Laboratory evaluation of secondary causes of bone loss in Veterans with spinal cord injury and disorders

An electronic health record (eHR) review of Veterans with a spinal cord injury and disorder (SCI/D) was conducted to understand the extent to which Veterans Affairs (VA) providers pursue workups for secondary causes of osteoporosis in this population. Laboratory tests for secondary causes were ordered in only one-third of Veterans, with secondary causes identified in two-thirds of those tested, most frequently, hypogonadism and hypovitaminosis D.

PURPOSE

To identify workups for secondary causes of osteoporosis in SCI/D and the extent to which subspecialty consultations are sought.

METHODS

A total of 3018 prescriptions for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, teriparatide) among 2675 Veterans were identified in fiscal years 2005-2015 from VA administrative databases. Approximately 10% of these prescriptions were selected for eHR review.

RESULTS

eHR records of 187 Veterans with a SCI/D who had received pharmacological treatment for osteoporosis were reviewed. Workups for secondary causes of osteoporosis were performed in 31.5% of Veterans (n = 59) with approximately 64.4% of those tested (n = 38) having at least one abnormality. Hypogonadism (52.0% of those tested) and hypovitaminosis D (50.0% of those tested) were the most common secondary causes of osteoporosis identified in this population. Approximately 10% of primary care and SCI providers consulted subspecialists for further evaluation and treatment of osteoporosis. Endocrinologists more frequently performed a workup for secondary causes of osteoporosis compared to other provider specialties.

CONCLUSIONS

Screening for secondary causes of osteoporosis, particularly for hypogonadism and hypovitaminosis D, should be considered in patients with a SCI/D.

Compound focusing mirror and X-ray waveguide optics for coherent imaging and nano-diffraction

A compound optical system for coherent focusing and imaging at the nanoscale is reported, realised by high-gain fixed-curvature elliptical mirrors in combination with X-ray waveguide optics or different cleaning apertures. The key optical concepts are illustrated, as implemented at the Göttingen Instrument for Nano-Imaging with X-rays (GINIX), installed at the P10 coherence beamline of the PETRA III storage ring at DESY, Hamburg, and examples for typical applications in biological imaging are given. Characteristic beam configurations with the recently achieved values are also described, meeting the different requirements of the applications, such as spot size, coherence or bandwidth. The emphasis of this work is on the different beam shaping, filtering and characterization methods.

Scanning x-ray nanodiffraction on Dictyostelium discoideum

We have performed scanning x-ray nanobeam diffraction experiments on single cells of the amoeba Dictyostelium discoideum. Cells have been investigated in 1), freeze-dried, 2), frozen-hydrated (vitrified), and 3), initially alive states. The spatially resolved small-angle x-ray scattering signal shows characteristic streaklike patterns in reciprocal space, which we attribute to fiber bundles of the actomyosin network. From the intensity distributions, an anisotropy parameter can be derived that indicates pronounced local variations within the cell. In addition to nanobeam small-angle x-ray scattering, we have evaluated the x-ray differential phase contrast in view of the projected electron density. Different experimental aspects of the x-ray experiment, sample preparation, and data analysis are discussed. Finally, the x-ray results are correlated with optical microscopy (differential phase contrast and confocal microscopy of mutant strains with fluorescently labeled actin and myosin II), which have been carried out in live and fixed states, including optical microscopy under cryogenic conditions.

Nano-scale morphology of melanosomes revealed by small-angle X-ray scattering

Melanosomes are highly specialized organelles that produce and store the pigment melanin, thereby fulfilling essential functions within their host organism. Besides having obvious cosmetic consequences – determining the color of skin, hair and the iris – they contribute to photochemical protection from ultraviolet radiation, as well as to vision (by defining how much light enters the eye). Though melanosomes can be beneficial for health, abnormalities in their structure can lead to adverse effects. Knowledge of their ultrastructure will be crucial to gaining insight into the mechanisms that ultimately lead to melanosome-related diseases. However, due to their small size and electron-dense content, physiologically intact melanosomes are recalcitrant to study by common imaging techniques such as light and transmission electron microscopy. In contrast, X-ray-based methodologies offer both high spatial resolution and powerful penetrating capabilities, and thus are well suited to study the ultrastructure of electron-dense organelles in their natural, hydrated form. Here, we report on the application of small-angle X-ray scattering – a method effective in determining the three-dimensional structures of biomolecules – to whole, hydrated murine melanosomes. The use of complementary information from the scattering signal of a large ensemble of suspended organelles and from single, vitrified specimens revealed a melanosomal sub-structure whose surface and bulk properties differ in two commonly used inbred strains of laboratory mice. Whereas melanosomes in C57BL/6J mice have a well-defined surface and are densely packed with 40-nm units, their counterparts in DBA/2J mice feature a rough surface, are more granular and consist of 60-nm building blocks. The fact that these strains have different coat colors and distinct susceptibilities to pigment-related eye disease suggest that these differences in size and packing are of biological significance.

