Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

Balance Right in Multiple Sclerosis (BRiMS): a guided self-management programme to reduce falls and improve quality of life, balance and mobility in people with secondary progressive multiple sclerosis: a protocol for a feasibility randomised controlled trial

BACKGROUND

Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed 'Balance Right in MS' (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial.

METHODS/DESIGN

This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include:Feasibility outcomes, including trial recruitment, retention and completionAssessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level)Measures of adherence to the BRiMS programmeData to inform the economic evaluation in a future trialProcess evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience).

DISCUSSION

The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial.

TRIAL REGISTRATION

ISRCTN13587999.

Standing up in multiple sclerosis (SUMS): protocol for a multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of a home-based self-management standing frame programme in people with progressive multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an incurable, unpredictable but typically progressive neurological condition. It is the most common cause of neurological disability in young adults. Within 15 years of diagnosis, approximately 50 % of affected people are unable to walk unaided, and over time an estimated 25 % depend on a wheelchair. Typically, people with such limited mobility are excluded from clinical trials. Severely impaired people with MS spend much of their day sitting, often with limited ability to change position. In response, secondary complications can occur including: muscle wasting, pain, reduced skin integrity, spasms, limb stiffness, constipation, and associated psychosocial problems such as depression and lowered self-esteem. Effective self-management strategies, which can be implemented relatively easily and cheaply within people's homes, are needed to improve or maintain mobility and reduce sedentary behaviour. However this is challenging, particularly in the latter stages of disease. Regular supported standing using standing frames is one potential option.

METHODS/DESIGN

SUMS is a pragmatic multi-centre randomised controlled trial evaluating use of Oswestry standing frames with blinded outcome assessment and full economic evaluation. Participants will be randomly allocated (1:1) to either a home-based, self-management standing programme (with advice and support) along with their usual care or to usual care alone. Those in the intervention group will be asked to stand for a minimum of 30 min three times weekly over 20 weeks. Each participant will be followed-up at 20 and 36 weeks post baseline. The primary clinical outcome is motor function, assessed using the Amended Motor Club Assessment. The primary economic endpoint is quality-adjusted life years. The secondary outcomes include measures of explanatory physical impairments, key clinical outcomes, and health-related quality of life. An embedded qualitative component will explore participant's and carer's experiences of the standing programme.

DISCUSSION

This is the first large scale multi-centre trial to assess the clinical and cost effectiveness of a home based standing frame programme for people who are severely impaired by MS. If demonstrated to be effective and cost-effective, we will use this evidence to develop recommendations for a health service delivery model which could be implemented across the United Kingdom.

TRIAL REGISTRATION

ISRCTN69614598 DATE OF REGISTRATION: 3.2.16 (retrospectively registered).

The effect of core stability training on balance and mobility in ambulant individuals with multiple sclerosis: a multi-centre series of single case studies

BACKGROUND

Core stability training is popular in the management of people with multiple sclerosis (MS); however, scientific evidence to support its effectiveness is scarce.

OBJECTIVE

To explore the effectiveness of core stability training on balance and mobility.

METHOD

A multi-centre series of eight single case studies was undertaken. Eight ambulant individuals with stable MS participated in 16 face-to-face core stability training sessions, delivered by a neurophysiotherapist, plus a daily home exercise programme. A range of outcomes were measured: 10-m timed walk, 12-item MS walking scale, timed get up and go, functional reach tests, timed single leg stance, visual analogue scales of two activities, and the Activities-specific Balance Confidence Scale.

RESULTS

Visual analysis of trend, level and slope demonstrated improvement in five subjects (62%) in seven measures. This was confirmed by the two standard deviation band method of analysis for six measures. Analysis of group data (repeated measures within subjects analysis of variance) indicated significant improvement between baseline and intervention phases for timed walk (p = 0.019), MSWS-12 Scale (p = 0.041), forward (p = 0.015) and lateral reach (p = 0.012). In general, no further improvements were made following withdrawal of the intervention.

CONCLUSIONS

This study provides preliminary evidence of the effectiveness of an 8-week core stability training programme in improving balance and mobility in ambulant people with MS. Variations in response to intervention are evident. Assessor-blinded randomized controlled studies are required to confirm these findings and determine patient characteristics which identify those who benefit most from this intervention.

Evaluating neurorehabilitation: lessons from routine data collection

BACKGROUND

Clinical databases are being used increasingly to assess outcomes in healthcare services to provide evidence of clinical effectiveness in routine clinical practice.

OBJECTIVES

To explore the benefits of a database for routine collection of clinical outcomes within an inpatient neurorehabilitation setting; determine the effectiveness of inpatient neurorehabilitation in a range of neurological conditions; and determine variables influencing change in functional outcome.

METHODS

Over a nine year period, demographic and diagnostic characteristics were collected for the 1458 patients admitted consecutively to a neurorehabilitation unit. The level of function was measured on admission and discharge using the Barthel Index (BI) and Functional Independence Measure (FIM). Patient perception of rehabilitation benefit was evaluated using visual analogue scales (VAS).

RESULTS

Of the 1413 patients (mean (SD) age 48 (14.8), range 16 to 87) whose length of stay was more than 10 days (mean 34 (24) range 10 to 184), 282 had stroke, 614 multiple sclerosis, 248 spinal cord injuries, 93 a neuromuscular condition, and 176 other brain pathology. Patients improved in functional ability as measured by both BI and the FIM motor subscale (effect sizes 0.93 to 1.44 and 1.01 to 1.48, respectively). VAS ratings demonstrated high levels of patient perceived benefit. Diagnosis, functional activity score on admission, and length of stay were significant predictors of functional gain, explaining 44% of the variability in the change scores.

