Performance of the IMPACT and CRASH prognostic models for traumatic brain injury in a contemporary multicenter cohort: a TRACK-TBI study

OBJECTIVE

The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization After Significant Head Injury (CRASH) prognostic models for mortality and outcome after traumatic brain injury (TBI) were developed using data from 1984 to 2004. This study examined IMPACT and CRASH model performances in a contemporary cohort of US patients.

METHODS

The prospective 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years 2014-2018) enrolled subjects aged ≥ 17 years who presented to level I trauma centers and received head CT within 24 hours of TBI. Data were extracted from the subjects who met the model criteria (for IMPACT, Glasgow Coma Scale [GCS] score 3-12 with 6-month Glasgow Outcome Scale-Extended [GOSE] data [n = 441]; for CRASH, GCS score 3-14 with 2-week mortality data and 6-month GOSE data [n = 831]). Analyses were conducted in the overall cohort and stratified on the basis of TBI severity (severe/moderate/mild TBI defined as GCS score 3-8/9-12/13-14), age (17-64 years or ≥ 65 years), and the 5 top enrolling sites. Unfavorable outcome was defined as GOSE score 1-4. Original IMPACT and CRASH model coefficients were applied, and model performances were assessed by calibration (intercept [< 0 indicated overprediction; > 0 indicated underprediction] and slope) and discrimination (c-statistic).

RESULTS

Overall, the IMPACT models overpredicted mortality (intercept -0.79 [95% CI -1.05 to -0.53], slope 1.37 [1.05-1.69]) and acceptably predicted unfavorable outcome (intercept 0.07 [-0.14 to 0.29], slope 1.19 [0.96-1.42]), with good discrimination (c-statistics 0.84 and 0.83, respectively). The CRASH models overpredicted mortality (intercept -1.06 [-1.36 to -0.75], slope 0.96 [0.79-1.14]) and unfavorable outcome (intercept -0.60 [-0.78 to -0.41], slope 1.20 [1.03-1.37]), with good discrimination (c-statistics 0.92 and 0.88, respectively). IMPACT overpredicted mortality and acceptably predicted unfavorable outcome in the severe and moderate TBI subgroups, with good discrimination (c-statistic ≥ 0.81). CRASH overpredicted mortality in the severe and moderate TBI subgroups and acceptably predicted mortality in the mild TBI subgroup, with good discrimination (c-statistic ≥ 0.86); unfavorable outcome was overpredicted in the severe and mild TBI subgroups with adequate discrimination (c-statistic ≥ 0.78), whereas calibration was nonlinear in the moderate TBI subgroup. In subjects ≥ 65 years of age, the models performed variably (IMPACT-mortality, intercept 0.28, slope 0.68, and c-statistic 0.68; CRASH-unfavorable outcome, intercept -0.97, slope 1.32, and c-statistic 0.88; nonlinear calibration for IMPACT-unfavorable outcome and CRASH-mortality). Model performance differences were observed across the top enrolling sites for mortality and unfavorable outcome.

CONCLUSIONS

The IMPACT and CRASH models adequately discriminated mortality and unfavorable outcome. Observed overestimations of mortality and unfavorable outcome underscore the need to update prognostic models to incorporate contemporary changes in TBI management and case-mix. Investigations to elucidate the relationships between increased survival, outcome, treatment intensity, and site-specific practices will be relevant to improve models in specific TBI subpopulations (e.g., older adults), which may benefit from the inclusion of blood-based biomarkers, neuroimaging features, and treatment data.

Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated: A TRACK-TBI Study

Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI; enrollment years 2014-2019) enrolled participants who presented to the ED and received a clinically-indicated head CT within 24 hours (h) of TBI. A subset of TRACK-TBI participants underwent venipuncture within 24h for plasma glial fibrillary acidic protein (GFAP) analysis, and research MRI at 2-weeks post-injury. In the current study, TRACK-TBI participants aged ≥17 years with ED arrival GCS 13-15, isolated tSAH on initial head CT, plasma GFAP level, and 2-week MRI data were analyzed. In 57 participants, median age was 46.0 years [quartile 1 to 3 (Q1-Q3): 34-57] and 52.6% were male. At ED disposition, 12.3% were discharged home, 61.4% were admitted to hospital ward, and 26.3% to intensive care unit. MRI identified CT-occult traumatic intracranial lesions in 45.6% (26 of 57 participants; 1 additional lesion type: 31.6%; 2 additional lesion types: 14.0%); of these 26 participants with CT-occult intracranial lesions, 65.4% had axonal injury, 42.3% had subdural hematoma, and 23.1% had intracerebral contusion. GFAP levels were higher in participants with CT-occult MRI lesions compared to without (median: 630.6 pg/ml, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p=0.049), and were associated with axonal injury (no: median 226.7 pg/ml [109.6-435.1], yes: 828.6 pg/ml [204.0-1194.3], p=0.009). Our results indicate that isolated tSAH on head CT is often not the sole intracranial traumatic injury in GCS 13-15 TBI. Forty-six percent of patients in our cohort (26 of 57 participants) had additional CT-occult traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries, including axonal injury. These findings should be interpreted cautiously given our modest sample size and await validation from larger studies.

Longitudinal Recovery Following Repetitive Traumatic Brain Injury

Importance

One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited.

Objective

To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years.

Design, Setting, and Participants

This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023.

Exposures

Postindex TBI(s).

Main Outcomes and Measures

Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs.

Results

Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains.

Conclusions and Relevance

In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.

Time spent outside of target glucose range for young children with type 1 diabetes: a continuous glucose monitor study

AIM

To assess the associations between demographic and clinical characteristics and sensor glucose metrics in young children with type 1 diabetes, using masked, continuous glucose monitoring data from children aged 2 to < 8 years.

RESEARCH DESIGN AND METHODS

The analysis included 143 children across 14 sites in the USA, enrolled in a separate clinical trial. Eligibility criteria were: age 2 to <8 years; type 1 diabetes duration ≥3 months; no continuous glucose monitoring use for past 30 days; and HbA_1c concentration 53 to <86 mmol/mol (7.0 to <10.0%). All participants wore masked continuous glucose monitors up to 14 days.

RESULTS

On average, participants spent the majority (13 h) of the day in hyperglycaemia (>10.0 mmol/l) and a median of ~1 h/day in hypoglycaemia (<3.9 mmol/l). Participants with minority race/ethnicity and higher parent education levels spent more time in target range, 3.9-10.0 mmol/l, and less time in hyperglycaemia. More time in hypoglycaemia was associated with minority race/ethnicity and younger age at diagnosis. Continuous glucose monitoring metrics were similar in pump and injection users.

CONCLUSIONS

Given that both hypo- and hyperglycaemia negatively impact neurocognitive development, strategies to increase time in target glucose range for young children are needed.

Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for youth with Type 2 diabetes: reliability and validity

AIM

To test the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module originally developed in Type 1 diabetes in youth with Type 2 diabetes.

METHODS

The PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were administered in a field test study to 100 young people aged 9-25 years with Type 2 diabetes. Factor analysis was conducted to determine the factor structure of the items.

RESULTS

The 15-item Diabetes Symptoms Summary Score and 12-item Type 2-specific Diabetes Management Summary Score were empirically derived through factor analysis. The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores showed acceptable to excellent reliability across the age groups tested (α = 0.85-0.94). The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores evidenced construct validity through large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.67 and 0.57, respectively). HbA_1c was correlated with the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores (r = -0.13 and -0.22). Minimal clinically important difference (MCID) scores were 5.91 and 7.39 for the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores.

