Lateral decubitus positioning for cervical nerve root block using CT image guidance minimizes effective radiation dose and procedural time

BACKGROUND AND PURPOSE

Cervical steroid injections are a minimally invasive means of providing pain relief to patients with cervical radiculopathy. CT guidance offers many potential advantages. We developed a technique with the patient in the lateral position with a lateral needle trajectory to minimize the required needle depth from skin to target and a near-vertical needle trajectory. The aim of this study was to analyze the cohort for complications, procedural time, and effective radiation dose.

MATERIALS AND METHODS

This was a retrospective evaluation of a single-center patient cohort. PACS images from the procedures were reviewed for needle depth, procedural time, and CTDI(vol). An anatomically relevant conversion factor was used to calculate the effective dose.

RESULTS

One hundred sixteen cases from 110 patients were identified. The average patient age was 55 years. There were no complications. In 50% of cases, C5-6 was targeted. The average time was 6 minutes, and the average effective radiation dose, 0.51 mSv (0.21-2.56 mSv). Needle-insertion length from the skin to the target was highly correlated with a need for >3 needle repositioning adjustments and scan series (ρ = 0.52, P < .001) and increased procedural time (ρ = 0.42, P < .001). The angle of needle insertion relative to the floor was significantly correlated with an increased number of needle adjustments for depths >25 mm and a longer procedural time (ρ = 0.29, P = .01) but not for depths <25 mm.

CONCLUSIONS

The lateral patient position with CT guidance is safe and allows use of a short needle in a vertical trajectory. This reduces the number of needle adjustments and imaging series to provide a short procedural time with a low effective radiation dose from the procedure.

The utility of rifampin in diagnosing Gilbert's syndrome

OBJECTIVE

The aim of this study was to evaluate the effect of rifampin (the "rifampin test") on serum bilirubin in patients with and without Gilbert's syndrome.

METHODS

We conducted a clinical trial in which the effect of rifampin on serum bilirubin level in 15 patients with Gilbert's syndrome was compared with 10 patients without Gilbert's syndrome (controls) in a General Internal Medicine/Primary Care clinic of a Veterans Affairs medical center. Each participant underwent a "rifampin test," i.e., bilirubin measurement at baseline and 2, 4, and 6 h after the administration of 900 mg of rifampin. Measurements included complete blood count, blood chemistry including liver panel tests (ALP, AST, LDH, and albumin) along with total serum bilirubin levels. Ten patients with Gilbert's and nine control patients had haptoglobin level measured at baseline and 6 h after the administration of rifampin.

RESULTS

While fasting, the mean rise in total serum bilirubin at 2, 4, and 6 h after the administration of rifampin, respectively, was 0.5, 0.7, and 0.7 mg/dl (analysis of variance, p < 0.001) in control patients and 0.6, 1.0, and 1.1 mg/dl (p < 0.001) in the study patients. In 15 fed subjects (six control and nine study), the mean rise in total serum bilirubin at 2, 4, and 6 h, respectively, was 0.3, 0.5, and 0.6 mg/dl (p < 0.001) in controls and 0.5, 1.0, and 1.2 mg/dl (p < 0.001) in study subjects. In the fasting state, rise in total serum bilirubin to >1.9 mg/dl distinguished patients with Gilbert's syndrome from those without at 2, 4, and 6 h (sensitivity 100%, 93%, and 93%; specificity 100%, 100%, and 100% at 2, 4, and 6 h, respectively). In the nonfasting state, rise in total serum bilirubin to > 1.5 mg/dl at 4 and 6 h after rifampin administration distinguished the two groups (sensitivity 90% and 100%; specificity 100% and 100%, respectively).

CONCLUSIONS

Rifampin increases total serum bilirubin levels in patients with and without Gilbert's syndrome. On fasting for 12 to 24 h, an absolute increase of bilirubin to >1.9 mg/dl 2 to 6 h after the administration of 900 mg of rifampin distinguishes patients with Gilbert's syndrome from those without it. In the nonfasting state, an increase in total serum bilirubin to > 1.5 mg/dl 4 to 6 h after the administration of rifampin distinguishes persons with Gilbert's syndrome from those without it.

