Turf Toe Injury: A Pictorial Review and a Didactic Case Report

Hyperextension of the first metatarsophalangeal joint can lead to a turf toe injury of the plantar plate complex, resulting in significant morbidity for athletes. This article reviews the anatomy, pathophysiology, classification, and imaging findings of turf toe injuries. In turf toe trauma, many different structures can be injured, with the sesamoid-phalangeal ligaments the most common. Diagnosis, classification, and treatment options rely on clinical evaluation and specific magnetic resonance imaging findings. It is vital for radiologists to understand the anatomy, pathophysiology, and imaging findings of turf toe injuries to ensure an accurate diagnosis and appropriate management.

Combined cervicosternotomy and cervicotomy for true retrosternal goiters: a surgical cohort study

Objective

Intrathoracic goiters are a heterogeneous group characterized by limited or extensive substernal extension. Whereas the former can be treated through cervicotomy, the latter sometimes requires a cervicosternotomy. Whether cervicosternotomy leads to more morbidity remains unclear.

This study aimed to compare intra- and postoperative morbidity in patients treated by cervicotomy or cervicosternotomy for intrathoracic goiters and standard thyroidectomy.

Methods

In a prospectively gathered cohort undergoing thyroid surgery (2010–2019) intra- and postoperative morbidity of cervicotomy (N = 80) and cervicosternotomy (N = 15) for intrathoracic goiters was compared to each other and to a ‘standard’ thyroidectomy (N = 1500).

Results

An intrathoracic extension prior to surgery was found in 95 (6%) of all thyroidectomies. Eighty patients (84%) were operated by cervicotomy and 15 (16%) by cervicosternotomy. The risk of temporary recurrent laryngeal nerve palsy was much higher in the cervicosternotomy group (21%) compared to cervicotomy (4%) and standard thyroidectomy (3%). The risk of temporary hypocalcemia after cervicotomy (28%) was comparable to a standard thyroidectomy (32%) but higher after cervicosternotomy (20%). No cases of permanent hypocalcemia or laryngeal nerve palsy were observed in both groups with substernal extension. The need for surgical reintervention was significantly higher in the cervicotomy group (6%) compared to cervicosternotomy (0%) and standard thyroidectomy (3%).

Conclusion

In patients undergoing thyroid surgery for an intrathoracic goiter, cervicosternotomy was associated with more temporary laryngeal nerve palsy, but none of the interventions resulted in higher risks of permanent nerve damage, permanent hypocalcemia, or reintervention for bleeding. Reintervention was even more common after cervicotomy compared to cervicosternotomy.

Level of evidence

IV

Supplementary Information

The online version contains supplementary material available at 10.1007/s13304-021-01027-1.

Clinical impact of CT coronary angiography without exclusion of small coronary artery segments: a real-world and long-term study

OBJECTIVES

CT coronary angiography (CTCA) has become a valuable diagnostic test in the workup of patients with possible coronary artery disease (CAD). Because of inherent limitations in spatial resolution, epicardial vessels with a small diameter, in general less than 1.5-2 mm, have so far been excluded in studies assessing clinical utility of CTCA. This study sought to assess the clinical impact of CTCA taking into account pathology in small coronary arteries.

METHODS

We conducted a retrospective cohort study of all patients with possible CAD who underwent dual-source CTCA and subsequent invasive coronary angiography (ICA) between January 2010 and July 2017. Patients with an Agatston calcium score ≥1000 were reported separately. Diagnostic accuracy of CTCA on a patient, vessel and segment level was calculated. The physician's therapeutic decision was defined as conservative, medical antianginal treatment or revascularisation. Using ICA as the reference, we calculated the precision of CTCA to replicate these therapeutic recommendations.

RESULTS

In total, 1209 patients underwent both CTCA and ICA. Overall diagnostic performance of CTCA showed a sensitivity of 90% (95% CI 86% to 93%) and specificity of 40% (95% CI 36% to 45%). With regard to clinical decision making, CTCA showed good performance: 91% of patients who were treated medically or by revascularisation were correctly identified. Prevalence of disease in small vessel segments was low: 16% showed significant CAD on ICA. Prevalence of significant disease was 70% in patients with an Agatston score ≥1000: the majority underwent revascularisation.

CONCLUSIONS

From a true patient perspective, without exclusion of smaller coronary artery segments, CTCA allows safe patient management.

Forefoot Pain in the Lesser Toes: Anatomical Considerations and Magnetic Resonance Imaging Findings

Various conditions may result in forefoot pain. Magnetic resonance (MR) imaging allows accurate assessment of many of these conditions. We provide an overview of forefoot disorders divided into bones, capsule and plantar plate, musculotendinous structures, neurovascular structures, and subcutaneous tissue. We review normal anatomical features as well as MR imaging findings of common disorders.