CONCLUSIONS

The PedsQL 3.2 Diabetes Module Diabetes Symptoms Summary Score and Type 2-specific Diabetes Management Summary Score exhibited satisfactory measurement properties for use as youth self-reported diabetes symptoms and diabetes management outcomes for clinical research and clinical practice for young people with Type 2 diabetes.

The effectiveness of cerebral oxygenation monitoring during arthroscopic shoulder surgery in the beach chair position: a randomized blinded study

BACKGROUND

Beach chair positioning for shoulder surgery is associated with measurable cerebral desaturation events (CDEs) in up to 80% of patients. Near-infrared spectroscopy (NIRS) technology allows real-time measurement of cerebral oxygenation and may minimize the frequency of CDEs. The purpose of this study was to investigate the incidence of CDEs when anesthetists were aware of and blinded to NIRS monitoring and to determine the short-term cognitive effects of surgery in the beach chair position.

METHODS

NIRS was used to monitor cerebral oxygenation saturation in 41 consecutive patients undergoing arthroscopic shoulder surgery in the beach chair position. Patients were randomized to 2 groups, anesthetists aware of or blinded to NIRS data. The Montreal Cognitive Assessment (MoCA) was used to assess cognitive function preoperatively, immediately postoperatively, and at 2 and 6 weeks postoperatively.

RESULTS

Overall, 7 (17.5%) patients experienced a CDE, 5 (25%) in the aware group and 2 (10%) in the blinded group. There was no significant difference in MoCA scores between the aware and blinded groups preoperatively (27.9.1 vs. 28.2; P = .436), immediately postoperatively (26.1 vs. 26.2; P = .778), 2 weeks postoperatively (28.0 vs. 28.1; P = .737), or 6 weeks postoperatively (28.5 vs. 28.4; P = .779). There was a correlation of NIRS with systolic blood pressure (r = 0.448), diastolic blood pressure (r = 0.708), and mean arterial pressure (r = 0.608).

CONCLUSION

In our series, the incidence of CDEs was much lower than previously reported and was not lowered by use of NIRS. Patients did not have significant cognitive deficits after arthroscopic surgery in the beach chair position, and there was a correlation between NIRS and intraoperative brachial blood pressure.

Is nonoperative management of partial distal biceps tears really successful?

BACKGROUND

The current treatment of partial distal biceps tears is a period of nonoperative management, followed by surgery, if symptoms persist. Little is known about the success rate and outcomes of nonoperative management of this illness.

METHODS

We identified 132 patients with partial distal biceps tears through an International Classification of Diseases, Ninth Revision code query of our institution's database. Patient records were reviewed to abstract demographic information and confirm partial tears of the distal biceps tendon based on clinical examination findings and confirmatory magnetic resonance imaging (MRI). Seventy-four patients completed an outcome survey.

RESULTS

In our study, 55.7% of the contacted patients who tried a nonoperative course (34 of 61 patients) ultimately underwent surgery, and 13 patients underwent immediate surgery. High-need patients, as defined by occupation, were more likely to report that they recovered ideally if they underwent surgery, as compared with those who did not undergo surgery (odds ratio, 11.58; P = .0138). For low-need patients, the same analysis was not statistically significant (P = .139). There was no difference in satisfaction scores between patients who tried a nonoperative course before surgery and those who underwent immediate surgery (P = .854). An MRI-diagnosed tear of greater than 50% was a predictor of needing surgery (odds ratio, 3.0; P = .006).

CONCLUSIONS

This study has identified clinically relevant information for the treatment of partial distal biceps tears, including the following: the failure rate of nonoperative treatment, the establishment of MRI percent tear as a predictor of failing nonoperative management, the benefit of surgery for the high-need occupational group, and the finding that nonoperative management does not negatively affect outcome if subsequent surgery is necessary.

Profile of Current Opinion on Arthroscopic Acromioplasty: A Video Survey Study

PURPOSE

To provide a baseline profile of current opinion on use of arthroscopic acromioplasty and evaluate the consistency of surgical decision making on whether or not to perform acromioplasty across different surgeon practices.

METHODS

Twenty-two fellowship-trained orthopaedic shoulder surgeons from the Association of Clinical Elbow and Shoulder Surgeons completed an Internet-based survey on practices associated with acromioplasty, including questions related to 15 arthroscopic videos. Based on video cases, interobserver and intraobserver agreement regarding clinically based decisions related to acromioplasty were assessed.

RESULTS

Acromioplasty was uncommonly performed in isolation among this group and was most commonly performed in conjunction with repair of full-thickness rotator cuff tears. Nineteen of 22 (86%) surgeons favored an arthroscopic approach for acromioplasty. Depth of bony resection was determined most commonly based on clinical judgment and experience (68%). The video portion of the survey revealed slight interobserver agreement for classification of acromion morphology (κ = 0.099), need for acromioplasty (κ = 0.020), and adequacy of decompression (κ = 0.1). In contrast, there was fair intraobserver reliability regarding acromion morphology (κ = 0.370) and decision whether to perform acromioplasty in a given case (κ = 0.348) whereas there was moderate intraobserver reliability in the presence of a reparable rotator cuff tear (κ = 0.507) and assessment of the adequacy of decompression (κ = 0.453).

CONCLUSIONS

Although surgeons had similarities regarding principles of acromioplasty, including indications, surgical approach, and technique, there was lack of consensus when surgeons reviewed the video of clinical cases. Although surgeons may have similar goals in terms of treatment of pathology related to subacromial impingement, individual surgeon thresholds for the need and adequacy of decompression are varied and are not standardized.

LEVEL OF EVIDENCE

Level V, expert opinion.

Adult Monteggia and Olecranon Fracture Dislocations of the Elbow

Monteggia fractures and olecranon fracture dislocations represent complex injuries with distinct patterns of bony and soft tissue involvement. Fractures of the proximal ulna and olecranon process may lead to disruption of the proximal radioulnar joint and/or ulnohumeral joint. The keys to treatment are recognition of the pattern of injury and formation of an algorithmic surgical plan to address all components of the injury process. Complications are common and may be related to the injury spectrum itself and/or inadequate fracture alignment or fixation.

Accuracy of measurement of hand compartment pressures: a cadaveric study

PURPOSE

To determine the accuracy of digital palpation for clinical assessment of elevated intracompartmental pressure compared with needle manometry in a simulated compartment syndrome of the hand.

METHODS

Three cadaveric hands were configured with interstitial fluid infusion and an arterial line pressure monitor to create and continuously measure intracompartmental pressure in the thenar and hypothenar compartments. Seventeen assessors clinically judged the presence or absence of compartment syndrome based on digital palpation for firmness and then measured pressures with a handheld manometer. An intracompartmental pressure threshold of 30 mm Hg or greater was used to diagnose compartment syndrome.

RESULTS

The sensitivity and specificity of digital palpation of the thenar eminence were 49% and 79%, respectively, with a positive predictive value (PPV) of 86% and negative predictive value (NPV) of 37%. Using the handheld manometer, the sensitivity and specificity increased to 97% and 86% with a PPV of 95% and NPV of 92%. The sensitivity and specificity of digital palpation of the hypothenar eminence were 62% and 83%, respectively, with improvement of 100% and 100%, respectively, with a handheld manometer. For the hypothenar compartment, use of a handheld manometer improved the PPV from 92% to 100% and the NPV from 40% to 100% compared with digital palpation.

