FAST implementation in Bangladesh: high frequency of unsuspected tuberculosis justifies challenges of scale-up

SETTING

National Institute of Diseases of the Chest and Hospital, Dhaka; Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka; and Chittagong Chest Disease Hospital, Chittagong, Bangladesh.

OBJECTIVE

To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a tuberculosis (TB) transmission control strategy.

DESIGN

FAST was implemented sequentially at three hospitals.

RESULTS

Using Xpert® MTB/RIF, 733/6028 (12.2%, 95%CI 11.4-13.0) patients were diagnosed with unsuspected TB. Patients with a history of TB who were admitted with other lung diseases had more than twice the odds of being diagnosed with unsuspected TB as those with no history of TB (OR 2.6, 95%CI 2.2-3.0, P < 0.001). Unsuspected multidrug-resistant TB (MDR-TB) was diagnosed in 89/1415 patients (6.3%, 95%CI 5.1-7.7). Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1-7.6, P < 0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding.

CONCLUSION

FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a previous history of TB have an increased risk of being diagnosed with unsuspected TB. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.

Vitamin D-deficiency and post-fracture changes in lower extremity function and falls in women with hip fractures

We determined the prevalence of vitamin D deficiency and lower extremity function in women with hip fractures. Women with extremely low vitamin D levels had reduced lower extremity muscle function and increased falls 1 year later. Ensuring vitamin D sufficiency after a hip fracture may improve function and reduce falls.

INTRODUCTION

Hip fractures are the most devastating of fractures, commonly leading to loss of independent ambulation and living. In this retrospective analysis we determined the prevalence of vitamin D deficiency in women with hip fractures and the association between 25-hydroxyvitamin D [25(OH)D] levels and functional impairment one year later.

METHODS

One hundred ten community-dwelling women with hip fractures were recruited from Boston, MA (n = 30) and Baltimore, MD (n = 80) before 1998 and 25(OH)D levels were measured by radioimmunoassay. In a subset of women from Baltimore, a performance measure of the lower extremities using the lower extremity gain scale (LEGS) was measured at 2, 6, and 12 months. Falls, grip strength, chair rise time, walking speed, and balance were also determined.

RESULTS

Vitamin D insufficiency defined as a 25(OH)D <or=32 ng/mL was present in 96% of the women with hip fractures and 38% had extremely low levels <or=9 ng/mL. At 1 year post-fracture, compared to women with a 25(OH)D >9 ng/mL, those with 25(OH)D <or=9 ng/mL had poorer LEGS performance (p < 0.0001) and higher fall rates, without group differences in grip strength or balance.

CONCLUSION

Vitamin D sufficiency may have important effects on lower extremity function following hip fractures, without excessive healthcare costs.

Tibial plafond fractures treated by articulated external fixation: a randomized trial of postoperative motion versus nonmotion

OBJECTIVES

Assess whether postoperative ankle motion after fixation of a fracture of the tibial plafond, treated with articulated external fixation, leads to a better outcome when compared with similar treatment without postoperative ankle motion.

DESIGN

Multicenter randomized trial.

SETTING

Three Level I trauma centers.

PATIENTS/PARTICIPANTS

Fifty-five patients were enrolled and entered into a Web-based database and randomized into 1 of 2 groups. Forty-one patients were evaluated at a 1-year follow-up visit, and 31 were seen at 2 years or longer after injury.

INTERVENTION

Patients were treated with a hinged external fixator and limited internal fixation of the articular surface. They were divided postoperatively into two groups, 1 of which had a locked hinge and the other had a mobile hinge and a motion protocol.

MAIN OUTCOME MEASUREMENTS

A general health status questionnaire, the SF-36 (short-form 36); a joint-specific ankle questionnaire, the Ankle Osteoarthritis Score (AOS); and range of motion (ROM) of the ankle joint.

RESULTS

There were no significant differences between the two groups at either follow-up interval in the ankle ROM measurement, the AOS pain and disability scale, or the SF-36 physical component summary (PCS) and mental component summary (MCS) scales.

CONCLUSIONS

These results indicate that treatment protocols that use long periods of cross-joint external fixation that immobilizes the ankle as definitive treatment result in similar patient outcomes compared to otherwise identical treatment protocols that incorporate and use an articulated hinge for ankle motion. However, the results should be interpreted with caution because the patient numbers were too small to detect potentially meaningful differences in outcomes and the follow-up was too short to assess for differences in the development of arthrosis.

Prognosis of status epilepticus: role of aetiology, age, and consciousness impairment at presentation

BACKGROUND

Identification of outcome-predictive factors could lower risk of under- or over-treatment in status epilepticus (SE). Older age and acute symptomatic aetiology have been shown to predict mortality, but other variables are controversial and level of consciousness has received relatively little attention. The objective of this study was to assess variables predictive of mortality, particularly those available at presentation.

METHODS

The discharge database (1997-2004) of two university hospitals was screened for adult patients with EEG confirmed SE, excluding cerebral anoxia. Outcome at discharge (mortality, return to baseline clinical conditions) was analysed in relation to demographics, clinical features, and aetiology. Aetiologies were also classified based on whether or not they were potentially fatal independently of SE.

RESULTS

Mortality was 15.6% among 96 patients with a first SE episode, 10 of whom also experienced recurrent SE during the study period. Eleven other patients had only recurrent SE. Mortality was 4.8% among these 21 patients with recurrent SE. Return to baseline condition was more frequent after recurrent than incident SE (p=0.02). For the first SE episode, death was associated with potentially fatal aetiology (p=0.01), age>or=65 (p=0.02), and stupor or coma at presentation (p=0.04), but not with gender, history of epilepsy, SE type, or time to treatment>or=1 h.

CONCLUSIONS

At initial evaluation, older age and marked impairment of consciousness are predictive of death. Surviving a first SE episode could lower the mortality and morbidity of subsequent episodes, suggesting that underlying aetiology, rather than SE per se, is the major determinant of outcome.

