The effectiveness of cervical rehabilitation interventions for pain in adults with myogenic temporomandibular disorders: A systematic review and meta-analysis

OBJECTIVE

Little evidence exists for the most effective conservative treatment approach for adults with myogenic temporomandibular disorders (MTMD). We aim to assess the effectiveness of cervical rehabilitation interventions on pain intensity and sensitivity in adults with MTMD compared to comparison intervention such as placebo, sham treatment, education or no intervention.

METHODS

For this systematic review and meta-analysis, we searched PubMed, EMBASE, Medline, PEDro databases, forward and backward citations and grey literature studies through PROSPERO, clinical trials and data registries without language or date restrictions between inception and 1 December 2021. We selected randomised controlled trials (RCTs) based on adult populations with MTMD who had a cervical rehabilitation intervention which was defined as any conservative intervention targeting the anatomical structures of the cervical spine. The primary outcome measures for pain were self-reported pain intensity and pain sensitivity through the pressure pain threshold (PPT) of the masseter and temporalis muscles. Secondary outcome measures of maximal mouth opening (on MMO) were included. Included studies were assessed for bias with the Cochrane risk of bias tool for randomised trials. Evidence from RCTs was synthesised to determine treatment effect size as differences between standardised mean difference (SMD) for changes in pain intensity, PPT and MMO comparing adults with MTMD who were treated with cervical rehabilitation interventions compared to a control group. This study is registered on Prospero, number CRD 42021289299.

RESULTS

Our general search yielded 2647 studies where seven RCTs met eligibility criteria with low to some concerns in their risk of bias. Pain intensity (five studies, n = 223, SMD -0.98, 95% CI -1.67 to -0.28, I2 = 79%), PPT of the masseter muscle (six studies, n = 395, SMD 0.64, 95% CI 0.43 to 0.86, I2 = 90%) and the temporalis muscles (five studies, n = 295, SMD 0.76, 95% CI 0.07 to 1.45, I2 = 84%) showed large treatment effect estimates favouring cervical rehabilitation interventions compared to no treatment, sham cervical treatment, patient education or non-cervical neuromuscular techniques. Compared to control interventions, one type of cervical rehabilitation intervention, cervical manual therapy alone or in combination with a neck exercise program was associated with statistically significant, large treatment effect estimates on pain intensity (four studies, n = 203, SMD -1.52, 95% CI -2.50 to -0.55).

CONCLUSIONS

This review found that in the short-term, cervical rehabilitation interventions especially upper cervical MT alone or in combination with a neck exercise program are effective in improving multiple pain outcomes in adults with MTMD. However, further research is needed to measure the long-term effects of this type of intervention.

Acute evening high-intensity interval training may attenuate the detrimental effects of sleep restriction on long-term declarative memory

Recent evidence shows that a nap and acute exercise synergistically enhanced memory. Additionally, human-based cross-sectional studies and animal experiments suggest that physical exercise may mitigate the cognitive impairments of poor sleep quality and sleep restriction, respectively. We evaluated whether acute exercise may offset sleep restriction's impairment of long-term declarative memory compared to average sleep alone. A total of 92 (82% females) healthy young adults (24.6 ± 4.2 years) were randomly allocated to one of four evening groups: sleep restriction only (S5, 5-6 h/night), average sleep only (S8, 8-9 h/night), high-intensity interval training (HIIT) before restricted sleep (HIITS5), or HIIT before average sleep (HIITS8). Groups either followed a 15-min remote HIIT video or rest period in the evening (7:00 p.m.) prior to encoding 80 face-name pairs. Participants completed an immediate retrieval task in the evening. The next morning a delayed retrieval task was given after their subjectively documented sleep opportunities. Long-term declarative memory performance was assessed with the discriminability index (d') during the recall tasks. While our results showed that the d' of S8 (0.58 ± 1.37) was not significantly different from those of HIITS5 (-0.03 ± 1.64, p = 0.176) and HIITS8 (-0.20 ± 1.28, p = 0.092), there was a difference in d' compared to S5 (-0.35 ± 1.64, p = 0.038) at the delayed retrieval. These results suggest that the acute evening HIIT partially reduced the detrimental effects of sleep restriction on long-term declarative memory.

The effectiveness of intratissue percutaneous electrolysis for the treatment of tendinopathy: a systematic review

Background

Tendinopathy is highly prevalent in the general public and common in athletes. It makes up nearly 50% of all sport injuries. A number of treatment techniques with varying evidence of effectiveness are currently available. Intratissue percutaneous electrolysis (EPI) is one such modality, however little consensus exists for EPI's efficacy or the most effective treatment parameters.

Objective

To review and appraise available evidence for Intratissue Percutaneous Electrolysis (EPI) in the treatment of tendinopathy, examining the effectiveness of EPI in conjunction with other modalities and identifying the strengths and limitations of the evidence base for EPI in order to make evidence-based recommendation for future studies of EPI.

Methods

PubMed, Embase and Scopus were searched with keywords related to EPI and tendinopathy. Grey literature searches were conducted with Embase, OpenGrey, and ProQuest. Extensive citation searching was undertaken. Randomised controlled trials (RCTs), uncontrolled and observational studies of the application of EPI in patients aged 18-65 years with Magnetic Resonance Imaging (MRI) or clinical Ultrasonography (US) confirmed diagnosis of tendinopathy were eligible.

Results

Eleven studies met inclusion criteria: six randomised control trials (RCTs) and five uncontrolled studies. Clinical trials of EPI as an adjunct modality with physical therapy reporting greater decreased pain and return to function than treatment with physical therapy alone. The evidence for EPI is limited and influenced by small sample sizes, varying treatment protocols, clinical heterogeneity and high risk of bias.

Conclusion

It is currently not possible to conclude that EPI is an effective modality for the treatment of tendinopathy. RCTs with clearly described EPI treatment protocols, larger sample sizes and intervention reporting sufficient to support reproducibility are needed to determine the effectiveness of EPI for the treatment of tendinopathy.