CONCLUSIONS

Systematic collection, analysis, and interpretation of standardised clinical outcomes data are feasible within routine clinical practice, and provide evidence that inpatient rehabilitation is effective in improving functional level in neurologically impaired patients. These data complement those of clinical trials and are useful in informing and developing clinical and research practice.

Using the SF-36 measure to compare the health impact of multiple sclerosis and Parkinson's disease with normal population health profiles

OBJECTIVE

To examine the relative impact of two chronic neurological disorders, multiple sclerosis and Parkinson's disease, by comparing patients' scores on the medical outcomes study 36-item short form health survey (SF-36) with the health profile of the United Kingdom population norms.

METHODS

638 people representing the full spectrum of multiple sclerosis and 227 patients with Parkinson's disease were studied. Health status was measured by the SF-36. Scores for the eight health domains were compared after controlling for age, sex, disease duration, mobility, social class, ethnicity, education, marital status, and employment status.

RESULTS

People with multiple sclerosis and those with Parkinson's disease had significantly worse health than the general population on all eight domains measured by the SF-36. The relative impact of multiple sclerosis and Parkinson's disease were similar, but multiple sclerosis resulted in poorer scores on physical functioning and better scores in mental health. People with mild multiple sclerosis who walked without an aid also had significantly worse scores in all dimensions than the general UK population.

CONCLUSIONS

The results highlight the need for further research into aspects of health measured by the SF-36. Nevertheless, generic measures that are applicable across multiple diseases may fail to address clinically important aspects of the impact of specific disorders.

Interferon-beta1b in the treatment of secondary progressive MS: impact on quality of life

BACKGROUND

The recent randomized, controlled trial of interferon-beta1b (IFN-beta1b) in 718 patients with secondary progressive MS (SP-MS) demonstrated a significant effect on the development of disability as evaluated by the physician. Its effect on patient-reported health-related quality of life (HrQoL) is reported herein.

METHODS

In this multicenter, double-blind, randomized, placebo-controlled trial, outpatients with SP-MS scoring between 3.0 and 6.5 on the Expanded Disability Status Scale received either 8 x 10(6) IU of IFN-beta1b or placebo for up to 3 years. A range of outcomes was measured, including HrQoL, which was assessed using the Sickness Impact Profile (SIP), a self-report questionnaire validated for use in MS. Measurements were undertaken at baseline and at 6-monthly intervals thereafter for 36 months.

RESULTS

A slight positive effect on the HrQoL of the IFN group in comparison with the placebo group was found, which reached significance in the physical scale of the SIP at 6 and 12 months and at last visit. There was moderate correlation between physician-assessed evaluation of change and patient-reported change.

CONCLUSIONS

IFN-beta1b may delay sustained deterioration in patient-reported HrQoL in SP-MS. Methods of interpreting change in HrQoL are currently insufficiently developed to determine how clinically important these changes are for this population.

SseBCD proteins are secreted by the type III secretion system of Salmonella pathogenicity island 2 and function as a translocon

The type III secretion system encoded by Salmonella pathogenicity island 2 (SPI2) is required for systemic infections and intracellular accumulation of Salmonella enterica. This system is induced by intracellular Salmonella and subsequently transfers effector proteins into the host cell. Growth conditions either inducing expression of the type III secretion system or the secretion of substrate proteins were defined. Here we report the identification of a set of substrate proteins consisting of SseB, SseC, and SseD that are secreted by the SPI2 system in vitro. Secretion was observed if bacterial cells were exposed to acidic pH after growth in minimal medium with limitation of Mg(2+) or phosphate. SseB, -C, and -D were isolated in a fraction detached from the bacterial cell surface by mechanical shearing, indicating that these proteins are predominantly assembled into complexes on the bacterial cell surface. The three proteins were required for the translocation of SPI2 effector proteins SspH1 and SspH2 into infected host cells. Thus, SseB, SseC, and SseD function as the translocon for effector proteins by intracellular Salmonella.

Evidence-based measurement: which disability scale for neurologic rehabilitation?

OBJECTIVE

To compare the 10-item Barthel Index (BI), 18-item Functional Independence Measure (FIM), and 30-item Functional Independence Measure + Functional Assessment Measure (FIM+FAM) as measures of disability outcomes for neurologic rehabilitation.

METHODS

A total of 149 inpatients from two rehabilitation units in South England specializing in neurologic disorders were studied. Traditional psychometric methods were used to evaluate and compare acceptability (score distributions), reliability (internal consistency, intrarater reproducibility), validity (concurrent, convergent and discriminant construct), and responsiveness (standardized response mean).

RESULTS

All three rating scales satisfied recommended criteria for reliable and valid measurement of disability, and are acceptable and responsive in this study sample. The FIM and FIM+FAM total scales are psychometrically similar measures of global disability. The BI, FIM, and FIM+FAM motor scales are psychometrically similar measures of physical disability. The FIM and FIM+FAM cognitive scales are psychometrically similar measures of physical disability.

CONCLUSIONS

In the sample studied, the BI, FIM, FIM+FAM have similar measurement properties, when examined using traditional psychometric analyses. Although instruments with more items and item response categories generate more qualitative information about an outcome, they may not improve its measurement. Results highlight the importance of using recognized techniques of scale construction to develop health outcome measures.

Does adding MS-specific items to a generic measure (the SF-36) improve measurement?

OBJECTIVE

The 36-item Short Form Health Survey Questionnaire (SF-36) is a widely used generic health status measure. Recently it has been adapted to produce a disease-specific measure for MS-the 54-item Multiple Sclerosis Quality of Life Scale (MSQOL-54)-composed of five unchanged SF-36 scales; three altered SF-36 scales (one item added to each scale); and five new scales incorporating 15 additional items. This study evaluates the impact of these additions by comparing the measurement properties of the MSQOL-54 with the SF-36.

