Factors associated with increased radiation exposure in the fixation of proximal femoral fractures

INTRODUCTION

When using radiation intraoperatively, a surgeon should aim to keep the radiation dose as low as is reasonably achievable to obtain the therapeutic goal. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures.

METHODS

We assessed 369 neck of femur fractures over a 1-year period in a district general hospital. All hip fracture subtypes that had undergone surgical fixation were included. We assessed the relationship between type of fracture, implants used and surgeon level of experience with the dose-area product (DAP; cGy/cm2) and screening time (dS). We also looked at the quality of reduction and fixation and its effect on the radiation exposure.

RESULTS

A total of 184 patients were included in our analysis; 185 patients who were treated with hip arthroplasty were excluded. There was a significant association between higher DAP and fracture subtype (p = 0.001), fracture complexity (p < 0.001), if an additional implant was used (p = 0.001), if fixation was satisfactory (p = 0.002) and operative time (p < 0.001). DAP was higher with a proximal femoral nail than with a dynamic hip screw, especially when a long nail was used. There was some evidence of an association between the surgeon's level of experience and DAP exposure, although this was not statistically significant (p = 0.069).

CONCLUSIONS

Increased radiation in proximal femur fractures is seen in the fixation of complex fractures, some subtypes, with certain types of implants used and if an additional implant was required. Surgeon seniority did not result in less radiation exposure, which is in contrast to other published studies.

Mechanistic In Situ ATR-FTIR Studies on the Adsorption and Desorption of Major Intermediates in CO2 Electrochemical Reduction on CuO Nanoparticles

Increasing levels of carbon dioxide (CO₂) from human activities is affecting the ecosystem and civilization as we know it. CO₂ removal from the atmosphere and emission reduction by heavy industries through carbon capture, utilization, and storage (CCUS) technologies to store or convert CO₂ to useful products or fuels is a popular approach to meet net zero targets by 2050. One promising process of CO₂ removal and conversion is CO₂ electrochemical reduction (CO₂ER) using metal and metal oxide catalysts, particularly copper-based materials. However, the current limitations of CO₂ER stem from the low product selectivity of copper electrocatalysts due to existing knowledge gaps of the reaction mechanisms using surfaces that normally have native oxide layers. Here, we report systematic control studies of the surface interactions of major intermediates in CO₂ER, formate, bicarbonate, and acetate, with CuO nanoparticles in situ and in real time using attenuated total reflection Fourier-transform infrared spectroscopy (ATR-FTIR). Spectra were collected as a function of concentration, pH, and time in the dark and the in absence of added electrolytes. Isotopic exchange experiments were also performed to elucidate the type of surface complexes from H/D exchange. Our results show that the organics and bicarbonate form mostly outer-sphere complexes mediated by hydrogen bonding with CuO nanoparticles with Gibbs free energy of adsorption of about -25 kJ mol^-1. The desorption kinetics of the surface species indicated relatively fast and slow regions reflective of the heterogeneity of sites that affect the strength of hydrogen bonding. These results suggest that hydrogen bonding, whether intermolecular or with surface sites on CuO nanoparticles, might be playing a more important role in the CO₂ER reaction mechanism than previously thought, contributing to the lack of product selectivity.

A Case Of Disseminated Histoplasmosis In A Patient With Sarcoidosis

Introduction/Objective

Sarcoidosis is a syndrome of unknown cause that may manifest with clinical, radiographic and pathological findings similar to those seen with histoplasmosis. We present a case of disseminated histoplasmosis in an immunocompetent patient previously diagnosed with sarcoidosis.

Methods/Case Report

A 69-year-old obese male with a history of hypertension, diabetes mellitus and long-standing sarcoidosis was admitted to the hospital for several months of intermittent fevers and pancytopenia. His sarcoidosis was diagnosed 21 years prior, initially involving the lungs and eventually showing cardiac involvement, requiring a pacemaker. He had been treated with methotrexate and prednisone. His recent medical history was also significant for COVID-19 infection, diagnosed 3 months before admission. His fevers were initially attributed to sarcoidosis and his pancytopenia to methotrexate. However, his symptoms continued despite discontinuation of his medications, and further workup was initiated.

Computed tomography showed hepatomegaly, splenomegaly, and lymphadenopathy, concerning for a lymphoproliferative disorder. The patient underwent a bone marrow biopsy that showed noncaseating granulomas and microorganisms consistent with histoplasmosis on fungal stain. Bone marrow cultures were not possible as the marrow was inaspirable. The patient subsequently underwent a lymph node biopsy with both morphology and culture identifying histoplasmosis. Urine and serum histoplasma antigen also returned positive. The patient’s overall clinical picture was consistent with disseminated histoplasmosis and he was administered intravenous Amphotericin B for 3 weeks followed by oral itraconazole for 1 year. One month follow-up after discharge showed significant improvement in the patient’s condition.

