The incidence of surgical intervention following a suspected scaphoid fracture

Aims

The underlying natural history of suspected scaphoid fractures (SSFs) is unclear and assumed poor. There is an urgent requirement to develop the literature around SSFs to quantify the actual prevalence of intervention following SSF. Defining the risk of intervention following SSF may influence the need for widespread surveillance and screening of SSF injuries, and could influence medicolegal actions around missed scaphoid fractures.

Methods

Data on SSF were retrospectively gathered from virtual fracture clinics (VFCs) across a large Scottish Health Board over a four-year period, from 1 January 2018 to 31 December 2021. The Bluespier Electronic Patient Record System identified any surgical procedure being undertaken in relation to a scaphoid injury over the same time period. Isolating patients who underwent surgical intervention for SSF was performed by cross-referencing the unique patient Community Health Index number for patients who underwent these scaphoid procedures with those seen at VFCs for SSF over this four-year period.

Results

In total, 1,739 patients were identified as having had a SSF. Five patients (0.28%) underwent early open reduction and internal fixation (ORIF). One patient (0.06%) developed a nonunion and underwent ORIF with bone grafting. All six patients undergoing surgery were male (p = 0.005). The overall rate of intervention following a SSF was 0.35%. The early intervention rate in those undergoing primary MRI was one (0.36%), compared with three in those without (0.27%) (p > 0.576).

Conclusion

Surgical intervention was rare following a SSF and was not required in females. A primary MRI policy did not appear to be associated with any change in primary or secondary intervention. These data are the first and largest in recent literature to quantify the prevalence of surgical intervention following a SSF, and may be used to guide surveillance and screening pathways as well as define medicolegal risk involved in missing a true fracture in SSFs.

Overview of the Langmuir probe system on the Mega Ampere Spherical Tokamak (MAST) Upgrade

A detailed description of the Langmuir probe system on Mega Ampere Spherical Tokamak Upgrade is presented. The system features 850 tile-embedded probes and 40 bespoke electronic modules that each have the capability to drive and acquire data from up to 16 probes in a time-multiplexed manner. The system provides spatiotemporal-resolved measurements (1 cm and ∼1 ms, respectively) in the divertor region of ion saturation current, electron temperature, and floating potential. The standard interpretation of current-voltage (IV) characteristics is to apply a four-parameter fit, based on unmagnetized probe theory, which includes a linear model for the ion saturation region. To mitigate the effect of the magnetic field, analysis is restricted to the region of the IV characteristic, which is sensitive to only the tail of the electron energy distribution function.

Controlling spin current polarization through non-collinear antiferromagnetism

The interconversion of charge and spin currents via spin-Hall effect is essential for spintronics. Energy-efficient and deterministic switching of magnetization can be achieved when spin polarizations of these spin currents are collinear with the magnetization. However, symmetry conditions generally restrict spin polarizations to be orthogonal to both the charge and spin flows. Spin polarizations can deviate from such direction in nonmagnetic materials only when the crystalline symmetry is reduced. Here, we show control of the spin polarization direction by using a non-collinear antiferromagnet Mn₃GaN, in which the triangular spin structure creates a low magnetic symmetry while maintaining a high crystalline symmetry. We demonstrate that epitaxial Mn₃GaN/permalloy heterostructures can generate unconventional spin-orbit torques at room temperature corresponding to out-of-plane and Dresselhaus-like spin polarizations which are forbidden in any sample with two-fold rotational symmetry. Our results demonstrate an approach based on spin-structure design for controlling spin-orbit torque, enabling high-efficient antiferromagnetic spintronics.

In the typical spin-hall effect, spin-current, charge current, and spin polarisation are all mutually perpendicular, a feature enforced by symmetry. Here, using an anti-ferromagnet with a triangular spin structure, the authors demonstrate a spin-hall effect without a perpendicular spin alignment.

Magnetism in iridate heterostructures leveraged by structural distortions

Fundamental control of magnetic coupling through heterostructure morphology is a prerequisite for rational engineering of magnetic ground states. We report the tuning of magnetic interactions in superlattices composed of single and bilayers of SrIrO₃ inter-spaced with SrTiO₃ in analogy to the Ruddlesden-Popper series iridates. Magnetic scattering shows predominately c-axis antiferromagnetic orientation of the magnetic moments for the bilayer, as in Sr₃Ir₂O₇. However, the magnetic excitation gap, measured by resonant inelastic x-ray scattering, is quite different between the two structures, evidencing a significant change in the stability of the competing magnetic phases. In contrast, the single layer iridate hosts a more bulk-like gap. We find these changes are driven by bending of the c-axis Ir-O-Ir bond, which is much weaker in the single layer, and subsequent local environment changes, evidenced through x-ray diffraction and magnetic excitation modeling. Our findings demonstrate how large changes in the magnetic interactions can be tailored and probed in spin-orbit coupled heterostructures by engineering subtle structural modulations.

Ferromagnetism and Charge Order from a Frozen Electron Configuration in Strained Epitaxial LaCoO_{3}

We report ordering of the cobalt electron configuration in ferromagnetic strained epitaxial LaCoO_{3}. Specifically, the presence of charge order is demonstrated from distinct features of the resonant cobalt contribution to superstructure reflections. Density functional theory calculations show that the observed order is consistent with the spin-state periodicity predicted to give rise to ferromagnetism in LaCoO_{3}. Through the modification of symmetry by strain, concurrent frozen charge and spin-state order are stabilized, giving rise to long-range magnetic order.

Artificial two-dimensional polar metal at room temperature

Polar metals, commonly defined by the coexistence of polar crystal structure and metallicity, are thought to be scarce because the long-range electrostatic fields favoring the polar structure are expected to be fully screened by the conduction electrons of a metal. Moreover, reducing from three to two dimensions, it remains an open question whether a polar metal can exist. Here we report on the realization of a room temperature two-dimensional polar metal of the B-site type in tri-color (tri-layer) superlattices BaTiO₃/SrTiO₃/LaTiO₃. A combination of atomic resolution scanning transmission electron microscopy with electron energy-loss spectroscopy, optical second harmonic generation, electrical transport, and first-principles calculations have revealed the microscopic mechanisms of periodic electric polarization, charge distribution, and orbital symmetry. Our results provide a route to creating all-oxide artificial non-centrosymmetric quasi-two-dimensional metals with exotic quantum states including coexisting ferroelectric, ferromagnetic, and superconducting phases.