Examining the empirical evidence for IDEAL 2b studies: the effects of preceding prospective collaborative cohort studies on the quality and impact of subsequent randomized controlled trials of surgical innovations – protocol for a systematic review and case–control analysis

Randomized controlled trials (RCTs) in surgery face methodological challenges, which often result in low quality or failed trials. The Idea, Development, Exploration, Assessment and Long-term (IDEAL) framework proposes preliminary prospective collaborative cohort studies with specific properties (IDEAL 2b studies) to increase the quality and feasibility of surgical RCTs. Little empirical evidence exists for this proposition, and specifically designed 2b studies are currently uncommon. Prospective collaborative cohort studies are, however, relatively common, and might provide similar benefits. We will, therefore, assess the association between prior ‘IDEAL 2b-like’ cohort studies and the quality and impact of surgical RCTs.

We propose a systematic review using two parallel case–control analyses, with surgical RCTs as subjects and study quality and journal impact factor (IF) as the outcomes of interest. We will search for surgical RCTs published between 2015 and 2019 and and prior prospective collaborative cohort studies authored by any of the RCT investigators. RCTs will be categorized into cases or controls by (1) journal (IF ≥or <5) and (2) study quality (PEDro score ≥or < 7). The case/control OR of exposure to a prior ‘2b like’ study will be calculated independently for quality and impact. Cases will be matched 1: 1 with controls by year of publication, and confounding by peer-reviewed funding, author academic affiliation and trial protocol registration will be examined using multiple logistic regression analysis.

This study will examine whether preparatory IDEAL 2b-like studies are associated with higher quality and impact of subsequent RCTs.

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.

METHODS

We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.

FINDINGS

Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.

INTERPRETATION

Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management.

FUNDING

The UK National Institute for Health Research Health Technology Assessment Programme.

Epidemiology of human alveolar echinococcosis in Armenia

Background

Since the 90s' E.multilocularis infection in foxes is rising and central-eastern European countries had seen first Alveolar echinococcosis (AE) human cases. AE is considered to be a very rare disease in Europe with average incidences of 0.03-0.20/100,000 inhabitants/year. Because of a suitable orography, this study aims to confirm whether there are human AE cases in Armenia, identify areas at risk, and also estimate AE annual incidence.

Methods

Retrospective AE case finding was carried out at main 6 multi-profile medical centers equipped with the most innovative diagnostic means. The medical records of all patients with liver surgery admitted between January 2008 and June 2020 were reviewed. A specific form was developed in EpiInfo v. 7.2. Annual national incidence was estimated using population denominators provided by the National Institute of Statistics (the population of Armenia is estimated at 2 963 243 people).

Results

From September 2019 until June 2020, overall 11 AE cases have been identified. All patients were diagnosed at advanced stages, with subsequent poor prognosis and costly treatment. Confirmation was based on tissue biopsy results. Age ranged from 19-59 years with a median of 39yrs. E. multilocularis was detected in rural communities, mostly in the Gegharkunik region (6 cases, 55%). Annual average incidence of AE was 0.033 varying between 0.032 in 2008 and 0.1 in 2017. For comparison with Armenia, an annual incidence in France was 0.026/100,000 in 2008 (the population of France is estimated at 65 273 511 people).

Conclusions

All cases were not notified by the surveillance system and the real prevalence of AE in the country is unknown. This young age could indicate widespread of infection in animals. Therefore, the burden of AE disease is difficult to estimate. The surveillance system in Armenia can be improved by the development of national guidelines for the prospective registry, AE awareness campaigns.

Key messages

First-time identification of human AE in Armenia calls for implementation of surveillance with a case definition and registry of all cases. AE is an emerging, and so far silent threat in Armenia.

Design, methods, and reporting of impact studies of cardiovascular clinical prediction rules are suboptimal: a systematic review

OBJECTIVES

To evaluate design, methods, and reporting of impact studies of cardiovascular clinical prediction rules (CPRs).

STUDY DESIGN AND SETTING

We conducted a systematic review. Impact studies of cardiovascular CPRs were identified by forward citation and electronic database searches. We categorized the design of impact studies as appropriate for randomized and nonrandomized experiments, excluding uncontrolled before-after study. For impact studies with appropriate study design, we assessed the quality of methods and reporting. We compared the quality of methods and reporting between impact and matched control studies.

RESULTS

We found 110 impact studies of cardiovascular CPRs. Of these, 65 (59.1%) used inappropriate designs. Of 45 impact studies with appropriate design, 31 (68.9%) had substantial risk of bias. Mean number of reporting domains that impact studies with appropriate study design adhered to was 10.2 of 21 domains (95% confidence interval, 9.3 and 11.1). The quality of methods and reporting was not clearly different between impact and matched control studies.

CONCLUSION

We found most impact studies either used inappropriate study design, had substantial risk of bias, or poorly complied with reporting guidelines. This appears to be a common feature of complex interventions. Users of CPRs should critically evaluate evidence showing the effectiveness of CPRs.

The "architect analogy" of evidence-based practice: Reconsidering the role of clinical expertise and clinician experience in evidence-based health care

The role of expertise in evidence-based medicine (EBM) and practice (EBP) has long been debated. In the early years of the EBP movement, the role of expertise and experience were diminished in clinical decision-making. However, the concepts of EBP are evolving. A more nuanced view of the value of clinician expertise, based on experience and clinical judgement, has emerged. This article proposes that clinical expertise does not belong within the evidence hierarchy's decision-making pyramid as the lowest form of evidence, but rather alongside it, representing a complementary source of knowledge that supports the processes of EBP. An "Architect Analogy of EBP" is proposed as a new model by which to describe this relationship. In this analogy, the clinician's use of expertise is likened to the role of an architect, using evidence as building blocks in the construction of the client's edifice, representing the patients' health and wellbeing. Much as an architect carefully designs the edifice in consultation with the client's needs and preferences, choosing appropriate material (evidence), rejecting faulty material, and ensuring construction stays on course, the clinician must sort through a plethora of sometimes contradictory evidence, evaluate its merits and appropriateness for the patients' unique biopsychosocial circumstances and values, and monitor the effects of interventions on patients' health and wellbeing. The expertise of practitioners, as the architects of EBP, is an important supporting source of knowledge that facilitates the "Five Steps of EBP," informs and facilitates EBP, and supports patient-centred care.