Stener-like lesion of the lateral collateral ligament of the first metatarsophalangeal joint

Displaced ulnar collateral ligament injuries of the metacarpophalangeal joint of the thumb, also known as Stener lesions, are a well-recognized clinical entity, requiring surgical intervention because of the trapped location of the torn lateral collateral ligament superficial to the adductor aponeurosis of the thumb. We report a similar lesion located at the first metatarsophalangeal joint, to our knowledge the first ever described in the literature. In our patient, magnetic resonance imaging showed a full-thickness tear of the lateral collateral ligament of the first metatarsophalangeal joint, as well as a full-thickness tear of the extensor hood, with dislocation of the proximal part of the ruptured lateral collateral ligament to a position superficial to the extensor hood. Analogous to true Stener lesions, we are convinced these patients also need early surgical repair. Therefore, we would like to raise awareness about their existence to ensure adequate management of these lesions, in order to prevent possible long-term complications like chronic pain, instability, and joint degeneration.

Does a polyaxial-locking system confer benefits for osteosynthesis of the distal fibula: A cadaver study

BACKGROUND

In plate osteosynthesis involving the distal fibula, antiglide plating is superior to lateral plating in terms of the biomechanical properties. The goal of this study was to examine whether polyaxial-locking implants confer additional benefits in terms of biomechanical stability.

METHODS

Seven pairs of human cadaveric fibulae were subjected to osteotomy in a standardized manner to simulate an uncomplicated Weber B fracture. The generated fractures were managed with a dorsolateral antiglide plate. To this end, one fibula of the pair was subjected to non-locking plating and the other to polyaxial-locking plating. Biomechanical tests included quantification of the primary bending and torsional stiffness. In addition, the number of cycles to failure in cyclic bending loading were determined and compared. Bone mineral density was measured in all specimens.

RESULTS

Bone mineral density was comparable in both groups. Primary stability was higher in the polyaxial-locking group under torsional loading, and higher in the non-locking group under bending loading. The differences, however, were not statistically significant. All specimens except for one fixed-angle construct failed the cyclic loading test. The number of cycles to failure did not differ significantly between polyaxial-locking and non-locking fixation.

CONCLUSION

In a cadaveric Weber B fracture model, we observed no differences in biomechanical properties between polyaxial-locking and non-locking fixation using an antiglide plate. Based on the biomechanical considerations, no recommendation can be made regarding the choice of the implant. Further biomechanical and clinical studies are required.

CLINICAL RELEVANCE

Information on the behavior of polyaxial-locking plates is relevant to surgeons performing internal fixation of distal fibula fractures.

The influence of the Peroneus Longus muscle on the foot under axial loading: A CT evaluated dynamic cadaveric model study

BACKGROUND

Subtle hypermobility of the first tarsometatarsal joint can occur concomitantly with other pathologies and may be difficult to diagnose. Peroneus Longus muscle might influence stability of this joint. Collapse of the medial longitudinal arch is common in flatfoot deformity and the muscle might also play a role in correcting Meary's angle.

METHODS

A radiolucent frame was used to simulate weightbearing during CT examination. Eight pairs fresh-frozen lower legs were imaged in neutral position under non-weightbearing (75N), weightbearing (700N) and with 15kg weights hung from Peroneus Longus tendon. Measurements included first metatarsal rotation, intermetatarsal angle, first tarsometatarsal joint subluxation and Meary's angle.

FINDINGS

Weightbearing significantly increased Meary's angle and significantly decreased first tarsometatarsal joint subluxation (both P<0.01). Pulling Peroneus Longus tendon significantly increased first metatarsal rotation (P<0.01), significantly decreased the intermetatarsal angle (P<0.01) and increased non-significantly Meary's angle (P=0.52).

INTERPRETATION

A considerable effect weightbearing has on the medial longitudinal arch and first tarsometatarsal joint was observed. Pulling Peroneus Longus tendon improved first metatarsal subluxation but increased its rotation. The study calls into question the importance of this tendon in maintaining the medial longitudinal arch and raises concerns about rotational deformity of the first metatarsal following hallux valgus correction without first tarsometatarsal arthrodesis.

CLINICAL RELEVANCE

Study outcomes will provide more insight in foot pathology.

WHAT IS KNOWN ABOUT THE SUBJECT

Weightbearing affects anatomy of the foot. No reliable information is available concerning the influence of the Peroneus muscle.

WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE

This study investigates the influence of weightbearing and the impact the Peroneus muscle on the anatomy of the foot.