METHODS

A total of 150 patients with MS, representing a broad spectrum of disease severity, completed a range of questionnaires, which included the MSQOL-54 (from which the SF-36 score was computed). Of these, 44 people completed the measures before and after inpatient rehabilitation to evaluate responsiveness. Standard psychometric methods were used to evaluate the measurement properties.

RESULTS

The measurement properties of the unchanged scales, inevitably, remain identical. Those of the three altered scales are virtually identical. Of the five new scales, the validity of the two sexual scales is questioned because of the high percentage of missing data, and the validity of the overall quality-of-life scale is limited as demonstrated by the low to moderate correlations with other related and unrelated measures. Responsiveness of the new scales also appears limited.

CONCLUSION

Modifying existing measures by simply adding clinically chosen items may not be as useful as anticipated in improving the measurement properties of an instrument.

Improving mobility and functional independence in persons with multiple sclerosis

Persons with multiple sclerosis (MS) commonly experience restrictions in mobility and everyday functional activities. A wide range of factors including physical, psychological, environmental and economic issues may contribute to these difficulties. This is particularly the case as the disease evolves, and the impairments and disabilities become more numerous, inter-related and hence more complex. Effective management of these complex problems requires assessment and intervention from a variety of different perspectives by using a coordinated, goal-oriented, multi-disciplinary management approach. Crucially, it requires management to be considered from a long-term perspective rather than as a fragmented series of isolated "quick-fixes".

Community services in multiple sclerosis: still a matter of chance

OBJECTIVES

People with multiple sclerosis often have multiple complex needs that require input from a wide range of services. Many complain that services are inadequate and poorly coordinated. Few studies have been undertaken to support this contention and objective data are scarce. The level of services and home modifications received by people with multiple sclerosis across a broad range of disease severity has been investigated.

METHODS

As part of a quality of life study, 150 adults with clinically definite multiple sclerosis were interviewed, using a structured questionnaire, to determine their current use of outpatient and community services and the home modifications in place. Disability, handicap, and emotional status were also measured.

RESULTS

Forty five per cent of people did not receive any community services other than contact with their general practitioner. Thirty nine per cent of people with moderate and 12% with severe disability failed to receive community services. For the services received: 17% had contact with a community nurse; 33% with a care attendant or home help; 23% with a physiotherapist, 21% with an occupational therapist, and 10% with a social worker. Fifty eight per cent of people had modifications to their home as a direct result of multiple sclerosis. The relation between level of disability and number of services and adaptations received was moderate (r=0.58 and 0.54 respectively) and the relation between level of services and age (r=0.12), living alone (r=0.16), and emotional status (r=0.10) was negligible.

CONCLUSIONS

Despite a shift of emphasis from hospital to community care, and the establishment of standards of care for multiple sclerosis, many people with moderate or severe disability fail to receive assistance. These results provide evidence to support the dissatisfaction felt by people with multiple sclerosis in relation to the services they receive. It raises questions about equitable allocation of resources and highlights the urgent need for a review of community services.

Exercise alone is an effective strategy for reducing obesity and related comorbidities

The commonly held view that exercise alone is not a useful strategy for obesity reduction is drawn from studies with limitations that confound interpretation. Recent evidence counters the dogma that daily exercise produces only modest weight loss and suggests that exercise without diet restriction is an effective strategy for reducing obesity and related co-morbidities.

Clinical appropriateness: a key factor in outcome measure selection: the 36 item short form health survey in multiple sclerosis

OBJECTIVES

Understanding the properties of an outcome measure is essential in choosing the appropriate instrument and interpreting the information it generates. The MOS 36 item short form health survey questionnaire (SF-36) is widely acknowledged as the gold standard generic measure of health status; few studies however have evaluated its use for clinical trials in multiple sclerosis. Its clinical appropriateness, internal consistency reliability, validity, and responsiveness was investigated across a broad range of patients with multiple sclerosis.

METHODS

A prospective study in which 150 adults with clinically definite multiple sclerosis completed a battery of questionnaires evaluating generic health status, disability, handicap, and emotional wellbeing. Of these, 44 patients undergoing inpatient rehabilitation completed the questionnaires before and after intervention to evaluate responsiveness.

RESULTS

Score distributions demonstrated significant floor and ceiling effects in four of the eight dimensions which were particularly marked when patient selection was restricted to a narrow band of disease severity (as is the case in most clinical trials). Internal consistency exceeded the standard for group comparisons for all dimensions. Convergent and discriminant construct validity was supported by the direction, magnitude, and pattern of correlations with other health measures. In comparison with instruments measuring associated constructs, the responsiveness of the SF-36 was poor in evaluating change in moderate to severely disabled patients participating in a programme of inpatient rehabilitation.

CONCLUSIONS

The SF-36 has some limitations as an outcome measure in multiple sclerosis. The results highlight the need for all instruments to be examined in the specific sample population under question and for the specific research question being investigated. In multiple sclerosis clinical trials, the SF-36 should be supplemented with other relevant measures.