Disentangled Cooperative Orderings in Artificial Rare-Earth Nickelates

Coupled transitions between distinct ordered phases are important aspects behind the rich phase complexity of correlated oxides that hinder our understanding of the underlying phenomena. For this reason, fundamental control over complex transitions has become a leading motivation of the designer approach to materials. We have devised a series of new superlattices by combining a Mott insulator and a correlated metal to form ultrashort period superlattices, which allow one to disentangle the simultaneous orderings in RENiO_{3}. Tailoring an incommensurate heterostructure period relative to the bulk charge ordering pattern suppresses the charge order transition while preserving metal-insulator and antiferromagnetic transitions. Such selective decoupling of the entangled phases resolves the long-standing puzzle about the driving force behind the metal-insulator transition and points to the site-selective Mott transition as the operative mechanism. This designer approach emphasizes the potential of heterointerfaces for selective control of simultaneous transitions in complex materials with entwined broken symmetries.

Mott Electrons in an Artificial Graphenelike Crystal of Rare-Earth Nickelate

Deterministic control over the periodic geometrical arrangement of the constituent atoms is the backbone of the material properties, which, along with the interactions, define the electronic and magnetic ground state. Following this notion, a bilayer of a prototypical rare-earth nickelate, NdNiO_{3}, combined with a dielectric spacer, LaAlO_{3}, has been layered along the pseudocubic [111] direction. The resulting artificial graphenelike Mott crystal with magnetic 3d electrons has antiferromagnetic correlations. In addition, a combination of resonant X-ray linear dichroism measurements and ab initio calculations reveal the presence of an ordered orbital pattern, which is unattainable in either bulk nickelates or nickelate based heterostructures grown along the [001] direction. These findings highlight another promising venue towards designing new quantum many-body states by virtue of geometrical engineering.

Relaxin-3 mRNA levels in nucleus incertus correlate with alcohol and sucrose intake in rats

BACKGROUND

Chronic alcohol intake produces multiple neuroadaptive changes, including up- and down-regulation of neuropeptides and receptors. There are widespread projections of relaxin-3 containing neurons to, and abundant relaxin family peptide 3 receptor (RXFP3) expression within, brain regions involved in modulating alcohol intake. Recently we demonstrated the involvement of relaxin-3/RXFP3 signalling in alcohol-seeking in rats; therefore in this study we examined whether relaxin-3 and/or RXFP3 expression were altered by chronic alcohol intake in alcohol-preferring iP rats.

METHODS

Expression of relaxin-3 mRNA in the hindbrain nucleus incertus and RXFP3 radioligand binding levels in discrete forebrain regions were investigated following voluntary intake of alcohol or sucrose for 12 weeks, with a 2 day washout, using quantitative in situ hybridisation histochemistry and in vitro receptor autoradiography, respectively, in cohorts of adult, male iP rats.

RESULTS

Levels of relaxin-3 mRNA in the hindbrain nucleus incertus were positively correlated with the level of intake of both alcohol (r(12)=0.59, p=0.03) and sucrose (r(7)=0.70, p=0.04) in iP rats. Dense binding of the RXFP3-selective radioligand, [(125)]-R3/I5, was detected in hypothalamic and extrahypothalamic sites, but no significant changes in the density of RXFP3 were observed in the brain regions quantified following chronic sucrose or ethanol intake.

CONCLUSIONS

Our findings suggest high endogenous relaxin-3 expression may be associated with higher intake of rewarding substances, rather than its expression being regulated in response to their intake, consistent with an active role for the relaxin-3/RXFP3 system in modulating ingestive and alcohol-related behaviours.

Structure of SrTiO3 films on Si

The epitaxial deposition of oxides on silicon opens the possibility of incorporating their diverse properties into silicon-device technology. Deposition of SrTiO(3) on silicon was first reported over a decade ago, but growing the coherent, lattice-matched films that are critical for many applications has been difficult for thicknesses beyond 5 unit cells. Using a combination of density functional calculations and x-ray diffraction measurements, we determine the atomic structure of coherent SrTiO(3) films on silicon, finding that the Sr concentration at the interface varies with the film thickness. The structures with the lowest computed energies best match the x-ray diffraction. During growth, Sr diffuses from the interface to the surface of the film; the increasing difficulty of Sr diffusion with film thickness may cause the disorder seen in thicker films. The identification of this unique thickness-dependent interfacial structure opens the possibility of modifying the interface to improve the thickness and quality of metal oxide films on silicon.

Asymmetric orbital-lattice interactions in ultrathin correlated oxide films

Using resonant x-ray spectroscopies combined with density functional calculations, we find an asymmetric biaxial strain-induced d-orbital response in ultrathin films of the correlated metal LaNiO3 which are not accessible in the bulk. The sign of the misfit strain governs the stability of an octahedral "breathing" distortion, which, in turn, produces an emergent charge-ordered ground state with an altered ligand-hole density and bond covalency. Control of this new mechanism opens a pathway to rational orbital engineering, providing a platform for artificially designed Mott materials.

Enhanced ordering temperatures in antiferromagnetic manganite superlattices

The disorder inherent to doping by cation substitution in the complex oxides can have profound effects on collective-ordered states. Here, we demonstrate that cation-site ordering achieved through digital-synthesis techniques can dramatically enhance the antiferromagnetic ordering temperatures of manganite films. Cation-ordered (LaMnO3)m/(SrMnO3)2m superlattices show Néel temperatures (TN) that are the highest of any La(1-x)Sr(x)MnO3 compound, approximately 70 K greater than compositionally equivalent randomly doped La(1/3)Sr(2/3)MnO3. The antiferromagnetic order is A-type, consisting of in-plane double-exchange-mediated ferromagnetic sheets coupled antiferromagnetically along the out-of-plane direction. Through synchrotron X-ray scattering, we have discovered an in-plane structural modulation that reduces the charge itinerancy and hence the ordering temperature within the ferromagnetic sheets, thereby limiting TN. This modulation is mitigated and driven to long wavelengths by cation ordering, enabling the higher TN values of the superlattices. These results provide insight into how cation-site ordering can enhance cooperative behaviour in oxides through subtle structural phenomena.

Charge order in LuFe2O4: antiferroelectric ground state and coupling to magnetism

X-ray scattering by multiferroic LuFe2O4 is reported. Below 320 K, superstructure reflections indicate an incommensurate charge order with propagation close to (1/3 1/3 3/2). The corresponding charge configuration, also found by electronic structure calculations as most stable, contains polar Fe/O double layers with antiferroelectric stacking. Diffuse scattering at 360 K, with (1/3 1/3 0) propagation, indicates ferroelectric short-range correlations between neighboring double layers. The temperature dependence of the incommensuration indicates that charge order and magnetism are coupled.