Surgical safety checklists : an update

Surgical safety checklists aim to improve patient safety by prompting the attention of the surgical team towards critical steps during the operation. The checklist's items are aimed to improve compliance with proven interventions, and to facilitate multidisciplinary communication and teamwork. Based on the current literature, corroborated by systematic reviews and meta-analysis, surgical safety checklists have a positive impact on communication and reduce postoperative complications including mortality. However, despite their effectiveness, the implementation of these checklists is not straightforward. Several determinants leading to behaviour were checklists are checked but not properly executed have been highlighted. As surgical safety checklists are in essence complex sociological interventions, they must be implemented accordingly. Key factors for the implementation of these checklists have been suggested in the literature, although, the most profound way of implementation remains unclear.

Spinal neurosurgery with the head-mounted "Varioscope" microscope

We present a preliminary report on the intra-operative use of a head-mounted microscope ("Varioscope" Leica HM500) in spinal neurosurgery. The Varioscope is a dynamic microscope mounted on a head-set. It weights 297 g and measures 73 x 120 x 63 mm (length x width x height). It offers an infinitely variable range of magnification from 3.6x to 7.2x. The working distance ranges from 300 to 600 mm. The field of view varies between 30-144 mm, depending on the selected enlargement factor and the working distance. In addition to the zoom function, the device offers a focus function (automatic or on demand). The optical elements for focus and zoom are located in two separate tubes which are mounted on a middle section containing the mechanical components as well as the receiver unit for the focussing elements. The lenses are adjusted by means of motor-driven push/pull cables. The autofocus works well in larger operative fields and a working distance between 30 and 60 cm. Nevertheless, when used in today's "keyhole" approaches, the autofocus is not helpful when operating in deep structures. Based on the satisfactory results achieved in our series, we can recommend the Varioscope, especially when no stationary microscope is available. The portable device can be packed in a suitcase and can travel with the consultant microsurgeon to different hospitals and distant units. The built-in video camera is ideal for patients, staff, assistant surgeons, and student education with real-time video monitoring of procedures from the microsurgeon's perspective. For daily microsurgery, we felt more comfortable with fixed, stationary operating microscopes.

Spondylolisthesis and posterior instability

We present the case of a patient with a spondylolisthesis of L5 on S1 due to spondylolysis at the level L5/S1. The vertebral slip was fixed and no anterior instability was found. Using functional magnetic resonance imaging (MRI) in an upright MRI scanner, posterior instability at the level of the spondylolytic defect of L5 was demonstrated. A structure, probably the hypertrophic ligament flava, arising from the spondylolytic defect was displaced toward the L5 nerve root, and a bilateral contact of the displaced structure with the L5 nerve root was shown in extension of the spine. To our knowledge, this is the first case described of posterior instability in patients with spondylolisthesis. The clinical implications of posterior instability are unknown; however, it is thought that this disorder is common and that it can only be diagnosed using upright MRI.

Iodixanol in multidetector-row computed tomography angiography (MDCTA): diagnostic accuracy for abdominal aorta and abdominal aortic major-branch diseases using four-, eight- and 16-detector-row CT scanners

PURPOSE

To compare iodixanol-enhanced multidetector-row computed tomography angiography (MDCTA) with digital subtraction angiography (DSA), perioperative angiography, or surgical findings in the evaluation of the abdominal aorta and its main branches.

MATERIAL AND METHODS

173 patients with known or suspected aortic aneurysms or stenosis/occlusion of the abdominal aorta or its major branches were enrolled. The iso-osmolar contrast medium iodixanol (320 mg Iota/ml) was used, and data were acquired using four-, eight-, or 16-active-detector-row scanners. Reference diagnoses were provided by surgical findings, interventional findings, or DSA. Diagnostic accuracy was estimated with reference to surgery or interventional arteriography or DSA. Image quality was assessed as excellent, good, sufficient, or insufficient, and correlations were made with attenuation values in the aortic lumen. Tolerability of iodixanol was monitored during the injection for discomfort and other adverse events, and for 72 hours after contrast injection.

RESULTS

In 132 of 136 evaluable cases, MDCTA diagnosis matched the reference diagnosis, yielding an agreement rate of 97.1% (95% CI 92.6-99.2%). The quality of most MDCTA scans (147/173) was rated as excellent. Overall mean attenuation was 305.7 HU. MDCTA appeared more accurate than DSA for identification of lesion calcification, thrombus, irregularity, and ulceration. Tolerability of iodixanol was good, and no serious adverse events were reported.

CONCLUSION

MDCTA using iodixanol is a promising, noninvasive alternative for evaluating patients with abdominal aortic disease.