A genetic analysis of the functions of LuxN: a two-component hybrid sensor kinase that regulates quorum sensing in Vibrio harveyi

The bioluminescent marine bacterium Vibrio harveyi controls light production using two parallel quorum-sensing systems. V. harveyi produces two autoinducers (AI-1 and AI-2), which are recognized by cognate membrane-bound two-component hybrid sensor kinases called LuxN and LuxQ respectively. Under conditions of low cell density, in the absence of autoinducer, the hybrid sensors are kinases, and under conditions of high cell density, in the presence of autoinducer, the sensors are phosphatases. These activities allow LuxN and LuxQ to modulate the level of phosphorylation of the response regulator protein LuxO. LuxO, in turn, controls the transcription of the genes encoding luciferase. The phosphorelay protein LuxU is required for signalling to LuxO. In this report, we present a genetic analysis of the activities of the AI-1 sensor LuxN. Point mutations and in frame deletions were constructed in luxN and recombined onto the chromosome of V. harveyi for in vivo phenotypic analysis. We show that the conserved histidine (H471) in the sensor kinase domain of LuxN is required for kinase activity but not for phosphatase activity. In contrast, the conserved aspartate (D771) in the response regulator domain of LuxN is required for both activities. Furthermore, the LuxN phosphatase activity is localized to the response regulator domain. Our results indicate that the LuxN kinase activity is regulated by the presence of AI-1, whereas the LuxN phosphatase activity is constitutive. We also show that signalling from the two V. harveyi quorum-sensing systems is not equivalent. AI-1 and LuxN have a much greater effect on the level of LuxO phosphate and therefore Lux expression than do AI-2 and LuxQ.

Rehabilitation in Multiple Sclerosis: Outcome Selection in Clinical Trials

In carrying out an evaluation of multidisciplinary rehabilitation in multiple sclerosis (MS), it is necessary to select relevant outcomes to measure and to identify instruments to use for their measurement. This requires a detailed understanding of the problems of MS, the aims of the rehabilitation, and the changes that are expected as a result of the rehabilitation. It also requires a thorough knowledge of the clinical and scientific properties of the measurement instruments, so that the most appropriate instruments can be selected and the data produced from them can be interpreted meaningfully. This article provides a structured and systematic approach to undertaking this selection process.

Right intrathoracic renal ectopia: a case report and review of the literature

We report a case of right intrathoracic renal ectopia associated with a previously unreported congenital anomaly (trisomy 21) and review of the literature.

Intra-abdominal pulmonary sequestration: a benign suprarenal mass

A 34-year-old white woman presented with an 8.5-cm left suprarenal mass. Evaluation revealed normal adrenal hormone function. Pathologic examination after surgical removal revealed a rare benign condition, intra-abdominal extralobar pulmonary sequestration (accessory lung).

Complex renal cysts: findings on MR imaging

OBJECTIVE

We retrospectively evaluated our experience with complex cystic renal masses on MR imaging, using T1-weighted, T2-weighted, and gadolinium-enhanced images, to determine whether imaging features could permit distinction between benign and malignant lesions.

MATERIALS AND METHODS

Thirty-seven patients with complex cystic renal lesions were included in this retrospective study. The patients selected had undergone T1-weighted, T2-weighted, and gadolinium-enhanced MR imaging examinations using 1.5-T scanners, with at least one of the following findings: cyst fluid of heterogeneous signal intensity, mural irregularity, septa, mural masses or nodules, increased mural thickness, or intense mural enhancement. The diagnosis was established by histology in 19 patients and by follow-up studies in the remaining 18 patients.

RESULTS

Fifty-five complex renal cystic lesions were present in the 37 patients. Among the 55 lesions, of 37 that contained fluid of a heterogeneous signal intensity, eight were malignant (22%); of 16 with irregular walls, 10 were malignant (63%); of four with septa, two were malignant (50%); of four with mural masses or nodules, three were malignant (75%); of 14 with a thick wall (>2 mm), 10 were malignant (71%); and of 32 with intense mural enhancement, 14 were malignant (44%). As independent variables, mural irregularity, mural masses or nodules, increased mural thickness, and intense mural enhancement each were highly associated with malignancy (p = .0003-.0022). The combination of mural irregularity and intense mural enhancement had the highest correlation with malignancy (p = .0002).

CONCLUSION

The combination of mural irregularity and intense mural enhancement is a strong predictor of malignancy in renal cystic lesions. However, the appearance of benign and malignant lesions may overlap, suggesting that distinct separation of these entities is not currently possible in all cases with MR imaging.

Adrenal neuroblastoma in an adult with tumor thrombus in the inferior vena cava

We describe the appearance of an adrenal neuroblastoma associated with tumor thrombus occurring in an adult patient. The tumor measured 14 x 12 x 12 cm, showed heterogeneous signal intensity on both T1-weighted and T2-weighted images, and displayed peripheral nodular enhancement on early post-gadolinium images. Tumor thrombus was identified within the inferior vena cava, which extended into the right atrium.

Measuring change in disability after inpatient rehabilitation: comparison of the responsiveness of the Barthel index and the Functional Independence Measure

BACKGROUND

The importance of evaluating disability outcome measures is well recognised. The Functional Independence Measure (FIM) was developed to be a more comprehensive and "sensitive" measure of disability than the Barthel Index (BI). Although the FIM is widely used and has been shown to be reliable and valid, there is limited information about its responsiveness, particularly in comparison with the BI. This study compares the appropriateness and responsiveness of these two disability measures in patients with multiple sclerosis and stroke.

METHODS

Patients with multiple sclerosis (n=201) and poststroke (n=82) patients undergoing inpatient neurorehabilitation were studied. Admission and discharge scores were generated for the BI and the three scales of the FIM (total, motor, and cognitive). Appropriateness of the measures to the study samples was determined by examining score distributions, floor and ceiling effects. Responsiveness was determined using an effect size calculation.