CONCLUSIONS

Digital palpation alone was insufficient to detect elevated compartment pressures in hands at risk for compartment syndrome. Handheld invasive pressure measurement was a useful adjunct for detecting elevated interstitial tissue pressures and may aid in diagnosing compartment syndrome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Upper extremity considerations for oncologic surgery

It was estimated that more than 3000 people would be diagnosed with a primary bone or joint malignancy and more than 11,000 people would be diagnosed with a soft tissue sarcoma in 2013. Although primary bone and soft tissue tumors of the upper extremity are infrequent, it is imperative that the clinician be familiar with a systematic approach to the diagnosis and treatment of these conditions to prevent inadvertently compromising patient outcome. With advances in chemotherapy, radiotherapy, tumor imaging, and surgical reconstructive options, limb salvage surgery is estimated to be feasible in 95% of extremity bone or soft tissue sarcomas.

Outcomes after repair of subacute-to-chronic grade III metacarpophalangeal joint collateral ligament injuries in fingers are suboptimal

PURPOSE

Although injury to the collateral ligaments of the metacarpophalangeal joint (MPJ) of the fingers is less common than corresponding injuries in the thumb, similar disability may result from chronic untreated injuries. We evaluated injury characteristics and the outcome after primary repair of subacute to chronic grade III collateral ligament injuries of the MPJs of the fingers.

METHODS

We retrospectively reviewed all patients who underwent primary repair of a finger MPJ collateral ligament over a 3-year period. Twenty-five digits in 23 patients with subacute to chronic injuries were identified, all of which had complete MPJ collateral ligament tear. Postoperatively, we assessed disability using DASH scores and evaluated joint stability, range of motion, and grip strength. These measures were compared to preoperative data to assess results. Post hoc analysis was used to compare the level of disability between index and small radial collateral ligaments and other finger CL injuries.

RESULTS

Intraoperative findings revealed complete tears in all cases and all ligaments were of sufficient quality to permit primary repair using a suture anchor. The average preoperative DASH score was 40 (range 17-77) in 7 patients (nine fingers) where this was available. Postoperative DASH scores were available in 19 patients (21 fingers). The average postoperative DASH score was 19 (range 0-65). In the subgroup of patients with preoperative and postoperative DASH scores, there was no statistically significant difference after surgery (preop DASH 39.1 vs. postop DASH 23.8, p = 0.17). The average grip strength as a percentage of the contralateral hand was 68 % (range 32-100 %). The average postoperative MPJ arc of motion was 75° (range 50-90°). Post hoc analysis showed statistically significant higher postoperative DASH scores among small finger RCL repairs compared to other finger CL repairs (p = 0.007).

DISCUSSION

Primary repair of complete MPJ collateral ligament injuries of the fingers may be performed in the subacute to chronic setting. Although joint stability was restored, patients continued to have decreased grip strength and residual disability.

Head computed tomography is not useful for evaluating patients change in mental status following total joint arthroplasty

We retrospectively reviewed 187 patients who presented with neurologic abnormality after total joint arthroplasty to establish the incidence of diagnosed organic brain disorders in these patients and determine the utility of advanced head imaging studies. 139 of 187 (74.3%) patients underwent imaging for altered mental status (AMS) and 48 patients for a focal neurologic deficit (FND). Acute findings on head imaging were more common in the FND group. The incidence of stroke and transient ischemic attack was significantly lower in the AMS group compared to FND group (Stroke: 0% vs 12.5%, p < 0.001; TIA: 0% vs. 16.7%, P < .001). Advanced head imaging for evaluation of TJA patients with a change in mental status is of low yield. An algorithm for evaluation of these patients is proposed.

Repair of acute extensor hallucis longus tendon injuries: a retrospective review

BACKGROUND

Extensor hallucis longus (EHL) tendon injuries may occur with lacerations sustained over the dorsum of the foot and lead to hallux dysfunction. Primary repair is performed when tendon edges are opposable; however, if a gap exists between tendon edges, then reconstruction with tendon graft or tendon transfer may be necessary to restore hallux alignment and dorsiflexion. We describe the surgical technique and report the results on a large series of patients having undergone primary repair or reconstruction of EHL tendon lacerations.

METHODS

We retrospectively reviewed all patients undergoing EHL tendon repair or reconstruction between January 2005 and May 2012. Information on patient demographics, mechanism of injury, time to surgery, intraoperative findings, surgical repair or reconstruction technique, and postoperative function were collected. Patients were contacted by telephone for administration of the Foot and Ankle Ability Measure (FAAM) and American Orthopaedic Foot and Ankle Society Hallux questionnaires.

RESULTS

Twenty of 23 patients undergoing EHL tendon repair or reconstruction were available for review at an average clinical follow-up of 12 months (range 3-89 months) and an average telephone follow-up of 5.1 years (range 1-10.4 years). Primary EHL repair was performed in 80% of cases, with the remaining patients undergoing reconstruction with deep tendon transfer of the extensor digitorum longus tendon from the second toe. At final follow-up, 19 of 20 patients had active hallux dorsiflexion. The average FAAM Activities of Daily Living score was 94.2% (range 58.3% to 100%) and the average FAAM Sports score was 94.2% (range 65.6% to 100%).

CONCLUSION

Primary repair or reconstruction of EHL tendon lacerations is a reliable procedure that restores hallux alignment and function in most patients as measured by the validated FAAM questionnaire. Deep tendon transfer from the extensor digitorum longus may be performed if EHL tendon edges are not opposable thus eliminating the need for allograft reconstruction.

A squeaky reputation: the problem may be design-dependent

BACKGROUND

Squeaking is reportedly a complication in patients having ceramic-on-ceramic total hip implants. The etiology remains unknown and multifactorial with recent studies suggesting a relationship between the audible squeak and implant design. When we evaluated our ceramic-on-ceramic cohort, we noticed squeaking primarily in patients receiving an acetabular system designed with an elevated titanium rim.

OBJECTIVES/PURPOSES

We therefore (1) determined the incidence of squeaking among four different ceramic-on-ceramic bearing surfaces used for THA at our institution; (2) evaluated the association between different acetabular designs and the incidence of squeaking; and (3) assessed other potential variables associated with squeaking.

METHODS

We retrospectively reviewed 1507 patients having a ceramic-on-ceramic THA between 2002 and 2009; we separately analyzed those receiving an acetabular system with and without an elevated titanium rim. Data were collected through phone-administered questionnaires and retrospective reviews of patient charts for intraoperative findings, followup reports, demographic information, and radiographic findings.

RESULTS

Squeaking occurred in 92 of the 1507 patients (6%). All 92 patients with squeaking received an elevated rim design (1291 patients) or an incidence of 7% with that design. We found no association between squeaking and any other examined factors.

CONCLUSION

Our findings complement the theory from in vitro studies suggesting that neck impingement on the elevated titanium rim is the probable cause of the increased frequency of squeaking with this design.

Prediction of the rate of decline in FEV(1) in smokers using quantitative Computed Tomography

BACKGROUND

A study was undertaken to determine if quantitative CT estimates of lung parenchymal overinflation and airway dimensions in smokers with a normal forced expiratory volume in 1 s (FEV(1)) can predict the rapid decline in FEV(1) that leads to chronic obstructive pulmonary disease (COPD).