Metabolic alkalosis and myoclonus

This is the first case reported of vomiting-induced metabolic alkalosis associated with myoclonus. The report describes an unusual presentation of myoclonus secondary to acid-base disturbance caused by recreational drug-induced vomiting. The severe derangement of hyponatraemia, hypokalaemia, and alkalosis appears to have been reasonably well tolerated due to the gradual onset and relatively long history. The causes, mechanism, and management of metabolic alkalosis are discussed.

High throughput screening of G-protein coupled receptors via flow cytometry

The molecular assemblies of signal transduction components, for example kinases and their target proteins or receptor-ligand complexes and intracellular signaling molecules, are critical for biological functions in cells. To better understand the interactions of these molecular assemblies and to screen for new pharmaceutics that could control and modulate these types of interactions, we have focused on developing high throughput approaches for the analysis of G-protein coupled receptors via flow cytometry. Flow cytometry offers a number of advantages including real-time collection of multicomponent data, and together with improvements in sample handling, the high throughput sampling rate is up to 100 samples per minute. For our targets, assemblies of solubilized GPCRs, a screening platform of a dextran bead has proven to be flexible, allowing different surface chemistries on the beads. The bead can be either ligand-labeled or have epitope-linked proteins attached to the bead surface, enabling several molecular assemblies to be constructed and analyzed. A major improvement with this system is that for screening ligands for GPCRs the underlying mechanism of action for these compounds can be investigated and incorporated into the definition of a 'hit'. Our current screening system is capable of simultaneously distinguishing GPCR agonists and antagonists.

Detection of epitope-tagged proteins in flow cytometry: fluorescence resonance energy transfer-based assays on beads with femtomole resolution

Epitope tagging of expressed proteins is a versatile tool for the detection and purification of the proteins. This approach has been used in protein-protein interaction studies, protein localization, and immunoprecipitation. Among the most popular tag systems is the FLAG epitope tag, which is recognized by three monoclonal antibodies M1, M2, and M5. We describe novel approaches to the detection of epitope-tagged proteins via fluorescence resonance energy transfer on beads. We have synthesized and characterized biotinylated and fluorescein-labeled FLAG peptides and examined the binding of FLAG peptides to commercial streptavidin beads using flow cytometric analysis. A requirement of assay development is the elucidation of parameters that characterize the binding interactions between component systems. We have thus compiled a set of Kd values determined from a series of equilibrium binding experiments with beads, peptides, and antibodies. We have defined conditions for binding biotinylated and fluoresceinated FLAG peptides to beads. Site occupancies of the peptides were determined to be on the order of several million sites per bead and Kd values in the 0.3-2.0 nM range. The affinity for antibody attachment to peptides was determined to be in the low nanomolar range (less than 10 nM) for measurements on beads and solution. We demonstrate the applicability of this methodology to assay development, by detecting femtomole amounts of N-terminal FLAG-bacteria alkaline phosphatase fusion protein. These characterizations form the basis of generalizable and high throughput assays for proteins with known epitopes, for research, proteomic, or clinical applications.

Adherence over 48 Weeks in An Antiretroviral Clinical Trial: Variable within Patients, Affected by Toxicities and Independently Predictive of Virological Response

Objectives

To investigate adherence to antiretroviral therapy over 48 weeks, to investigate the association between adherence and treatment-related symptoms and to investigate the impact of adherence on virological response over 48 weeks among established predictors of treatment success.

Methods

One-hundred-and-sixty HIV-1 infected protease inhibitor- and stavudine-naive patients participating in a trial of ritonavir/saquinavir versus ritonavir/saquinavir/ stavudine completed an adherence questionnaire and a symptom checklist at weeks 12, 24, 36 and 48. We calculated odds ratios between experienced symptoms and non-adherence. Regression models were used to determine predictors of HIV-1 RNA below 400 copies/ml at week 48, and of the area about the change from baseline over 48 weeks (ACFB) in serum HIV-1 RNA.

Results

The percentage of patients reporting missing medication, deviation from time schedule, and dietary prescriptions at separate time-points ranged from 12 to 15%, 32 to 35% and 17 to 22%, respectively. The percentage that changed their level of adherence during 48 weeks ranged from 29% for skipping medication to 48% for deviation from time-schedule. Experienced side-effects were associated with an increased likelihood of non-adherence. Not skipping medication was an independent predictor of both having a serum HIV-1 RNA below 400 copies/ml at week 48 and the ACFB over 48 weeks in serum HIV-1 RNA.

Conclusions

Adherence was an independent predictor of virological response over 48 weeks. The level of adherence is variable within patients over time. This suggests the need for continued adherence monitoring in all patients as part of standard medical practice.