Chiral-selective chemistry induced by spin-polarized secondary electrons from a magnetic substrate

We demonstrate for the first time that low-energy spin-polarized secondary electrons, produced by irradiation of a magnetic substrate, can induce chiral-selective chemistry. Our approach was to perform detailed measurements of the reaction rate for x-ray induced, secondary electron photolysis of a model chiral compound, (R)- or (S)-2-butanol, adsorbed on a magnetized Permalloy substrate. The results showed that there is an enhancement of approximately 10% in the rate of CO bond cleavage that depends on the chirality of the molecule and the spin polarization of the substrate secondary electrons.

Tumor-derived death receptor 6 modulates dendritic cell development

Studies in murine models of cancer as well as in cancer patients have demonstrated that the immune response to cancer is often compromised. This paradigm is viewed as one of the major mechanisms of tumor escape. Many therapies focus on employing the professional antigen presenting dendritic cells (DC) as a strategy to overcome immune inhibition in cancer patients. Death receptor 6 (DR6) is an orphan member of the tumor necrosis factor receptor superfamily (TNFRSF21). It is overexpressed on many tumor cells and DR6(-/-) mice display altered immunity. We investigated whether DR6 plays a role in tumorigenesis by negatively affecting the generation of anti-tumor activity. We show that DR6 is uniquely cleaved from the cell surface of tumor cell lines by the membrane-associated matrix metalloproteinase (MMP)-14, which is often overexpressed on tumor cells and is associated with malignancy. We also demonstrate that >50% of monocytes differentiating into DC die when the extracellular domain of DR6 is present. In addition, DR6 affects the cell surface phenotype of the resulting immature DC and changes their cytokine production upon stimulation with LPS/IFN-gamma. The effects of DR6 are mostly amended when these immature DC are matured with IL-1beta/TNF-alpha, as measured by cell surface phenotype and their ability to present antigen. These results implicate MMP-14 and DR6 as a mechanism tumor cells can employ to actively escape detection by the immune system by affecting the generation of antigen presenting cells.

Lung cancer, caring for the caregivers. A qualitative study of providing pro-active social support targeted to the carers of patients with lung cancer

INTRODUCTION

Carers of patients with lung cancer often have a short time to access the support they require. The Macmillan Carers Project (MCP) was set up to provide non-clinical social support targeted in the community to the carers of patients with lung cancer and this study describes its evaluation.

METHODS

Prospective case study using interviews with the carers, project workers and health and social care professionals to obtain qualitative data for thematic analysis. 81 patients' carers received support from the MCP; 20 carers, 2 MCP workers and their manager and 10 other professionals (chest consultant physician, lung cancer clinical nurse specialist, GP, four Macmillan nurses, hospice social worker and two community social workers) were interviewed.

RESULTS

Patients were predominantly male (62%), mean age 71 years and carers were predominantly female (70%) mean age 63 years. Carers identified the MCP as providing emotional support, more time, practical help, financial advice, information and back-up for a myriad of problems. Although there was some overlap with other services, the MCP was valued by carers and professionals as filling a gap in social care.

CONCLUSIONS

The unique aspect of this study was support targeted to the carers of a single cancer site (lung) rather than generic cancer support. As lung cancer may progress rapidly, patients and their carers have a short time to gather new information, access services and adjust to their new circumstances and roles. By focusing on the needs of carers from the time of lung cancer diagnosis, we have shown that the MCP was a valued additional service, well received by carers, patients and professionals.

Surface effects on the orbital order in the single-layered manganite La0.5Sr1.5MnO4

The question of how bulk electronic order is terminated at a surface is an intriguing one, and one with possible practical implications--for example in nanoscaled systems that may be characterized by their surface behaviour. One example of such order is orbital order, and in principle it should be possible to probe the termination of this order with surface X-ray scattering. Here, we report the first observation of the scattering arising from the termination of bulk orbital order at the surface of a crystal--so-called 'orbital truncation rods'. The measurements, carried out on a cleaved perovskite, La(0.5)Sr(1.5)MnO(4), reveal that whereas the crystallographic surface is atomically smooth, the orbital 'surface', which is observed through the atomic displacements caused by the orbital order, is much rougher, with a typical scale of the surface roughness of approximately 7 degrees A. Interestingly, the temperature dependence of this scattering shows evidence of a surface-induced second-order transition.

Vitamin D therapy in clinical practice. One dose does not fit all

INTRODUCTION

Vitamin D is given to most patients with osteoporosis particularly the elderly and those on bisphosphonates. The most widely advocated dose is 800 IU with or without calcium. Whether or not this enables all or most patients to become vitamin D replete in clinical practice is not established.

AIMS

This study investigated a large cohort of patients with osteoporosis attending a metabolic bone clinic to identify if those on vitamin D supplements were adequately treated and if those commenced on treatment developed normal vitamin D levels.

METHODS

Twenty-five hydroxy vitamin D measurements from new all patients attending a district general hospital metabolic bone clinic as part of their preclinic investigations was examined. It was noted as to whether or not they were taking calcium and or vitamin D supplements. Patients not on supplements but with a low baseline vitamin D were treated with supplements and then had a repeat measurement after at least 3 months to assess whether or not they were replete.

RESULTS

From the database of 1028 patients, 100 had preclinic and follow-up vitamin D levels. They were of average age 61 years (SD 12) with a mean baseline vitamin D of 26 nmol/l. The mean posttreatment level was 58 nmol/l (SD 25). Posttreatment vitamin D levels were < 60 nmol/l in 55%, < 50 nmol/l in 36%, < 40 nmol/l in 24% and < 30 nmol/l in 13% and < 20 nmol/l in 4%. In 41 patients on Calcichew D3 Forte two tablets per day pretreatment vitamin D was 24 nmol/l (SD 16) and posttreatment 62 nmol/l (SD 28). Of this subgroup posttreatment 41% were < 60 nmol/l, 27% < 50 nmol/l, 22% < 40 nmol/l and 10% < 30 nmol/l. Two hundred and ten patients on vitamin D treatment preclinic had a mean vitamin D level of 64 nmol/l (SD 28). One hundred and twenty-four patients already on two tablets of Calcichew D3 Forte per day had a mean of 68 nmol/l (SD 28) of whom 38% were < 60 nmol/l, 24% < 50 nmol/l, 16% < 40 nmol/l, 6% < 30 nmol/l and 3% < 20 nmol/l.

CONCLUSION

Vitamin D therapy with conventional treatment improves serum levels of 25 hydroxy vitamin D but still leaves some patients with significant insufficiency and therefore the same dose of vitamin D is not appropriate for all.