Two-Photon Microscopy and Spectroscopy Studies to Determine the Mechanism of Copper Oxide Nanoparticle Uptake by Sweetpotato Roots during Postharvest Treatment

The interaction of engineered nanoparticles with plant tissues is still not well understood. There is a lack of information about the effects of curing (postharvest treatment) and lignin content on copper uptake by sweetpotato roots exposed to copper-based nanopesticides. In this study, Beauregard-14 (lower lignin) and Covington (higher lignin) varieties were exposed to CuO nanoparticles (nCuO), bulk CuO (bCuO), and CuCl₂ at 0, 25, 75, and 125 mg/L. Cured and uncured roots were submerged into copper suspensions/solutions for 30 min. Subsequently, root segments were sliced for imaging with a 2-photon microscope, while other root portions were severed into periderm, cortex, perimedulla, and medulla. They were individually digested and analyzed for Cu content by inductively coupled plasma-optical emission spectroscopy. Microscopy images showed higher fluorescence in periderm and cortex of roots exposed to nCuO, compared with bCuO. At 25 mg/L, only bCuO showed higher Cu concentration in the periderm and cortex of Beauregard-14 (2049 mg/kg and 76 mg/kg before curing; 6769 mg/kg and 354 mg/kg after curing, respectively) and in cortex of Covington (692 mg/kg before curing and 110 mg/kg after curing) compared with controls ( p ≤ 0.05). In medulla, the most internal tissue, only Beauregard-14 exposed to 125 mg bCuO/L showed significantly ( p ≤ 0.05) more Cu before curing (17 mg/kg) and after curing (28 mg/kg), compared with control. This research has shown that the 2-photon microscope can be used to determine CuO particles in nondyed plant tissues. The lack of Cu increase in perimedulla and medulla, even in roots exposed to high CuO concentrations (125 mg/L), suggests that nCuO may represent a good alternative to protect and increase the shelf life of sweetpotato roots, without exposing consumers to excess Cu.

Evidence-Based Evaluation of Practice and Innovation in Physical Therapy Using the IDEAL-Physio Framework

The IDEAL framework is an established method for initial and ongoing evaluations of innovation and practice for complex health care interventions. First derived for surgical sciences and embedded at a global level for evaluating surgery/surgical devices, the IDEAL framework is based on the principle that innovation and evaluation in clinical practice can, and should, evolve together in an ordered manner: from conception to development and then to validation by appropriate clinical studies and, finally, longer-term follow-up. This framework is highly suited to other complex, nonpharmacological interventions, such as physical therapist interventions. This perspective outlines the application of IDEAL to physical therapy in the new IDEAL-Physio framework. The IDEAL-Physio framework comprises 5 stages. In stage 1, the idea phase, formal data collection should begin. Stage 2a is the phase for iterative improvement and adjustment with thorough data recording. Stage 2b involves the onset of formal evaluation using systematically collected group or cohort data. Stage 3 is the phase for formal comparative assessment of treatment, usually involving randomized studies. Stage 4 involves long-term follow-up. The IDEAL-Physio framework is recommended as a method for guiding and evaluating both innovation and practice in physical therapy, with the overall goal of providing better evidence-based care.

Grey literature: An important resource in systematic reviews

Systematic reviews aid the analysis and dissemination of evidence, using rigorous and transparent methods to generate empirically attained answers to focused research questions. Identifying all evidence relevant to the research questions is an essential component, and challenge, of systematic reviews. Grey literature, or evidence not published in commercial publications, can make important contributions to a systematic review. Grey literature can include academic papers, including theses and dissertations, research and committee reports, government reports, conference papers, and ongoing research, among others. It may provide data not found within commercially published literature, providing an important forum for disseminating studies with null or negative results that might not otherwise be disseminated. Grey literature may thusly reduce publication bias, increase reviews' comprehensiveness and timeliness and foster a balanced picture of available evidence. Grey literature's diverse formats and audiences can present a significant challenge in a systematic search for evidence. However, the benefits of including grey literature may far outweigh the cost in time and resource needed to search for it, and it is important for it to be included in a systematic review or review of evidence. A carefully thought out grey literature search strategy may be an invaluable component of a systematic review. This narrative review provides guidance about the benefits of including grey literature in a systematic review, and sources for searching through grey literature. An illustrative example of a search for evidence within grey literature sources is presented to highlight the potential contributions of such a search to a systematic review. Benefits and challenges of grey literature search methods are discussed, and recommendations made.

THE IMPACT OF ATTENTIONAL FOCUS ON THE TREATMENT OF MUSCULOSKELETAL AND MOVEMENT DISORDERS

Treatment plans employed by physical therapists involved in musculoskeletal rehabilitation may follow a conventional medical-model approach, isolating care at the tissue level but neglecting consideration for neurocognitive contributions to recovery. Understanding and integration of motor learning concepts into physical therapy practice is integral for influencing the human movement system in the most effective manner. One such motor learning concept is the use of verbal instruction to influence the attentional focus of the learner. Evidence suggests that encouraging an external focus of attention through verbal instruction promotes superior motor performance, and more lasting effects of a learning experience than an internal focus of attention. Utilizing an external focus of attention when instructing a patient on a motor task may facilitate improved motor performance and improved functional outcomes in treatment plans devised to address musculoskeletal injury and movement disorders. The purpose of this review is to summarize the basic principles of motor learning and available evidence on the influence an external focus of attention has on motor learning and performance, including the benefits of an external focus of attention over an internal focus of attention and how therapists may inadvertently encourage the latter. Furthermore, the benefits of possessing greater awareness of neurocognitive mechanisms are discussed to exhibit how implementing such concepts into musculoskeletal rehabilitation can maximize treatment outcomes.