METHODS

Study participants (n = 143; age 45-72 years; 54% male) were part of a lung cancer screening trial, had a smoking history of >30 pack years and a normal FEV(1) and FEV(1)/forced vital capacity (FVC) at baseline (mean (SD) FEV(1) 99.4 (12.8)%, range 80.2-140.7%; mean (SD) FEV(1)/FVC 77.9 (4.4), range 70.0-88.0%). An inspiratory multislice CT scan was acquired for each subject at baseline. Custom software was used to measure airway lumen and wall dimensions; the percentage of the lung inflated beyond a predicted maximal lung inflation, the low attenuation lung area with an x ray attenuation lower than -950 HU and the size distribution of the overinflated lung areas and the low attenuation area were described using a cluster analysis. Multiple regression analysis was used to test the hypothesis that these CT measurements combined with other baseline characteristics might identify those who would develop an excessive annual decline in FEV(1).

RESULTS

The mean (SD) annual change in FEV(1) was -2.3 (4.7)% predicted (range -23.0% to +8.3%). Multiple regression analysis revealed that the annual change in FEV(1)%predicted was significantly associated with baseline percentage overinflated lung area measured on quantitative CT, FEV(1)% predicted, FEV(1)/FVC and gender.

CONCLUSION

Quantitative CT scan evidence of overinflation of the lung predicts a rapid annual decline in FEV(1) in smokers with normal FEV(1).

Computed tomographic estimation of lung dimensions throughout the growth period

The aim of the current study was to use computed tomography (CT) to estimate airway wall and lumen, and arterial and parenchyma dimensions in children throughout the growth period, and to provide normative data to study alterations caused by pulmonary disease. Clinical CT scans reported as normal that were performed in children for nonpulmonary and noncardiac reasons were analysed for lung weight, gas volume, lung expansion, lung surface/volume ratio, airway wall area, airway lumen area, airway lumen perimeter, arterial area and airway surface length/area ratio. The age range of the 50 subjects was 0-17.2 yrs. The data showed only little increase in lung expansion throughout childhood (n = 32). There was substantial variability in lung expansion between subjects. Airway wall and lumen and arterial area were exponentially associated with subjects' height (n = 50). Airway surface length/area ratio was linearly associated to alveolar surface/volume ratio. The data from the current study provide normative computed tomography estimates of airway wall and lumen, and arterial and parenchyma dimensions throughout the growth period that may be useful for the study of alterations in disease.

QTL and candidate genes phytoene synthase and zeta-carotene desaturase associated with the accumulation of carotenoids in maize

Carotenoids are a class of fat-soluble antioxidant vitamin compounds present in maize ( Zea mays L.) that may provide health benefits to animals or humans. Four carotenoid compounds are predominant in maize grain: beta-carotene, beta-cryptoxanthin, zeaxanthin, and lutein. Although beta-carotene has the highest pro-vitamin A activity, it is present in a relatively low concentration in maize kernels. We set out to identify quantitative trait loci (QTL) affecting carotenoid accumulation in maize kernels. Two sets of segregating families were evaluated-a set of F2:3 lines derived from a cross of W64a x A632, and their testcross progeny with AE335. Molecular markers were evaluated on the F2:3 lines and a genetic linkage map created. High-performance liquid chromatography was performed to measure beta-carotene, beta-cryptoxanthin, zeaxanthin, and lutein on both sets of materials. Composite interval mapping identified chromosome regions with QTL for one or more individual carotenoids in the per se and testcross progenies. Notably QTL in the per se population map to regions with candidate genes, yellow 1 and viviparous 9, which may be responsible for quantitative variation in carotenoids. The yellow 1 gene maps to chromosome six and is associated with phytoene synthase, the enzyme catalyzing the first dedicated step in the carotenoid biosynthetic pathway. The viviparous 9 gene maps to chromosome seven and is associated with zeta-carotene desaturase, an enzyme catalyzing an early step in the carotenoid biosynthetic pathway. If the QTL identified in this study are confirmed, particularly those associated with candidates genes, they could be used in an efficient marker-assisted selection program to facilitate increasing levels of carotenoids in maize grain.

Synthesis of 7200 small molecules based on a substructural analysis of the histone deacetylase inhibitors trichostatin and trapoxin

Seventy-two hundred potential inhibitors of the histone deacetylase (HDAC) enzyme family, based on a 1,3-dioxane diversity structure, were synthesized on polystyrene macrobeads. The compounds were arrayed for biological assays in a "one bead-one stock solution" format. Metal-chelating functional groups were used to direct the 1,3-dioxanes to HDAC enzymes, which are zinc hydrolases. Representative structures from this library were tested for inhibitory activity and the 1,3-dioxane structure was shown to be compatible with HDAC inhibition. [structure: see text]

Annual occupational exposure to ultraviolet radiation in central Queensland

The purpose of this study was to determine annual occupational exposure to UV radiation by measurement and derive ambient exposure fractions for an entire year that could be applied in the human exposure model. Using polysulphone the daily occupational erythema effective solar ultraviolet radiation exposure at selected body sites of Australia Post mail delivery personnel and physical education teachers were measured over an 18-mo period on a daily basis in the Rockhampton (lat. 23.5 degrees S) region. The daily exposures were summed to estimate an annual exposure for these occupations in this region. For the Australia Post mail delivery personnel, who had very little change to the posture or route during delivery, the annual mean estimates of exposure to erythema effective solar irradiance for the chest, hands, and back were in the range of 192+/-27 kJ m(-2), 388+/-45 kJ m(-2), and 283+/-32 kJ m(-2), respectively. Physical education teachers had varied duties on a day-to-day basis and many changes in their posture and outdoor locations where the exposure occurred. Their annual mean exposure on the vertex (hat), chest, shoulder, thigh, and back were in the range 340+/-71 kJ m(-2), 140+/-28 kJ m(-2), 180+/-40 kJ m(-2), 129+/-24 kJ m(-2), and 212+/-42 kJ m(-2), respectively. The annual exposure range for erythema effective solar irradiance at different body sites during the experimental period was between 120 and 440 kJ m(-2) for the two occupational groups. These exposures greatly exceed the National Health and Medical Research Council occupational standard limit of 30 J m(-2) for daily exposure, which indicates the need for additional protective measures. The ambient exposure was also measured and used to compute ambient exposure fractions for the different body sites over an entire year, which are useful for model calculations on human exposure and assess increase in risk of n on melanoma skin cancer.

Quantitative assessment of diffusion abnormalities in posterior reversible encephalopathy syndrome

BACKGROUND AND PURPOSE

Previous studies have shown that lesions in posterior reversible encephalopathy syndrome are often isointense on diffusion-weighted MR images. We hypothesized that 1) apparent diffusion coefficient (ADC) maps using various thresholds would show larger abnormalities in posterior white matter (WM) and 2) isointense appearance of lesions on isotropic diffusion-weighted images results from a balance of T2 prolongation effects and diffusibility effects.

METHODS

T2-weighted MR images from 11 patients were reviewed. Hyperintense lesions were located in both anterior and posterior WM in eight patients and solely in posterior WM in three patients. The ADC maps were produced by use of ADC values > or = 3 SD and > or = 10 SD above the mean value of normal WM. Lesions on diffusion-weighted images were classified as isointense or hypointense. ADC values within lesions (ADC(L)) were compared with those of normal WM (ADC(N)), and compared for isointense lesions and hypointense lesions.

RESULTS

The distribution of lesions with ADC values > or = 3 SD was essentially identical to that on T2-weighted images. Regions with ADC values > or = 10 SD were found in both anterior WM and posterior WM in two patients and solely in posterior WM in nine patients. On diffusion-weighted images, lesions appeared isointense in seven patients and hypointense in four patients. Mean ADC(L)/ADC(N) for all lesions was 1.81; for hypointense lesions, 2.30.

