitor 20i, 20 micrograms administered it. 24, 48, and 72 h prior to HLE challenge, exhibits significant inhibition against hemorrhage at all time points (97%, 64% and 49%, respectively). In a 21-day chronic model of emphysema in hamsters, 200 micrograms of HLE administered it. caused an elastase-induced emphysema in the lungs which can be quantitated histologically utilizing image analysis. In this assay, 20i significantly inhibited pulmonary lesions associated with septal destruction and increased alveolar spaces, when dosed at 20 micrograms it. 5 min prior to challenge with HLE.

The effect of the three columns of the spine on the instantaneous axis of rotation in flexion and extension

Instrumentation designed for stabilization and correction of spinal deformities must limit the amount of motion in flexion and extension. In flexion or extension, the vertebral bodies move about a specific point called the instantaneous axis of rotation. The ability of the implant to limit this motion is a function of its relation to the axis of rotation of the spine. The goal of this study was threefold: 1) to define the instantaneous axis of rotation of the spine in flexion and extension; 2) to study the effect of the loss of the three columns of the spine on the location of the instantaneous axis of rotation; and 3) to determine how the above parameters relate to the choice of anterior or posterior instrumentation. Ten human cadaver spines were subjected to compressive loads in flexion and extension. The columns of the spine were then destroyed in sequence at L3. The instantaneous axis of rotation for each vertebral body was found by the method of Reuleaux, and the effect of the compromise of the columns on the location of the instantaneous axis of rotation was noted. Understanding the exact location of the instantaneous axis of rotation after a specific injury would allow the clinician to objectively choose the best surgical approach and the appropriate instrumentation.

Inhibition of human leukocyte elastase by N-substituted tripeptide trifluoromethyl ketones

Several tripeptide trifluoromethyl ketones containing non-naturally occurring N-substituted glycine residues at the P2-position are effective human leukocyte elastase (HLE) inhibitors in vitro and possess IC50 values in the submicromolar range. Deletion of the amino acid at the P3-subsite region affords inactive compounds. The trifluoromethyl ketone derivative of valine is the preferred residue at the P1-position; whereas, the corresponding glycine or alpha, alpha-dimethyl glycine analogs result in inactive compounds.

Regional and genotypic differences in stromal-vascular cells from obese and lean Zucker rats

LPL activity, total lipogenesis and rates of growth were determined for stromal-vascular cells derived from epididymal and inguinal depots of 13 1/2-week-old obese and lean Zucker rats. LPL activity, in cells of both depots, was found to increase between days 4 and 6 and decrease by day 8 in the presence of insulin. Inguinal derived fatty cell LPL activity increased between days 4 and 8 in contrast to lean cells which peaked at day 6 under basal growth conditions. LPL activity was elevated in fatty versus lean cells at days 6 and 8 in inguinal derived stromal vascular cells while in epididymal derived stromal vascular cells, LPL activity was elevated in lean versus fatty derived cells at day 4 and 6 but by day 8 the genotypic effect was reversed. Lipogenesis was elevated in lean versus fatty derived epididymal and inguinal cells at all concentrations of insulin and lean cells showed a dose-dependent response to insulin in contrast to fatty cells. There were no effects of genotype on the proliferative capacity of cells from either depot but some regional differences in growth were observed. These data illustrate that fa gene effects can be studied in primary cell culture.

Pharmacological modulation of plasminogen activator secretion by P388D1 cell line

P388D1 is a murine macrophage cell line which spontaneously secretes plasminogen activator (PA; activated function) and lysozyme (LYS; constitutive function). Compounds which decrease PA secretion without affecting LYS secretion have potential as "down-regulators" of macrophage function and, hence, of the immune system. Glucocorticoids (e.g., dexamethasone, IC50 less than 0.01 microM) and auranofin (IC50 = 1 microM) are positive in this model. In contrast, cyclooxygenase inhibitors (indomethacin, ibuprofen and piroxicam, all at 1 microM) boost PA secretion; lipoxygenase inhibitors (REV-5901, NDGA and piriprost, all at 10 microM) have little or no effect. Dexamethasone, but not auranofin, induces a urokinase-inhibitory activity which elutes between 0.13 and 0.19 M NaCl upon anion exchange HPLC (TSK-DEAE-5-PW). Fibrin overlay following SDS-PAGE of the HPLC peak reveals a urokinase-inhibitory band at approximately 90 Kd.

Lysis of erythrocytes and leukocytes in traumatic lumbar punctures

We created "bloody taps" by adding homologous blood to acellular samples of CSF and counted the RBCs and WBCs at specific time intervals. After two hours at room temperature (22 degrees C), 40% of the WBCs in the traumatic tap had lysed. At 4 degrees C, 15% of the cells lysed in the same period of time. After five hours at 22 degrees C, 53% of the WBCs had lysed, while refrigeration reduced this figure to 31%. The clinical implications of these data are clear. If a sample of CSF is not promptly refrigerated and analyzed, WBC lysis will result in a false impression of the number of WBCs that are present. This lysis of WBCs reduces the reliability of the corrective formula that uses CSF and blood RBC and WBC counts to estimate the number of WBCs in CSF that are attributable to contamination with blood.

Comparison of donor site dressings

A comparison study of donor site care using 5 common modalities was undertaken. A total of 210 treated donor areas were examined for healing differences, comfort, complications, and cost. At the conclusion of the study we were able to recommend certain treatment methods depending on the nature of the donor wound.