Results (if a Case Study enter NA)

N/A

Conclusion

Sarcoidosis reduces T-cell activity, and treatment with steroids causes further immunosuppression and vulnerability for development of a disseminated infection. COVID-19 also presumably increases the predisposition to acquire bacterial or fungal co-infections. Clinicians and pathologists should be aware of the overlap in clinical, radiologic and pathological presentations of sarcoidosis and histoplasmosis to make the correct diagnosis and administer the appropriate treatment.

Metal exposure causes rDNA copy number to fluctuate in mutation accumulation lines of Daphnia pulex

Ribosomal (r)DNA is a highly dynamic, conserved, multigene family whose sequence homogeneity is thought to be maintained by intra- and interchromosomal recombination, which are capable of changing rDNA copy number. It is generally not known how environmental stress such as sublethal exposure to environmentally relevant concentrations of metals impacts rDNA copy number. To determine how chronic metal exposure affects rDNA, we measured copy number of the 18S rRNA gene in 355 copper and nickel-exposed samples and 132 metal-free samples derived from 325 mutation accumulation (MA) lines of two genetically distinct Daphnia pulex lineages. The MA lines were sampled at four time points over 100+ generations of clonal propagation. The copy number of rDNA was also measured in 15 individuals sampled from a metal-free non-MA control population established from the same progenitor as one of the MA lineages. We found that mean rDNA copy number fluctuated across lines exposed to metals with a tendency to decrease over time. In contrast, mean rDNA copy number in the metal-free control lines and the non-MA population remained stable over time. It is generally accepted that extreme rDNA loss results in the loss of organism fitness. Thus, fluctuations in rDNA copy number, including losses, could affect the long-term viability of natural populations of Daphnia in metal-contaminated habitats.

In vitro validation of in silico identified inhibitory interactions

BACKGROUND

Understanding how neuronal signals propagate in local network is an important step in understanding information processing. As a result, spike trains recorded with multi-electrode arrays (MEAs) have been widely used to study the function of neural networks. Studying the dynamics of neuronal networks requires the identification of both excitatory and inhibitory connections. The detection of excitatory relationships can robustly be inferred by characterizing the statistical relationships of neural spike trains. However, the identification of inhibitory relationships is more difficult: distinguishing endogenous low firing rates from active inhibition is not obvious.

NEW METHOD

In this paper, we propose an in silico interventional procedure that makes predictions about the effect of stimulating or inhibiting single neurons on other neurons, and thereby gives the ability to accurately identify inhibitory effects.

COMPARISON

To experimentally test these predictions, we have developed a Neural Circuit Probe (NCP) that delivers drugs transiently and reversibly on individually identified neurons to assess their contributions to the neural circuit behavior.

RESULTS

Using the NCP, putative inhibitory connections identified by the in silico procedure were validated through in vitro interventional experiments.

CONCLUSIONS

Together, these results demonstrate how detailed microcircuitry can be inferred from statistical models derived from neurophysiology data.

Action potential propagation recorded from single axonal arbors using multielectrode arrays

We report the presence of co-occurring extracellular action potentials (eAPs) from cultured mouse hippocampal neurons among groups of planar electrodes on multielectrode arrays (MEAs). The invariant sequences of eAPs among coactive electrode groups, repeated co-occurrences, and short interelectrode latencies are consistent with action potential propagation in unmyelinated axons. Repeated eAP codetection by multiple electrodes was widespread in all our data records. Codetection of eAPs confirms they result from the same neuron and allows these eAPs to be isolated from all other spikes independently of spike sorting algorithms. We averaged co-occurring events and revealed additional electrodes with eAPs that would otherwise be below detection threshold. We used these eAP cohorts to explore the temperature sensitivity of action potential propagation and the relationship between voltage-gated sodium channel density and propagation velocity. The sequence of eAPs among coactive electrodes "fingerprints" neurons giving rise to these events and identifies them within neuronal ensembles. We used this property and the noninvasive nature of extracellular recording to monitor changes in excitability at multiple points in single axonal arbors simultaneously over several hours, demonstrating independence of axonal segments. Over several weeks, we recorded changes in interelectrode propagation latencies and ongoing changes in excitability in different regions of single axonal arbors. Our work illustrates how repeated eAP co-occurrences can be used to extract physiological data from single axons with low-density MEAs. However, repeated eAP co-occurrences lead to oversampling spikes from single neurons and thus can confound traditional spike-train analysis. NEW & NOTEWORTHY We studied action potential propagation in single axons using low-density multielectrode arrays. We unambiguously identified the neuronal sources of propagating action potentials and recorded extracellular action potentials from several positions within single axonal arbors. We found a surprisingly high density of axonal voltage-gated sodium channels responsible for a high propagation safety factor. Our experiments also demonstrate that excitability in different segments of single axons is regulated independently on timescales from hours to weeks.