CONCLUSION

Vasogenic edema was more severe in posterior WM. Isointense lesions result from a balance of T2 effects and increased water diffusibility. Hypointense lesions have higher ADC values, which are not balanced by T2 effects.

The influence of homologous blood transfusion on immunity and clinical outcome in aortic surgery

OBJECTIVES

To evaluate the influence of homologous blood transfusion on immune responses and post-operative morbidity in aortic surgery.

DESIGN

Analysis of the effects of homologous blood transfusion in 128 patients in a prospective randomised trial evaluating homologous and autologous blood transfusion in aortic surgery.

MATERIALS AND METHODS

Blood sampled before and at five times after surgery was assayed for C-reactive protein (CRP), neutrophil elastase, TNF-alpha and IL-6. Transfusions, morbidity and mortality were recorded; factors associated with poor outcome were identified by logistic regression.

RESULTS

homologous transfusion during surgery was required in 32 patients and precipitated an increase in neutrophil elastase (p=0.008) and TNF-alpha (p=0.015) but not IL-6 and CRP. Elastase peaked early in transfused patients at 41.27 (13.92-52.11) Deltang/ml by 2 h compared to a peak of 21.51 (10.64-31.13) Deltang/ml by 24 h in those who were not transfused. TNF-alpha peaked at 1.2 (0-4.33) Deltapg/ml by wound closure in transfused patients and at -0.1 (-2.05-2.52) Deltapg/ml by 2 h without transfusion. Intra-operative homologous transfusion was associated with increased mortality (p=0.01) and prolonged intensive care stay (p=0.03). Mortality increased with age (p=0.003) and was inversely related to the CRP peak (p=0.007). Prolonged surgery predicted post-operative complications (p=0.025).

CONCLUSION

Homologous transfusion increased the inflammatory response to aortic surgery and was associated with mortality.

Solar ultraviolet exposures at ground level in tree shade during summer in south east Queensland

Data are presented on the effect of the tree canopy transmittance in the visible waveband (VT), canopy width, height and height of the start of the tree canopy (CH) on the solar UV in tree shade on a horizontal plane at ground level during a Southern Hemisphere summer. Of these factors, the VT and CH have an influence on the UV irradiances in the tree shade. The shade ratios (UV in tree shade to that in full sun) for erythemal UV ranged from 0.71 to 0.42, 0.54 to 0.29 and 0.63 to 0.41 for morning, noon and afternoon, respectively, for the VT range of 0.4-1.0. Over the same VT range, the shade ratios for UVA ranged from 0.61 to 0.28, 0.50 to 0.22 and 0.49 to 0.29 for morning, noon and afternoon, respectively. The UV exposures in the tree shade decreased with the VT with a marginally higher decrease in the irradiances for the UVA compared to the erythemal UV. Despite the protection by the tree shade, significant UV in the tree shade of approximately 4 MED (minimum erythemal dose) were received for the latitude in this research on a cloud free summer day on a horizontal plane over a 2-h period centred about solar noon.

Comparison between seasons of the ultraviolet environment in the shade of trees in Australia

BACKGROUND/PURPOSE

This paper has considered the erythemal UV (UVery), UVA and visible irradiances in the shade of Australian trees for each season at a sub-tropical southern hemisphere site.

METHODS

The irradiances in tree shade have been measured with radiometers as a percentage of the irradiances in the sun for each season of the year.

RESULTS

Although the solar irradiances are lower in winter, the percentages of the UV in tree shade compared to the UV in full sun are marginally higher (by up to 7%) in the winter compared to summer. The range of percentages for UVery was up to double that of the percentages of the visible waveband. The percentages for UVery were also higher than for the UVA waveband. The percentages of the irradiances in the tree shade compared to full sun are 8-14% lower at noon compared to the morning and afternoon for the UVery waveband. The ratio of UVA to UVery is lower in the tree shade compared to the full sun.

CONCLUSIONS

The UVA to UVery ratio is expected to be even lower in the tree shade as a result of ozone depletion. This, combined with the visible irradiances in the tree shade not being a reliable indication of the biologically damaging UV irradiances, has consequences for public health and skin cancer prevention.

Temporal trends and molecular epidemiology of HIV-1 infection in Taiwan from 1988 to 1998

Eight hundred and seventy-nine HIV-1-infected patients (comprising 46% of reported HIV-1/AIDS cases in Taiwan) were recruited for this study of the molecular epidemiology of HIV-1 in Taiwan from 1988 to 1998. HIV-1 subtypes were determined using a modified peptide-enzyme immunoassay complemented with DNA sequencing and phylogenetic analysis. Of the 807 HIV-1 infected men, 68.2% were infected with HIV-1B, 29.5% with HIV-1 circulating recombinant form (CRF)01_AE and 2.3% with other subtypes. Of the 72 HIV-1-infected women, 72.2% were infected with HIV-1 CRF01_AE, 13.9% with HIV-1B, and 13.9% with other subtypes. All of 8 foreign-born, Southeast Asian women and 6 of 7 (85.7%) Taiwan-native female commercial sex workers were infected with HIV-1 CRF01_AE. Fourteen of the 33 (42.4%) heterosexual married men with CRF01_AE had transmitted HIV-1 to their wives, whereas only 1 of 17 (5.9%) men with HIV-1 B had transmitted HIV-1 to their spouses (p < .01). Of 18 heterosexual male injecting drug users, 1 of 12 (8.5%) with HIV-1B and 5 of 6 (83.3%) with HIV-1 CRF01_AE had had sexual contact with female commercial sex workers (p < .01). Therefore, in this population, CRF01_AE was preferentially associated with heterosexual risk groups, a finding compatible with differences in transmission capability between B and non-B subtypes.

Split--pool synthesis of 1,3-dioxanes leading to arrayed stock solutions of single compounds sufficient for multiple phenotypic and protein-binding assays

Diversity-oriented organic synthesis offers the promise of advancing chemical genetics, where small molecules are used to explore biology. While the split--pool synthetic method is theoretically the most effective approach for the production of large collections of small molecules, it has not been widely adopted due to numerous technical and analytical hurdles. We have developed a split--pool synthesis leading to an array of stock solutions of single 1,3-dioxanes. The quantities of compounds are sufficient for hundreds of phenotypic and protein-binding assays. The average concentration of these stock solutions derived from a single synthesis bead was determined to be 5.4 mM in 5 microL of DMSO. A mass spectrometric strategy to identify the structure of molecules from a split--pool synthesis was shown to be highly accurate. Individual members of the 1,3-dioxane library have activity in a variety of phenotypic and protein-binding assays. The procedure developed in this study allows many assays to be performed with compounds derived from individual synthesis beads. The synthetic compounds identified in these assays should serve as useful probes of cellular and organismal processes.

Intracytoplasmic sperm injection increased fertilization and good-quality embryo formation in patients with non-male factor indications for in vitro fertilization: a prospective randomized study

OBJECTIVE

To compare the fertilization rate and formation of good-quality embryos with conventional IVF and ICSI in patients with non-male factor infertility.

DESIGN

Prospective controlled study.

SETTING

Infertility clinic.

PATIENT(S)

Thirty-five patients with non-male factor infertility.

INTERVENTION(S)

Retrieved sibling oocytes were randomly assigned to conventional IVF or ICSI. Of sibling oocytes assigned to ICSI, only metaphase II oocytes were injected with sperm.

MAIN OUTCOME MEASURE(S)

Fertilization rate and formation of good-quality embryos per retrieved oocyte.