Role of individual predisposition in orthostatic intolerance before and after simulated microgravity

Orthostatic intolerance (OI) is a major problem after spaceflight. Its etiology remains uncertain, but reports have pointed toward an individual susceptibility to OI. We hypothesized that individual predisposition plays an important role in post-bed rest OI. Twenty-four healthy male subjects were equilibrated on a constant diet, after which they underwent tilt-stand test (pre-TST). They then completed 14-16 days of head-down-tilt bed rest, and 14 of the subjects underwent repeat tilt-stand test (post-TST). During various phases, the following were performed: 24-h urine collections and hormonal measurements, plethysmography, and cardiovascular system identification (a noninvasive method to assess autonomic function and separately quantify parasympathetic and sympathetic responsiveness). Development of presyncope or syncope defined OI. During pre-TST, 11 subjects were intolerant and 13 were tolerant. At baseline, intolerant subjects had lower serum aldosterone (P < 0.01), higher excretion of potassium (P = 0.01), lower leg venous compliance (P = 0.03), higher supine parasympathetic responsiveness (P = 0.02), and lower standing sympathetic responsiveness (P = 0.048). Of the 14 subjects who completed post-TST, 9 were intolerant and 5 were tolerant. Intolerant subjects had lower baseline serum cortisol (P = 0.03) and a higher sodium level (P = 0.02) compared with tolerant subjects. Thus several physiological characteristics were associated with increased susceptibility to OI. We propose a new model for OI, whereby individuals with greater leg venous compliance recruit compensatory mechanisms (activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, and withdrawal of the parasympathetic nervous system) in the face of daily postural challenges, which places them at an advantage to face orthostatic stress. With head-down-tilt bed rest, the stimulus to recruit compensatory mechanisms disappears, and differences between the two subgroups attenuate.

Retrospective analysis of malleolar fractures in an impact environment

To protect against malleolar fractures in frontal crashes it is important to understand the mechanisms of injury. We have investigated the accuracy of Orthopaedic Specialists in deducing the injury mechanisms of experimentally generated malleolar fractures from radiographs; and the applicability of classic descriptors of injury mechanisms, such as the Lauge-Hansen classification system, in analysing impact induced trauma. Orthopaedic Specialists did not consistently deduce the mechanism of ankle injuries suggesting there may not be a unique fracture pattern for every injury mechanism and that the Lauge-Hansen classification system does not reliably describe ankle fractures created in the impact environment.

A randomized study comparing Crinone 8% and intramuscular progesterone supplementation in in vitro fertilization-embryo transfer cycles

OBJECTIVE

To compare the efficacy of Crinone 8% intravaginal progesterone gel vs. IM progesterone for luteal phase and early pregnancy support after IVF-ET.

DESIGN

Randomized, open-label study.

SETTING

Academic medical center.

PATIENT(S)

Two hundred and one women undergoing IVF-ET.

INTERVENTION(S)

Women were randomized to supplementation with Crinone 8% (90 mg once daily) or IM progesterone (50 mg once daily) beginning the day after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Pregnancy, embryo implantation, and live birth rates.

RESULT(S)

The women randomized to luteal phase supplementation with IM progesterone had significantly higher clinical pregnancy (48.5% vs. 30.4%; odds ratio [OR], 2.16; 95% confidence interval [CI], 1.21, 3.87), embryo implantation (24.1% vs. 17.5%; OR, 1.89; 95% CI, 1.08, 3.30), and live birth rates (39.4% vs. 24.5%; OR, 2.00; 95% CI, 1.10, 3.70) than women randomized to Crinone 8%.

CONCLUSION(S)

In women undergoing IVF-ET, once-a-day progesterone supplementation with Crinone 8%, beginning the day after oocyte retrieval, resulted in significantly lower embryo implantation, clinical pregnancy, and live birth rates compared with women supplemented with IM progesterone.

Retrospective review of eighteen patients who underwent transtibial amputation for intractable pain

BACKGROUND

Amputations are rarely performed solely for pain relief because of concerns regarding the persistence of pain and disability after the procedure. The purpose of this study was to assess the outcome of below-the-knee amputations performed to relieve intractable foot and ankle pain.

METHODS

A chart review was conducted to identify all below-the-knee amputations that had been performed for the treatment of chronic foot and ankle pain by three orthopaedic foot and ankle specialists at three institutions. The inclusion criteria included (1) intractable foot or ankle pain as the surgical indication, (2) failure of maximal medical therapy, (3) failure of prior surgical reconstruction, and (4) a minimum follow-up period of twenty-four months after below-the-knee amputation. Patients with diabetes mellitus, peripheral vascular occlusive disease, or peripheral neuropathy were excluded. Each participant completed a two-part questionnaire with regard to the levels of disability, function, pain, and recreational activity both before and after the amputation.

RESULTS

Twenty patients met the inclusion criteria, and eighteen completed the study. The study group included four women and fourteen men who had an average age of forty-two years (range, twenty-six to sixty-one years) and were followed for an average of forty-one months (range, twenty-five to eighty-five months) after the amputation. When asked whether they would have the below-the-knee amputation done again under similar circumstances, sixteen patients said yes, one was unsure, and one said no. The same distribution was observed when the patients were asked whether they were satisfied with the outcome: sixteen said yes, one was unsure, and one said no. Disability, pain, and recreational status were assessed with a 10-cm visual analog scale. After the amputation, the patients reported a decrease in both pain frequency (with the average score improving from 9.8 to 1.7; p < 0.0001) and pain intensity (with the average score improving from 8.4 to 2.6; p < 0.0001). Ten patients discontinued the use of narcotics, and seven decreased the level and/or dosage. Three patients worked before the amputation, and eight worked after the amputation. The average walking distance increased from 0.3 to 0.8 mile (p = 0.0034).

CONCLUSION

In selected patients, a below-the-knee amputation may be a good salvage procedure for intractable foot and ankle pain that is unresponsive to all medical and local surgical reconstructive techniques.

Adrenal response to angiotensin II in black hypertension: lack of sexual dimorphism

Adrenal responsiveness to angiotensin (Ang) II is markedly blunted in black hypertensive patients compared with white hypertensive patients. One characteristic of this blunted adrenal response in whites is a powerful sexual dimorphism: premenopausal white women rarely show blunted responses. This abnormality, most evident when the system is activated by a low-salt diet, is a cardinal feature of the syndrome of nonmodulation, affecting a large percentage of white hypertensive patients. Nonmodulation is also marked by an increase in cardiovascular risk beyond that from hypertension itself. This study investigated whether young black women are likewise spared its expression or whether the adrenal unresponsiveness common among black hypertensive patients is unaccompanied by a gender bias. We compared the adrenal response to Ang II in 382 hypertensive patients (313 white, 69 black; 238 male, 144 female). Ang II was infused when subjects were in balance on a 10-mmol Na(+) intake. As anticipated, white hypertensive patients showed a very strong sexual dimorphism, with women having twice the aldosterone response of men (P=0.0001). Blacks, on the other hand, showed no gender difference (P=0.9). Increasing age had the dramatic effect of reducing responsiveness in white women but not in blacks. Young black women demonstrated the same blunting of adrenal responsiveness as older black women and black men of all ages. Mechanisms protecting against a blunted adrenal response to Ang II in young white women are absent in blacks. These differences may contribute to the markedly increased prevalence of hypertension in young black women.