Hard X-ray imaging of bacterial cells: nano-diffraction and ptychographic reconstruction

Ptychographic coherent X-ray diffractive imaging (PCDI) has been combined with nano-focus X-ray diffraction to study the structure and density distribution of unstained and unsliced bacterial cells, using a hard X-ray beam of 6.2keV photon energy, focused to about 90nm by a Fresnel zone plate lens. While PCDI provides images of the bacteria with quantitative contrast in real space with a resolution well below the beam size at the sample, spatially resolved small angle X-ray scattering using the same Fresnel zone plate (cellular nano-diffraction) provides structural information at highest resolution in reciprocal space up to 2nm(-1). We show how the real and reciprocal space approach can be used synergistically on the same sample and with the same setup. In addition, we present 3D hard X-ray imaging of unstained bacterial cells by a combination of ptychography and tomography.

A two-dimensional waveguide beam for X-ray nanodiffraction

The micro- and nanofocus X-ray scattering (MINAXS) beamline of PETRA III is equipped with two consecutively arranged endstations, the last of which is the nanofocus endstation. The first in-beam commissioning of the experimental equipment was successfully performed at the end of 2010, using two-dimensionally confining hard X-ray silicon waveguides with cross sections of 50 nm × 50 µm to 50 nm × 2 µm for nanobeam generation. A full characterization of the waveguide-generated beams was performed, giving values for the beam geometries, the transmission efficiencies of the waveguides and absolute fluxes. Along with these results a detailed description of the setup is presented in this paper. A first high-resolution nanodiffraction experiment on a nanocrystalline TiN hard coating was performed to verify the resolution of the nanodiffraction setup and to reveal the local gradients across the blasted TiN coating. In conclusion, the main concern is the availability of the nanobeam, how it was generated and the fact that a beam out of a two-dimensionally confining waveguide was used for diffraction experiments for the first time.

[First clinical results in a study of contrast enhanced magnetic resonance angiography with the 1.0 molar gadobutrol in peripheral arterial occlusive disease--comparison to intraarterial DSA]

PURPOSE

To assess the value of contrast enhanced (CE)-MR angiography (MRA) with 1.0 molar Gadobutrol (Schering, Germany) in comparison to intraarterial DSA in peripheral arterial occlusive disease (PAOD).

MATERIALS AND METHODS

Within 48 hours, 30 symptomatic patients with PAOD were examined by CE-MRA (Gadobutrol dose 0.2-0.3 mmol/kg body weight) and DSA. For CE-MRA, a 1.5 T magnet (Vision, Siemens, Germany) was used (FA 35 degrees, TR/TE 4.6/1.8 ms, FOV 400 mm, matrix 230 x 512, total acquisition time 81 sec). Two radiologists evaluated a total of 600 vessel segments for stenotic lesions and image quality (1 = not visible to 5 = excellent). Treatment was independently planned on the basis of the MRA and DSA findings.

RESULTS

The Kendall's tau-b coefficient was 0.92 for overall stenotic grading, and 0.92, 0.93 and 0.92, respectively, for the vascular flow in the iliac, femoropopliteal and crural arteries. Sensitivity, specificity, negative and positive predictive value, and accuracy were, respectively, 94, 97, 98 and 92, 96 % for > 50 % stenoses, 95, 99, 99, 95 and 99 % for iliac arteries, 96, 98, 98%, 94 and 97 % for femoropopliteal arteries, and 92, 94, 96, 89 and 94 % for crural arteries. Therapy planning by MRA and DSA coincided in 51 of 54 cases. No relevant adverse event occurred.

CONCLUSION

CE-MRA with 1.0 molar Gadobutrol is highly efficient in diagnosing peripheral arterial occlusive disease and correlates excellently with DSA.