Training of staff for the delivery of PET/CT services in the UK

Evidence for the cost effectiveness of PET/CT imaging is now driving the widespread introduction of PET/CT services throughout the UK. The provision of PET/CT facilities will require a workforce of medical, scientific, technical and engineering staff who are adequately trained and fit for purpose. Suitably trained staff in this speciality are scarce. The development and accreditation of training courses and other educational resources for training programmes in all disciplines will therefore be required at a national and regional level. The implementation of PET/CT training can be achieved more cost-effectively by developing multi-professional learning resources whenever possible. It is intended that the recommendations would be implemented by close co-operation of both public and private healthcare providers together with educational establishments.

Influence of quantum size effects on island coarsening

Surface x-ray scattering and scanning-tunneling microscopy experiments reveal novel coarsening behavior of Pb nanocrystals grown on Si(111)-(7 x 7). It is found that quantum size effects lead to the breakdown of the classical Gibbs-Thomson analysis. This is manifested by the lack of scaling of the island densities. In addition, island decay times tau are orders of magnitude faster than expected from the classical analysis and have an unusual dependence on the growth flux F (i.e., tau is approximately 1/F). As a result, a highly monodispersed 7-layer island height distribution is found after coarsening if the islands are grown at high rather than low flux rates. These results have important implications, especially at low temperatures, for the controlled growth and self-organization of nanostructures.

Single photon emission computed tomography scanning in the diagnosis of knee pathology

PURPOSE

To evaluate the role of single photon emission computed tomography (SPECT) bone scan for the diagnosis of knee lesions in routine clinical practice.

METHODS

40 consecutive case records were examined in patients who underwent a SPECT scan prior to knee arthroscopy in routine clinical practice. The accuracy of clinical examination, SPECT scan results, and arthroscopic findings (as the gold standard) in diagnosing knee lesions were compared.

RESULTS

The sensitivity of SPECT scans in detecting medial meniscal, lateral meniscal, anterior cruciate ligament lesions, osteochondral defects, and chondromalacia patellae was 77%, 14%, 33%, 50%, and 74%, respectively. The specificities for the same structural lesions were high at 89%, 94%, 97%, 94%, and 69%, respectively.

CONCLUSION

SPECT bone scan appears to be useful in the diagnosis of knee pathology in routine practice and in selecting patients for arthroscopy, especially most useful for the diagnosis of medial meniscal tears.

Bupropion as an aid to smoking cessation: a review of real-life effectiveness

Clinical trials rigorously demonstrate the efficacy of new products and justify their marketing. However, it is only after use in real-life settings that the clinical value (effectiveness) of a new treatment is fully known. The purpose of this review was to summarise the effectiveness data for bupropion SR as an aid to smoking cessation. Available reports of effectiveness data for bupropion SR were obtained from the literature, presentations at smoking cessation meetings and from the manufacturer. Twelve sources of effectiveness data were found and included clinical practice trials, observational studies/surveys, motivational support programme results and employer-based cessation programme results. The 6-month point prevalence smoking cessation rates ranged from 25 to 49%. There is a growing body of evidence supporting the effectiveness of bupropion SR as an aid to smoking cessation. Real-life quit rates for bupropion SR are similar to those seen in the original clinical trial programme.

Leukoscan for orthopaedic imaging in clinical practice

Studies have suggested that orthopaedic infection can be successfully imaged with 99mTc antigranulocyte antibody Fab' fragments (Leukoscan). This study examined the value of the technique in a UK clinical practice. A retrospective review of the first 55 patients imaged was performed. Patients had three-phase bone scintigraphy followed by Leukoscan imaging. The latter was performed using planar views 2 h and 6 h post-injection of 750 MBq 99mTc Leukoscan. In 47 patients there was adequate clinical information available to compare to the scintigraphy result. There were 13 positive infections. The Leukoscan findings produced 11 true positives, 26 true negatives, eight false positives and two false negatives with resulting sensitivity 85%, specificity 77%, positive predictive accuracy 58%, and negative predictive accuracy 93%. This study suggests that Leukoscan can be used successfully to image orthopaedic infection, with its greatest strength being a high negative predictive accuracy. Positive studies may require further correlative imaging.

Depot medroxyprogesterone and bone mineral density

OBJECTIVE

To investigate depot medroxyprogesterone (DMPA)-associated bone loss in a general practice setting.

DESIGN

Forty-eight patients from a single practice who had used DMPA for contraception for more than 2 years. All patients had a serum oestradiol and if the serum level was <52 pmol/l or >52 pmol/l with menopausal symptoms, bone mineral densitometry (BMD) measurements were made at the lumbar spine (LS) and femoral neck (FN) using dual-energy x-ray absorptiometry (DEXA). Thirty-two patients had bone densitometry, of whom 27 had a serum oestradiol <52 pmol/l and five >52 pmol/l associated with menopausal symptoms. Of the remaining 16 patients, nine patients had a serum oestradiol <52 pmol/l but did not have a BMD as they moved away (five women) or switched to another contraceptive (four women).

RESULTS

BMD results showed a significantly reduced bone mass at both sites with mean Z score LS -0.84 (95% CI -1.17 to -0.52) and FN -0.32 (95% CI -0.62 to -0.02). Eighteen women (56% of 32 women) had either osteopenia (15 cases) (T score < -1.0) or osteoporosis (three cases) (T score < -2.5) at the LS. There were trends to an association of a family history of height loss or tobacco smoking (current or past) for LS and FN Z scores that did not quite achieve significance. There was also a trend to lower body weight in those with a possible family history of osteoporosis or who were smokers and an inverse correlation of weight with BMD at the FN (p < 0.05) and a non-significant inverse correlation at the LS.

CONCLUSION

The present results demonstrate that a low bone mass should be considered in patients with prolonged DMPA usage especially if they have risk factors for osteoporosis.

Bone densitometry in the management of Colles' fractures: which site to measure?