Bone Tissue Properties Measurement by Reference Point Indentation in Glucocorticoid-Induced Osteoporosis

Glucocorticoids, widely used in inflammatory disorders, rapidly increase bone fragility and, therefore, fracture risk. However, common bone densitometry measurements are not sensitive enough to detect these changes. Moreover, densitometry only partially recognizes treatment-induced fracture reductions in osteoporosis. Here, we tested whether the reference point indentation technique could detect bone tissue property changes early after glucocorticoid treatment initiation. After initial laboratory and bone density measurements, patients were allocated into groups receiving calcium + vitamin D (Ca+D) supplements or anti-osteoporotic drugs (risedronate, denosumab, teriparatide). Reference point indentation was performed on the cortical bone layer of the tibia by a handheld device measuring bone material strength index (BMSi). Bone mineral density was measured by dual-energy X-ray absorptiometry (DXA). Although Ca+D-treated patients exhibited substantial and significant deterioration, risedronate-treated patients exhibited no significant change, and both denosumab- and teriparatide-treated participants exhibited significantly improved BMSi 7 weeks after initial treatment compared with baseline; these trends remained stable for 20 weeks. In contrast, no densitometry changes were observed during this study period. In conclusion, our study is the first to our knowledge to demonstrate that reference point indentation is sensitive enough to reflect changes in cortical bone indentation after treatment with osteoporosis therapies in patients newly exposed to glucocorticoids.

Study of indentation of a sample equine bone using finite element simulation and single cycle reference point indentation

In an attempt to study the mechanical behavior of bone under indentation, methods of analyses and experimental validations have been developed, with a selected test material. The test material chosen is from an equine cortical bone. Stress-strain relationships are first obtained from conventional mechanical property tests. A finite element simulation procedure is developed for indentation analyses. The simulation results are experimentally validated by determining (1) the maximum depth of indentation with a single cycle type of reference point indentation, and (2) the profile and depth of the unloaded, permanent indentation with atomic force microscopy. The advantage of incorporating in the simulation a yield criterion calibrated by tested mechanical properties, with different values in tension and compression, is demonstrated. In addition, the benefit of including damage through a reduction in Young's modulus is shown in predicting the permanent indentation after unloading and recovery. The expected differences in response between two indenter tips with different sharpness are predicted and experimentally observed. Results show predicted indentation depths agree with experimental data. Thus, finite element simulation methods with experimental validation, and with damage approximation by a reduction of Young's modulus, may provide a good approach for analysis of indentation of cortical bone. These methods reveal that multiple factors affect measured indentation depth and that the shape of the permanent indentation contains useful information about bone material properties. Only further work can determine if these methods or extensions to these methods can give useful insights into bone pathology, for example the bone fragility of thoroughbred racehorses.

Long-term safety and efficacy of certolizumab pegol in the treatment of Crohn's disease: 7-year results from the PRECiSE 3 study

BACKGROUND

The efficacy and safety of certolizumab pegol (CZP) in moderate-to-severe Crohn's disease were demonstrated in two 26-week double-blind studies (PRECiSE 1 & 2).

AIM

To report the safety and efficacy outcomes of long-term, CZP therapy from PRECiSE 3, in which patients received treatment up to 7 years treatment.

METHODS

Patients completing PRECiSE 1 or 2 were eligible to enter PRECiSE 3 in which they received CZP 400 mg, open-label, every 4 weeks (without additional induction therapy) for up to 7 years, for up to 91 doses from study start. Safety (adverse events, including infections and malignancies) and efficacy (Harvey-Bradshaw Index, faecal calprotectin, C-reactive protein) were prospectively monitored. Remission was analysed using observed cases, last observation carried forward imputation and nonresponder imputation.