RESULTS

The BI, FIM total, and FIM motor scales show good variability and have small floor and ceiling effects in the study samples. The FIM cognitive scale showed a notable ceiling effect in patients with multiple sclerosis. Comparable effect sizes were found for the BI, and two FIM scales (total and motor) in both patients with multiple sclerosis and stroke patients.

CONCLUSION

All measures were appropriate to the study sample. The FIM cognitive scale, however, has limited usefulness as an outcome measure in progressive multiple sclerosis. The BI, FIM total, and FIM motor scales show similar responsiveness, suggesting that both the FIM total and FIM motor scales have no advantage over the BI in evaluating change.

Sequence and function of LuxU: a two-component phosphorelay protein that regulates quorum sensing in Vibrio harveyi

Vibrio harveyi regulates the expression of bioluminescence (lux) in response to cell density, a phenomenon known as quorum sensing. In V. harveyi, two independent quorum-sensing systems exist, and each produces, detects, and responds to a specific cell density-dependent autoinducer signal. The autoinducers are recognized by two-component hybrid sensor kinases called LuxN and LuxQ, and sensory information from both systems is transduced by a phosphorelay mechanism to the response regulator protein LuxO. Genetic evidence suggests that LuxO-phosphate negatively regulates the expression of luminescence at low cell density in the absence of autoinducers. At high cell density, interaction of the sensors with their cognate autoinducers results in dephosphorylation and inactivation of the LuxO repressor. In the present report, we show that LuxN and LuxQ channel sensory information to LuxO via a newly identified phosphorelay protein that we have named LuxU. LuxU shows sequence similarity to other described phosphorelay proteins, including BvgS, ArcB, and Ypd1. A critical His residue (His 58) of LuxU is required for phosphorelay function.

A genetic analysis of the function of LuxO, a two-component response regulator involved in quorum sensing in Vibrio harveyi

Two independent quorum-sensing systems control the expression of bioluminescence (lux) in the marine bacterium Vibrio harveyi. Each system is composed of an autoinducer (AI-1 or AI-2) and its cognate sensor (LuxN or LuxQ). The sensors are two-component hybrid kinases, containing both sensor kinase domains and response regulator domains. Sensory information from the two systems is relayed by a phosphotransfer mechanism to a shared integrator protein called LuxO. LuxO is a member of the response regulator class of the two-component family of signal transduction proteins, and LuxO acts negatively to control luminescence. In this report, missense and in frame deletion mutations were constructed in luxO that encoded proteins mimicking either the phosphorylated or the unphosphorylated form, and these mutations were introduced into the V. harveyi chromosome at the luxO locus. Phenotypical analyses of the resulting mutant V. harveyi strains indicate that the phosphorylated form of LuxO is the repressor, and that the unphosphorylated form of the protein is inactive. Analysis of the lux phenotypes of V. harveyi strains containing single and double luxN and luxQ mutations indicate that LuxN and LuxQ have two activities on LuxO. They act as LuxO protein kinases at low cell density in the absence of autoinducers, and they switch to LuxO protein phosphatases at high cell density in the presence of autoinducers. Furthermore, the timing and potency of inputs from the two systems into regulation of quorum sensing are different.

Inpatient rehabilitation in multiple sclerosis: do the benefits carry over into the community?

OBJECTIVE

To determine the duration and pattern of carry-over of benefits gained after a short period of multidisciplinary inpatient rehabilitation.

BACKGROUND

Few studies have evaluated the outcome of rehabilitation after discharge. Long-term follow-up is required to establish whether gains made during the inpatient stay are sustained over time and in the patient's own environment.

METHODS

Prospective single-group longitudinal study. Fifty consecutive patients with progressive MS undergoing inpatient rehabilitation were followed for 12 months after discharge. Assessments were undertaken on admission (A), at discharge, and subsequently at 3-month intervals for 1 year (1Y) with a battery of measures addressing neurologic status, disability, handicap, quality of life, and emotional well-being. The time taken to return to baseline level was calculated using summary measures, and trends in performance levels were plotted.

RESULTS

Twelve-month data were collected for 92% of patients. Although neurologic status declined (median Expanded Disability Status Scale scores: A = 6.8, 1Y = 8.0), improvements were maintained in disability and handicap for 6 months, emotional well-being for 7 months, and health-related quality of life (physical component) for 10 months.

CONCLUSIONS

The benefits gained from rehabilitation were partly maintained after discharge despite worsening neurologic status. Carry-over of benefits, however, declined over time, reinforcing the need for continuity of care between the inpatient setting and the community.

A comparison of techniques for placement of double-lumen endobronchial tubes

STUDY OBJECTIVE

To compare two methods of double-lumen endobronchial tube placement for thoracic surgery and to identify factors that provide a rational basis for placement method selection.

DESIGN

Prospective, randomized study.

SETTING

Teaching hospital.

PATIENTS

58 ASA physical status II, III, and IV patients scheduled for surgical procedures requiring elective left-sided endobronchial intubation.

INTERVENTIONS

Patients were assigned randomly to either a group in which the initial placement method was the traditional approach of placing the endobronchial tube through the larynx and then advanced blindly into the left mainstem bronchus, or to a second group in which the left mainstem bronchus was intubated under direct vision using the fiberoptic bronchoscope.

MEASUREMENTS AND MAIN RESULTS

Of the 32 patients who underwent the traditional approach, primary success occurred in 27 patients and eventual success in 30. In 27 patients undergoing the directed approach, primary success occurred in 21 patients and eventual success in 25. Two patients in each group required the alternative method. The blind approach took 88 (+/- 91) seconds and the directed approach took 181 (+/- 193) seconds (p = 0.029). Timing data were analyzed using analysis of variance with respect to method and secretions and then t-tests as appropriate. Categorical data were analyzed using the Kruskal-Wallis and Fisher's exact tests as appropriate. All values are reported as means +/- SD.