This study assessed whether patients with Colles' fractures can be evaluated by measurement of peripheral bone mineral density (BMD) instead of the more established axial BMD technique. 205 consecutive patients who had sustained a recent Colles' fracture were invited to attend for BMD measurement at the lumbar spine, hip and forearm by dual energy X-ray absorptiometry (DXA) using a Hologic QDR4500C instrument. Hologic normal reference ranges were used for spine and ultradistal radius BMD, and the NHANES 111 reference range was used for the femoral neck. 158 patients attended, of whom only 61 had a T-score below -2.5 at one of the three measured sites (84 T<-2.0, 112 T<-1.5). 36 patients had bilateral forearm fractures and did not undergo a forearm measurement. After excluding these patients and using a T-score of -2.5 as a diagnostic threshold, a spine and hip measurement strategy missed 26% of osteoporotic patients and a forearm only strategy missed 33%. If a forearm strategy is adopted, with axial BMD performed only on those patients with an ultradistal radial T-score of <-1.5 and >-2.5, 27 further scans would be required and only four patients with T<-2.5 at the spine or hip would be undetected. Where axial BMD measurement is performed, this should be accompanied by forearm BMD measurement in some patients with Colles' fractures. A peripheral bone mineral densitometry strategy using forearm BMD alone will miss many individuals with osteoporosis. Therefore where forearm, and probably any peripheral scanning method, only is used for patient assessment there should be close liaison with an axial BMD centre with agreed joint protocols, as some patients should be advised to have an additional axial BMD measurement following their peripheral BMD measurement.

Production of colony-stimulating factors and IL-5 by organs from three types of mice with inflammatory disease due to loss of the suppressor of cytokine signaling-1

Organs from neonatal mice dying from IFN-gamma-dependent inflammatory disease initiated by loss of the gene encoding the suppressor of cytokine signaling-1 (SOCS-1) had a normal capacity to produce G-CSF in vitro but a reduced capacity to produce GM-CSF, most evident with the lung, and some reduction in the production of M-CSF by muscle tissue. In contrast, organs from mice lacking the genes for both SOCS-1 and IFN-gamma had a normal capacity to produce CSFs. Organs from young adult mice dying with polymyositis and myocarditis that lacked SOCS-1 but were heterozygous for IFN-gamma had a normal capacity to produce GM-CSF and M-CSF, but muscle tissue produced significantly increased amounts of G-CSF and IL-5 with IL-5 production also being elevated for the salivary gland, thymus, and heart. Loss of the IFN-gamma gene alone had no impact on organ production of these cytokines in vitro. In none of the inflammatory disease models was IL-3 production detected. The SOCS-1 protein appears to have no direct influence on the cellular production of these cytokines and the abnormalities observed either depend on the coaction of IFN-gamma, or more likely, are linked with the invasion and destruction of tissue by T lymphocytes, macrophages, eosinophils, and neutrophils. The ability of local organs to produce these proinflammatory cytokines could contribute to the development and progression of these inflammatory lesions.

The multi-organ origin of interleukin-5 in the mouse

Murine Ba/F3 cells were transfected with cDNA for the alpha-chain of the murine interleukin-5 (IL-5) receptor and cloned lines of these cells were able to proliferate in response to as little as 2.5 pg/ml of IL-5. The bioassay was demonstrated to be specific for IL-5 and was able to measure IL-5 produced in culture by organs from adult C57BL/6 and BALB/c mice. The highest levels of IL-5 were produced by lung tissue but thymus and bladder consistently produced IL-5 and more variable production was observed by the heart, spleen, muscle, bone shaft, uterus and testes. Bone marrow cells produced no detectable IL-5. Observed levels of production of IL-5 were similar when using organs from mice lacking high-affinity receptors for IL-5 and from nu/nu, RAG-1-/- and NOD/SCID mice lacking T lymphocytes. In inflammatory peritoneal exudates induced by the injection of casein plus bacteria, levels of induced IL-5 were higher if the mice lacked high-affinity receptors for IL-5. The data indicate that T lymphocytes are not the dominant cellular source of IL-5 in organ-conditioned media and that local IL-5 production can occur with a wide range of normal murine organs.

Timing of cyclical etidronate

OBJECTIVE

The importance of the timing of the etidronate component of cyclical etidronate was investigated in a study examining changes in lumbar spine BMD.

METHODS

Seventy patients who had been taking cyclical etidronate for at least 1 year and who had baseline BMD studies and a further scan 1 year later were mailed a questionnaire asking about the time of day they took the etidronate component. Replies were received from 52 patients who were of average age 67.5 years (SD 6) and had been on therapy for an average of 2.7 years. Patients were divided into 3 groups according to when they took etidronate: Group A--Fasting on waking, Group B--During the day, and Group C--Before retiring to bed or during the night. All patients except 2 claimed to avoid food and drink apart from water for 2 hours either side of taking etidronate.

RESULTS

The mean increases in BMD over 1 year were 3.1% group A, -0.14% Group B, and 5.4% Group C and the total change over duration of use were 5.6%, 1.2% and 7.5%, respectively. There were significant differences (P < 0.05) between group B and the other 2 groups at 1 year and over 2.7 years.

CONCLUSION

We conclude that the 2-hour rule may be insufficient for taking etidronate during the day and that the etidronate component of cyclical etidronate is best taken in the early morning or late evening/at night.

The long-term performance of DXA bone densitometers

Long-term performance of a bone mass measuring device is an important criterion when considering the purchase of such equipment and has been regarded as an important feature of dual X-ray absorptiometry (DXA). The performance of a 6-year-old bone densitometer, the Lunar DPX alpha, which has undertaken 1500 scans annually over this period, was assessed. The short-term coefficient of variation calculated from 15 measurements with repositioning on a single day, using the Lunar aluminium phantom, was 0.242%. Long-term precision, also calculated by the coefficient of variation, was 0.548%. The manufacturer's quality control (QC) procedure was performed daily and allowed the machine to be used except on 15 occasions when bone density measurements could be acquired after rebooting. However, a 2.2% shift in phantom values occurred in July 1996 owing to a photomultiplier tube failure, but this did not produce a failure in the Lunar QC. The optical disc drive was replaced in July 1997. The machine failed to back up on six occasions over the last 2 years owing to software corruption and the acquired femur data were not saved on seven occasions owing to overloading of the memory buffer. In conclusion, expected hardware failure and minor software problems have occurred. We were concerned that the manufacturer's QC failed to detect a 2% shift in the phantom bone mineral density values and recommend regular measurements of the Lunar aluminum phantom in addition to the daily QC measurement of the tissue-equivalent block. We were nevertheless impressed by the long-term stability and reproducibility of the Lunar DPX alpha.