LEVEL OF EVIDENCE

5.

Gray literature: An important resource in systematic reviews

Systematic reviews aide the analysis and dissemination of evidence, using rigorous and transparent methods to generate empirically attained answers to focused research questions. Identifying all evidence relevant to the research questions is an essential component, and challenge, of systematic reviews. Gray literature, or evidence not published in commercial publications, can make important contributions to a systematic review. Gray literature can include academic papers, including theses and dissertations, research and committee reports, government reports, conference papers, and ongoing research, among others. It may provide data not found within commercially published literature, providing an important forum for disseminating studies with null or negative results that might not otherwise be disseminated. Gray literature may thusly reduce publication bias, increase reviews' comprehensiveness and timeliness, and foster a balanced picture of available evidence. Gray literature's diverse formats and audiences can present a significant challenge in a systematic search for evidence. However, the benefits of including gray literature may far outweigh the cost in time and resource needed to search for it, and it is important for it to be included in a systematic review or review of evidence. A carefully thought out gray literature search strategy may be an invaluable component of a systematic review. This narrative review provides guidance about the benefits of including gray literature in a systematic review, and sources for searching through gray literature. An illustrative example of a search for evidence within gray literature sources is presented to highlight the potential contributions of such a search to a systematic review. Benefits and challenges of gray literature search methods are discussed, and recommendations made.

Pegylated interferon-α2b and ribavirin decrease claudin-1 and E-cadherin expression in HepG2 and Huh-7.5 cells

BACKGROUND

Hepatitis C virus (HCV) infection usually results in long-term viremia. Entry of HCV into the hepatocyte requires claudin-1, -6, -9 and occludin. The efficacy of Pegylated interferon-α (PEG-IFN) treatment against HCV infection increased when ribavirin (RBV) was added to the therapeutic scheme. Our aim was to investigate if PEG-IFN plus RBV regulate claudin expression.

MATERIAL AND METHODS

HepG2, Huh-7 and Huh-7.5 cells were treated with PEG-IFN-α2a or α2b and/or RBV at different times before obtaining the cytosolic, membrane and cytoskeletal fractions. Claudin-1, 3, 4, 6, and 9, E-cadherin and occludin expression was evaluated by Western blot analysis. Transepithelial electrical resistance (TER) was also determined.

RESULTS

Claudin-1, 3, 4, 6, E-cadherin and occludin are constitutively expressed mainly in HepG2 cell membrane. Claudin-1 and E-cadherin cell membrane expression diminished after exposure to PEGIFNα2b (50 ng) + RBV(50 μg); the maximal decrease was observed with 200 ng of PEG-IFNα2b + 200 μg of RBV. The effect was less intense with PEG-IFNα2a. The inhibition of claudin-1 and E-cadherin expression in Huh-7 and Huh-7.5 cells was only observed with 200 ng of PEG-IFNα2b + 200 μg of RBV. TER diminished marginally in the HCV containing hepatoma cells with 200 ng of PEG-IFNα2b + 200 μg of RBV. Claudin-1 mRNA expression level was not affected by the combined treatment.

CONCLUSION

The increased therapeutic efficacy of the PEG-IFNα2b plus RBV treatment could be secondary to the inhibition of claudin-1 and E-cadherin cell membrane expression.

2009 pandemic H1N1-associated myocarditis in a previously healthy adult

Influenza infection most commonly affects the upper and lower respiratory tracts, but can involve extrapulmonary sites, including the myocardium. We report on a case of myocarditis caused by documented 2009 pandemic H1N1 influenza in a previously healthy adult, and review the literature on influenza myocarditis.

The altered expression of inflammation-related molecules and secretion of IL-6 and IL-8 by HUVEC from newborns with maternal inactive systemic lupus erythematosus is modified by estrogens

Systemic lupus erythematosus (SLE) predominantly affects women, especially those in reproductive age. Genetic contributions to disease susceptibility as well as immune dysregulation, particularly persistent inflammatory responses, are considered essential features. Our aim was to determine whether human umbilical vein endothelial cells (HUVEC) isolated from healthy newborns to women with inactive SLE show inflammation-related abnormalities that might lead to an early development of SLE in the offsprings. HUVEC isolated from six women with inactive SLE were stimulated with 2.5 ng/mL of TNF-alpha and/or physiological and pharmacological doses of 17-I(2) estradiol (E2). Then the expression of VCAM-1, ICAM-1, E-selectin, toll-like receptor-9 (TLR-9), heat shock protein 70 (HSP70) and HSP90 were measured. The concentrations of IL-6, IL-8, and IL-10 were also determined in maternal serum and in TNF-alpha stimulated and non-stimulated HUVEC culture supernatant. HUVEC from children with no family history of autoimmune disease served as controls. Our results showed that in HUVEC from SLE+ mothers, a constitutively low expression of adhesion molecules was enhanced by TNF-alpha treatment. The E2 (1 ng/mL) increased the expression of adhesion molecules but had no effect upon TNF-alpha-treated cells. IL-6 was constitutively higher in SLE+ HUVEC, whereas IL-8 was lower; E2 treatment diminished the latter. The E2 had no effect upon IL-6 and IL-8 secretions in TNF-alpha-treated cells. SLE+ HUVEC showed a disordered cytoskeleton and overexpressed HSP70, HSP90, and TLR-9. Our results indicate that endothelial cells of newborns to SLE+ mothers are in a proinflammatory condition which can be upregulated by estrogens.