CONCLUSION

Both the blind and directed approaches resulted in successful left mainstem placement of the endobronchial tube in the majority of patients but either method may fail when used alone. More time was required using the directed approach. Operator experience with both methods will increase the likelihood of success. The choice of the initial approach may be influenced by patient factors as well as available equipment and personnel.

Prognostic markers in bladder cancer: a contemporary review of the literature

PURPOSE

We provide a contemporary review of bladder tumor markers and summarize their role as prognostic indicators.

MATERIALS AND METHODS

A comprehensive review of the literature on prognostic markers for transitional cell carcinoma of the bladder was performed.

RESULTS

Intense research efforts are being made to identify and characterize better various bladder cancers and their true biological potential. The need to predict which superficial tumors will recur or progress and which invasive tumors will metastasize has led to the identification of a variety of potential prognostic markers. Blood group antigens, tumor associated antigens, proliferating antigens, oncogenes, peptide growth factors and their receptors, cell adhesion molecules, tumor angiogenesis and angiogenesis inhibitors, and cell cycle regulatory proteins have recently been identified. The potential clinical applications of these tumor markers are under active investigation. Recent attention has focused on which tumor markers may predict the responsiveness of a particular bladder cancer to systemic chemotherapy.

CONCLUSIONS

At present conventional histopathological evaluation of bladder cancer (tumor grade and stage) cannot predict accurately the behavior of most bladder tumors. With a better understanding of the cell cycle, and cell to cell and cell to extracellular matrix interactions as well as improved diagnostic techniques (immunohistochemistry), progress is being made to identify and characterize other potential prognostic markers for transitional cell carcinoma of the bladder. The ultimate goal is to develop reliable prognostic markers that will accurately predict not only the course but also the response of a tumor to therapy. This information may then be used to dictate more aggressive treatment for tumors that are likely to progress and less aggressive treatment for those that are unlikely to progress. In the future these biological markers may also be used in gene therapy for the treatment of bladder cancer.

Prospective pathologic analysis of female cystectomy specimens: risk factors for orthotopic diversion in women

OBJECTIVES

To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion.

METHODS

Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra).

RESULTS

Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section.

CONCLUSIONS

We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.

Primary malignant melanoma with rhabdoid features: a histologic and immunocytochemical study of three cases

Malignant rhabdoid tumors are morphologically characterized by the presence of sheets of large polygonal cells with abundant cytoplasm containing eosinophilic inclusions. They have vesicular nuclei, often with prominent central nucleoli. The term rhabdoid tumor was originally coined to describe a group of rare, aggressive renal neoplasms of childhood. Since then, similar lesions, so-called extrarenal malignant rhabdoid tumors have been increasingly reported. The evidence to date suggests that, at least in extrarenal locations, rhabdoid tumors do not constitute a homogeneous entity, but rather represent the shared morphological pattern of a diverse range of malignant neoplasms. Although such rhabdoid features are not uncommon in metastatic malignant melanoma, they have only once been briefly described in a primary lesion. We report three further cases of cutaneous primary malignant melanoma with rhabdoid morphology.

Tricyclic pyrone analogs: a new class of microtubule-disrupting anticancer drugs effective against murine leukemia cells in vitro

Novel 1H,7H-5a,6,8,9-tetrahydro-1-oxopyrano [4,3-b][1]benzopyrans were synthesized in Hua's laboratory (code names H5, H10, H14 and H15) and tested for their ability to prevent L1210 leukemic cells from synthesizing macromolecules and growing in vitro. The aryl groups of these tricyclic pyrone (TP) analogs are either 3, 4-dimethoxyphenyl in H5 and H15 or 3-pyridyl in H10 and H14. Since 50 M H5 and H10 both inhibit DNA synthesis and tumor cell growth by 79-100%, concentrations 25 M were used in this study to assess the structure-activity relationships for this class of compounds. At 10-25 M, H5 and H14 are more potent inhibitors of DNA, RNA and protein synthesis than H10. In contrast, at 5-25 M, H10 is much more effective than H5 and H14 at inhibiting the growth of L1210 cells over a 4-day period. Interestingly, H15 inhibits DNA synthesis as much as H10 but fails to alter tumor cell growth. This discrepancy between the ability of TPs to inhibit macromolecule synthesis and leukemic cell growth suggests that other molecular targets may be involved in the antitumor action of these drugs. Their short-term inhibition of nucleic acid synthesis is reversible following drug removal but their long-term inhibition of tumor cell growth is not. Moreover, 25 M H5 and H10 are not cytotoxic at 2 days but equally decrease cell viability at 4 days, suggesting that the potent and irreversible inhibition of cell proliferation observed 1-4 days after H10 treatment is not solely caused by drug cytotoxicity. The effectiveness of H10 as inhibitor of L1210 cell growth is comparable to that of a spectrum of representative anticancer drugs. A critical finding is that 5 M H10 blocks the polymerization of purified tubulin by 90% and, therefore, may be a novel microtubule de-stabilizing drug. Indeed, H10 inhibits tubulin polymerization and L1210 cell growth as much as 5 M of vincristine (VCR). In contrast, 5 M H5 alters neither tubulin polymerization nor tumor cell growth. The ability of H10 to disrupt microtubule dynamics indirectly suggests that TPs may be novel cell cycle-specific anticancer drugs useful for arresting mammalian cells in mitosis.