MR arthrography of the rotator cuff and capsulolabral complex

MR arthrography of the shoulder has reached maturity in recent years. As opposed to conventional MRI of the shoulder it is less prone to artefacts frequently leading to equivocal interpretation. The spectrum of pathology in which MR arthrography has significant advantages is reviewed, with emphasis on the rotator cuff and the capsulolabral complex.

Patients with pulmonary fibrosis: cardiac function assessed with MR imaging

PURPOSE

To detect abnormalities in cardiac function by using magnetic resonance (MR) imaging in patients with mild to moderate pulmonary fibrosis and to evaluate the relationship between pulmonary function and cardiac function.

MATERIALS AND METHODS

Sixteen patients were compared with 16 sex- and age-matched healthy control subjects. Systolic function was assessed by using multisection multiphase cine MR imaging. Diastolic function was assessed with flow-sensitive MR imaging across the mitral and tricuspid valves. MR imaging results were compared with the severity of impairment in pulmonary function.

RESULTS

Biventricular systolic function and left ventricular diastolic function were normal in patients, but right ventricular diastolic function was significantly impaired versus that of control subjects, with a ratio of peak flow during early diastolic (E) filling to peak flow during atrial contraction (A) of 0.85 +/- 0.40 versus 1.28 +/- 0.50 (P =.035). Biventricular E/A ratios were strongly correlated to age in patients and control subjects. The right ventricular E/A ratio in patients corresponded with values that are normally expected in people 20 years older. Diastolic left and right ventricular functions were significantly correlated with each other. There was no relationship between pulmonary function and cardiac function.

CONCLUSION

Impairment of right ventricular diastolic function was found by using MR imaging in patients with mild to moderate pulmonary fibrosis, whereas left ventricular diastolic function and biventricular systolic function were preserved.

Baseline HIV type 1 genotypic resistance to a newly added nucleoside analog is predictive of virologic failure of the new therapy

We evaluated the predictive value of baseline HIV-1 genotypic resistance mutations for failure of a nucleoside reverse transcriptase inhibitor (NRTI) containing therapy. The change in therapy of 88 HIV-1-infected patients was analyzed retrospectively, relating the genotypic resistance profile at baseline to the evolution of viral load and CD4+ T cell counts. Genotypic resistance at baseline and at 6 months was evaluated with the LiPA HIV-1 RT, which detects mutations at codons 41, 69, 70, 74, 184, and 215. At 1 to 3 months after change in therapy, patients without preexisting resistance mutations to the new drug (group S) had a significantly better evolution in viral load (reduction of 0.37 log(10)) compared with patients with known preexisting resistance mutation(s) (group R) (increase of 0.08 log(10)). This difference was particularly striking for patients with the baseline M184V mutation and whose treatment was modified by the addition of lamivudine. After 6 months the median difference in viral load evolution between the two groups increased to 0.61 log(10): the viral load of patients of group S was still 0.18 log(10) below baseline while patients of group R had an increase of 0.43 log(10) in viral load above baseline. Changes in CD4+ T cell counts were not significantly different. The evolution in viral load in HIV-1-infected patients with and without baseline resistance mutation(s) toward a newly added NRTI is significantly different at 1-3 months and at 6 months after changing or adding one NRTI.

Posterior labrocapsular periosteal sleeve avulsion complicating locked posterior shoulder dislocation

This case presents the imaging features of a posterior shoulder dislocation complicated by a rare but surgically relevant lesion of the posterior labrum. Due to the attachment of the posterior capsule to the posterior portion of the labrum, which in itself is attached to the posterior scapular periosteum, stripping of the labrum by the posterior capsule resulted in a posterior labrocapsular periosteal sleeve avulsion.

Cost effectiveness of an allergy consultation in the management of asthma

In a large Denver HMO, a retrospective study of asthma management was reviewed. Seventy moderate to severe asthmatic patients' charts were reviewed through April 1994. All patients admitted to the study had to be followed for at least 1 year by a primary care physician before the allergy evaluation (AE) and for at least one year of followup (F/U) after the AE. All patients had at least two acute care (ER) visits and/or one hospitalization before the AE. All primary care, AE, and F/U were done by staff physicians in the Kaiser Permanente system. The findings included 1) Forty-five percent decrease (308 to 169) in the number of sick care office visits (P = 0.0001); 2) fifty-five percent decrease (266 to 118) in acute care visits (P = 0.0001); 3) sixty-seven percent decrease (34 to 11) in the number of hospitalizations after the AE (P = 0.001); 4) average hospital days before AE were four days and after AE, 2.5 days; 5) estimated cost saving of $145,500, or $2,100 per patient.