HUVECs from newborns with a strong family history of myocardial infarction overexpress adhesion molecules and react abnormally to stimulating agents

Atherosclerosis is a complex disease involved in major fatal events such as myocardial infarction and stroke. It is the result of interactions between metabolic, dietetic and environmental risk factors acting on a genetic background that could result in endothelial susceptibility. Our aim was to determine the patterns of expression of adhesion molecules and whether phosphatidylserine is translocated to the cell surface of human umbilical vein endothelial cells (HUVECs) isolated from healthy newborns born to parents with a strong family history of myocardial infarction under TNF-alpha or oxLDL stimulated conditions. Compared to control HUVECs, experimental cords showed: (a) a four-fold increase in VCAM-1 expression under basal conditions, which showed no change after stimulation with the pro-atherogenic factors; (b) a two-fold increase in basal P-selectin expression that reached a 10-fold increase with any of the pro-atherogenic factors; (c) a basal ICAM-1 expression similar to P-selectin that was not modified by the pro-atherogenic molecules; (d) a similar PECAM-1 expression. Unexpectedly, phospathidylserine expression in experimental cord HUVECs was significantly increased (211 817 versus 3354 TFU) but was not associated to apoptotic death as the percentage of dead cells induced by TNF-alpha treatment was very low (0.55 versus 9.87% in control HUVECs). The latter result was corroborated by TUNEL staining. T cell adherence to HUVECs was highly up-regulated in the genetically predisposed samples. The analysis of nonpooled HUVECs, from newborns to family predisposed myocardial-infarction individuals, might represent a useful strategy to identify phenotypical and functional alterations, and hopefully, to take early preventive actions.

Prostate cancer detection and tumor characteristics in men with multiple biopsy sessions

PURPOSES

To address prostate cancer (PCa) detection with respect to the number of biopsy sessions performed, to identify risk factors for detection after a negative biopsy, and to analyze the clinical characteristics of the detected tumors.

SCOPE

Only biopsied men (sextant) were included. A total of 1011 biopsy sessions were carried out in 770 men; 172 underwent a second prostate biopsy and 51 a third biopsy. During the first biopsy round, 111 cancers were found (14.4%), 27 in the second (15.7%), and five during the third round (9.8%), P=0.156. Only high-grade PIN or atypia were identified as independent predictors or PCa detection in subsequent biopsies (P=0.008). A nonsignificant increase of clinically localized tumors, and a decrease of metastatic and poorly differentiated cases were found when more biopsy sessions were needed for detection.

CONCLUSIONS

A nonsignificant trend to lower cancer detection rates and less clinical relevance of the tumors detected can be observed when more biopsy rounds are needed for detection.

Prostate apoptosis after doxazosin treatment in the spontaneous hypertensive rat model

OBJECTIVE

To validate the spontaneous hypertensive rat (SHR) model for basic research into benign prostate hyperplasia (BPH), and to assess doxazosin-induced changes in prostatic structure and apoptotic status.

MATERIALS AND METHODS

Four groups of rats were assessed: group 1, 15 SHRs treated with doxazosin; group 2, 14 SHRs with unilateral excision of the major pelvic ganglion; group 3, 14 untreated SHRs; and group 4, 16 intact Wistar-Kyoto (WKY) rats. The doxazosin mesylate (0.03 mg daily) was given compacted in rat food for 3 months. The prostatic ventral lobe (VL) was excised and weighed. Stereological light microscopy, multiplex reverse transcription-polymerase chain reaction of prostate caspases, and caspase-3 activity (cellular enzymatic assay) were assessed.

RESULTS

There was more development of the glandular epithelium (P < 0.001) in SHR rats than in controls, which was even greater after doxazosin exposure (P = 0.027). SHR animals had higher caspase expression (P < 0.05) and activity (P = 0.008) than WKY rats, but both were reduced after doxazosin therapy (P < 0.01 and 0.028, respectively).

CONCLUSIONS

This study confirmed prostate hyperplasia in the SHR model. Doxazosin exposure did not reduce the volume of glandular epithelium and contributed to protecting against caspase-induced apoptosis. The SHR model may be not a valid option to study doxazosin-induced apoptosis in BPH.

Prostate specific antigen density. Is there a role for this parameter when screening for prostate cancer?

The objective of this paper is to validate prostate specific antigen (PSA) density (PSAD) routine use to enhance PSA specificity in men with normal digital rectal examination and intermediate PSA values. It is a retrospective study of 235 men from a prostate cancer (PCa) screening program. All of them presented PSA values between 4 and 10 ng/ml, normal digital rectal examination, and a transrectal ultrasound (TRUS) guided biopsy available (PSA>/=4 ng/ml as the sole criterion for biopsy). Multivariate analysis failed to demonstrate higher PSAD values in men with PCa. PSAD cutoff points higher than 0.07 ng/ml per cc were considered as unacceptable, with less than 95% sensitivity. When a cutoff point of 0.15 was considered, as many as 30.6% of the cancers were missed. In conclusion we cannot recommend the use of this parameter for the above mentioned purpose.Prostate Cancer and Prostatic Diseases (2001) 4, 146-149.

Complex PTSD: a review of current issues

The diagnostic formulation of PTSD has made a great advance since its inception in the early 1980s. Yet it may be argued that PTSD as now formulated does not go far enough in capturing the psychological response to traumatic events. The notion of "complex PTSD" is reviewed as an extension of the current formulations of PTSD. Complex PTSD transcends current formulations of PTSD in three main areas of disturbance: 1) complex symptom presentations, 2) characterological issues, and 3) vulnerability to repeated trauma. These issues are reviewed and support is provided for a formal recognition of "complex PTSD".