Expectant management as an option for men with stage T1c prostate cancer: a preliminary study

The outcome of patients selecting observation of clinical stage T1c prostate cancer is unknown. A total of 101 men with clinical stage T1c prostate cancer were evaluated, counseled, and monitored in a standard fashion. Altogether, 27 men who elected observation were older and had greater co-morbidity but similar tumor characteristics as compared with 74 men who elected radical prostatectomy. In all, 9 men demonstrated clinical or biochemical evidence of progression after a mean follow-up of 23 months; 4 men who underwent radical prostatectomy had specimen-confined disease and undetectable post-operative levels of PSA. Observation appears to be a viable option for some men with clinical stage T1c prostate cancer.

Antitumor activity of novel octalactin A analogs in murine leukemia cells in vitro

Octalactin A and B (code names K1 and K2) are eight-membered-ring lactones from a marine bacterium. K1 is reportedly cytotoxic. Since access to this natural product is severely limited, the entire synthesis of K1 has been achieved in K. Buszek's laboratory, and several of its structural and stereochemical analogs (code names K3-K9) have been tested for their ability to prevent murine L1210 leukemic cells from synthesizing macromolecules and growing in vitro. At 50 microM, K1 is inactive and the eight-membered lactone K4, an oxocene, is the only compound found to inhibit tumor cell growth by about 90% in the L1210 system. The long-term inhibition of L1210 cell growth by K4 is concentration dependent (IC50 around 10 microM) and not reversible following drug removal. The delayed and weaker cytotoxic effects of K4 suggest that the inhibition of tumor cell proliferation observed 1-4 days after K4 treatment is not solely caused by drug cytotoxicity. When compared to a spectrum of representative anticancer drugs, higher concentrations of K4 must be used to maximally inhibit tumor cell growth. In contrast to its antiproliferative activity, 50 microM K4 fails to alter the rates of DNA, RNA and protein synthesis in L1210 cells. This discrepancy between the ability of K4 to inhibit macromolecule synthesis and leukemic cell growth suggests that other molecular targets are involved in the antitumor action of this drug. At 50 microM, K4 inhibits the polymerization of purified tubulin by about 45%, and therefore may be a novel microtubule de-stabilizing drug weaker than vincristine. Even though other mechanisms may be involved in its antitumor action, the ability of K4 to partially disrupt microtubule dynamics indirectly suggests that this synthetic oxocene may be a cell cycle-specific anticancer drug that blocks mammalian cells in M-phase.

Orthotopic reconstruction in a woman following cystectomy and cutaneous urinary diversion. The 1st reported case

Orthotopic lower urinary tract reconstruction has become the procedure of choice in selected male and female patients at our institution following cystectomy with excellent functional results. A natural extension of the orthotopic neobladder is undiversion to the intact native urethra in patients who had previously undergone cystectomy and cutaneous urinary diversion. Undiversion has been successfully performed in selected male patients; however, to our knowledge, undiversion has not been reported in women. Herein, we present the 1st case of undiversion in a female patient who had undergone prior cystectomy and cutaneous urinary diversion.

Anaesthetists' attitudes towards an anaesthesia simulator. A comparative survey: U.S.A. and Australia

Anaesthesia simulation has been suggested as a method to enhance the training of clinicians without exposing patient to risk. Recently, two anaesthesia simulators have become commercially available in the U.S.A. Attitudes towards anaesthesia simulators have not been previously surveyed. With institutional approval, a survey questionnaire was given to 1. all clinical staff of the Department of Anesthesiology, University of Pittsburgh Medical Center, and 2. all anaesthetists attending the Annual General Meeting of the Australian Society of Anaesthetists. An information sheet containing details about anaesthesia simulation in general and the special capabilities of a particular commercial anaesthesia simulator was included with the survey instrument. The survey was anonymous and contained 15 questions. Attitudinal responses were recorded using an anchored visual analog 100 mm scale. We surveyed anaesthetists during September-October 1993. Completed forms were returned by 183 anaesthetists. Respondents were aged 25-67 years (mean age 41 +/- 10 yr) and were grouped by staff position (78% faculty, 22% trainees), sex (79% male; 21% female), country of practice (44% Aust, 56% U.S.A.) and years in practice. Seventy-three per cent staff were in favour (VAS > 60) of departmental purchase of a simulator (with no significant difference between countries) and 76% expressed willingness (VAS > 60) to undergo testing in their own time (with Australian anaesthetists significantly more willing to do so). However, 65% were not in favour (VAS < 40) of the compulsory use of a simulator for re-certification or re-accreditation of anaesthesia practitioners, with American anaesthetists (anesthesiologists) significantly more opposed to it. The most frequent comment related to the cost. There is majority support for the purchase of an anaesthesia simulator but there is widespread concern for its high cost. In general, anaesthesia simulation is perceived more as an education tool rather than an instrument for (re)certification.

Early cystectomy for clinical stage T1 transitional cell carcinoma of the bladder

Early radical cystectomy for a high-grade tumor invading the lamina propria (T1) remains controversial. In 1997, we cannot identify accurately which of these high-risk tumors will progress to muscle-invasive disease and metastases. In the near future, urologists may be able to use the presence of genetic alterations, such as p53 mutations, to help make therapeutic decisions. Previous reports on superficial bladder cancer treated with intravesical bacillus Calmette-Guérin immunotherapy have demonstrated a decrease in recurrence and progression. Unfortunately, there is no reliable method to predict which patients with a high-grade T1 tumor will fail to respond to intravesical therapy. Failure of intravesical therapy to control these aggressive tumors is associated with a significant rate of pathological upstaging and metastases. Radical cystectomy will cure a high percentage of these T1 tumors with acceptable morbidity and low mortality. In an era of nerve-sparing cystectomy and orthotopic neobladder reconstruction, early radical cystectomy is an alternative that should be discussed with the patient before instituting intravesical therapy.