Expanding the orthopaedist's role in the treatment of foot and ankle disorders

Many opportunities exist and more will become available for expanding the role of orthopaedic surgeons in the treatment of patients with foot and ankle conditions in the United States. The current authors present the main areas of opportunity: giving comprehensive foot care to patients who already are treated by orthopaedic surgeons and the application of advanced scientific biotechnology that will improve outcomes for patients with foot and ankle conditions who currently do not have satisfactory treatment. Orthopaedic surgeons must maintain a high level of commitment in their education and professional availability to patients and primary care physicians to expand their participation in foot and ankle care. Networking with physician and nonphysician primary care providers and volunteering educational services for fellow professionals in the evaluation and treatment of the entire spectrum of foot and ankle conditions is necessary. The general orthopaedist and the orthopaedic foot and ankle specialist can share in the future of treatment of patients with foot and ankle conditions in the United States.

Influence of sodium intake on the reliability of active renin as a measure of the renin-angiotensin system in essential hypertension

Plasma renin activity (PRA), active renin (AR), prorenin, and angiotensinogen were assessed in 486 hypertensive and 175 normotensive subjects with a sodium intake of 10 or 200 mEq/d during supine and upright posture and after infusion of angiotensin II. PRA and AR levels were compared in hypertensive subjects in each condition. With low sodium intake, particularly while upright, there was a significant correlation between PRA and AR. In upright subjects with low sodium intake who had a PRA of 2.4 ng/mL per hour or less (1.85 nmol.L-1.h-1 or less), the correlation was also strong. With high sodium intake, the correlation was weaker. With intermediate sodium excretion, the correlation was intermediate. Prorenin was less predictive of PRA than was AR, and angiotensinogen had a marginal role. Using PRA during sodium restriction while upright as the standard for determining renin status, the precision of AR for predicting renin status was excellent. AR may be used for surrogate assessment of the renin-angiotensin system activity when the system is activated.

Adjunctive salvage therapy with inhaled aminoglycosides for patients with persistent smear-positive pulmonary tuberculosis

A proportion of patients with drug-resistant and drug-susceptible tuberculosis (TB) have sputum that is smear and culture positive for Mycobacterium tuberculosis for a prolonged period of time, despite conventional therapy. Among such patients with refractory TB, an unblinded, observational study was undertaken that used conventional TB therapy and adjunctive aerosol aminoglycosides. Patients with persistent smear- and culture-positive sputum for M. tuberculosis (despite > or =2 months of optimal systemic therapy) were selected for adjunctive treatment via inhalation with aminoglycosides, and microbiological responses were monitored. Thirteen of 19 patients converted to smear negativity during the study: 6 of 7 with drug-susceptible TB and 7 of 12 with drug-resistant TB. Among patients with drug-susceptible TB, the median time to sputum conversion was 23 days, a shorter time than for a population of historical control patients. Recurrent infection was not observed. Adjunctive aerosol aminoglycosides may expedite sterilization of sputum among certain patients with refractory TB and diminish the risk of transmission.

Optimal antidepressant dosing. Practical framework for selection, titration, and duration of therapy

Appropriate antidepressant dosing and trial duration are crucial for successful treatment of depression. Before prescribing an antidepressant, primary care physicians should take into account each patient's history, responses to previous antidepressants, depressive symptoms, coexisting illnesses, and current prescriptions. Physicians must be able to help patients manage side effects and know when to discontinue treatment, switch antidepressants, or refer patients to a psychiatrist.

Association of posterior tibial tendon abnormalities with abnormal signal intensity in the sinus tarsi on MR imaging

OBJECTIVE

To evaluate the association of abnormal signal intensity within the sinus tarsi with abnormalities of the posterior tibial tendon (PTT) on MR imaging.

DESIGN AND PATIENTS

Sinus tarsi abnormalities were identified on 30 ankle MR examinations in 29 patients. The PTT and anterior talofibular ligament were retrospectively analyzed for abnormalities in these same patients.

RESULTS AND CONCLUSIONS

Tears of the anterior talofibular ligament were found in 13 of 30 (43%) ankles. PTT abnormalities (complete tear, partial tear or dislocation) were seen in 14 of 30 (47%) studies, and were distributed relatively equally between those patients with and without lateral ligament tears. Our results provide evidence of an association between abnormalities of the PTT and the sinus tarsi. The finding of abnormal signal intensity within the sinus tarsi on MR imaging should alert the radiologist to potential abnormalities of the PTT.

Use of enhanced green fluorescent protein to monitor retroviral-mediated gene therapy in human keratinocytes

Keratinocytes have great promise as targets for gene therapy involving both skin as well as for systemic disorders due to their availability and potential long life span. Improvement of gene transfer into keratinocytes will be greatly facilitated by markers that will allow both rapid detection and efficient selection of transduced cells. For these purposes, a recombinant version of the Aequorea victoria green fluorescent protein that is enhanced for high-level expression in mammalian cells (EGFP) was placed into a replication-deficient retroviral vector. High-titer retrovirus was used to transduce both primary cultures of neonatal foreskin-derived human keratinocytes (HK) as well as the immortalized keratinocyte-derived cell line HaCaT. Both cell types stably expressed the EGFP, and this marker allowed rapid purification of transduced cells by fluorescence-activated cell sorting. EGFP expression was seen in HaCaT keratinocytes for at least 40 passages, and the presence of this construct did not effect cell growth, or apoptosis in response to UVB or etoposide. Transduced populations of HK were grafted into SCID mice, resulting in a functional epidermis. EGFP expression was readily seen in vivo by exposing the xenografts to an ultraviolet light source. These studies demonstrate the feasibility of using EGFP as a convenient and rapid marker to monitor keratinocyte gene transfer both in vitro and in vivo.

Radiographic fracture assessments: which ones can we reliably make?

OBJECTIVE

To identify the fracture characteristics that can be reliably assessed by analysis of plain radiographs of tibial plateau fractures.

DESIGN

Radiographic review study.

PARTICIPANTS

Five orthopaedic traumatologists served as observers.

INTERVENTION

Observers made assessments based on the radiographs of fifty-six tibial plateau fractures. Precise definitions of the assessments to be made were agreed on by all observers. The tested assessments included raters' abilities to identify and locate fracture lines, identify the presence of fracture displacement and comminution, make quantitative measurements of displacement, and characterize qualitative features of fractures. For thirty-eight of the fractures that had a computed tomography (CT) scan available, assessments were repeated using both radiographs and CT scans.

MAIN OUTCOME MEASURES

To characterize interobserver reliability, percentage agreement and kappa statistics were calculated for categorical variables, and intraclass correlation coefficients (ICC) were calculated for noncategorical variables.

RESULTS

Reliability of the assessments varied widely. Determining the location of fracture lines had the greatest reliability, whereas the subjective assessments of fracture stability and energy showed the poorest reliability. Although the ICCs for quantitative measurements approached acceptable levels, the tolerance limits were extremely wide. The addition of a CT scan improved the reliability of most assessments, but not to a statistically significant degree.