Growth, soluble carbohydrates, and aloin concentration of Aloe vera plants exposed to three irradiance levels

Research was conducted on Aloe vera, a traditional medicinal plant, to investigate the effects of light on growth, carbon allocation, and the concentrations of organic solutes, including soluble carbohydrates and aloin. The plants were vegetatively propagated and grown under three irradiances: full sunlight, partial (30% full sunlight), and deep shade (10% full sunlight) for 12-18 months. After 1 year of growth, five plants from each treatment were harvested to determine total above- and below ground dry mass. Four plants from the full sunlight and the partial shade treatments were harvested after 18 months to assess the soluble carbohydrate, organic acid and aloin concentrations of the clear parenchyma gel and the yellow leaf exudate, separately. Plants grown under full sunlight produced more numerous and larger axillary shoots, resulting in twice the total dry mass than those grown under partial shade. The dry mass of the plants grown under deep shade was 8.6% that of plants grown under full sunlight. Partial shade increased the number and length of leaves produced on the primary shoot, but leaf dry mass was still reduced to 66% of that in full sunlight. In contrast, partial and deep shade reduced root dry mass to 28 and 13%, respectively, of that under full sunlight, indicating that carbon allocation to roots was restricted under low light conditions. When plants were sampled 6 months later, there were only minor treatment effects on the concentration of soluble carbohydrates and aloin in the leaf exudate and gel. Soluble carbohydrate concentrations were greater in the gel than in the exudate, with glucose the most abundant soluble carbohydrate. Aloin was present only in the leaf exudate and higher irradiance did not induce a higher concentration. Limitation in light availability primarily affected total dry mass production and allocation, without substantial effects on either primary or secondary carbon metabolites.

Prostate specific antigen variation in patients without clinically evident prostate cancer

PURPOSE

We address long-term within individual variation of serum prostate specific antigen (PSA) in men without clinical or biopsy evidence of prostate cancer.

MATERIALS AND METHODS

We studied 943 men from a prostate cancer screening program with 2 PSA (PSA1 and PSA2) measurements available. A third PSA (PSA3) was obtained from 571 men. Only participants with no clinical evidence of cancer were included in the study. Within individual PSA variability was calculated based on indexes of percent coefficient of variation, ratio difference and PSA velocity. The relationship among these indexes, interval between measurements and number of PSA samples was assessed.

RESULTS

Mean interval was 670.4 days between PSA1 and PSA2, and 801.8 days between PSA2 and PSA3 (p<0.001). Mean coefficient of variation was 18% after 2 and 15.7% after 3 PSA measurements. Mean ratio differences were -0.047 ng./ml. for 2 and 0.033 ng./ml. for 3 samples. Mean PSA velocity was -0.128 ng./ml. per year for 2 and -0.055 ng./ml. per year for 3 samples, with 95% confidence intervals of 0.634 and 0.315, respectively. Variability was higher if only 2 PSA measurements were done (p<0.001). No clear relationship was found between individual variability and interval between measurements.

CONCLUSIONS

PSA velocity is within normal limits in almost all men (more than 95%) without clinically relevant prostate cancer. PSA individual variability is not fully dependent on the time between measurements when intervals are long, and can be substantially decreased with a third PSA sample.

Differential effect of estradiol on antibody secretion of murine hybridomas

The need for increased antibody production by hybridomas has been approached by the addition to cell cultures of different growth factors; in vitro addition of estradiol-17beta (E2) to human blood lymphocytes increases the accumulation of plasma-blasts and Ig-secreting cells. Four different murine-murine hybridomas secreting different monoclonal antibodies (MAbs) were treated with E2. Specific antibody concentration was measured by enzyme-linked immunoadsorbent assay (ELISA) in culture supernatants whereas expression of E2-receptor in the hybridoma cells was determined by polymerase chain reaction (PCR). When E2 was added as a growth supplement to alpha-estrogen receptor positive murine-murine hybridomas it enhanced MAb secretion by as much as 255%, in a dose-dependant manner. This effect lasted for as long as the alpha-estrogen receptor was detected in the hybridoma cells, was inhibited by tamoxifen and was not observed in alpha-estrogen receptor negative hybridomas. The synthetic estrogen analogue diethylstilbestrol had no effect. Estradiol-17beta should be added to the list of hybridoma-inducing growth factors.

The biosynthesis and post-translational modification of Pbs21 an ookinete-surface protein of Plasmodium berghei

Radiolabelled methionine incorporation into synchronised Plasmodium berghei gametocytes or ookinete cultures, showed that Pbs21 is not synthesised in bloodstage parasites; synthesis was detected within three hours of induction of gametogenesis; synthesis was triggered at gametogenesis, not by fertilisation. We show native Pbs21 to be a hydrophobic membrane protein that was insensitive to cleavage by phosphatidylinositol phospholipase C (PI-PLC), but sensitive to alkaline hydroxylamine, and partially sensitive to glycosylphosphatidylinositol-dependent phospholipase D (GPI-PLD) and HNO2. 3H-myristic and palmitic acid, 3H-glucosamine and mannose incorporation indicated Pbs21 was acylated and glycosylated. Linkage of the acyl group was sensitive to HNO2, which released an acyl-phosphatidylinositol more hydrophobic than that released from P3 of Trypanosoma brucei. All these properties are consistent with the presence of a malaria-specific glycosylphosphatidylinositol (GPI) anchor. In contrast recombinant Pbs21 (rPbs21), expressed in Spodoptera frugiperda cells, was sensitive to both PI-PLC and GPI-PLD, consistent with the protein being modified by a different (S. frugiperda) GPI anchor. Brefeldin A blocked secretion of rPbs21 within a cytoplasmic reticular compartment. Following deletion of the putative GPI anchor addition site (amino acids 189 213), the protein was transported to the cell surface and secreted directly into the aqueous phase of the culture medium. Deletion of amino acids 205-213 disrupted Pbs21 processing, transport through the ER and distribution onto the cell surface. Deletion of amino acids 1-28 prevented transport of Pbs21 into the ER. This suggests that correct processing of the GPI anchor in the ER-Golgi network is essential for the successful secretion of the recombinant protein, which is additionally dependent upon an N-terminal secretory signal sequence.

Differential tolerance is induced in T cells recognizing distinct epitopes of myelin basic protein

Experimental allergic encephalomyelitis (EAE) is induced by T cell-mediated immunity to central nervous system antigens. In H-2u mice, EAE is mediated primarily by T cells specific for residues 1-11 of myelin basic protein (MBP). We demonstrate that differential tolerance to MBP1-11 versus epitopes in MBP121-150 is induced by expression of endogenous MBP, reflecting extreme differences in stability of peptide/MHC complexes. The diverse MBP121-150-specific TCR repertoire can be divided into three fine specificity groups. Two groups were identified in wild-type mice despite extensive tolerance, but the third group was not detected. Activated MBP121-150-specific T cells induce EAE in wild-type mice. Thus, encephalitogenic T cells that escape tolerance either recognize short-lived peptide/MHC complexes or express TCRs with unique specificities for stable complexes.