Hydrocortisone inhibits granulocyte-macrophage colony-stimulating factor production from normal human peripheral blood mononuclear cells and CD3+ T cells

Normal human peripheral blood mononuclear cells (MNCs), particularly T lymphocytes (T cells), are a rich source of granulocyte-macrophage colony-stimulating factor (GM-CSF). Glucocorticoids are known to inhibit GM-CSF production in in vitro cultures of a human fibroblast cell line and in normal human blood monocytes and alveolar macrophages. To determine whether glucocorticoids also inhibit GM-CSF production from normal human MNCs and T cells, we set up cultures of normal human MNCs and T cells in a liquid system in the presence and absence of 5, 50, and 250 microg/dL of hydrocortisone, and an hour later, a constant dose of 50-ng/mL Escherichia coli lipopolysaccharide (LPS) or 10-microg/mL phytohemagglutinin (PHA) was added. After three days, cell counts and GM-CSF levels were determined. Administering 50- and 250-microg/dL hydrocortisone decreased lymphocyte recovery from MNC cultures with LPS (p < or = 0.01), and 250 microg/dL of hydrocortisone decreased lymphocyte recovery from MNC and T-cell cultures with PHA (p < or = 0.03). The amount of GM-CSF produced from PHA-stimulated MNCs was about 100-fold higher than that produced from LPS-stimulated MNCs. The magnitude of GM-CSFs produced in MNC and T-cell cultures stimulated by PHA was comparable (p=0.88). Administering hydrocortisone at 5, 50, and 250 pg/dL decreased GM-CSF production (p < 0.003) in LPS- or PHA-stimulated MNC cultures and in PHA-stimulated T-cell cultures. PHA (not tested with LPS)-stimulated GM-CSF messenger RNA (mRNA) expression was blocked by hydrocortisone. These results indicate that lower concentrations of hydrocortisone inhibit GM-CSF production from normal human blood MNCs and T cells entirely by inhibiting the expression of GM-CSF mRNA, and higher concentrations of hydrocortisone inhibit by a combined effect of inhibiting the expression of GM-CSF mRNA and decreasing the lymphocyte count.

Chronic relapsing thrombotic thrombocytopenic purpura: role of therapy with cyclosporine

Relapsing thrombotic thrombocytopenic purpura (TTP) is a rare disorder with most individuals experiencing 1 to 5 relapses. We report a patient with 18 episodes of thrombotic thrombocytopenic purpura (TTP), the highest number of relapses thus far described. The last 11 episodes were treated with regimens containing cyclosporine. The patient's medical record was reviewed for pertinent clinical, laboratory, and treatment data. We summarized various parameters for each episode and compared characteristics of relapses treated with vs. without cyclosporine. The initial episode of TTP was unusual in that it failed to respond to plasmapheresis, glucocorticoids, and fresh frozen plasma (FFP). It remitted only following splenectomy. Episodes 2-7 responded to FFP plus prednisone. Episode 8 failed to respond to prednisone plus FFP but remitted promptly with cyclosporine plus prednisone. Subsequently, 2 relapses responded to cyclosporine alone, 2 to cyclosporine plus FFP, 4 to cyclosporine plus prednisone +/- FFP, and 2 to cyclosporine, FFP, prednisone, and plasma exchange. There was no difference in remission duration, or in severity or duration of relapses treated with vs. without cyclosporine. Use of cyclosporine, however, significantly decreased the requirement for prednisone and the length of maintenance therapy; thus it is effective mainly as an adjunctive therapy for TTP.

Involvement of CD44 and its variant isoforms in membrane-cytoskeleton interaction, cell adhesion and tumor metastasis

CD44s (standard form of CD44) is a transmembrane glycoprotein whose external domain displays extracellular matrix adhesion properties by binding both hyaluronic acid (HA) and collagen. The cytoplasmic domain of CD44s interacts with the cytoskeleton by binding directly to ankyrin. It has been shown that post-translational modifications, such as phosphorylation (by protein kinase C), acylation (by acyl-transferase) and GTP-binding enhanced CD44's interaction with cytoskeletal proteins. Most importantly, the interaction between CD44s and the cytoskeletal protein, ankyrin, is required for the modulation of CD44s cell surface expression and its adhesion function. Recently, a number of tumor cells and tissues have been shown to express CD44 variant (CD44v) isoforms. Using RT-PCR and DNA sequence analyses, we have found that unique CD44 splice variant isoforms are expressed in both prostate and breast cancer cell lines and carcinomas. Most importantly intracellular ankyrin is preferentially accumulated underneath the patched/capped structures of CD44 variant isoform in both breast and prostate cancer cells attached to HA-coated plates. We propose that selective expression of CD44v isoforms unique for certain metastatic carcinomas and their interaction with the cytoskeleton may play a pivotal role in regulating tumor cell behavior during tumor development and metastasis.