CONCLUSIONS

Many basic radiographic interpretations relied on in making treatment decisions are made variably by observers. Using experienced raters and precise definitions of fracture assessments does not guarantee a high level of agreement. Discrete assessments have higher interrater agreements than do more qualitative assessments. Quantitative measures have wide tolerance limits and, therefore, probably cannot be used reproducibly to classify fractures or make treatment decisions. We conclude the reliability of fracture classification is limited by raters' abilities to agree on basic radiographic assessments.

Effects of age on serum dehydroepiandrosterone sulfate, IGF-I, and IL-6 levels in women

Data from animal and in vitro studies suggest that the growth-promoting effects of the adrenal androgen dehydroepiandrosterone sulfate (DHEAS) may be mediated by stimulation of insulin-like growth factor-I (IGF-I) and/or inhibition of interleukin 6 (IL-6), a cytokine mediator of bone resorption. This study tests the hypotheses that there are effects of age on serum DHEAS, IGF-I, and IL-6 levels, and that levels of IGF-I and IL-6 are related to DHEAS levels. The study included 102 women: 27 premenopausal and 75 postmenopausal, including 35 postmenopausal women with osteoporosis, as defined by bone mineral density scores by dual X-ray energy absorptiometry. DHEAS levels decreased significantly with age (r = -0.52, P < 0.0001) and IGF-I levels decreased significantly with age (r = -0.49, P < 0.0001). IL-6 levels increased significantly with age (r = 0.36, P = 0.008). IGF-I was positively correlated to DHEAS levels (r = 0.43, P < 0. 0001, n = 102) and IL-6 levels were negatively correlated to DHEAS levels (r = -0.32, P = 0.021, n = 54). Levels of DHEAS and IGF-I were correlated with T scores of the spine and some hip sites. In a multiple variable model to predict DHEAS, age was an important predictor (P < 0.001), but osteoporosis status, IGF-I, and IL-6 were not. The median DHEAS level was lower in the postmenopausal osteoporotic women (67 microg/dl, n = 35) than in the nonosteoporotic postmenopausal women (106.3 microg/dl, n = 40, P = 0. 03), but this was not significant after correction for age. Age accounted for 32% of the variance in DHEAS levels. In summary, DHEAS levels decreased with age and had a positive association with IGF-I levels and a negative association with IL-6 levels. DHEA deficiency may contribute to age-related bone loss through anabolic (IGF-I) and anti-osteolytic (IL-6) mechanisms.

The effect of light intensity on growth and development of turkey toms

1. The effect of light intensities from 10 to 700 lux on the performance of 5 to 18 week-old turkey males was studied in 2 trials. 2. Body weight of 18 week-old turkeys, in both experiments, was highest under the lowest light intensity This coincided with higher weight gain and lower food intake, which resulted in significantly better food conversion efficiency 3. Light intensity affected heart muscle weight but not weight of breast muscle, abdominal fat or testis as proportions of body weight. 4. The decline in plasma T3 concentration with age differed from other treatments at the low light intensity, which resulted in a significantly higher T3 concentration in turkeys exposed to 10 lux at the age of 10 to 15 weeks. 5. It is concluded that light intensity significantly affects food conversion efficiency in turkey males. This is likely to be related to differential investment of energy expenditure for maintenance.

A pilot study evaluating ceftriaxone and penicillin G as treatment agents for neurosyphilis in human immunodeficiency virus-infected individuals

To compare intravenous (iv) ceftriaxone and penicillin G as therapy for neurosyphilis, blood and CSF were collected before and 14-26 weeks after therapy from 30 subjects infected with human immunodeficiency virus (HIV)-1 who had (1) rapid plasma reagin (RPR) test titers >/=1&rcolon;16, (2) reactive serum treponemal tests, and (3) either reactive CSF-Venereal Disease Research Laboratory (VDRL) tests or CSF abnormalities: (a) CSF WBC values >/=20/microL or (b) CSF protein values >/=50 mg/dL. At baseline, more ceftriaxone recipients had skin symptoms and signs (6 [43%] of 14 vs. 1 [6%] of 16; P=.03), and more penicillin recipients had a history of neurosyphilis (7 [44%] of 16 vs. 1 [7%] of 14; P=.04). There was no difference in the proportion of subjects in each group whose CSF measures improved. Significantly more ceftriaxone recipients had a decline in serum RPR titers (8 [80%] of 10 vs. 2 [13%] of 15; P=. 003), even after controlling for baseline RPR titer, skin symptoms and signs, or prior neurosyphilis were controlled for. Differences in the 2 groups limit comparisons between them. However, iv ceftriaxone may be an alternative to penicillin for treatment of HIV-infected patients with neurosyphilis and concomitant early syphilis.

The effects of age and gender on parathyroid hormone dynamics

BACKGROUND AND AIMS

Hyperparathyroidism is a risk factor for bone loss. An age-related increase in parathyroid hormone (PTH) level has been demonstrated in several studies. It has been suggested that the type II osteoporotic syndrome, a condition of increased prevalence among elderly women, may be at least partially caused by elevations in intact parathyroid hormone (iPTH) levels. To date, however, the effects of age and gender per se on PTH dynamics in healthy subjects independent of other risk factors such as vitamin D deficiency and/or impaired renal function that can impact on parathyroid function, remain unknown. In this study, we used citrate and calcium (Ca) infusions to characterize the impact of age and gender on PTH dynamics in normal subjects.

SUBJECTS AND METHODS

Twelve young women with mean age +/- SD of 26.4 +/- 1.6 years, 12 young men with mean age of 26.6 +/- 1.3 years, 12 older women with mean age of 68.6 +/- 1.3 years and 12 older men with mean age of 67.2 +/- 1.6 years were studied. The sigmoidal curves relating serum iPTH to serum levels of ionized Ca (Cai) were characterized by maximal and minimal iPTH levels, the set-points (levels of Cai causing half-maximal suppression of iPTH), and the slopes of the curves at the set-points.

RESULTS

Baseline serum Ca, Cai, 25 hydroxyvitamin D [25(OH)D] and 1,25 dihydroxyvitamin D [1,25(OH)2D3] levels, as well as the set-points, slopes and minimal values of the sigmoidal curves relating Cai to iPTH, did not differ among the four groups. iPTH levels at baseline were slightly but not significantly higher in the older age groups (P = 0.18). The maximal iPTH level was 25% higher in the older women than in the younger women, although this difference was not significant (P = 0.29). However, the integrated iPTH responses calculated from the areas under the curves (AUC) of iPTH levels vs. time during the calcium and citrate infusions were significantly higher in postmenopausal women than in young women during both infusions and in older men than in young men during the calcium infusion. There was no effect of gender on serum iPTH levels.