RESULT(S)

Per retrieved oocyte, ICSI resulted in better fertilization rate compared with conventional IVF (71.3% [134 of 188] vs. 57.2% [107 of 187]). Per retrieved oocyte, ICSI also resulted in better formation of good-quality embryos at 48 hours after retrieval compared with conventional IVF (64.4% [121 of 188] vs. 47.1% [88 of 187]).

CONCLUSION(S)

In IVF patients with non-male factor infertility, subjecting some sibling oocytes to ICSI increased the fertilization rate and formation of good-quality embryos per retrieved oocyte. It also avoided the problem of total fertilization failure in almost all cases.

Exposure of human oocytes to endometrioma fluid does not alter fertilization or early embryo development

BACKGROUND

Extensive endometriosis causes a mechanical disturbance in the pelvis leading to obstructive-type infertility. However, minimal or mild endometriosis is suspected to cause infertility, possibly through a humoral agent. Previous studies reported the presence of a factor in the serum of patients with endometriosis which reduced fertilization and early embryo formation in a rat IVF model.

METHODS

In the present article, we report a comparison of oocytes exposed to endometrioma fluid and oocytes not exposed (controls) in the context of a human IVF setting. We have been in the practice of aspirating oocytes into prewarmed 60-ml syringes containing culture medium. We have shown previously that this technique reduces the length of oocyte retrieval without compromising success. In 14 women undergoing oocyte retrieval, we inadvertently entered an endometrioma. This resulted in retrieved oocytes that were either exposed or not exposed to endometrioma fluid.

RESULTS

In contrast to previous reports, we found no difference in fertilization or early embryo development between the two groups. The fertilization rate for oocytes exposed to an endometrioma was 60%, versus 56% for controls. The good-quality embryo formation rate for oocytes exposed to an endometrioma was 45%, versus 46% for controls.

Bone mineral density in adolescent females with recently diagnosed anorexia nervosa

Anorexia nervosa (AN) can lead to osteoporosis and fractures.

OBJECTIVE

This study evaluated adolescent females with AN diagnosed within the previous 12 months to determine whether there is bone mass reduction and to investigate relationships between nutritional indices (weight, body mass index [BMI], lean mass, fat mass, and percentage fat) and total body (TB) and lumbar spine (LS) bone mineral densities (BMD) and content (BMC).

METHOD

TB and LS BMD and BMC and body composition were measured in 24 adolescent females with AN.

RESULTS

There was no significant reduction in TB or LS BMD. Regression analysis shows significant correlation (p < 0.001) between lean mass and TB BMD (r = +0.83), TB BMC (r = +0.92), LS BMD (r = +0.81), and LS BMC (r = +0.92). There was also a significant relationship between weight percentile and LS BMD z score (p < 0.005; r = +0.60).

DISCUSSION

Adolescent females with early AN do not appear to have reduced bone mass. Lean mass is correlated to BMD and BMC.

Nuclear medicine imaging in early vertebral osteomyelitis: still of clinical utility

A case is presented of vertebral osteomyelitis in an elderly confused patient with poorly localizing signs. The lesion was not diagnosed on the initial MRI study of the spine due to poor targeting. The abnormality was detected on a bone scan the following day. This was confirmed with a gallium scan 3 days later, and also a repeat MRI study 11 days after the first MRI, using an optimized protocol over the region of interest established by the bone scan.

The status of controlled prospective clinical trials for efficacy of intracytoplasmic sperm injection in in vitro fertilization for non-male factor infertility

PURPOSE

Intracytoplasmic sperm injection (ICSI) of some sibling oocytes may have a beneficial effect in couples going through in vitro fertilization for causes of infertility not related to the male factor. Our purpose was to critically appraise the randomized controlled studies done in this area and arrive at some recommendations.

METHODS

The four controlled trials done so far have utilized similar methodology, i.e., they randomly allotted sibling oocytes to ICSI versus standard insemination in patients going through in vitro fertilization and embryo transfer.

RESULTS

In the first trial reported in 1995 there was no difference in fertilization rate, whereas the later trials reported in 1997, 1999, and 2000 showed improvement with ICSI that reached statistically significant level in the last two studies.

CONCLUSIONS

Total fertilization failure of an in vitro fertilization cycle can be prevented and fertilization can be improved if half of sibling oocytes are subjected to ICSI.

Cloning and analysis of the mouse Fanconi anemia group A cDNA and an overlapping penta zinc finger cDNA

Despite the cloning of four disease-associated genes for Fanconi anemia (FA), the molecular pathogenesis of FA remains largely unknown. To study FA complementation group A using the mouse as a model system, we cloned and characterized the mouse homolog of the human FANCA cDNA. The mouse cDNA (Fanca) encodes a 161-kDa protein that shares 65% amino acid sequence identity with human FANCA. Fanca is located at the distal region of mouse chromosome 8 and has a ubiquitous pattern of expression in embryonic and adult tissues. Expression of the mouse cDNA in human FA-A cells restores the cellular drug sensitivity to normal levels. Thus, the expression pattern, protein structure, chromosomal location, and function of FANCA are conserved in the mouse. We also isolated a novel zinc finger protein, Zfp276, which has five C(2)H(2) domains. Interestingly, Zfp276 is situated in the Fanca locus, and the 3'UTR of its cDNA overlaps with the last four exons of Fanca in a tail-to-tail manner. Zfp276 is expressed in the same tissues as Fanca, but does not complement the mitomycin C (MMC)-sensitive phenotype of FA-A cells. The overlapping genomic organization between Zfp276 and Fanca may have relevance to the disease phenotype of FA.

Evaluation of differences in ultraviolet exposure during weekend and weekday activities

The weekday UV exposures to anatomical sites were evaluated for outdoor workers, home workers, adolescents, indoor workers, school staff and students in south-east Queensland, Australia. Additionally, the UV exposures at weekends of school staff, school students, indoor workers and outdoor workers were evaluated. The weekday exposures per day ranged from 1.0 to 11.0 SED for winter to summer respectively. During spring, the ratios of the personal exposures divided by the ambient exposures at the weekend to the personal exposures divided by the ambient exposures on the weekdays to the neck, hand and left arm were at least 3.4, 2.0 and 0.67 for the indoor workers, school staff and students and outdoor workers respectively. The same ratios for the erythemal UV exposures over the year, estimated from the exposures on four days in each of the four seasons, were at least 2.3 for the school staff and at least 1.3 for the 13 to 19 year old school students. These results reinforce the importance of targeting prevention programmes to both weekend and weekday exposures.

An estimation of biological hazards due to solar radiation

A spectrum evaluator based on four different dosimeter materials has been employed to estimate the spectral irradiances of solar radiation for exposed humans. The result is used to calculate the biologically effective irradiance using the erythemal action spectrum and a fish melanoma action spectrum. Measurements are made in winter at a sub-tropical site on the chest and shoulder of subjects during normal daily activities. Up to 95% of the total UV exposure received is in the UV-A waveband (320-400 nm). The UV-A waveband is found to contribute approximately 14% of the erythemal UV and 93% of the biologically effective UV for fish melanoma. Extrapolation to humans suggests that exposure to the UV-A band will contribute to photodamage in human skin during exposure to solar radiation.