Bone marrow biopsy imprints (touch preparations) for assessment of iron stores

Noninvasive evaluation for iron deficiency is compromised in many individuals due to the presence of chronic inflammatory processes and/or malignancy, thus necessitating bone marrow examination for definitive diagnosis. However, bone marrow aspiration is not obtainable or is inadequate for interpretation (dry tap) in some individuals, and decalcified bone marrow biopsies require 24-48 hr to prepare, and may falsely indicate absence of iron. We evaluated the accuracy of bone marrow biopsy imprints (touch preparations) compared with aspirate particle smears for semiquantitation of bone marrow iron stores. Results indicate that Prussian blue-stained bone marrow biopsy imprints accurately reflect the quantity of iron, compared with bone marrow aspirate particle smears, allowing for rapid determination of iron stores in individuals in whom a bone marrow aspirate cannot be obtained.

Lipoxygenase products regulate proliferation of granulocyte-macrophage progenitors

We studied the role of lipoxygenase products on the proliferation and recovery of granulocyte-macrophage progenitors (CFU-GM) in liquid cultures of normal human blood mononuclear cells containing physiologic or slightly higher than physiologic concentrations of hydrocortisone (HC). Lipoxygenase blockade by addition of nordihydroguaiaretic acid (NDGA) resulted in enhanced recovery of CFU-GM (mean increase of 230%). The number of CFU-GM recovered from 14-day liquid cultures containing 1.0 microM HC plus 10 microM NDGA was a mean of six times higher than the number present in the inoculum. Effects of addition of selected 5-lipoxygenase products into the culture containing a lipoxygenase blocker on the CFU-GM recovery and proliferative activity were dose- and metabolite-specific. Leukotriene (LT) B4 and 5-hydroxy-eicosatetraenoic acid (5-HETE) decreased recovery of CFU-GM while LTC4 and LTD4 had biphasic effects--lower doses decreased while higher doses had no effect on CFU-GM recovery. Lipoxygenase blockade decreased the percent of CFU-GM in DNA synthesis phase. Readdition of LTB4 did not reverse this effect while LTD4 had a biphasic effect--low concentrations increased the percent of CFU-GM in DNA synthesis phase to levels equivalent to CFU-GM in cultures without NDGA while higher concentrations had no effect. In semisolid CFU-GM assays, lipoxygenase blockade with NDGA completely prevented CFU-GM colony formation, suggesting that NDGA inhibits proliferation and/or differentiation of CFU-GM in semisolid culture assays. The results of our studies suggest that 5-lipoxygenase metabolites are physiologically important in regulating the proliferation of CFU-GM and, thus, granulopoiesis.

Cyclosporine and prednisone therapy for pure red cell aplasia in patients with chronic lymphocytic leukemia

We describe the characteristics of response to treatment with cyclosporine (CYA) plus prednisone in seven episodes of pure red cell aplasia (PRCA) in four patients with B cell chronic lymphocytic leukemia (CLL). Fourteen episodes of PRCA occurred in four patients with CLL. Eleven episodes were treated with conventional therapies which included an alkylating agent and prednisone. Four episodes that failed to respond to conventional therapies and an additional three episodes were treated with CYA and prednisone. Six of the seven episodes, including three of four which had failed conventional therapies, responded to CYA plus prednisone compared with six of eleven episodes treated with conventional therapies. Response to CYA and prednisone occurred without a reduction in leukemic mass. In contrast, PRCA remission did not occur until after leukemic mass reduction in three of four patients treated successfully with conventional therapies. Time to response was shorter (14 +/- 3 days) with CYA plus prednisone than with conventional therapies (154 +/- 97 days) in three of four patients. These results indicate that CYA plus prednisone is an effective therapy for the induction of remission from PRCA in patients with CLL.

Influence of hydrocortisone on the survival and cluster and colony forming characteristics of normal human granulocyte-macrophage progenitors