CONCLUSIONS

In both women and men, ageing per se, independent of changes in vitamin D economy or renal function, is associated with an increase in integrated PTH secretory response to changes in serum calcium. No alterations in the Cai/iPTH set-point were present. The biological relevance of these modest increments in integrated iPTH levels during dynamic testing in older healthy men and women remain uncertain.

Expression of calcium-sensing receptor gene by avian parathyroid gland in vivo: relationship to plasma calcium

Calcium-sensing receptor (CaR) gene expression and parathyroid hormone (PTH) content were evaluated in situ in chicken parathyroid glands (PG) in relation to changes in plasma calcium. The CaR gene is expressed by the parathyroid chief cells, the same cells that store and secrete PTH. An increase in plasma calcium, achieved by repletion of vitamin D-deficient chicks with a normal diet, by PTH injection, or during eggshell formation, increased the expression of the CaR gene. Low plasma calcium concentration in vitamin D-deficient chicks or in layers, before or after eggshell formation, was associated with decrease in CaR gene expression in the PG. The level of CaR gene expression was inversely correlated with the PTH content of the PG. The results of this study demonstrate for the first time that, in contrast to mammals, the CaR gene expression in the PG of the chicken is inversely associated with changes in plasma calcium.

Glucocorticoid-remediable aldosteronism and pregnancy

Glucocorticoid-remediable aldosteronism (GRA) is a hereditary form of primary hyperaldosteronism that presents with hypokalemia and hypertension from childhood onward. GRA is characterized by the ectopic production of aldosterone in the cortisol-producing zona fasciculata under the regulation of adrenocorticotrophic hormone. Despite the early age of onset, no previous reports of pregnancy and GRA exist. Therefore, we set out to describe the maternal and fetal outcomes of pregnancy in women with GRA. Data regarding the blood pressure and pregnancy outcomes were collected in a retrospective chart review of prenatal and hospital records of 35 pregnancies in 16 women with genetically proven GRA. A total of 6% of pregnancies in women with GRA (GRA+) were complicated by preeclampsia. The published rates of preeclampsia in general obstetric populations vary from 2.5% to 10%. Despite the lack of an apparent increase in the rate of preeclampsia, GRA+ women with chronic hypertension had a high rate (39%) of pregnancy-aggravated hypertension. Starting with a higher baseline blood pressure, maternal blood pressure plotted over the time course of pregnancy followed a quadratic curve similar to that previously described in normal pregnancy. Mean gestational age at delivery was 39.1 weeks. Mean birth weight, excluding the 3 sets of twins, was 3219 g. However, infants of GRA+ mothers with pregnancy-aggravated hypertension tended to have lower birth weights than those that did not (3019 g versus 3385 g, respectively; P=0.08). The primary cesarean section rate was 32%, which is approximately double that seen in other general or hypertensive obstetric populations. In summary, GRA+ women did not seem to have an increased risk of preeclampsia. However, GRA+ women with chronic hypertension seem to be at an increased risk for an exacerbation of their hypertension during pregnancy.

Collapsing glomerulopathy in HIV and non-HIV patients: a clinicopathological and follow-up study

Collapsing glomerulopathy in HIV and non-HIV patients: A clinicopathological and follow-up study.

BACKGROUND

Collapsing glomerulopathy (CG) is a pattern of renal injury that is seen in association with HIV infection and that is increasingly recognized in non-HIV patients.

METHODS

A review of native kidney biopsies with CG that were diagnosed between 1979 and 1997 in 18 HIV and 42 non-HIV patients is provided.

RESULTS

HIV and non-HIV patients with CG were similar in terms of age, sex ratio, serum creatinine, proteinuria, the extent of collapsing and sclerosing glomerular lesions, and interstitial damage. A slight female predominance was found in both groups. In contrast to non-HIV patients, the HIV group was characterized by a high prevalence of blacks (94 vs. 57%), frequent tubuloreticular inclusions (76 vs. 29%), and microcystic tubular changes (72 vs. 40%). In 13 non-HIV patients, CG was associated with a systemic lupus erythematosus (SLE)-like disease (5), hepatitis C virus (HCV) infection (3), HTLV-I infection, MCTD, acute monoblastic leukemia, multiple myeloma, and cerebral arteritis. Overall, the renal survival of human immunodeficiency virus (HIV) and non-HIV patients with CG was not significantly different. Cox regression revealed that HIV infection had an adverse effect on short-term renal survival, with other significant risk factors being extensive interstitial fibrosis, high serum creatinine, proteinuria, and a low percentage of glomeruli with collapse. The slope of reciprocal creatinine was best predicted by the degree of proteinuria. Serum creatinine correlated with the extent of interstitial fibrosis, the male gender, and the percentage of glomeruli with collapse. Proteinuria was best predicted by the extent of effacement of podocyte foot processes.

CONCLUSIONS

CG shares many clinicopathological similarities in HIV and non-HIV patients. In some non-HIV patients, CG was associated with autoimmune diseases, lymphoproliferative disorders, and viral infections.

Altered adrenal sensitivity to angiotensin II in low-renin essential hypertension

Low-renin essential hypertension (LREH) describes a widely recognized classification validated by clinical features, including salt-sensitive blood pressure and diuretic responsiveness. Classic physiological teaching has cited normal plasma aldosterone concentration despite suppressed renin as evidence for adrenal supersensitivity to angiotensin II (Ang II). We studied 94 patients with LREH, 242 normal-renin hypertensives, and 135 normal subjects as controls. Low-renin hypertensives did not differ significantly from the other groups in either basal or Ang II-stimulated aldosterone concentrations on a high-sodium diet. Stimulated with a low-sodium diet, LREH patients demonstrated the smallest rise in basal aldosterone secretion. Ang II responsiveness was also subnormal: the rise in aldosterone after Ang II infusion in LREH (613+/-39 pmol/L), although greater than in nonmodulators (180+/-17 pmol/L; P=0.001), was less than either the patients with intact modulation (940+/-53 pmol/L; P=0.001) or normotensives (804+/-50 pmol/L; P<0.05). Blacks with LREH demonstrated an even lower response than low-renin whites ((388+/-50 versus 610+/-47 pmol/L; P=0.0001). In contrast, the rise in systolic blood pressure with Ang II infusion on a low-salt diet was greatest among LREH patients (P=0. 001). Patients with LREH and nonmodulators were equally salt-sensitive. These results indicate that the adrenal response in LREH is normal on a high-salt diet but becomes progressively more abnormal as sodium control mechanisms are stressed. The factors that mediate enhanced adrenal response to Ang II with sodium restriction may be defective, suggesting the existence of alternative physiological mechanisms for sodium homeostasis in the low-renin state.