Initiation and regulation of CNS autoimmunity

Our studies addressed the questions of how self-reactive T cells escape tolerance and what stimuli cause these T cells to initiate autoimmune responses. We employed experimental allergic encephalomyelitis (EAE) as an animal model of multiple sclerosis (MS). Endogenous expression of myelin basic protein (MBP) induces tolerance in T cells that recognize one region of MBP, whereas T cells specific for a different region escape tolerance. Triggers of disease induction were investigated in a T-cell receptor (TCR) transgenic model in which the majority of T cells recognize the MBP epitope that does not induce tolerance. EAE occurs spontaneously in this model and the incidence of disease depends on microbial exposure. EAE can also be actively induced by immunization with MBP peptide accompanied by injection of pertussis toxin as well as by administration of pertussis toxin alone. Immunization with MBP peptide without pertussis toxin, however, stimulates the transgenic T cells, but the activated T cells do not accumulate in the central nervous system (CNS) or induce EAE. Our studies suggest that initiation of autoimmune disease involves complex interactions between the neuroendocrine system as well as the innate and specific immune systems.

Triggers of autoimmune disease in a murine TCR-transgenic model for multiple sclerosis

The combination of genetic and environmental factors that contribute to human autoimmune responses has made potential triggers of these diseases difficult to identify. We examined how experimental allergic encephalomyelitis (EAE), an animal model of multiple sclerosis, is triggered using TCR-transgenic mice specific for myelin basic protein (MBP). In these TCR-transgenic mice, EAE can be actively induced and also occurs spontaneously. The incidence of spontaneous EAE in this model is largely confined to adolescence and early adulthood and is more prevalent among males than females, indicating that hormonal influences may contribute to triggering central nervous system autoimmune disease. Disease induction studies show that not all stimuli that activate MBP-specific T cells in vivo also induce EAE. Immunization with MBP peptide stimulates the transgenic T cells to produce Th1 cytokines; however, the activated T cells do not accumulate in the central nervous system and induce EAE unless pertussis toxin is also administered. EAE can be induced by intrathecal injection of either stimulated or nonstimulated transgenic T cells into nontransgenic or transgenic recipients. Therefore, gaining access to the central nervous system appears to be the critical step in this model for the induction of EAE, regardless of the activation state of the T cells.

Triggers of autoimmune disease in a murine TCR-transgenic model for multiple sclerosis

The combination of genetic and environmental factors that contribute to human autoimmune responses has made potential triggers of these diseases difficult to identify. We examined how experimental allergic encephalomyelitis (EAE), an animal model of multiple sclerosis, is triggered using TCR-transgenic mice specific for myelin basic protein (MBP). In these TCR-transgenic mice, EAE can be actively induced and also occurs spontaneously. The incidence of spontaneous EAE in this model is largely confined to adolescence and early adulthood and is more prevalent among males than females, indicating that hormonal influences may contribute to triggering central nervous system autoimmune disease. Disease induction studies show that not all stimuli that activate MBP-specific T cells in vivo also induce EAE. Immunization with MBP peptide stimulates the transgenic T cells to produce Th1 cytokines; however, the activated T cells do not accumulate in the central nervous system and induce EAE unless pertussis toxin is also administered. EAE can be induced by intrathecal injection of either stimulated or nonstimulated transgenic T cells into nontransgenic or transgenic recipients. Therefore, gaining access to the central nervous system appears to be the critical step in this model for the induction of EAE, regardless of the activation state of the T cells.

The influence of acute and chronic alcohol treatment on brain edema, cerebral infarct volume and neurological outcome following experimental head trauma in rats

The aim of this study was to determine the influence of acute and chronic ethanol treatment on neurological outcome following head trauma in rats. Eight-two Sprague-Dawley rats were divided into 10 groups. Four groups received sham head trauma (surgical incision of the scalp but no trauma) and were treated with (A) nothing, (B) chronic ethanol (6% ethanol in drinking water for 40 days), (C) acute ethanol 1.5 g/kg, intraperitoneally (IP) and (D) acute ethanol 3 g/kg IP. Four groups (E-H) received the same treatment; in addition, head trauma was delivered using a weight-drop device to the left cranium (2 h after ethanol treatment in the acute ethanol groups). To assess the influence of acute plus chronic alcohol and whether the glutamate antagonist ketamine can modify the neurologic outcome following head trauma, two additional head trauma groups were studied: group I received both acute and chronic ethanol treatment and group J received acute ethanol (1.5 g/kg) IP plus ketamine (180 mg/kg). Neurologic assessment was performed at 1, 2, 4, 8, 10, and 24 hours after head trauma or sham trauma in all animals who survived the treatment (omitted in group J animals while still under the anesthetic influence of ketamine). At the end of 24 hours, or at the time of death, the animals were decapitated. Specific gravity was determined from brain tissues adjacent to the injury and the contralateral hemispheres and the volume of hemorrhagic necrosis was quantified. None of the rats in the sham trauma groups died or had neurologic deficits. Of the head trauma groups, the mortality in animals that received 3 g/kg of ethanol and the animals that received acute plus chronic ethanol treatment was 100% before the end of 24 hours. Fifty percent of the animals receiving low-dose acute ethanol treatment (1.5 g/kg) died before 24 hours. In contrast, the mortality in the other groups was only 30% (p < 0.05). The neurologic severity score was significantly higher (greater neurological deficit) in the surviving animals that received acute ethanol treatment at 10 and 24 hours than in rats receiving no ethanol or chronic ethanol treatment. Specific gravity was also lower in the acute ethanol-treated groups compared with no ethanol, chronic ethanol, and acute ethanol plus ketamine groups (p < 0.03). Based on these observations, we conclude that in this rat head trauma model acute ethanol treatment increases mortality, neurological deficit, hemorrhagic necrosis volume, and brain edema. On the other hand, chronic ethanol treatment has no apparent effect and ketamine treatment does not counteract the effect of acute ethanol treatment.