Effect of childhood and adolescent ultraviolet exposures on cumulative exposure in South East Queensland schools

Quantitative estimates of the childhood and adolescent erythemal ultraviolet (UV) exposure received in South East Queensland schools are provided in this paper for age groups 0 to 6, 7 to 12 and 13 to 19 years. For the neck, hand and lower arm, sites of high UV exposure that are generally not covered by clothing, 13 to 19 year olds received the highest exposure of the three age groups, followed by 7 to 12 year olds. Exposure for 13 to 19 year olds contributed up to 44% of cumulative exposure to 20 years of age, and exposures for the 7 to 12 year olds contributed up to 31%. If the annual UV exposure for these two age groups were reduced to the average of all the age groups, cumulative erythemal UV exposure from 0 to 20 years would be reduced by up to 16%. On the other hand, if mothers can protect their babies by reducing the level of annual exposure to 30% of the annual UV exposure of the 7 to 12 year olds for the first four years then cumulative exposure to UV to age 20 would be reduced by up to 19%. These data confirm the importance of targeting young age groups in public campaigns for sun protection.

Diffuse component of solar ultraviolet radiation in tree shade

The first set of quantitative data of diffuse erythemal UV and UV-A radiation in tree shade at a sub-tropical Southern Hemisphere latitude is presented. Over the summer, approximately 60% of the erythemal UV radiation in tree shade is due to the diffuse component. Similarly, approximately 56% of the UV-A radiation in tree shade is due to the diffuse component. In tree shade these diffuse UV percentages are relatively constant from the morning to noon to afternoon periods. In comparison, in full sun, there is a decrease in the percentage of diffuse UV from morning to noon to afternoon. The exposures to diffuse UV on a horizontal plane in tree shade between 9:00 EST and 15:00 EST are of the order of 4 MED (minimum erythemal dose) and 14 J cm(-2) for erythemal UV and UV-A, respectively. The high diffuse UV component in the shade may result in high UV exposures not only to unprotected parts of the body on a horizontal plane, but also in equally high UV irradiances to parts of the body, including the eyes and face, that are not UV protected.

Personal exposure distribution of solar erythemal ultraviolet radiation in tree shade over summer

The personal radiant exposure distribution of solar erythemal UV in tree shade for an upright posture was measured, with measurements over the whole summer for a total of 17 trees. For each tree, the personal radiant exposure distribution was measured for both the morning and afternoon periods. The exposure ratios averaged over all the trees and over the morning and afternoon periods ranged from 0.16 to 0.49 for the different anatomical sites. A numerical model was employed to estimate the UV radiant exposure to humans in tree shade over the entire summer. The body sites with the higher exposure ratios in the tree shade were the vertex of the head, shoulders and forearms with radiant exposures over the summer of 1300 MED to the vertex of the head and 1100 MED to the shoulders and forearms. These radiant exposures in the shade are substantially higher than the ambient erythemal UV measured in full sun on a horizontal plane over a full summer at a more temperate northern hemisphere latitude. The average radiant exposures per day to each anatomical site for a complete day in the tree shade ranged from 4.6 to 14.6 MED. This research has provided new data that is essential to quantify human UV exposure during outdoor activities.

Influence of surgery on aortic valve prolapse and aortic regurgitation in doubly committed subarterial ventricular septal defect

Doubly committed subarterial ventricular septal defects should be closed surgically once aortic valve deformity is present before the onset of aortic regurgitation.

Lifetime ultraviolet exposure estimates for selected population groups in south-east Queensland

The lifetime erythemal UV exposures received by selected population groups in southeast Queensland from birth up to an age of 55 years have been quantitatively estimated. A representative sample of teachers and other school workers received (64 +/- 22) x 10(5) J m(-2) to the neck compared with (4.1 +/- 1.4) x 10(5) J m(-2) to the upper leg. A sample of indoor workers (bank officers, solicitors and psychologists) received approximately 2% less and a sample of outdoor workers (carpenters, tilers, electricians and labourers) received approximately 10% more to the neck than the school workers. These differences in erythemal UV exposures may influence the risk of non-melanoma skin cancer.

Synthesis of furanonaphthoquinones with hydroxyamino side chains

Several furanonaphthoquinones have shown useful activity in a yeast assay for DNA-damaging agents and cytotoxicity in mammalian cell culture assays. These results, together with the planar aromatic character of the furanonaphthoquinones, suggested that they might be acting as DNA intercalators. In an attempt to improve this activity, various analogues containing a hydroxyamino side chain have been synthesized. The analogues were prepared by standard methods, but some unexpected reactions were observed nonetheless. Thus, 8-formyl-5-methoxy-4,9-dihydronaphtho[2,3-b]furan-4,9-dione (24) showed an unusual reactivity toward reductive amination, with the reaction proceeding further to give one of two different cyclized products, depending on the amination reagent used. Bioassay results indicated that only simple furanonaphthoquines showed activity in a yeast assay for DNA-damaging agents; compounds with a substituted hydroxyamino side chain were uniformly inactive in this assay. Most of the compounds with a substituted hydroxyamino side chain on the furan ring did, however, show cytotoxicity, although none of them was any more active than the simple aldehyde 2-formyl-4, 9-dihydronaphtho[2,3-b]furan-4,9-dione (14). This evidence tends to suggest that the furanonaphthoquinones do not serve primarily as DNA intercalators, because if this were the case, they would have been expected to show an increased activity on conversion to their hydroxyamino side chain derivatives.

Further study on the effects of histamine H2 receptor agonist and antagonists on restraint-induced antinociception in mice

In previous studies, histamine was shown to affect the antinociceptive activity induced by stress in mice. The present work was carried out to further examine the role of histamine in this phenomenon. Restraint for 1 h induced significant antinociceptive activity as assessed by the hot plate test in both male and female mice. The antinociceptive activity was enhanced by prior administration of the histamine H2 receptor agonist dimaprit (6.0 mg/kg s.c.) 15 min before restraint. Furthermore, the induction of antinociceptive activity by restraint was antagonized by prior administration of histamine H2 receptor antagonists (10.0 mg/kg s.c.), cimetidine or zolantidine. In the male mice, naloxone (4.0 mg/kg s.c.) administered 10 min before or immediately after restraint did not affect the antinociception induced by restraint. In addition, the potentiating effect of dimaprit and the inhibitory effect of cimetidine and zolantidine were not affected by administration of naloxone. However, in female mice, naloxone given 10 min before restraint completely abolished the induction of antinociceptive activity by restraint and the effects of histamine H2 receptor agonist and antagonists on restraint induced antinociception were not observed. Moreover, the antinociceptive activity induced by restraint and the dimaprit-induced potentiation of antinociceptive activity were diminished by naloxone administered immediately after the restraint. The present findings further support our previous studies which suggested that the histamine H2 receptor most probably is involved in enhancing the intensity of stress in restraint-induced antinociception thus altering the degree of antinociception observed.

Penetration of solar erythemal UV radiation in the shade of two common Australian trees

The penetration of solar erythemal ultraviolet radiation has been measured in the shade of a gum (Eucalyptus sp.) and a she oak (Casaurina) tree, both on a horizontal plane and with polysulphone dosimeters to human anatomical sites. This has provided new data useful for protection strategies against harmful ultraviolet radiation. For larger solar zenith angles, the relative penetration of solar erythemal ultraviolet in the shade of the trees is higher. On a horizontal plane, at noon, in winter, the shade erythemal ultraviolet ranged from 44 to 55% of that in the sun whereas in spring it ranged from 29 to 37% of the irradiances in the sun. Similarly, at 9:00 EST and 15:00 EST, the shade erythemal ultraviolet in winter ranged from 51 to 81% of the irradiances in the sun whereas in spring and summer they ranged from 35 to 51% of the unshaded irradiances. The shade ratios for specific body sites provided by the shade of the two trees were 0.05 to 0.45 for the solar zenith angles in this research. The shade ratios ranged from 0.14 to 0.45 for the gum tree and from 0.05 to 0.28 for the she oak. The denser foliage of the she oak provided higher ultraviolet protection compared to that of the gum tree.