Spatial and temporal characteristics of saline springs: Sea of Galilee, Israel

Spatial and temporal characteristics of the saline springs that emerge along the western shore of the Sea of Galilee (Lake Kinneret) are analyzed. Three groups of onshore springs (Tiberias, Fuliya, and Tabgha) and two groups of offshore springs (Barbutim and Maagan), contribute saline water to the lake with concentrations in the range of 300 to 18,000 mg Cl/L, depending on location and season. It is well accepted that water emerging from these springs is a mixture of two endmembers: deep-seated saline ground water and shallow, fresh circulating ground water. Temporal trends of discharge rates and of chloride (representing the deep saline aquifer) and nitrate (representing the shallow fresh water aquifer) concentrations within each group of springs are presented. Results show the proportions of the two water bodies while mixing are time dependent. Discharge and concentration peaks in Tabgha springs precede those in Fuliya and Tiberias springs by approximately two months. An analytical solution shows that in Tabgha, variations of these parameters are mainly controlled by recharge variations in the Galilee, and follow an exponential function. In Fuliya and Tiberias, variations of these parameters are mainly dependent on lake level, and follow a sine-cosine function. The different patterns are attributed to different hydraulic properties of the discharge area.

Reduced hypothalamic-pituitary and sympathoadrenal responses to hypoglycemia in women with fibromyalgia syndrome

PURPOSE

To perform a detailed comparison of the hypothalamic-pituitary-adrenal axis and the sympathoadrenal system in women with and without fibromyalgia.

SUBJECTS AND METHODS

Fifteen premenopausal women who met the 1990 American College of Rheumatology criteria for the diagnosis of fibromyalgia and 13 healthy, premenopausal women were enrolled. We measured baseline 24-hour urinary free cortisol levels and evening and morning adrenocorticotropic hormone (ACTH) and cortisol levels, performed stepped hypoglycemic hyperinsulinemic clamp studies in which serum glucose levels were decreased from 5.0 to 2.2 mmol/L, and compared the effects of infusions of placebo and ACTH.

RESULTS

Women with fibromyalgia had normal 24-hour urinary free cortisol levels and normal diurnal patterns of ACTH and cortisol. There was a significant, approximately 30%, reduction in the ACTH and epinephrine responses to hypoglycemia in women with fibromyalgia compared with controls. Prolactin, norepinephrine, cortisol, and dehydroepiandrosterone responses to hypoglycemia were similar in the two study groups. In subjects with fibromyalgia, the epinephrine response to hypoglycemia correlated (P = 0.01) inversely with overall health status as measured by the fibromyalgia impact questionnaire. Graded ACTH infusion revealed similar increases in cortisol in women with fibromyalgia and healthy controls.

CONCLUSIONS

Patients with fibromyalgia have an impaired ability to activate the hypothalamic-pituitary portion of the hypothalamic-pituitary-adrenal axis as well as the sympathoadrenal system, leading to reduced ACTH and epinephrine responses to hypoglycemia.

Occult vitamin D deficiency in postmenopausal US women with acute hip fracture

CONTEXT

Low vitamin D levels may contribute to hip fractures in women, although limited data are available on vitamin D levels in US women admitted with acute hip fractures.

OBJECTIVE

To determine whether postmenopausal women with hip fractures have low vitamin D and high parathyroid hormone levels compared with nonosteoporotic and osteoporotic women admitted for elective joint replacement.

DESIGN

Comparative case series conducted between January 1995 and June 1998.

SETTING AND PATIENTS

Ninety-eight postmenopausal community-dwelling women with no secondary causes of bone loss admitted for hip replacement, of whom 30 women had acute hip fractures and 68 women were admitted for elective joint replacement. Of the women admitted for elective joint replacement, 17 had osteoporosis and 51 did not. Women with comorbid conditions or who were taking medications that affect bone density and turnover were excluded.

MAIN OUTCOME MEASURES

Primary measures were levels of vitamin D and parathyroid hormone; secondary measures were body composition and markers of bone turnover.

RESULTS

Women with hip fractures had lower levels of 25-hydroxyvitamin D than women without osteoporosis admitted for elective joint replacement (P = .02) and than women with osteoporosis admitted for elective joint replacement (P = .01) (medians, 32.4, 49.9, and 55.0 nmol/L, respectively; comparisons adjusted for age and estrogen intake). Parathyroid hormone levels were higher in women with fractures than women in the nonosteoporotic control group (P<.001) or than elective osteoporotic women (P = .001) (medians, 5.58, 3.26, and 3.79 pmol/L, respectively; comparisons adjusted for age and estrogen intake). Fifteen patients (50.0%) with hip fractures had deficient vitamin D levels (< or =30.0 nmol/L) and 11 (36.7%) had a parathyroid hormone level greater than 6.84 pmol/L. Levels of N-telopeptide, a marker of bone resorption, were greater in the women with hip fractures than in the elective nonosteoporotic controls (P = .004).

CONCLUSIONS

Postmenopausal community-living women who presented with hip fracture showed occult vitamin D deficiency. Repletion of vitamin D and suppression of parathyroid hormone at the time of fracture may reduce future fracture risk and facilitate hip fracture repair. Because vitamin D deficiency is preventable, heightened awareness is necessary to ensure adequate vitamin D nutrition, particularly in northern latitudes.

Longitudinal changes in bone density in hyperparathyroidism

Primary hyperparathyroidism (HPTH) is a known risk factor for cortical bone loss. The primary objective of this study was to examine the time course and location of changes in bone mass within the first year after parathyroidectomy (PAX). The secondary goal was to evaluate the efficacy of combined estrogen therapy and parathyroidectomy in postmenopausal women. Thirty-two subjects with primary HPTH participated in a prospective, longitudinal study for at least 1 yr. Twenty-seven subjects underwent PTX, while five received no therapy (control). Among the PTX patients, 21 were postmenopausal women, and 8 of these women also received estrogen. Subjects had serial measurements of parathyroid hormone levels, serum chemistries, and bone density at multiple sites. Among all PTX patients, lumbar spine, hip, and whole body bone mineral content increased significantly (3.8-6%; p < 0.005) at 12 mo, with most of the increments observed by 3 mo. In postmenopausal women, estrogen treatment resulted in higher increments in the femoral neck (8.6 +/- 2% vs 4.9 +/- 1.2%, respectively; p = 0.07) and the whole body (6 +/- 2% vs 2.4 +/- 1.6%, respectively; p = 0.07). In HPTH, early and generalized increments in bone mass follow PTX, and the combination of surgery with estrogen therapy may be superior to surgery without estrogen treatment. A randomized, controlled trial including PTX, estrogen, and a combination of the two is needed to determine the optimal therapy in postmenopausal women.