The VT+ and VT- isoforms of the fibroblast growth factor receptor type 1 are differentially expressed in the presumptive mesoderm of Xenopus embryos and differ in their ability to mediate mesoderm formation

Previously, we cloned a variant form of the type 1 fibroblast growth factor receptor (FGFR1), FGFR-VT-, from Xenopus embryos (Gillespie, L. L., Chen, G., and Paterno, G. D. (1995) J. Biol. Chem. 270, 22758-22763). This isoform differed from the reported FGFR1 sequence (FGFR-VT+) by a 2-amino acid deletion, Val(423)-Thr(424), in the juxtamembrane region. This deletion arises from the use of an alternate 5' splice donor site, and the activity of the VT+ and VT- forms of the FGFR1 was regulated by phosphorylation at this site. We have now investigated the expression pattern and function of these two isoforms in mesoderm formation in Xenopus embryos. Cells within the marginal zone are induced to form mesoderm during blastula stages. RNase protection analysis of blastula stage embryos revealed that the VT+ isoform was expressed throughout the embryo but that the VT- isoform was expressed almost exclusively in the marginal zone. The ratio of VT+:VT- transcripts in the marginal zone indicated that the VT+ form was predominant throughout blastula stages except for a brief interval, coinciding with the start of zygotic transcription, when a dramatic increase in VT- expression levels was detected. This increase could be mimicked in part by treatment of animal cap explants with FGF-2. Overexpression of the VT+ isoform in Xenopus embryos resulted in development of tadpoles with severe reductions in trunk and tail structures, while embryos overexpressing the VT- isoform developed normally. A standard mesoderm induction assay revealed that a 10-fold higher concentration of FGF-2 was required to reach 50% induction in VT+-overexpressing animal cap explants compared with those overexpressing the VT- isoform. Furthermore, little or no expression of the panmesodermal marker Brachyury (Xbra) was detected in VT+-overexpressing embryos, while VT--overexpressing embryos showed normal staining. This demonstrates that VT+ overexpression had a negative effect on mesoderm formation in vivo. These data are consistent with a model in which mesoderm formation in vivo is regulated, at least in part, by the relative expression levels of the VT+ and VT- isoforms.

Intermittent oral disodium pamidronate in established osteoporosis: a 2 year double-masked placebo-controlled study of efficacy and safety

The effect of oral pamidronate on bone mineral density and its adverse effect profile was investigated by a double-masked placebo-controlled study of 122 patients aged 55-75 years with established vertebral osteoporosis. Patients on active therapy received disodium pamidronate 300 mg/day (group A) for 4 weeks every 16 weeks, 150 mg/day (group B) for 4 weeks every 8 weeks or placebo (group C). All patients additionally received 500 mg of calcium and 400 IU vitamin D daily. Dual-energy X-ray absorptiometry measurements of the spine, hip, forearm and total body were performed at baseline and 6-monthly for 2 years using a Hologic QDR 1000 device at two sites. Serum osteocalcin and urinary deoxypyridinoline were measured at the above visits and at 3 months. The percentage change (SEM) in spine bone mineral density (BMD) at 2 years based on intention-to-treat analysis was 4.64 (1.01) in group A, 6.10 (0.87) in group B and 1.13 (1.32) in group C. Analysis of variance showed significant increases in group A and B compared with placebo (p < 0.01). There were also significant rises in femoral neck BMD for group A (p = 0.005), trochanter BMD for groups A and B (p < 0.01) and total-body BMD for groups A and B (p < 0.001). There was a significant reduction in serum osteocalcin and urinary deoxypyridinoline for groups A and B (p < 0.01). There was an excess of gastrointestinal side-effects in the treated groups, particularly group A. We conclude that intermittent pamidronate therapy can prevent bone loss at both the lumbar spine and femoral neck in patients with established vertebral osteoporosis, although due to gastrointestinal side-effects the 300 mg dose in particular does not appear suitable for clinical usage.

Identification and cloning of a connective tissue growth factor-like cDNA from human osteoblasts encoding a novel regulator of osteoblast functions

We have identified and cloned a novel connective tissue growth factor-like (CTGF-L) cDNA from primary human osteoblast cells encoding a 250-amino acid single chain polypeptide. Murine CTGF-L cDNA, encoding a polypeptide of 251 amino acids, was obtained from a murine lung cDNA library. CTGF-L protein bears significant identity ( approximately 60%) to the CCN (CTGF, Cef10/Cyr61, Nov) family of proteins. CTGF-L is composed of three distinct domains, an insulin-like growth factor binding domain, a von Willebrand Factor type C motif, and a thrombospondin type I repeat. However, unlike CTGF, CTGF-L lacks the C-terminal domain implicated in dimerization and heparin binding. CTGF-L mRNA ( approximately 1.3 kilobases) is expressed in primary human osteoblasts, fibroblasts, ovary, testes, and heart, and a approximately 26-kDa protein is secreted from primary human osteoblasts and fibroblasts. In situ hybridization indicates high expression in osteoblasts forming bone, discrete alkaline phosphatase positive bone marrow cells, and chondrocytes. Specific binding of 125I-labeled insulin-like growth factors to CTGF-L was demonstrated by ligand Western blotting and cross-linking experiments. Recombinant human CTGF-L promotes the adhesion of osteoblast cells and inhibits the binding of fibrinogen to integrin receptors. In addition, recombinant human CTGF-L inhibits osteocalcin production in rat osteoblast-like Ros 17/2.8 cells. Taken together, these results suggest that CTGF-L may play an important role in modulating bone turnover.

A prospective comparison of clinical examination, MRI, bone SPECT, and arthroscopy to detect meniscal tears

Recent studies have shown that SPECT bone scintigraphy is valuable to detect meniscal tears of the knee. This has not been formally assessed in a prospective study, and no substantive study has compared bone SPECT with other noninvasive diagnostic methods. One hundred consecutive patients referred to an orthopedic surgeon with undiagnosed knee pain were assessed by clinical examination, MRI, SPECT bone scintigraphy, and arthroscopy. The MRI and SPECT bone scan findings were reported blinded to other information. Using arthroscopy as a gold standard, both MRI and SPECT showed high diagnostic ability to detect meniscal tears, with respective sensitivity rate, specificity rates, and positive and negative predictive accuracies of 80%, 71%, 84%, and 71% for MRI and 84%, 80%, 88%, and 76% for SPECT. Some meniscal tears were detected by MRI alone (n = 5) or SPECT alone (n = 8). SPECT bone scintigraphy is a suitable alternative to MRI to detect meniscal tears. The comparable diagnostic ability of SPECT bone scintigraphy implies that it can be used successfully when MRI is unavailable or unsuitable.

Identification of phosphorylated proteins associated with the fibroblast growth factor receptor type I during early Xenopus development

Signaling through the FGF receptor (FGFR) is required for mesoderm induction in Xenopus. Some of the downstream signaling molecules implicated in this developmental process include Ras, Raf and MAP kinase. In a previous report, we demonstrated that PLC gamma 1, Grb-2, SOS and Nck were associated with activated FGFR1s in a signaling complex in Xenopus blastulae. In addition, several unidentified phosphotyrosylproteins were present in the FGFR1 complex. Here we identify three of these proteins as Ras-GAP, the p85 of P13'K and SHP2, while demonstrating that c-Src and She were not associated with the FGFR1. Furthermore, we show that three additional phosphotyrosylproteins from the FGFR1 complex specifically bound to the adaptor molecule Nck.