Epidural hemorrhage: is it abuse?

OBJECTIVE

To determine whether children presenting with epidural hemorrhage (EDH) are as likely to have been abused as are children presenting with subdural hemorrhage (SDH).

DESIGN

Retrospective chart review.

SETTING

Level I regional trauma center and a regional children's hospital.

PATIENTS

All children at both institutions 3 years old or younger with a diagnosis of EDH or SDH identified by a search of the computerized trauma registry and hospital medical records from 1985 through 1991.

MEASUREMENT AND RESULTS

Complete records were found for 93 of 94 eligible subjects. The diagnosis of accidental or inflicted injury was ascertained from the patient's hospital medical record or the records of Child Protective Services. Of all subjects (n = 93), 52% (48/93) were male and the median age was 15 months. Abuse was diagnosed in 47% (28/59) of children with SDH and 6% (2/34) of those with EDH. Other significant injuries were found in 47% of children with SDH and 18% of children with EDH. There was no statistically significant difference between the two groups with respect to the likelihood of identifying a skull fracture, the need for surgical evacuation of the hemorrhage, or mortality.

CONCLUSIONS

Our data are consistent with current biomechanical concepts of intracranial injury. EDHs results from brief linear contact forces that commonly occur in unintentional falls. SDHs are caused by global high-energy rotational acceleration/deceleration forces that are commonly generated in episodes of abuse. Compared with SDH, EDH rarely results from abuse.

Identification of a 20-kDa protein with calcium uptake transport activity. Reconstitution in a membrane model

This paper presents results of experiments designed to further purify the membrane system involved in mitochondrial calcium transport. A partially purified extract, which transported calcium with a specific activity of 1194 nmol 45Ca2+/mg protein/5 min, was used to obtain mouse hyperimmune serum. This serum inhibited calcium uptake both in mitoplasts and in vesicles reconstituted with mitochondrial proteins containing cytochrome oxidase. Western blot analysis of the semipurified fraction showed that the serum recognized specifically two antigens of 75 and 20 kDa. Both antibodies were purified by elution from the nitrocellulose sheets and their inhibition capacity was analyzed. The antibody that recognized the 20-kDa protein produced a higher degree of inhibition than the other one.

[High pressure filling bladder]

A complete urodynamic study was carried out on 41 consecutive patients presenting in the cystomanometry a vesical filling pressure at maximum capacity higher than 30 cm H2O. Two groups were evident: group I with neurogenic etiology, and group II without an obvious neurogenic etiology. From its results it can be seen that a diminished vesical accommodation is not a urodynamic fact restricted to vesicourethral neurogenic dysfunction, but it happens in several non-neurogenic conditions. Within the neurogenic group, the urodynamic element most frequently associated to a diminished vesical accommodation was an inferior motor neuron-like vesicourethral dysfunction. An increased vesical filling pressure was not enough to produce urinary incontinence, being also necessary an added factor to prompt involuntary loss of urine.

[Urinary incontinence in the elderly: clinical and urodynamic review of 195 cases]

One hundred ninety-five male and female patients over 65 years old presenting with urinary incontinence were evaluated by clinical and urodynamics. Urinary incontinence was in the form of urgency-incontinence in 68% of the cases, incontinence at cough in 26%, and urinary incontinence which the patient referred to no specific situation in 6%. Among the different urodynamics data, bladder instability was the most common (73%). Urinary stress incontinence was observed in 35% of the cases. Bladder instability was demonstrated in 77% of the cases with urgency-incontinence and in 69% of the cases with incontinence not referred to a specific situation. All the male patients with lower urinary tract obstruction had urgency-incontinence. Stress incontinence was demonstrated in 60% of the cases with incontinence at cough. Stress incontinence was not observed in male patients without associated diseases. The associated neurological disorder was accompanied by bladder hyperreflexia in 90% of the cases. A prior adenomectomy or hysterectomy was associated with a greater number of cases with stress urinary incontinence, accounting for 62% in both males and females.

Post-transplant renal artery stenosis: a possible immunological phenomenon

A retrospective review of 110 consecutive kidney transplants performed during 4 years revealed the development of renal artery stenosis in 9 patients (8.18%). A comparison of this group with a control group similar in patient age and interval elapsed since transplantation revealed no significant differences in donor and recipient ages, degree of HLA compatibility or serum creatinine levels. However, there was a significant difference in the number of acute rejection episodes. In our series only male patients were affected. A sizable proportion of the patients (50%) had no detectable murmur over the graft area despite high blood pressure and increased creatinine levels. The absence of surgical injury during extraction and implantation of the grafts, together with the anatomical site of the stenosis and correlation with the degree of immunological intolerance suggest an immunological factor as the underlying cause in post-transplant renal artery stenosis.

Basic physiopathological patterns of perfusion and inhalation pulmonary scintigraphy

^113mIn is an excellent radiopharmaceutical for pulmonary scanning. Seven physiopathological patterns are described after the study of the results of successive perfusion and inhalation pulmonary scans—pulmonary artery obstruction, complete bronchial obstruction, partial bronchial obstruction, bronchiolar obstruction, anatomical changes in the pulmonary parenchyma, pathological pulmonary dead space, and intrapulmonary arterio-venous shunting. Pulmonary artery obstruction can be diagnosed early, precisely, and safely by this method. Pathological pulmonary dead space and intrapulmonary shunting have well-defined characteristics; the ability to demonstrate their topography and size in patients with pulmonary emphysema may lead to surgical removal of the affected regions, thus improving overall pulmonary function. The scintigraphic procedures used revealed that bronchial obstruction is associated with absent pulmonary arterial perfusion in the corresponding bronchial territory; this finding is of the utmost importance, as it may permit the diagnosis of bronchial carcinoma before any radiological changes occur.