This study was performed to determine the colony and cluster forming ability of granulocyte-macrophage (CFU-GM) progenitors of normal human blood low density cells cultured in a liquid culture system in the presence and absence of physiological doses of hydrocortisone (Hc). The CFU-GM recovered from the liquid cultures were assayed in soft agar medium. The results of the assays indicated that time-related development of clusters and colonies over 1-16 days, proliferative responsiveness to a source of colony stimulating activity, number of cells developed per colony, and the cellular composition of clusters and colonies produced from CFU-GM recovered from 14-day-old liquid cultures with 1.0 microM Hc, were all similar to those that developed from the normal human blood low density cells. However, a higher fraction of the CFU-GM in day 14 liquid cultures with 1.0 microM Hc were in DNA synthesis phase compared with the CFU-GM from the peripheral blood. This study confirmed the results of previous studies showing lower numbers of recognizable neutrophilic granulocytes and improved survival/proliferation of CFU-GM at day 14 in liquid cultures with 1.0 microM Hc compared with cultures without Hc. The present results suggest that the normal human blood CFU-GM which persists and proliferates under the influence of Hc in a liquid culture system is similar in ontogeny to the blood CFU-GM, and that the recovery of CFU-GM from liquid cultures under the influence of Hc appears to be exerted through stimulation of proliferation and controlled differentiation.

Hydrocortisone promotes survival and proliferation of granulocyte-macrophage progenitors via monocytes/macrophages

We have determined the mechanism by which hydrocortisone (Hc) promotes the survival and proliferation of normal human granulocyte-macrophage progenitors (granulocyte-macrophage colony-forming units, CFU-GM). Peripheral blood mononuclear cells were cultured in a liquid system with 0-10.0 microM Hc over 3 weeks. At 7-day intervals 50% of the culture media along with the cells (suspension cells) present in the media were removed and replaced with fresh media. No CFU-GM or very small numbers of CFU-GM were contained in the suspension cells of the 14- and 21-day-old liquid cultures without Hc; CFU-GM were present and increased with increasing concentrations of Hc. The CFU-GM content in suspension cells of 14- and 21-day-old liquid cultures with 1.0 microM Hc was at least threefold higher compared to liquid cultures without Hc. In a double-layer CFU-GM agar culture system, the suspension cells from liquid cultures with 1.0 microM Hc, but not from liquid cultures without Hc, supported CFU-GM proliferation from normal human bone marrow cells. The CFU-GM proliferation-inducing ability was confined to the monocytes/macrophages (Mo). CFU-GM colony inhibitory and stimulatory activities were detected in cell-free media recovered from liquid cultures without Hc, but only colony stimulatory activity was detected in the media from cultures with 1.0 microM Hc. These results indicate that greater than or equal to physiological concentrations of Hc (0.1-1.0 microM) are required for the persistence and proliferation of CFU-GM, and the effect of Hc is mediated through the Mo, probably by inhibiting the production of one or more of the CFU-GM colony inhibitory molecules.

Granulocyte colony-stimulating factor (G-CSF) induces synthesis of alkaline phosphatase in neutrophilic granulocytes of chronic myelogenous leukemia patients

The monocyte, monocyte conditioned media (MoCM), giant cell tumor conditioned media (GCT) and a purified colony-stimulating factor (G-CSF) promote granulocyte-macrophage progenitors (CFU-GM) growth and differentiation along the neutrophil lineage and also induce alkaline phosphatase (NAP) synthesis in the neutrophilic cells of normal subjects and of patients with chronic phase chronic myelogenous leukemia (CML). However, it is not known if granulocyte-macrophage-CSF (GM-CSF), macrophage-CSF (CSF-1) or other cytokines can induce NAP synthesis from the neutrophilic cells of CML patients. The objective of this study were (a) to ascertain which of the three CFU-GM CSFs would induce NAP synthesis, and (b) to test if any of the other cytokines--interleukin-1 (IL-1), interleukin-2 (IL-2), alpha- and gamma-interferons (alpha-INF and r-INF), and phytohemagglutinin-stimulated T-cell conditioned media (TCM) would induce NAP synthesis. Light density cells obtained from the blood of patients with chronic phase CML were depleted of T cells and monocytes. These cells were cultured with various amounts of G-CSF, GM-CSF, CSF-1, IL-1, IL-2, alpha-INF, r-INF, MoCM, GCT and TCM in a suspension culture system over 6-7 days. Evaluation of the cultures indicated that G-CSF, MoCM and GCT, but not the other factors or cytokines, consistently induced NAP synthesis in a dose-dependent manner. Actinomycin-D and puromycin in separate cultures inhibited NAP synthesis without any significant reduction in cell counts. This indicated that NAP is not prepackaged in neutrophilic cells, and its synthesis occurs by a sequential transcription at the DNA level and translation at the ribosomal level. Our results suggest that the molecule which is responsible for promotion of CFU-GM growth and differentiation along the neutrophilic cell lineage is also responsible for derepression of NAP gene and initiation of NAP synthesis.