The impact of influenza and influenza-like illness on productivity and healthcare resource utilization in a working population

Four hundred and eleven subjects who either reported to Occupational Health at onset of influenza or influenza-like illness (I/ILI) symptoms or on return to work completed questionnaires on entry to the study and after 28 days. On average they were incapacitated or confined to bed for 2.4 days, missing 2.8 days from work per episode of illness. On return to work, they reported reduced effectiveness and inability to resume normal activity until a mean 3.5 days after the onset of symptoms. Each participant reported a mean of 6.5 I/ILI symptoms. There was a positive correlation between the number of symptoms and bed days (r = 0.24) and missed work days (r = 0.18). There was a positive correlation between the number of healthcare contact and the number of reported symptoms (r = 0.23). A relatively high level of contact with general practitioners and pharmacists was observed and there was substantial use of both prescription and over-the-counter medication. In conclusion, the impact of I/ILI on productivity in a working population and the resultant cost to employers and employees may be considerable.

Orthopaedic manifestations of systemic disease

Nuclear medicine studies can be initiated to detect or evaluate systemic diseases such as inflammatory arthritis or Paget's disease. This is usually because of the strengths of nuclear medicine studies such as high sensitivity, an ability to easily image the whole body, and typical diagnostic patterns of abnormalities. In other instances, a systemic disease may be incidentally suggested by a scintigram such as osteoporosis or hyperparathyroidism; or a focal abnormality such as a vascular necrosis may be detected that should indicate a systemic condition should be sought. Although most nuclear medicine studies have high sensitivity for disease, specificity is often less and, for a particular scan abnormality, several conditions may have to be considered. Familiarity with the varying patterns of abnormality associated with different disease is therefore vital to correct assessment.

Spinal bone SPECT in chronic symptomatic ankylosing spondylitis

Bone SPECT has acquired a useful role in the evaluation of acute and chronic back pain. Spinal pain is also a characteristic of chronic ankylosing spondylitis. The authors investigated the bone SPECT appearances of the lower thoracic and lumbar spine in 28 symptomatic patients with established ankylosing spondylitis, half of whom had complete ankylosis of the sacroiliac and one third complete ankylosis of the intervertebral joints. SPECT abnormalities were identified in 89%. Facetal joint uptake was found in 16 (57%) patients, of whom 7 (25%) had three or more, and 2 (7%) had seven or more active sites. The only other common site of uptake was in the vertebral body, in which 15 patients (54%) showed increased uptake with three or more sites found in 3 (11%) patients. The authors conclude that SPECT abnormalities in the lower thoracic and lumbar spine are frequently found in patients with ankylosing spondylitis, with the most common sites of abnormality in the facetal joints or vertebral body. Multiple sites of uptake in the facetal joints maybe striking in such patients and has not been previously described.

cDNA cloning of a novel, developmentally regulated immediate early gene activated by fibroblast growth factor and encoding a nuclear protein

We have utilized the polymerase chain reaction (PCR)-based differential display methodology (Liang, P., and Pardee, A. B. (1992) Science 257, 967-969) to identify a novel transcript whose expression levels increased in Xenopus embryo explants during mesoderm induction by fibroblast growth factor. The PCR product was used to clone a 2.3-kilobase pair cDNA representing this transcript, which we have named er1 (early response 1). The er1 cDNA contained a single open reading frame predicted to encode a protein of 493 amino acid residues. A data base homology search revealed that the predicted ER1 amino acid sequence contains three regions of similarity to the rat and human proteins encoded by the metastasis-associated gene, mta1, and two regions of similarity to the Caenorhabditis elegans sequence that is similar to mta1. The fibroblast growth factor-induced increase in er1 steady-state levels was not dependent on de novo protein synthesis, demonstrating that er1 is an immediate-early gene. Northern blot analysis revealed a single 2.8-kilobase pair mRNA that was observed predominantly during the initial cleavage and blastula stages of Xenopus development, with little or no detectable mRNA during subsequent development. Quantitative PCR analysis of early developmental stages showed that er1 peaked during late blastula. Computer-assisted analysis of the predicted ER1 amino acid sequence revealed two putative nuclear localization signals, four highly acidic regions clustered at the N terminus and a proline-rich region located near the C terminus. Subcellular localization by immunocytochemistry revealed that the ER1 protein was targeted exclusively to the nucleus. Transactivation assays using various regions of ER1 fused to the DNA binding domain of GAL4 demonstrated that the N-terminal acidic region is a potent transactivator. These data suggest that ER1 may function as a transcription factor.

The prevention of early postmenopausal bone loss by cyclical etidronate therapy: a 2-year, double-blind, placebo-controlled study

PURPOSE

To determine whether intermittent cyclical etidronate therapy can prevent early postmenopausal bone loss.

PATIENTS AND METHOD

This was a 2-year outpatient, randomized, double-blind, placebo-controlled clinical trial. The subjects were 152 women within 1 to 10 years of the onset of menopause and bone mineral density (BMD) between 0 and -2 SD of normal values for a 50 year old woman. The women were stratified according to years since the menopause (1 to 3 years: n = 43; 4 to 6 years: n = 53; 7 to 10 years: n = 56). Measurements of lumbar spine, proximal femur and total body BMD were performed at baseline, 12 and 24 months by dual x-ray absorptiometry. Biochemical markers of bone resorption and bone formation were measured on the same visits.

RESULTS

One hundred thirty-five subjects completed the study. Mean percentage change in lumbar spine BMD (and SEM) at 2 years was +2.14 (0.47)% in the etidronate group and -1.72 (0.41)% in the placebo group. Results for lumbar spine BMD in the treated and control groups stratified according to years since the menopause were: 1 to 3 years: +1.73 (0.84)% and -3.30 (0.70)%; 4 to 6 years: +1.37 (0.88)% and -1.80 (0.61)%; 7 to 10 years: +3.42 (0.61)% and -0.38 (0.70)%. The effect of both treatment group and menopausal stratum were highly statistically significant for lumbar spine and total body BMD. Treatment group, but not stratum, was significant for BMD in the proximal femur. Markers of bone resorption and bone formation were significantly decreased by etidronate therapy.

CONCLUSIONS

Cyclical etidronate prevents bone loss in the total skeleton and at the clinically relevant sites (spine and proximal femur) even in the early postmenopausal years. Hence, it appears to be an effective and safe nonhormonal therapy in postmenopausal women with normal or low BMD.