RESULTS

A total of 595 patients entered the study; 117 (20%) completed 7 years. Discontinuation rates were 29.2%, 13.6%, 16.1%, 7.9%, 5.0%, 4.5% and 3.9% (years 1-7 respectively). During 1920 patient-years of exposure to CZP, no new safety signals were observed. Incidence rates (new cases/100 patient-years) for serious infections and malignant neoplasms were 4.37 and 1.06 respectively. No lymphoproliferative malignancies were reported. Clinical remission rates were ≥68% at each year (observed cases); rates by last observation carried forward and nonresponder imputation were 58% and 45% at year 1, 56% and 26% at year 3 and 55% and 13% at year 7 respectively.

CONCLUSION

Certolizumab pegol was well tolerated in the long-term treatment of Crohn's disease, with sustained remission in some patients continuing in the study for up to 7 years. ClinicalTrials.gov identifier NCT00552058.

A new ion sensing deep atomic force microscope

Here we describe a new deep atomic force microscope (AFM) capable of ion sensing. A novel probe assembly incorporates a micropipette that can be used both for sensing ion currents and as the tip for AFM imaging. The key advance of this instrument over previous ion sensing AFMs is that it uses conventional micropipettes in a novel suspension system. This paper focuses on sensing the ion current passively while using force feedback for the operation of the AFM in contact mode. Two images are obtained simultaneously: (1) an AFM topography image and (2) an ion current image. As an example, two images of a MEMS device with a microchannel show peaks in the ion current as the pipette tip goes over the edges of the channel. This ion sensing AFM can also be used in other modes including tapping mode with force feedback as well as in non-contact mode by utilizing the ion current for feedback, as in scanning ion conductance microscopy. The instrument is gentle enough to be used on some biological samples such as plant leaves.

Reduced glucose uptake and Aβ in brain regions with hyperintensities in connected white matter

Interstitial concentration of amyloid beta (Aß) is positively related to synaptic activity in animal experiments. In humans, Aß deposition in Alzheimer's disease overlaps with cortical regions highly active earlier in life. White matter lesions (WML) disrupt connections between gray matter (GM) regions which in turn changes their activation patterns. Here, we tested if WML are related to Aß accumulation (measured with PiB-PET) and glucose uptake (measured with FDG-PET) in connected GM. WML masks from 72 cognitively normal (age 61.7 ± 9.6 years, 71% women) individuals were obtained from T2-FLAIR. MRI and PET images were normalized into common space, segmented and parcellated into gray matter (GM) regions. The effects of WML on connected GM regions were assessed using the Change in Connectivity (ChaCo) score. Defined for each GM region, ChaCo is the percentage of WM tracts connecting to that region that pass through the WML mask. The regional relationship between ChaCo, glucose uptake and Aß was explored via linear regression. Subcortical regions of the bilateral caudate, putamen, calcarine, insula, thalamus and anterior cingulum had WM connections with the most lesions, followed by frontal, occipital, temporal, parietal and cerebellar regions. Regional analysis revealed that GM with more lesions in connecting WM and thus impaired connectivity had lower FDG-PET (r = 0.20, p<0.05 corrected) and lower PiB uptake (r = 0.28, p<0.05 corrected). Regional regression also revealed that both ChaCo (β = 0.045) and FDG-PET (β = 0.089) were significant predictors of PiB. In conclusion, brain regions with more lesions in connecting WM had lower glucose metabolism and lower Aß deposition.

Tramadol deaths in Northern Ireland: a review of cases from 1996 to 2012

In the UK tramadol is a frequently prescribed opioid analgesic which is becoming increasingly popular as a drug of misuse. Its use varies worldwide and in the last decade it has been upgraded to a controlled substance in several countries, due to an increased number of deaths associated with its use. A review of all deaths associated with tramadol in Northern Ireland was performed and this highlighted 127 cases from 1996 to the end of 2012. A 10% increase in deaths due to tramadol was noted. In 2001 tramadol deaths represented 9% of all drug misuse deaths rising to 40% in 2011. The majority of the deaths occurred in males (62%), with a median age of 41 years, living in the Belfast city area (36%). Tramadol fatalities were found in combination with other drugs/medicines (49%), alcohol (36%) or alone (23%). Most of those who died did not reach hospital, with only 2% presenting with multi-organ or acute liver failure. In just over half of the deaths tramadol had not been prescribed by a medical practitioner (53%). Depression, addiction and seizures were recognised risk factors. An increase in awareness of tramadol toxicity is needed amongst the public and doctors.