Venous pumps of the hand. Their clinical importance

Oedema remains one of the most common causes of hand stiffness. Local venous return is intimately associated with oedema formation and management. To elucidate the underlying mechanisms of venous return, the venous pumping systems in the hand were objectively and quantitatively investigated using Doppler ultrasound, cadaveric dissection and venography. It was demonstrated that functionally there are three independent venous systems: the superficial palmar, deep palmar and dorsal veins, which are activated by palm compression, isometric intrinsic muscle contraction, and dorsum compression, respectively. Each system was investigated independently and found to increase venous blood velocity in both the cephalic and ulnar veins. These systems were also shown to act in synergy, producing the greatest velocity increase when concurrently activated during fist-clenching. The volume of blood pumped during fist-clenching could also be potentiated by preloading by digit abduction. The clinical applications of these findings are discussed.

Xeroderma pigmentosum--Cockayne syndrome complex: a further case

We report on a male patient born to healthy, first cousin, Moroccan parents. During the pregnancy growth retardation was observed. Birth weight, length, and OFC were all well below the 3rd centile. Facial anomalies, microphthalmia, cleft palate, small penis, and flexion contractures of large joints were noted. Cerebral MRI showed dysmyelination. The clinical course was characterised by feeding difficulties, growth failure, lack of development, photosensitivity, and death at 7 months. The main differential diagnoses were COFS syndrome and early onset Cockayne syndrome (CS). UV exposure of cultured fibroblasts showed inhibition of nucleic acids synthesis. Further DNA repair studies showed extreme cellular sensitivity to UV and xeroderma pigmentosum (XP)-like defective nucleotide excision repair (NER), which in combination with the clinical symptoms indicated the very rare XP-CS complex. Complementation analysis showed that the XPG gene is affected in this patient. In cases suspected of having COFS syndrome and early onset CS, extensive DNA repair studies are needed to reach the definitive diagnosis, thereby allowing reliable genetic counselling and prenatal diagnosis.

Percutaneous nucleus pulposus denaturation in treatment of lumbar disc protrusions--a prospective study of 50 neurosurgical patients

In a prospective study on 50 patients, the 1064-nm Nd-YAG laser was used to denaturate protruding lumbar discs. The method of Ascher [1] was modified using a saline pressure infusion system. Early results show a very good decompressive effect with 48 out of 50 patients in the categories very good and good. At follow-up (mean 184 days postoperation) 31 out of 46 were in these categories, indicating a longer lasting retrieval of the protruded mass. A marked reduction of clinical nerve compression signs was noted. No severe complications occurred. Due to the irrigation system less low back pain was reported. The method seems promising in the standard neurosurgical setting.

[Carcinoid tumor, a late diagnosis]

Carcinoid tumor is often a late diagnosis due to the unspecificity of symptoms leading the radiologist rely on different investigation procedures. We present a case illustrating the contribution of US by demonstrating the suggestive combination of radiating mesenteric densities with a mesenteric mass.

Myth of substituted judgment. Surrogate decision making regarding life support is unreliable

OBJECTIVE

To identify factors predicting the accuracy of surrogate decision making in life support decisions.

DESIGN

Questionnaire.

SETTING

Urban Veterans Affairs hospital.

PATIENTS AND DESIGN

Fifty hospitalized patients and their chosen surrogates were given questionnaires describing life support modalities and four common medical scenarios in which life support would be contemplated. An additional 50 patients also completed the questionnaire. Patients gave their choices of life support in the different scenarios. Surrogates guessed the patients' answers (substituted judgment). Details of the patient-surrogate relationship were asked. Patients completed a depression inventory.

MAIN RESULTS

Surrogates correctly guessed patients' wishes about life support overall on 59.3% of the questions, not better than random chance (kappa = .09). The only predictor of accurate surrogate decision making was specific discussion between patient and surrogate about life support. SECONDARY RESULTS: Patients had an overall low desire for life support (35%), and a majority favored euthanasia under some circumstances (62%). There was no relationship between depression score and desire for life support.

CONCLUSIONS

Substituted judgment by surrogates is not more accurate than random chance. Discussion between patient and surrogate about life support correlated with more accurate substituted judgment.

Lesbian (in)visibility in Italian Renaissance culture: Diana and other cases of donna con donna

Current conceptualizations of sexual identity in the West are not necessarily useful to an historian investigating "lesbianism" in the social history and visual representations of different periods. After an overview of Renaissance documents treating donna con donna relations which examines the potentially positive effects of condemnation and silence, the paper focuses on Diana, the goddess of chastity, who bathed with her nymphs as an exemplar of female bodies preserved for heterosexual, reproductive pleasures. Yet the self-sufficiency and bodily contact sometimes represented in images of this secluded all-female gathering might suggest "deviant" responses from their viewers.