Selective water excitation for faster MR imaging of articular cartilage defects: initial clinical results

Our objective was to compare a water-excitation (WE) 3D fast low-angle shot (FLASH) MR sequence for faster imaging of articular cartilage defects of the knee to a conventional fat-saturated (FS) 3D FLASH MR sequence. This prospective study included 16 knees of 16 patients with suspected cartilage lesions. The MR imaging in transverse and sagittal planes included (a) FS 3D FLASH (TR/TE: 45 ms/11 ms, scan time 8 min, flip angle 50 degrees), and (b) WE 3D FLASH (TR/TE: 28 ms/11 ms, scan time 4 min 58 s, flip angle 40 degrees). For each sequence signal-to-noise ratios (SNR) and contrast-to-noise ratios (CNR) were quantified. The detected cartilage lesions were evaluated using a semi-quantitative four-scale scoring system (grades 0-III). The data were compared between the sequences using the paired Student's t-test. No statistically significant differences between the sequences were found for SNR, CNR, and cartilage defect grading (p=0.14-0.8). The WE 3D FLASH MR imaging seems to be promising for fast imaging of articular cartilage lesions of the knee.

Gadobutrol: an alternative contrast agent for digital subtraction dacryocystography

We report the application of gadobutrol as a contrast medium for digital subtraction dacryocystography (DS-DCG) in patients with known allergy to iodinated contrast agent. Gadobutrol has the double gadolinium concentration (1.0 mmol/ml) of other gadolinium-based contrast agents. Quality of the DS-DCG images obtained with gadobutrol was comparable to DS-DCG images obtained with iodinated contrast medium. Radiodensity measurements using a micro-CT scanner confirmed a high radiodensity of gadobutrol which was comparable to the radiodensity of iopentol with a iodine concentration of 250 mg/ml and only approximately 20% lower than the radiodensity of iopentol with a concentration of 300 mg/l. Gadobutrol is a well-suited substitute for DS-DCG in patients with allergy to iodinated contrast agents.

[Mechanical brush-catheter abrasion method for the isolation and culture of human umbilical vein endothelial cells. First in vitro results]

Mechanical brush-catheter abrasion method for the isolation and culture of human umbilical vein endothelial cells. First in vitro results.

PURPOSE

To determine the value of a nylon brush (Cragg thrombolytic catheter system) with regard to the isolation and culture of viable human vascular umbilical vein endothelial cells (HUVEC).

MATERIAL AND METHODS

Fresh human umbilical cords were collected after a maximum of 6 - 8 h post delivery. They were stored in sterile tubes till further preparation. After predilation the umbilical cord veins, a 6 French brush catheter was inserted, expanded, and removed by hand using rotating movements. The nylon brush was shaken out in cell medium containing serum proteins by a connected motor drive. After repeating these procedures, the detached endothelial cells were centrifugated and resuspended. The cell numbers were assessed and cell viability controlled.

RESULTS

The endothelial cell (EC) viability depended on the umbilical cord's age and was the highest (29.8 +/- 11.4 %) within 3 h after delivery. The brush abrasion (3.32 x 10(5) +/- 52016 viable EC/10 cm vein segment) enabled us to culture these cells under different cell concentrations. They grew to confluence after 2 - 3 weeks.

CONCLUSIONS

The brush-catheter abrasion is an effective method for collecting viable human endothelial cells in vitro.

The role of oxybutynin in spinal cord injured patients with indwelling catheters

PURPOSE

The long-term benefits of oral oxybutynin in spinal cord injured patients with indwelling catheters is unknown. We reviewed our experience with this population of men and present the results of our analysis.

MATERIALS AND METHODS

A total of 109 male spinal cord injured patients at the Houston Veterans Affairs Medical Center have been treated with chronic indwelling catheters (80 transurethral and 29 suprapubic). Thirty-eight patients (35%) were identified as using oxybutynin on a regular basis. These patients were compared to those not using oxybutynin with regard to urodynamic parameters and upper tract deterioration. Specifically examined were bladder compliance, bladder leak point pressure, vesicoureteral reflux, hydronephrosis, urolithiasis, febrile urinary tract infections and serum creatinine greater than 2 mg./dl.