Bone scintigraphy in metabolic bone disease

The bone scan has well-recognized appearances in metabolic bone diseases, with its main clinical value found in focal conditions or the focal complications of disease. In clinical practice, the bone scan is most widely used to detect fractures in osteoporosis and pseudofractures in osteomalacia and to evaluate Paget's disease.

Overview of role of BMD measurements in managing osteoporosis

The advent of effective treatments and the opportunity to precisely and accurately measure bone mass have probably been the greatest advances in the field of osteoporosis in the last decade. Bone densitometry has become the most widespread noninvasive method for the detection of osteoporosis and to provide advice on risk of future fractures. It has achieved an unquestioned role in clinical decision making for the management of osteoporotic patients.

Distinction between pleural mesothelioma and pulmonary adenocarcinoma using MOC31 in an asbestos sprayer

Asbestos exposure may cause asbestosis, pleural plaques and benign pleural disease, and may pre-dispose to malignant mesothelioma and other neoplasms. The occurrence to two primary tumours in the same patient is rare, and the appearance of a pleural mesothelioma and another lung tumour is exceptional. The present case report describes a patient who, by standard immunohistochemistry, was thought to have mesothelioma at pleuro-pneumonectomy, and adenocarcinoma in the other lung at post-mortem 5 months later. Subsequent investigation using the MOC31 antibody demonstrated a single pathology of adenocarcinoma of the lung. The additional use of this antibody has important histopathological and legal implications.

Measurement of the secretion of technetium-99m hexamethylpropylene amine oxime into breast milk

There are no published data for the activity of technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) found in breast milk. The amount of radioactivity in breast milk following the administration of 500 MBq 99mTc-HMPAO for a brain perfusion study has been measured. The effective dose to the infant was calculated to be 0.26 mSv, so necessitating no interruption of breast feeding. Unbound 99mTc is readily secreted into breast milk and the effective dose will remain less than 1 mSv if the 99mTc-HMPAO labelling efficiency is >/=99% for the worse reported case, and could remain <1 mSv for the mean reported case for 99mTc-HMPAO labelling efficiencies down to 94%.

The value of SPECT scans in identifying back pain likely to benefit from facet joint injection

Lumbar facet disease is sometimes implicated in low back pain. Identification is difficult and this may account for a variable response. Single photon emission computerized tomography (SPECT) is a scanning technique which enables localization of facet joint pathology. We determined whether recognition of facet disease by this method improved the response to corticosteroid injection treatment. Fifty-eight patients with low back pain and displaying accepted clinical criteria for facet joint disease were evaluated by SPECT. Twenty-two had facetal uptake of isotope. These and the tender facet joints of 36 scan-negative patients were injected with 40 mg methylprednisolone and 1 ml 1% lignocaine under X-ray control. Pain was assessed by a blind observer using the McGill questionnaire (MGQ), Present Pain Intensity score (PPI) and a Visual Analogue Scale (VAS). VAS, PPI and MGQ were reduced in the scan-positive patients at 1 month (P = 0.05, P = 0.0005, P = 0.005) and MGQ at 3 months (P = 0.01), whilst scan-negative patients were unchanged. The percentage of scan-positive patients who reported improvement was 95% at 1 month and 79% at 3 months, significantly greater than the control group (P = 0.0005, P = 0.01). Within 6 months, pain improvement in the SPECT-positive group was no longer statistically significant. Tenderness did not correlate with increased uptake on SPECT scan. Osteoarthritis of the facets was more common in the SPECT-positive patients (P < 0.001), but did not correspond with sites of increased uptake on SPECT scan. These results suggest that SPECT can enhance the identification of back pain sufferers likely to obtain short-term benefit from facet joint injection.

Isotope imaging

Patients with a wide variety of rheumatological conditions can be usefully investigated by nuclear medicine techniques and particularly by bone scintigraphy. This aspect of nuclear medicine work is increasing and the trend can be expected to continue. The principal conditions that can be imaged are sports medicine injuries, osteomyelitis, avascular necrosis, reflex sympathetic dystrophy syndrome, enthesopathies and bio-mechanical stress lesions, inflammatory arthropathies, metabolic bone disease and miscellaneous bone conditions such as costo-chondritis. Single photon emission tomography (SPECT) has provided new indications for bone scintigraphy such as the evaluation of spondylolysis and facet syndrome in the spine and of meniscal tears and ligamental lesions.

SPECT bone scintigraphy of anterior cruciate ligament injury

This retrospective analysis of SPECT bone scans of the knee was undertaken to define typical bone scan appearances and to assess the sensitivity of this method. We looked at 14 patients, mostly with chronic knee pain, who had anterior cruciate ligament (ACL) tears detected by MRI.

METHOD

Of the 14 patients, 10 were referred for bone scanning following injury and 4 complained of chronic knee pain without injury. Planar scans were performed 4 hr after the injection of 750 MBq of 99mTc-MDP. Tomographic images were obtained by a 64 x 20-sec acquisition over 360 degrees using a high-resolution collimator. MRI imaging included axial and sagittal, T1 weighted and coronal fast field echo (FFE) sequences. Ten patients also had arthroscopy performed.

RESULTS

MRI scans showed 6 lone ACL tears and 8 combined with other ligamentous injuries. SPECT scans showed abnormalities in 10 patients in the region of ACL insertions but only 4 planar studies were abnormal. SPECT identified focal activity at the upper (n = 8) or lower (n = 2) insertion of the ACL. Six of 10 arthroscopies confirmed ACL tears, 2 complete and 4 partial. Overall, agreement was found with MRI in 10 of 14 cases and in 8 of 10 with arthroscopy. Abnormalities were identified in 10 of 11 regions of other ligament or bone injury identified by MRI.

CONCLUSION

SPECT bone scanning of the knee is superior to planar imaging in detecting ACL injury and is a sensitive technique. Focal activity may be seen at either end of ACL attachment but more commonly at the upper femoral insertion. Knee SPECT may be a valuable examination in suspected ACL injury, particularly if MRI is not available, is equivocal or where clinical signs are absent.

Co-existing conjunctival non-Hodgkin's lymphoma and pulmonary sarcoidosis

A 55 year old woman with a conjunctival non-Hodgkin's lymphoma was found to have pulmonary nodules on a thoracic computed tomographic scan which were initially thought to be lymphomatous deposits. A subsequent biopsy specimen demonstrated granulomas consistent with sarcoidosis. The relationship between sarcoidosis and malignancy, in particular lymphoma, is discussed.