Development of avian tibial dyschondroplasia: gene expression and protein synthesis

Age-dependent gene expression and protein synthesis associated with chondrocyte differentiation were evaluated in the epiphyseal growth plates of normal and tibial dyschondroplasia (TD)-afflicted chickens. In the normal growth plate, collagen type II gene is expressed mainly by chondrocytes at the upper zone of the growth plate and by the chondrocytes in the articular cartilage. Collagen type X and osteopontin (OPN) genes are expressed in the lower zone of the growth plate and in the zone of cartilage-to-bone transition. No age-dependent changes in the pattern of OPN and collagen type II or X gene expression were observed up to 20 days of age. In the TD-afflicted growth plates, the lesion is enlarged with age, and chondrocytes expressing the collagen type II gene were observed in the hypertrophic zone as early as 8 days posthatching. Abnormal expression of OPN and collagen type X genes was also observed starting at 13 days of age. At day 20, the entire TD lesion-which was significantly enlarged-was surrounded by collagen type II, collagen type X, and OPN expressing cells. The level of OPN in TD was reduced with increasing age, and at 20 days almost no OPN could be detected in either the upper or the lower hypertrophic zones. The level of bone sialoprotein (BSP) also diminished with increasing age in the TD growth plates. In contrast to OPN, the age-dependent reduction in BSP levels was mainly in the lower hypertrophic zone (LHZ), and at 20 days of age, BSP was barely detected in the LHZ, whereas in the upper hypertrophic zone, the levels of BSP were similar to those in normal growth plate. In summary, our results suggest that the primary event of the TD lesion occurs in cells of proliferative phenotype within the hypertrophic zone. These cells divide and form the TD lesion, which consists of cells that do not express the genes associated with hypertrophy.

Response of turkeys to relative humidity at high ambient temperature

1. The effects of relative humidity on growth rate and thermoregulation at high ambient temperature were evaluated in turkeys. Male turkeys were exposed to ambient temperature (Ta) of 35 degrees C and relative humidity (RH) of 40% to 75% and 50% to 85%, at ages of 13 to 19 weeks (trial 1) and 10 to 15 weeks (trial 2), respectively. 2. Body weight and food intake in both trials increased as RH increased up to 70% to 75%. When RH increased further to 80% to 85% (Trial 2) both body weight and food intake declined significantly. 3. Blood CO2 partial pressure (pCO2) did not change significantly at different RHs (trial 1). However, in trial 2 it dropped significantly at 80% to 85% RH. This response coincided with an increase in blood pH. 4. The effect of RH on body temperature (Tb) was not significant in either trial. 5. Triiodothyronine (T3) concentrations increased with the increase in RH up to 70% to 75% RH (trials 1 and 2). A significant decrease was observed when RH was further increased to 80% to 85% RH (Trial 2). Positive linear correlations between T3 and food intake or weight gain were observed in both trials. 6. The results indicate that turkeys can thermoregulate efficiently in the face of extreme changes in RH and that only at high RH (above 75%) did the performance of turkeys deteriorate.

The effect of dietary protein level on the lysine and arginine requirements of growing chickens

Comparisons were made of the growth and carcass fat responses to dietary lysine and of the lysine requirements of 1-wk-old broiler chickens receiving diets containing either 18, 20, 23 or 25% protein. Similar comparisons were made of the responses elicited by dietary arginine in diets containing 18 or 23% dietary protein. The responses to lysine supplementation and the lysine requirements of chicks receiving 23 or 25% protein diets were similar. In comparing the 18 or 20% to the 23% protein diet, the initial responses of growth and feed efficiency to dietary lysine were augmented, but the maximal weight gain diminished as dietary protein decreased, leading to a decrease in the lysine requirements. The amounts of extractable carcass fat or abdominal fat pad increased as dietary protein was lowered and, in general, were reduced either by lysine or arginine supplementation. Percentage of pectoral muscle increased slightly with dietary arginine and protein supplementation. The results suggest that when total dietary amino acid level is reduced, the requirements for the individual amino acid decrease due to growth retardation resulting from single or multiple amino acid deficiencies. Single amino acid supplementation of low protein diet is more effective in improving the amino acid balance than supplementation of high protein diets, resulting in a further decrease in the requirements.

Thermoregulation in naked neck chickens subjected to different ambient temperatures

1. Heterozygous (Na/na) naked neck chickens and their normally feathered (na/na) sibs, were exposed to constant ambient temperatures (Ta) ranging between 15 and 35 degrees C and 12h: 12h diurnal high:low temperatures of 15 degrees C:35 degrees C. 2. No significant effect of genotype was obtained in weight gain and food intake. However, the naked neck birds tended to gain somewhat more weight at high Ta and consume more food at low Ta. 3. At 35 degrees C Na birds showed better regulation of body temperature (Tb) and demonstrated considerably higher radiation from the neck. 4. The greater food intake of the naked neck chickens at 15 degrees C was associated with significantly higher packed cell volume, haemoglobin concentration, heart and liver size. These appear to involve both higher heat production and haemodynamic changes to accommodate the higher oxygen demands of the naked neck chickens at low Ta. 5. The results indicate the ability of the naked neck chickens, on the one hand to thermoregulate at low Tas and, on the other their slightly better capacity to maintain Tb at high Tas. However, no genotype advantage was obtained under diurnal cyclic temperature conditions.

A randomized, double-blind trial of valaciclovir prophylaxis for cytomegalovirus disease in patients with advanced human immunodeficiency virus infection. AIDS Clinical Trials Group Protocol 204/Glaxo Wellcome 123-014 International CMV Prophylaxis Study Group

Cytomegalovirus (CMV) disease is a common complication of advanced human immunodeficiency virus (HIV) infection. Administration of oral valaciclovir, a valine ester of acyclovir, achieves sufficient plasma acyclovir levels to inhibit many clinical isolates. Acyclovir has been associated with enhanced survival in AIDS but not with CMV disease prevention. CMV-seropositive patients (1227) with CD4 cell counts <100/mm3 were enrolled in a randomized, double-blind trial. Valaciclovir, 8 g/day, was compared with acyclovir, 3.2 or 0.8 g/day, for CMV prevention; all three arms were compared for survival. The confirmed CMV disease rate was 11.7% among valaciclovir recipients and 17.5% in the pooled acyclovir arms, a 33% reduction in risk. Time to confirmed CMV disease was significantly longer for the valaciclovir group (P = .03). A trend toward earlier mortality for valaciclovir recipients was seen (P = .06). Toxicity and earlier medication discontinuation were more common in this group. Valaciclovir significantly reduces the risk of CMV disease. Further exploration of a better-tolerated dose is warranted.