Outcome of surgical closure of doubly committed subarterial ventricular septal defect

BACKGROUND

From 1986 to March 1997, 128 patients diagnosed to have doubly committed subarterial ventricular septal defects (VSD) were reviewed. Patients with aortic regurgitation (AR), and aortic valve (AV) deformity or a large left-to-right shunt across the VSD were offered operation. Forty-five patients (27 men, 18 women) agreed to surgical closure of their VSDs.

METHODS

Thirty-eight patients had VSD closure alone, and 7 had an additional AV repair. Other associated defects corrected at operation were closure of atrial septal defects, closure of other ventricular septal defects, ligation of patent ductus arteriosus, and repair of ruptured sinus Valsalva aneurysm.

RESULTS

There was no mortality nor major morbidity associated with operation. In the 26 patients with AR and AV deformity preoperatively, valve repair was performed in 6 patients. The condition of AR improved in 4, and remained unchanged in 22 patients. In the 10 patients with a deformity of the AV and no AR preoperatively, the condition remained unchanged in 5 patients, from whom 1 had valve operation, but progressed in 5 patients postoperatively at a mean follow-up of 6.4 years. In 9 patients with no deformity of the AV and no AR preoperatively, there was no postoperative AR and no progress of valve deformity.

CONCLUSIONS

Excellent results were obtained with VSD closure and AV repair. Surgical closure of VSD, if performed before the onset of AV deformity, may prevent progressive AR. If AV repair is performed after the onset of AV deformity, progressive AR may not always be prevented.

Bidirectional cavopulmonary anastomosis

The Fontan operation has been used to palliate patients with a functional single ventricle. In many such patients the operative risk for a Fontan procedure is high. The bidirectional cavopulmonary anastomosis (BCPA) is a useful intermediate palliative procedure before Fontan correction. It may reduce the deleterious sequelae of chronic hypoxaemia and long-term ventricular overload, thus yielding a more suitable Fontan candidate. We reviewed our experience of 9 patients with univentricular hearts who were at the time of the BCPA not considered suitable candidates for conventional Fontan operation. Two patients had double inlet right ventricle (DIRV) with pulmonary stenosis (PS) and ventricular septal defect (VSD), 2 had univentricular heart, 4 had tricuspid atresia (TA) and hypoplastic right ventricle (RV), 1 patient had atrioventricular septal defect (AVSD) with double outlet right ventricle (DORV) with hypoplastic RV. Two of the 9 patients had bilateral superior vena cavae. All except one had undergone prior palliative operations. The mean age at BCPA was 4.7 years (range 1.5 years to 6 years) and the mean weight at surgery was 15 kg (range 7 to 22 kg). There were no operative deaths. The mean hospitalization stay was 8.5 days (range 5 to 13 days) with a mean follow up of 14 months. Median oxygen saturation improved from 78.7 +/- 6.3% to 85.9 +/- 3.9%. The BCPA is a useful palliative procedure to stage Fontan type reconstruction in selected patients with univentricular hearts.

General protease assay method coupling solid-phase substrate extraction and capillary electrophoresis

Capillary electrophoresis with laser-induced fluorescence detection was used to develop a universal, highly specific protease assay. In this method, a peptide, biotinylated at the N-terminus, is labeled with fluorescein at a lysine residue near the C-terminus. Impurities are removed from the fluorescence labeling mixture by solid-phase extraction of the substrate on immobilized streptavidin, followed by extensive washing. The purified fluorescent substrate is dissociated from the streptavidin and incubated with the protease. The peptide sequence between the biotin and fluorescent label contains the cleavage sequence of the protease of interest. After cleavage, the fluorescent product does not contain a biotin group. A second solid-phase extraction is used to remove unreacted substrate to dramatically lower the background signal. The product is detected by capillary electrophoresis, which provides powerful discrimination against products generated by nonspecific proteases. With chymotrypsin as a test protease, product was detected with as little as 10 pg/mL (4.6 x 10(-13) M) chymotrypsin, or 5 amol of enzyme in the 10-microL sample volume.

Effects of high sound levels on responses to the vowel "eh" in cat auditory nerve

The vowel "eh" was used to study auditory-nerve responses at high sound levels (60-110 dB). By changing the playback sampling rate of the stimulus, the second formant (F2) frequency was set at best frequency (BF) for fibers with BFs between 1 and 3 kHz. For vowel stimuli, auditory-nerve fibers tend to phase-lock to the formant component nearest the fiber's BF. The responses of fibers with BFs near F2 are captured by the F2 component, meaning that fibers respond as if the stimulus consisted only of the F2 component. These narrowband responses are seen up to levels of 80-100 dB, above which a response to F1 emerges. The F1 response grows, at the expense of the F2 response, and is dominant at the highest levels. The level at which the F1 response appears is BF dependent and is higher at lower BFs. This effect appears to be suppression of the F2 response by F1. At levels near 100 dB, a component 1/component 2 transition is observed. All components of the vowel undergo the transition simultaneously, as judged by the 180 degrees phase inversion that occurs at the C2 transition. Above the C2 threshold, a broadband response to many components of the vowel is observed. These results demonstrate that the neural representation of speech in normal ears is degraded at high sound levels, such as those used in hearing aids.

Sodium dodecyl sulfate-capillary electrophoresis of proteins in a sieving matrix utilizing two-spectral channel laser-induced fluorescence detection

We report a method for protein labeling, separation by capillary electrophoresis in a polymer sieving matrix, and detection by laser-induced fluorescence. Different dyes are used to label standard and sample proteins. A two-spectral channel detector resolves fluorescence from the sample and standards. Comparison of the migration time of the sample and standards permits the precise determination of molecular weight, irrespective of variations in run-to-run migration times.

[11C]Methionine positron emission tomography for patients with persistent or recurrent hyperparathyroidism after surgery

OBJECTIVE

Reoperation in patients with recurrent hyperparathyroidism usually requires localisation of abnormal glands. Current imaging techniques are not always successful in this group of patients. An evaluation of [11C]methionine positron emission tomography (PET) has been made to assess the ability of the technique to localise abnormal glands in patients with hyperparathyroidism after previous surgery.

SUBJECTS AND METHODS

Eight patients (five with primary, and three with tertiary hyperparathyroidism) who had undergone one to three previous surgical explorations were studied. [11C]methionine PET scans of the neck and mediastinum were performed in all patients. All had recent technetium-99m (99mTc)-labelled sestamibi (n = 7) or thallium-201 (201Tl)/99mTc subtraction (n = 1) parathyroid scans available for comparison. Subsequent surgical correlation was available in all cases.

RESULTS

[11C]methionine PET correctly located an abnormal site of uptake in all five patients with primary hyperparathyroidism compared with only one when conventional nuclear medicine methods were used. In the patients with tertiary hyperparathyroidism, [11C]methionine PET correctly located one, confirmed the absence of cervical or mediastinal abnormality in a patient with an autotransplanted forearm autonomous gland, and failed to demonstrate an abnormality in a third. 99mTc-labelled sestamibi scans were negative in all three patients.

CONCLUSION

[11C]methionine PET correctly locates abnormal parathyroid glands in the majority of patients with persistent or recurrent hyperparathyroidism after surgery in whom conventional non-invasive nuclear medicine imaging has failed.