Applications of a New Handheld Reference Point Indentation Instrument Measuring Bone Material Strength

A novel, hand-held Reference Point Indentation (RPI) instrument, measures how well the bone of living patients and large animals resists indentation. The results presented here are reported in terms of Bone Material Strength, which is a normalized measure of how well the bone resists indentation, and is inversely related to the indentation distance into the bone. We present examples of the instrument's use in: (1) laboratory experiments on bone, including experiments through a layer of soft tissue, (2) three human clinical trials, two ongoing in Barcelona and at the Mayo Clinic, and one completed in Portland, OR, and (3) two ongoing horse clinical trials, one at Purdue University and another at Alamo Pintado Stables in California. The instrument is capable of measuring consistent values when testing through soft tissue such as skin and periosteum, and does so handheld, an improvement over previous Reference Point Indentation instruments. Measurements conducted on horses showed reproducible results when testing the horse through tissue or on bare bone. In the human clinical trials, reasonable and consistent values were obtained, suggesting the Osteoprobe® is capable of measuring Bone Material Strength in vivo, but larger studies are needed to determine the efficacy of the instrument's use in medical diagnosis.

Deep atomic force microscopy

The Atomic Force Microscope (AFM) possesses several desirable imaging features including the ability to produce height profiles as well as two-dimensional images, in fluid or air, at high resolution. AFM has been used to study a vast selection of samples on the scale of angstroms to micrometers. However, current AFMs cannot access samples with vertical topography of the order of 100 μm or greater. Research efforts have produced AFM scanners capable of vertical motion greater than 100 μm, but commercially available probe tip lengths are still typically less than 10 μm high. Even the longest probe tips are below 100 μm and even at this range are problematic. In this paper, we present a method to hand-fabricate "Deep AFM" probes with tips of the order of 100 μm and longer so that AFM can be used to image samples with large scale vertical topography, such as fractured bone samples.

A new device for performing reference point indentation without a reference probe

Here we describe a novel, hand-held reference point indentation (RPI), instrument that is designed for clinical measurements of bone material properties in living patients. This instrument differs from previous RPI instruments in that it requires neither a reference probe nor removal of the periosteum that covers the bone, thus significantly simplifying its use in patient testing. After describing the instrument, we discuss five guidelines for optimal and reproducible results. These are: (1) the angle between the normal to the surface and the axis of the instrument should be less than 10°, (2) the compression of the main spring to trigger the device must be performed slowly (>1 s), (3) the probe tip should be sharper than 10 μm; however, a normalized parameter with a calibration phantom can correct for dull tips up to a 100 μm radius, (4) the ambient room temperature should be between 4 °C and 37 °C, and (5) the effective mass of the bone or material under test must exceed 1 kg, or if under 1 kg, the specimen should be securely anchored in a fixation device with sufficient mass (which is not a requirement of previous RPI instruments). Our experience is that a person can be trained with these guidelines in about 5 min and thereafter obtain accurate and reproducible results. The portability, ease of use, and minimal training make this instrument suitable to measure bone material properties in a clinical setting.

The long range voice coil atomic force microscope

Most current atomic force microscopes (AFMs) use piezoelectric ceramics for scan actuation. Piezoelectric ceramics provide precision motion with fast response to applied voltage potential. A drawback to piezoelectric ceramics is their inherently limited ranges. For many samples this is a nonissue, as imaging the nanoscale details is the goal. However, a key advantage of AFM over other microscopy techniques is its ability to image biological samples in aqueous buffer. Many biological specimens have topography for which the range of piezoactuated stages is limiting, a notable example of which is bone. In this article, we present the use of voice coils in scan actuation for an actuation range in the Z-axis an order of magnitude larger than any AFM commercially available today. The increased scan size will allow for imaging an important new variety of samples, including bone fractures.

Microindentation for in vivo measurement of bone tissue mechanical properties in humans

Bone tissue mechanical properties are deemed a key component of bone strength, but their assessment requires invasive procedures. Here we validate a new instrument, a reference point indentation (RPI) instrument, for measuring these tissue properties in vivo. The RPI instrument performs bone microindentation testing (BMT) by inserting a probe assembly through the skin covering the tibia and, after displacing periosteum, applying 20 indentation cycles at 2 Hz each with a maximum force of 11 N. We assessed 27 women with osteoporosis-related fractures and 8 controls of comparable ages. Measured total indentation distance (46.0 +/- 14 versus 31.7 +/- 3.3 microm, p = .008) and indentation distance increase (18.1 +/- 5.6 versus 12.3 +/- 2.9 microm, p = .008) were significantly greater in fracture patients than in controls. Areas under the receiver operating characteristic (ROC) curve for the two measurements were 93.1% (95% confidence interval [CI] 83.1-100) and 90.3% (95% CI 73.2-100), respectively. Interobserver coefficient of variation ranged from 8.7% to 15.5%, and the procedure was well tolerated. In a separate study of cadaveric human bone samples (n = 5), crack growth toughness and indentation distance increase correlated (r = -0.9036, p = .018), and scanning electron microscope images of cracks induced by indentation and by experimental fractures were similar. We conclude that BMT, by inducing microscopic fractures, directly measures bone mechanical properties at the tissue level. The technique is feasible for use in clinics with good reproducibility. It discriminates precisely between patients with and without fragility fracture and may provide clinicians and researchers with a direct in vivo measurement of bone tissue resistance to fracture.