The impact of inpatient rehabilitation on progressive multiple sclerosis

One of the primary aims of rehabilitation for patients with multiple sclerosis (MS) is to reduce their levels of disability and handicap, yet little systematic research into the outcomes of this intervention has been undertaken. This stratified, randomized, wait-list controlled study evaluated the effectiveness of a short period of multidisciplinary inpatient rehabilitation in people with MS. Sixty-six patients in the progressive phase of the disease were assessed at 0 and 6 weeks with validated measures of impairment (Expanded Disability Status Scale and Functional Systems), disability (Functional Independence Measure), and handicap (London Handicap Scale). Both groups were comparable in terms of age, sex, disease duration and severity, disability, and handicap. At the end of 6 weeks, although the level of impairment in both groups remained the same, those who participated in a short period of inpatient rehabilitation (average of 25 days) significantly improved their level of disability and handicap compared with those in the wait-list control group. Despite unchanging impairment, inpatient rehabilitation resulted in reduced disability and handicap in patients with progressive MS.

Orthotopic lower urinary tract reconstruction in women using the Kock ileal neobladder: updated experience in 34 patients

PURPOSE

Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction at our institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients.

MATERIALS AND METHODS

Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70).

RESULTS

There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ. Complete daytime and nighttime continence was reported by 29 (88%) and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming.

CONCLUSIONS

The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy.

Evaluation of an on-line patient exposure meter in neuroradiology

PURPOSE

To assess the clinical performance and usefulness of an on-line patient exposure meter installed on a neuroradiologic biplane imaging system.

MATERIALS AND METHODS

A commercial on-line patient exposure meter was installed on each plane of a biplane neuroradiologic imaging system. The meter computed skin exposures on the basis of selected technique factors (tube potential and current) and information about patient location relative to the x-ray tube. Simulations were performed to measure the system accuracy with an angiographic anthropomorphic head phantom with the skin exposures measured with an ionization chamber. Skin doses were computed for 114 consecutive patients who underwent diagnostic and interventional neuroradiologic procedures.

RESULTS

Agreement between measured and computed skin exposures in fluoroscopy, plain radiography, and digital imaging was generally within 5% of the true skin dose. For all fluoroscopic and radiographic procedures, total median skin doses were 1.20 and 0.64 Gy for the frontal and lateral planes, respectively. In both planes, patient skin doses resulted primarily from digital subtraction angiographic acquisitions. In 29 (25%) patients, the skin dose exceeded 2.00 Gy, but no radiation-induced deterministic effects were observed.

CONCLUSION

An on-line patient exposure meter can provide accurate radiation skin dose data in patients undergoing diagnostic and therapeutic neuroradiologic procedures.

New technique of vaginal reconstruction following anterior exenteration

Vaginal reconstruction is important in sexually active females undergoing anterior exenteration for malignant disease. We describe a technique for vaginal reconstruction used in two women who underwent radical cystectomy that required en bloc removal of the anterior vaginal wall. A polyglycolic acid mesh with a pedicle graft of greater omentum creates the anterior 270 degrees and the apex of the neovagina. The technique is simple and adds to the urologist's armamentarium of reconstructive procedures that improve quality of life following exenterative surgery.

Rigid fixation and strain patterns in the pig zygomatic arch and suture

PURPOSE

In orthognathic surgery, rigid fixation is routinely used to hold together bone fragments that may experience heavy force from attached masticatory muscles. Internal fixation plates are assumed to hold bony parts rigidly, but the mobility at such sites subjected to normal masticatory function has not been measured. The purpose of this study was to investigate in vivo the degree to which a linear plate immobilizes separated bones, specifically sutures.

MATERIALS AND METHODS

Three female miniature pigs (Sus scrofa) had 1.3-mm Synthes titanium plates placed across the suture in the zygomatic arch. Foil strain gauges were used to record load deformation in the zygomatic and squamosal (temporal) bones and across the vertical and horizontal parts of the suture. Strain was recorded in vivo during mastication and in anesthetized pigs with electrical stimulation of masticatory muscles.

RESULTS

Strain at the suture was not reduced from normal levels. The plate induced increases in strain within the bones, but the changes were slight.

CONCLUSION

The results indicate that linear "rigid fixation" does not immobilize sutures.

Renal cell cancer: incidence of hemorrhage on MR images in patients with chronic renal insufficiency

This study describes the occurrence of hemorrhage in renal cancer in patients with chronic renal insufficiency as shown on MR images. Thirteen consecutive patients with chronic renal insufficiency who had histologically proven renal cancer and underwent MRI at 1.5 T were entered in the study. MR examinations included spoiled gradient echo (SGE) and T1-weighted fat-suppressed imaging pre- and postgadolinium administration. All renal cancers were well shown on MR images and were most clearly depicted on postgadolinium T1-weighted fat-suppressed images. Tumors in 12 of 13 patients had regions of high signal intensity on precontrast T1-weighted images. Histology demonstrated intratumoral hemorrhage in all 12 of these patients. Four hemorrhagic tumors were largely cystic on imaging studies. One of these cancers altered in appearance from largely cystic with extensive hemorrhage to largely solid with substantial enhancement after a 2.5-year interval. Renal cancers demonstrated minimal enhancement (11 patients) on early postgadolinium images and were minimally enhanced on delayed images in 10 of 13 tumors. Two renal cancers demonstrated intense enhancement. Renal cancers are well shown on MR images in patients with chronic renal insufficiency. Because of the common occurrence of hemorrhage into renal cancers in patients with renal insufficiency, caution should be exercised when evaluating hemorrhagic cystic lesions in these patients.