Effect of pyritinol on EEG and SSEP in comatose patients in the acute phase of intensive care therapy

The extent and duration of acute disturbances of consciousness depend on the severity and localization of the underlying cerebral dysfunction. The Glasgow Coma Scale (GCS) permits a relevant statement to be made on the course and recovery tendency of functional damage patterns in cerebral, mesencephalic, and brain stem structures. Therapy is directed at exerting a beneficial effect on the disturbed cerebral metabolism by administration of centrally active substances and at utilizing the available reserve plasticity of the brain for any possible recovery of mental performance. The bioavailability and profile of action of pyritinol have been well documented in animal experiments. We have studied the question as to the extent to which the substance influences the depth of coma in patients receiving acute intensive care therapy, and how this can be objectified electrophysiologically in the form of a specific central effect on basal brain structures. In a phase-II pilot study over five days the acute effect of intravenous 60-min. administration of 1,000 mg pyritinol on the depth of coma, the central conduction time (CCT) and the primary complex amplitude (N20/P25) of the SSEP, and on vigilance behavior (spectral edge frequencies and power) was investigated for 90 minutes in each case under intensive-medical steady-state conditions in 10 comatose patients. Because of the differences in the underlying brain damage, the primary depth of coma, age (30-89 years), sex (two female, eight male), as well as previous treatment (surgery, conservative), the significance of the results could not be evaluated by confirmatory statistical analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

High Level Expression of Active Human Alpha-1-Antitrypsin in the Milk of Transgenic Sheep

We describe the generation of five sheep transgenic for a fusion of the ovine beta-lactoglobulin gene promotor to the human alpha 1-antitrypsin (h alpha 1AT) genomic sequences. Four of these animals are female and one male. Analysis of the expression of h alpha 1AT in the milk of three of these females shows that all express the human protein at levels greater than 1 gram per liter. In one case initial levels exceeded 60 grams per liter and stabilized at approximately 35 grams per liter as lactation progressed. Human alpha 1AT purified from the milk of these animals appears to be fully N-glycosylated and has a biological activity indistinguishable from human plasma-derived material.

Commissioning new buildings: equipment

Any new building will, with occasional exceptions, require new furnishings and equipment. In principle the organisation of this is straightforward. In practice it is a complicated exercise, full of snags. Phillip Simons discusses some of the problems.

Validity of a hinged constant force probe and a similar, immobilised probe in untreated periodontal disease

The validity of a hinged constant force probe (0.25 N) was compared with that of a similar but immobilised instrument, using the same interchangeable tip for both (0.64 mm diameter; 2 mm divisions). 60 sites were measured on teeth which were extracted subsequently, in patients with untreated periodontal disease, and the connective tissue attachment level was used as validity criterion. The clinical measurements of both probes correlated well with each other, but they differed significantly from the post-extraction connective tissue attachment level measurements, indicating a point 1.2 mm coronally to this, on average. A companion investigation of intra-operator probing depth reproducibility with the 2 probes, was undertaken in 14 patients, at 2 visits separated by 1 week in each case. All patients had untreated periodontal disease. A difference between probes was found at the first visit, but not at the second; the immobilised probe showed a difference between visits, reducing mean probing depth slightly at the second; when the immobilised probe was used first, there was a difference between probes. Further analysis of the results indicated that there was greatest agreement between probes when the constant force probe had been used before the immobilised probe at the second visit. The results suggested that these probes indicated a point above the connective tissue attachment level, related to pocket morphology, and that there was a moderate learning effect due to operator use of the constant force probe, which modified use of the immobilised probe.

1H NMR spectral simplification with achiral and chiral lanthanide shift reagents — IV. Thiopental and barbiturate analogues

The 60 MHz (1)H NMR spectra of racemic thiopental, 1, have been studied with the achiral shift reagent, tris(6,6,7,7,8,8,8-heptafluoro-2,2-dimethyl-3,5-octanedionato) europium(III), 2, and the chiral tris[3-(trifluoromethylhydroxymethylene)-d-camphorato] europium(III), 3, and tris[3-(heptafluoropropylhydroxymethylene)-d-camphorato] europium(III), 4. Enantiomeric shift differences, DeltaDeltadelta, were clearly observed for all three methyl signals of 1 with 3 or 4, with larger values obtained using the former reagent. Thus, a 0.216 molal solution of 1 in CDCl(3) at 28 degrees C with a 3:1 molar ratio of 0.359 displayed DeltaDeltadelta values of about 17 Hz for the proximal methyl of the methylbutyl group (at the chiral centre), 13 Hz for the CH(3) of the ethyl group, and 6 Hz for the distal CH(3) of the methylbutyl group. Results are compared for those obtained with 2 and 3 using secobarbital, talbutal, butabarbital and pentobarbital.