Cyclosporin-A for the treatment of pure red cell aplasia in a patient with chronic lymphocytic leukemia

A 62-year-old man with B-cell chronic lymphocytic leukemia had three separate episodes of pure red cell aplasia (PRCA). The last episode was treated with cyclosporin-A (CyA) and prednisone. After the patient was on the therapy for 2 weeks, erythropoietic recovery was observed and with continued therapy the hematocrit (Hct) became normal. The PRCA remission was associated with a fall in the blood lymphocyte count, and a reduction in the spleen and lymph node size and bone marrow lymphocyte density. At diagnosis of PRCA the blood T-cells bearing IgG Fc receptors (T gamma cells) were increased, and the marrow contained very few or no late-stage erythroid progenitors. After remission of PRCA the T gamma cell fraction decreased, and the marrow erythroid progenitor's number became normal. We speculate that therapy with CyA and prednisone inhibited the production of interleukins-1 and -2 from monocytes and T-cells, respectively, and was responsible for the reduction of the T gamma cell fraction and B-cell leukemic mass in this patient. Further, we believe that normalization of T gamma cells in association with the therapy was responsible for the PRCA remission.

Comparative evaluation of bone marrow aspirate particle smears, biopsy imprints, and biopsy sections

Bone marrow aspirate particle smears, biopsy imprints, and biopsy sections were compared to determine the accuracy of the three samples in assessing for overall cellularity, differential cell count, megakaryocyte density, iron stores, and tumor infiltration. Aspirate particle smears and biopsy imprints were stained by Wright-Giemsa method. Aspirate particle smears were also stained with Prussian-blue. Biopsy sections were 1 1/2-2 micron thick and were prepared from non-decalcified plastic embedded samples and stained with combined Prussian-blue-hematoxylin-eosin, and Giemsa. One hundred-eight sets of specimens from 99 patients were examined. In 20 cases, chi-square analysis showed a comparable degree of cellularity (p less than 0.001) and megakaryocyte density (p less than 0.001) among the three preparations. Differential count comparison by regression analysis indicated that mean percentages of neutrophilic cells in the proliferation compartment were comparable in the three groups (p less than 0.01). A better correlation was obtained among the three groups in the percent neutrophilic cells in the maturation-storage compartment, normoblasts, eosinophils, and plasma cells (p less than 0.001). Lymphocytes in the aspirate smears correlated with the biopsy imprints (p less than 0.01) but not with the biopsy sections (p greater than 0.05). Monocytes did not correlate in any of the groups (p greater than 0.05). In 47 cases, chi-square analysis of iron stores in the aspirate particle smears correlated well with those in the biopsy sections (p less than 0.001). Fifty-two marrows that were done for staging nonhematological malignancies revealed malignant cells in 21 cases, biopsy sections were positive in all, biopsy imprints were positive in 19 (90%), and aspirate particle smears were positive in 7 (33%). Thirty-six marrows done for staging non-Hodgkin's lymphoma showed malignant cells in 13 cases. Twelve (92%) biopsy sections, three (23%) biopsy imprints, and nine (69%) aspirate particle smears contained lymphoma cells. In conclusion, a satisfactory evaluation of marrow samples for diagnostic studies can be achieved by examination of biopsy sections along with aspirate particle smears or biopsy imprints. Any of the three marrow preparations alone is not sufficient for accurate diagnosis in all cases. The biopsy imprint is an accurate modality for identifying nonhematological tumor metastasis in the bone marrow.

Thrombocytopenia with decreased megakaryocytes. Evaluation and prognosis

The presenting clinical pictures and courses of seven patients with thrombocytopenia, decreased megakaryocytes in the marrow, and minimal changes in other hematopoietic cell lines are described. Little information exists in the literature on such patients. Initial bone marrow aspiration and biopsy in all patients showed decreased megakaryocytes with an otherwise normal marrow. Erythrocyte mean corpuscular volume was elevated in five of seven patients. Bone marrow karyotypes of six of the seven patients were normal. Chromium-51 platelet survival studies with platelet sizing, done in five of the seven patients, showed normal results. In two patients the course progressed to aplastic anemia. One of these died 9 months after presentation, and one responded dramatically to lithium. One patient developed preleukemia and died. The other four patients have remained thrombocytopenic but clinically stable. No useful therapy was identified. The differential diagnosis of such patients should include idiopathic thrombocytopenic purpura with misinterpretation of morphologic findings, hereditary and acquired aplastic anemia, preleukemia, and systemic lupus erythematosus.