In situ Materials Characterization using the Tissue Diagnostic Instrument

An understanding of the mechanical behavior of polymers is critical towards the design, implementation, and quality control of such materials. Yet experiments and method for the characterization of material properties of polymers remain challenging due the need to reconcile constitutive assumptions with experimental conditions. Well-established modes of mechanical testing, such as unconfined compression or uniaxial tension, require samples with specific geometries and carefully controlled orientations. Moreover, producing specimens that conform to such specifications often requires a considerable amount of sample material. In this study we validate a micromechanical indentation device, the Tissue Diagnostic Instrument (TDI), which implements a cyclic indentation method to determine the material properties of polymers and elastomeric materials. Measurements using the TDI require little or no sample preparation, and they allow the testing of sample materials in situ. In order to validate the use of the TDI, we compared measurements of modulus determined by the TDI to those obtained by unconfined compression tests and by uniaxial tension tests within the limit of small stresses and strains. The results show that the TDI measurements were significantly correlated with both unconfined compression (p<0.001; r(2) = 0.92) and uniaxial tension tests (p<0.001; r(2)=0.87). Moreover, the measurements across all three modes of testing were statistically indistinguishable from each other (p=0.92; ANOVA) and demonstrate that TDI measurements can provide a surrogate for the conventional methods of mechanical characterization.

The bone diagnostic instrument III: testing mouse femora

Here we describe modifications that allow the bone diagnostic instrument (BDI) [P. Hansma et al., Rev. Sci. Instrum. 79, 064303 (2008); Rev. Sci. Instrum. 77, 075105 (2006)], developed to test human bone, to test the femora of mice. These modifications include reducing the effective weight of the instrument on the bone, designing and fabricating new probe assemblies to minimize damage to the small bone, developing new testing protocols that involve smaller testing forces, and fabricating a jig for securing the smaller bones for testing. With these modifications, the BDI was used to test the hypothesis that short-term running has greater benefit on the mechanical properties of the femur for young growing mice compared to older, skeletally mature mice. We measured elastic modulus, hardness, and indentation distance increase (IDI), which had previously been shown to be the best discriminators in model systems known to exhibit differences in mechanical properties at the whole bone level. In the young exercised murine femora, the IDI was significantly lower than in young control femora. Since IDI has a relation to postyield properties, these results suggest that exercise during bone development increases post yield mechanical competence. We were also able to measure effects of aging on bone properties with the BDI. There was a significant increase in the IDI, and a significant decrease in the elastic modulus and hardness between the young and old groups. Thus, with the modifications described here, the BDI can take measurements on mouse bones and obtain statistically significant results.

The tissue diagnostic instrument

Tissue mechanical properties reflect extracellular matrix composition and organization, and as such, their changes can be a signature of disease. Examples of such diseases include intervertebral disk degeneration, cancer, atherosclerosis, osteoarthritis, osteoporosis, and tooth decay. Here we introduce the tissue diagnostic instrument (TDI), a device designed to probe the mechanical properties of normal and diseased soft and hard tissues not only in the laboratory but also in patients. The TDI can distinguish between the nucleus and the annulus of spinal disks, between young and degenerated cartilage, and between normal and cancerous mammary glands. It can quantify the elastic modulus and hardness of the wet dentin left in a cavity after excavation. It can perform an indentation test of bone tissue, quantifying the indentation depth increase and other mechanical parameters. With local anesthesia and disposable, sterile, probe assemblies, there has been neither pain nor complications in tests on patients. We anticipate that this unique device will facilitate research on many tissue systems in living organisms, including plants, leading to new insights into disease mechanisms and methods for their early detection.