Response of the local heme environment of (carbonmonoxy)hemoglobin to protein dehydration

The effects of protein dehydration upon the equilibrium and dynamic properties of the heme active site in human hemoglobin (HbA) have been probed by resonance Raman scattering. Spectra of equilibrium carbonmonoxy-HbA and the photolytic heme transient species generated within 10 ns of ligand photolysis have been obtained from thin films of protein in various stages of dehydration. These data provide detailed information concerning the response of the heme and its bonding interactions with both the proximal histidine and carbon monoxide as a function of protein hydration. For protein hydration levels of 0.4-1.0 g of H2O/g of protein, our results indicate that the C = O stretching mode of carbonmonoxy-HbA is dramatically affected by protein hydration levels, thus corroborating the infrared results of Brown et al. [Brown, W. E., Sutcliffe, J. W., & Pulsinelli, P. D. (1983) Biochemistry 22, 2914-2923]. However, we find that both heme skeletal modes and the Fe-C bond strength are largely insensitive to dehydration. Moreover, the proximal pocket geometry (as reflected in the behavior of the Fe-proximal histidine stretching mode) immediately following ligand photolysis was found to be very similar to that of R-state solution hemoglobin. At protein hydration levels below the theoretical monolayer limit, small changes in the resonance Raman spectra of both equilibrium HbCO and the transient heme species generated subsequent to ligand photolysis are detected. These include broadening of the Fe-C stretching mode in equilibrium HbCO and a small shift to lower frequency of the Fe-His mode in the photolytic transient species.(ABSTRACT TRUNCATED AT 250 WORDS)

CGP-12177. A hydrophilic beta-adrenergic receptor radioligand reveals high affinity binding of agonists to intact cells

A new, hydrophilic beta-adrenergic receptor radioligand, (+/-)-[3H]CGP-12177 (4-(3-tertiarybutylamino-2-hydroxypropoxy)-benzimidazole-2-on hydrochloride), was synthesized and radiolabeled to 40 Ci/mmol. The nonspecific binding of this compound to turkey erythrocyte ghosts and C6 glioma cell membranes was less than 5% of the total binding at five times the appropriate KD. Binding assays of intact C6 glioma cells also showed low nonspecific binding, less than 20% of the total binding at five times the appropriate KD. The affinities of the antagonists (-)- and (+)-propranolol as well as of the agonist (-)-isoproterenol were examined by their potency to displace various radioligands from intact C6 glioma cell and membrane preparations. With membrane preparations, both [3H] CGP-12177 and [3H]dihydroalprenolol (DHA) were displaced stereospecifically by the antagonists (-)- and (+)-propranolol and the agonist (-)-isoproterenol. With whole cells, [3H]CGP-12177 and [3H]DHA behaved differently. [3H]DHA and [3H]carazolol could be stereospecifically displaced by antagonists but only partially displaced by agonists, while [3H]CGP-12177 could be completely displaced by both antagonists and agonists as in membranes. In contrast to [3H]CGP-12177, the lipophilic ligand [3H]DHA is actually taken up by cells. The inability of agonists to displace lipophilic radioligands from receptors on intact cells may not be due to a low affinity of agonists for receptors on cells, but to an agonist-induced change in the receptors which renders them inaccessible to hydrophilic agonists and antagonists. This change is likely to be their internalization into the cell.

Rapid and reversible disappearance of beta-adrenergic cell surface receptors

The water soluble beta-adrenergic ligand [3H]CGP-12177 was used to measure the cell surface receptors in intact cells. In two cell lines, C6 glioma and WEHI 7 lymphoma cells, -50% of the cell surface receptors disappear within minutes of incubation of the cells with isoproterenol. The receptors can still be detected in homogenates and reappear on the cell surface when cells are washed and reincubated at 37 degrees C. The data agree with a disappearance of the receptors from the cell surface by an agonist-mediated endocytosis.

Attitudes toward mental illness: a conflict between students and professionals

A study was undertaken of the attitudes of professionals and students in two “gatekeeper” professions (medicine and law). Results indicated, as predicted, that lawyers ( n = 52) and physicians ( n = 58) were significantly more oriented to the medical model than were the students in those same professions ( ns = 37 and 21, respectively). The implications of such divergent attitudes are briefly discussed.