The response of laying hens to induced molt as affected by strain and age

Molt was induced in 502-d-old Lohmann, Hy-Line W-77, Yafa, and Yarkon strains of laying hens (Experiment 1), and at different ages during the 1st yr of production in the Lohmann strain (Experiment 2). The induced molt treatment included an 8-d feed withdrawal period followed by a 22-d rest period during which the birds received 60 or 70 g/d of a low-nutrient maintenance diet, in both experiments, respectively, and a reduced duration of daylight. In both experiments, induced molt resulted in an increase in postmolt egg production rate and a diminution of the rate of decline of production with age. The first eggs during the postmolt period were smaller than those of the unmolted birds but egg size increased rapidly to control levels. Egg breakage was markedly reduced by induced molt and its rate of increase with age was diminished. Postmolt feed intake was higher than that of the unmolted birds and body weights reached values higher than those of the controls. Those responses were not different among strains but the ranking among the strains in the molted group was similar to that of the unmolted controls, for all production traits. The postmolt rate of production approached that of first cycle peak and was not affected by treatment age. Shell quality as reflected by the percentage of breakage during the postmolt period was similar to that of the unmolted controls approximately 3 to 4 mo earlier.

Generation of growth hormone binding protein by avian growth plate chondrocytes is dependent on cell differentiation

Growth hormone receptor (GH-R) gene expression was evaluated in avian growth-plates in situ and in cultured chondrocytes. In the epiphyseal growth-plate, chondrocytes at different stages of differentiation located at the proliferative and upper hypertrophic zones express the GH-R gene. In culture, addition of ascorbic acid facilitated chondrocyte differentiation as evaluated by decrease in collagen type II gene expression and increase in alkaline phosphatase activity and osteopontin gene expression. Both the ascorbic acid-treated and untreated chondrocytes expressed the gene coding for the chicken growth hormone receptor (cGH-R), but only the undifferentiated cells were capable of binding the hormone. This reduction in GH-binding resulted in alteration in GH-dependent regulation of the GH-R gene expression: only the undifferentiated chondrocytes responded to chicken GH (cGH) by down-regulation of the cGH-R gene expression. Chondrocyte differentiation induced by either ascorbic acid or retinoic acid was associated with the appearance of two growth hormone binding-proteins (GHBPs) in the culture medium with estimated MWs of 32 and 70 kDa, respectively. These GHBPs differ in their MW from the major GHBP found in chicken plasma. Chondrocyte GHBPs specifically bind [125I]cGH, which can be displaced by an excess of unlabeled cGH. The differentiation-dependent increase in the 70 kDa GHBP was observed also using specific chicken GHBP antiserum. Our data suggest that the reduction of the differentiated chondrocytes response to GH is due to differentiation-dependent loss of the extracellular domain of the GH-R, resulting in a lack of functional receptors on the cell surface and generation of GHBP.

Cloning, expression, and tissue localization of the calcium-sensing receptor in chicken (Gallus domesticus)

In previous studies, we characterized an extracellular Ca2+ (Cao(2+))-sensing receptor (CaR) that plays a central role in regulating parathyroid hormone secretion in mammals by sensing Cao2+. In the present study, we have cloned and characterized the chicken (Gallus domesticus) homolog of the CaR. The chicken parathyroid CaR shares a high degree of homology (84% amino acid identity) with the human CaR and displays a similar topology. Moreover, amino acid residues where mutations cause disorders of Cao(2+)-sensing in the human CaR share the wild-type human sequence in the chicken CaR. However, a single region in the extracellular domain of the chicken CaR differs substantially from its mammalian homologs. Xenopus laevis oocytes injected with chicken CaR cRNA respond to elevated ambient levels of Cao2+, extracellular Mg2+, or extracellular Gd3+ with the characteristic activation of inositol trisphosphate-dependent, intracellular Ca(2+)-induced Cl- currents elicited by mammalian CaRs as well as by G protein-linked receptors coupled to activation of phospholipase C. By in situ hybridization, clusters of cells in chicken parathyroid glands were shown to express CaR messenger RNA. Northern analysis and immunohistochemistry demonstrated expression of receptor transcripts and/or protein in kidney tubules and intestine as well as in brain. The close conservation of the amino acid sequence of the chicken CaR with its mammalian homologs as well as its similar tissue distribution suggest that the receptor may also play an important role in avian calcium homeostasis.

MRI of the foot and ankle

The foot and ankle are among the hardest of all areas to image because of the complex three-dimensional anatomy. Magnetic resonance imaging (MRI), with its multiplanar capabilities, excellent soft-tissue contrast, ability to image bone marrow, noninvasiveness, and lack of ionizing radiation, has become a valuable tool in evaluating patients with foot and ankle problems. MRI is more specific than bone scintigraphy and provides more information than ultrasound and computed tomography. Arthroscopy of the ankle is limited to the articular surface and joint space. MRI allows a global evaluation of the bones, tendons, ligaments, and other structures with a single examination that exceeds the capabilities of all other available techniques. This monograph was written to provide a useful guide to basic technique, indications, positioning, anatomy, and interpretation of foot and ankle MRI. The first part describes the performance of the MRI examination with reference to the positioning of the foot, types of coils, and advantages and disadvantages of the different sequences and imaging planes. The next section was written by an experienced foot and ankle orthopedic surgeon and outlines the indications for MRI for the common foot and ankle symptom complexes and the information that the surgeon hopes to obtain from the study. This is followed by a review of pertinent anatomy, as it applies to imaging, with emphasis on osseous structures, ligaments, tendons, and muscles. The final section is a comprehensive review of the common pathologic conditions encountered in the foot and ankle. We hope that radiologists and radiologists-in-training find this article a useful reference tool and gain a better understanding of this complex area of musculoskeletal imaging.

The response of broiler chickens and turkey poults to steam-pelleted diets supplemented with fat or carbohydrates

The responses of growth and feed efficiency to pelleted feed was investigated in 4- to 7-wk-old broiler chickens, and in 8- to 12- and 16- to 20-wk-old turkeys. In all cases, the growth and feed efficiency responses were linear within the ranges of dietary energy tested. When energy was added by carbohydrate supplementation, weight gain and feed efficiency responses were parallel for both mash and pellets, but due to the growth response to pellets, the elevation was higher for pellets than for mash. When energy was added by fat, the growth response to pellets also resulted in an increase in function elevation but the slope of the response was lower than in mash feeding, possibly due to a decline in pellet quality as dietary fat increased. Grinding of pellets completely abolished the growth and feed efficiency responses observed when the physical form was preserved. In chickens, comparisons of ground pellets to mash suggested some decline in nutritional quality due to the process of pelleting when either carbohydrates or fat were increased in the diets. In both chickens and turkeys, the feeding of pelleted diets resulted in an increase in abdominal fat.