The bone diagnostic instrument II: indentation distance increase

The bone diagnostic instrument (BDI) is being developed with the long-term goal of providing a way for researchers and clinicians to measure bone material properties of human bone in vivo. Such measurements could contribute to the overall assessment of bone fragility in the future. Here, we describe an improved BDI, the Osteoprobe IItrade mark. In the Osteoprobe IItrade mark, the probe assembly, which is designed to penetrate soft tissue, consists of a reference probe (a 22 gauge hypodermic needle) and a test probe (a small diameter, sharpened rod) which slides through the inside of the reference probe. The probe assembly is inserted through the skin to rest on the bone. The distance that the test probe is indented into the bone can be measured relative to the position of the reference probe. At this stage of development, the indentation distance increase (IDI) with repeated cycling to a fixed force appears to best distinguish bone that is more easily fractured from bone that is less easily fractured. Specifically, in three model systems, in which previous mechanical testing and/or tests reported here found degraded mechanical properties such as toughness and postyield strain, the BDI found increased IDI. However, it must be emphasized that, at this time, neither the IDI nor any other mechanical measurement by any technique has been shown clinically to correlate with fracture risk. Further, we do not yet understand the mechanism responsible for determining IDI beyond noting that it is a measure of the continuing damage that results from repeated loading. As such, it is more a measure of plasticity than elasticity in the bone.

Dental management of the myasthenic patient

Myasthenia gravis (MG) is an auto-immune disorder of neuromuscular transmission which results in weakness and fatigue of skeletal muscles. The defect in neuromuscular transmission is most commonly seen in the muscles of the eyes, face, neck and shoulders but, in some patients, the respiratory muscles are involved. Patients with this condition may present with problems that necessitate special consideration when managing their dental treatment. Patients who are only mildly affected by MG can be treated in general dental practice for routine care. There are no contra-indications to the use of local anaesthetic agents and the presence of a vasoconstrictor is desirable. More severely affected patients and those who are very anxious about dental treatment should be cared for within the hospital environment. In these patients, respiratory muscles may be affected and, as a result, a myasthenic crisis may arise which requires assisted ventilation and, in some cases, intubation. Those patients who are fearful of the dental environment are likely to be emotionally stressed during such times and this increases the risk of a myasthenic crisis; sedation techniques can be beneficial in this group of patients.

A rare cause of upper airway obstruction in a 5-year-old girl: a laryngeal web

A case is described of a 5-year-old girl with respiratory distress. She was intubated without difficulty, but developed respiratory distress on extubation. Laryngoscopy/bronchoscopy via a laryngeal mask airway revealed an extensive layngeal web which was removed with laser therapy. The causes and differential diagnosis of laryngeal web are discussed.

Molecular characterization of putative yolk processing enzymes and their expression during oogenesis and embryogenesis in rainbow trout (Oncorhynchus mykiss)

Vitellogenin is the major yolk protein precursor in fish, but little is known about its processing pathway in the oocyte, nor about mobilization of yolk proteins during embryogenesis. In this study we cloned three putative yolk processing enzymes; specifically, cathepsin B and L, and lipoprotein lipase (LPL), from the rainbow trout ovary and determined their patterns of gene expression, together with cathepsin D, during oogenesis and embryogenesis using reverse transcription-polymerase chain reaction. The approximate sizes of both cathepsin B and cathepsin L transcripts were estimated as 1.7-1.8 kilobases by Northern blot analysis. Cathepsin D mRNA and cathepsin L mRNA were expressed constitutively throughout vitellogenesis and embryogenesis, showing the highest levels of expression at around fertilization. Cathepsin B and LPL were expressed exclusively during oogenesis. Quantitatively, expression of cathepsin D mRNA was higher than cathepsin B, cathepsin L, and LPL mRNA throughout the period studied. The different patterns of expression for these genes during oogenesis and embryogenesis signify specific temporal roles in yolk protein processing.

Safe and easy method for secondary tracheo-oesophageal puncture

We describe a method for performing secondary tracheo-oesophageal puncture in patients who have undergone total laryngectomy. The technique is straightforward and easy. It uses a minimum of readily available equipment with a simple modification to a standard pharyngoscope.

Adolescent Obsessive-Compulsive Drinking Scale: an assessment tool for problem drinking

Alcoholism has been studied in adults and found to share obsessive-compulsive characteristics. The Yale-Brown Obsessive Compulsive Scale (YBOC) was used to quantify the measurements of this disorder. This study adapted the YBOC for use with adolescents/young adults in an attempt to measure the "craving" expressed as obsessive and compulsive phenomenon. The primary findings show that the obsessive compulsive dimensions of alcohol cravings, as described in adult populations, also exist in adolescent/young adults. The Adolescent Obsessive Compulsive Drinking Scale (A-OCDS) was developed utilizing idioms and language typical for the 17-20 age group. Various quantitative evaluations proved that the Interference and Irresistibility sub-scales were the primary dimensions causing the obsessive behavior. This study begins to address this aspect of adolescent substance abuse utilizing a tool that is easy to administer. Because of the ease of use, although not a diagnostic instrument, the A-OCDS may be useful for identifying problem drinking in adolescents as well as detecting impairment in function related to drinking.