RESULTS

The mean duration of indwelling catheter use was 11.9 years (12.4 without oxybutynin and 10.9 on oral oxybutynin). Of the 31 patients with normal compliance (greater than 20 ml./cm. water), 24 (77%) were using oxybutynin (p = 0.001). Bladder leak point pressures were abnormal (greater than 35 cm. water) in 5 of 32 patients (16%) on oxybutynin versus 34 of 60 (57%) without it (p <0.001). Hydronephrosis was present in 15 of 66 patients (23%) without oxybutynin versus 1 of 36 (3%) with oxybutynin (p = 0.009). Febrile urinary tract infections occurred in 4 of 35 patients (11%) versus 17 of 62 patients (27%) with or without oxybutynin, respectively (p = 0.077). No significant differences were found between the 2 groups with regard to reflux, renal scars, stones or elevated serum creatinine.

CONCLUSIONS

It appears that regular use of oxybutynin may be beneficial in spinal cord injured patients who require chronic indwelling catheters for bladder management. Our analysis reveals that patients who take oxybutynin regularly have better bladder compliance, lower bladder leak point pressures and less hydronephrosis. Until a prospective, randomized trial reveals contradicting outcomes, empiric use of oxybutynin in all spinal cord injured patients requiring chronic indwelling catheters seems justified.

Limited vs full microbiological investigation for the management of symptomatic polymicrobial urinary tract infection in adult spinal cord-injured patients

Spinal cord-injured (SCI) patients often suffer from symptomatic polymicrobial urinary tract infection (UTI). The objective of this study was to evaluate the clinical outcome and cost-savings associated with antibiotic therapy based on limited vs full microbiological investigation of urine cultures in adult SCI patients with symptomatic polymicrobial UTI (> or = 2 organisms growing in urine cultures). In the first part of the study, a total of 40 evaluable patients were prospectively randomized in a single-blinded fashion to receive antibiotic therapy based on either limited (21 patients) or full microbiologic investigation (19 patients) of urine cultures. The practicality of a limited microbiological investigation was further examined in the second part of the study where 12 consecutive patients with symptomatic polymicrobial UTI initially had only limited microbiological investigation of urine cultures and received antibiotic therapy accordingly. When analyzing all patients in the study, the likelihood of adequate clinical response was not significantly different between those who received antibiotic therapy based on limited (28/33 = 85%) vs full (18/19 = 95%) microbiological investigation of urine cultures (P = 0.40). An average of 183 US dollars could be saved per patient by managing symptomatic polymicrobial UTI based on a limited vs a full microbiological investigation. These results suggest that in adult SCI patients with symptomatic polymicrobial UTI antibiotic therapy guided by a limited microbiological investigation may be practical, adequate and cost-saving.

Home mechanical ventilation in mitochondrial encephalomyopathy syndrome

Long-term home mechanical ventilation of children has only recently become more practically feasible and ethically acceptable by the medical community. It has been particularly controversial in cases of degenerative myopathies in which quality of life has been questioned. There are no reports in the literature of long-term home mechanical ventilation of a child with mitochondrial encephalomyopathy (MELAS) syndrome despite the many descriptions of possible etiologies of the concomitant respiratory failure. The patient reported here has used home mechanical ventilation for 6 years with few medical complications, no hospitalizations in the past 3 years, and increased function in activities of daily living. Despite the ill-defined nature of the disease and uncertain prognosis, we believe that long-term home mechanical ventilation of children with early onset MELAS syndrome is a viable option for both patients and their families and results in overall improvement in quality of life for the patient.

Exercise testing and training in patients with peripheral vascular disease and lower extremity amputation

Patients with peripheral vascular disease have a high risk of coronary artery disease. The risk is even greater when the peripheral vascular disease leads to lower extremity amputation. Exercise testing using lower extremity exercise has been the "gold standard" for screening for coronary artery disease, but many patients with peripheral vascular disease and those with amputations have difficulty doing this type of exercise. Arm exercise ergometry has been shown to be a safe and effective alternative for the detection of coronary artery disease in patients who cannot do leg exercise. This test has also been used to determine safe exercise levels and may be able to predict the ultimate level of prosthetic use in amputees. Exercise training with arm ergometry also improves cardiovascular efficiency and upper body strength in poorly conditioned patients. Studies are needed to appreciate fully the role of exercise testing and training in the recovery of these patients after amputation.