Field-based measurements of personal erythemal ultraviolet exposure through a common summer garment

The research in this paper quantifies the solar erythemal UV exposures to the skin through a common summer garment during outdoor activities. The erythemal exposures under the garment for the wet white garment exceeded a MED (minimum erythemal dose) at some anatomical sites in summer for a two-hour period. An erythemal exposure of 1.7 MED, in excess of the occupational limit for UV exposure, was measured under the white garment during swimming for a one-hour period. Clothing must form an important component of a UV protection strategy. However, it must be realised that total UV protection is not provided and significant UV exposures may be received beneath the garment, particularly for a white garment in the wet state. This re-enforces the necessity of a combination of several UV prevention strategies to minimise UV exposure.

Randomized controlled trial of nettle sting for treatment of base-of-thumb pain

There are numerous published references to use of nettle sting for arthritis pain but no randomized controlled trials have been reported. We conducted a randomized controlled double-blind crossover study in 27 patients with osteoarthritic pain at the base of the thumb or index finger. Patients applied stinging nettle leaf (Urtica dioica) daily for one week to the painful area. The effect of this treatment was compared with that of placebo, white deadnettle leaf (Lamium album), for one week after a five-week washout period. Observations of pain and disability were recorded for the twelve weeks of the study. After one week's treatment with nettle sting, score reductions on both visual analogue scale (pain) and health assessment questionnaire (disability) were significantly greater than with placebo (P = 0.026 and P = 0.0027).

Effects of melatonin on liver estrogen receptor and vitellogenin expression in rainbow trout: an in vitro and in vivo study

Although melatonin is believed to mediate many seasonal and circadian effects of photoperiod on reproduction in salmonids, the precise mechanisms underlying such effects are still largely unknown. Recent data of the literature indicate a relationship between melatonin and expression of estrogen receptors (ER) in various tissues. In this study, the effects of melatonin on estrogen receptor and/or vitellogenin expression were studied by a combination of in vivo and in vitro experiments. In yeast stably expressing ER and transfected with an estrogen-responsive element-beta-galactosidase reporter gene, melatonin had no effect on basal or E2-stimulated ER expression. Incubation of hepatocyte aggregates with melatonin (10(-8) to 10(-4)) for 16 or 48 h did not modify the E2-stimulated ER and vitellogenin mRNA, as measured by dot blots. Finally, neither pinealectomy nor melatonin implants caused any effect on basal or E2-stimulated ER and vitellogenin mRNA contents in the liver. Altogether, these results suggest that, although we cannot exclude potential effects at the brain or pituitary levels, melatonin has no or little effects on estrogen receptor in the liver.

Nettle sting of Urtica dioica for joint pain--an exploratory study of this complementary therapy

This exploratory study aims to explore the present use of the common stinging nettle to treat joint pain. Eighteen self-selected patients using the nettle sting of Urtica dioica were interviewed. Information regarding patients' use of nettle therapy was elicited, in particular mode of application, dosage and effects. All except one respondent were sure that netles had been very helpful and several considered themselves cured. No observed side effects were reported, except a transient urticarial rash. This exploratory study suggests nettle sting is a useful, safe and cheap therapy which needs further study. A randomized controlled trial is planned in collaboration with a rheumatology specialist.

Central melatonin receptors in the rainbow trout: comparative distribution of ligand binding and gene expression

To better define the role of melatonin in fish, we have compared in detail the distribution of 2-[125I]iodomelatonin binding sites with gene expression for melatonin receptor subtypes in a widely studied seasonal species, the rainbow trout. Three distinct partial sequences of the melatonin receptor gene were cloned from trout genomic DNA. Two of the sequences corresponded to the Mella receptor subtype, and one corresponded to the Mellb receptor subtype. Analysis of numerous clones failed to find a sequence equivalent to the Mel1c receptor subtype. Comparison of receptor gene expression with 2-[125I]iodomelatonin binding distribution indicated dendritic transport of the receptor. Melatonin receptors were associated predominantly with visually related areas of the trout brain, such as the thalamic region, the pretectal area, and the optic tectum. The pituitary was devoid of 2-[125I]iodomelatonin binding, and melatonin receptor gene expression was not detectable. It would appear from the results of the present study that melatonin in this species is involved primarily in the processing of visual signals. How melatonin interacts with circannual rhythms of growth and reproduction is unclear, although a direct interaction between melatonin and the hypothalamo-pituitary axis is not clearly indicated.