Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Faculty development participants' experiences of working with change in clinical settings

OBJECTIVES

Many universities offer faculty development to support teachers in developing and improving clinical education in the health professions. Although research shows outcomes on individual levels after faculty development, little is known about its contribution to change within the organisation. To advance current faculty development and ensure that it can support wider educational change in healthcare organisations, a better understanding of educational change practices in these settings is needed. This study therefore explores the experiences of working with educational change in clinical workplaces from the perspective of clinical educators that have undergone faculty development training. The study adopts perspectives on change as influenced by context to include the impact from clinical workplaces on individuals' change work.

METHODS

A collective case study design with a multi-institutional approach was applied and individual interviews with 14 clinical educators from two universities, one in Sweden and one in South Africa, were conducted. Data were analysed separately before a cross-case analysis was performed, synthesising the findings from both sites.

FINDINGS

Participants shared experiences of having limited opportunities to work with educational change beyond their own individual teaching practices within their clinical workplaces. Also, participants appeared to refrain from leading change and rather pursued change on their own or relied on indirect approaches to change. They described several workplace aspects influencing their work, including the organisation and management of teaching, the resources and incentives for teaching and the attitudes and beliefs about teaching within the clinical community.

CONCLUSIONS

The study shows that clinical educators are part of communities and contexts that shape their approaches to educational change and influence which changes are feasible and which ones are not. It thus adds to the understanding of change as contextual and dynamic and contributes with implications for how to advance faculty development to better support change in practice.

Representation, interaction and interpretation. Making sense of the context in clinical reasoning

BACKGROUND

All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised.

AIMS

Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning.

DISCUSSION

We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning.

CONCLUSION

The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.

Study Engagement and Burnout of the PhD Candidates in Medicine: A Person-Centered Approach

This study focused on exploring individual variations in doctoral candidates' well-being, in terms of experienced research engagement and burnout by using a person-centered approach. In addition, the associations between well-being profiles and gender, country of origin, study status (full-time or part-time), research group status and drop-out intentions were explored. The participants were 692 PhD candidates in the field of medicine. Latent profile analysis was employed to identify the well-being profiles. Four distinct profiles were identified: high engagement-low burnout, high engagement-moderate burnout, moderate engagement-moderate burnout, and moderate engagement-high burnout. Working in a clinical unit or hospital and working in a research group seemed to be related to increased engagement and reduced risk for suffering burnout, while the intentions to quit one's doctoral studies were more frequently reported in profiles with moderate levels of engagement. The findings imply that although a significant number of PhD candidates in medicine had an increased risk for developing burnout, for most of the PhD candidates research education is an engaging experience.

Unravelling the polyphony in clinical reasoning research in medical education

RATIONALE

Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion.

AIMS AND OBJECTIVES

We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses.

METHODS

A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review.

RESULTS

A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described.

CONCLUSIONS

Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.

Collaborative knotworking - transforming clinical teaching practice through faculty development

BACKGROUND

Faculty development is important for advancing teaching practice in health professions education. However, little is known regarding how faculty development outcomes are achieved and how change in practice may happen through these activities. In this study, we explored how clinical educators integrated educational innovations, developed within a faculty development programme, into their clinical workplaces. Thus, the study seeks to widen the understanding of how change following faculty development unfolds in clinical systems.

METHODS

The study was inspired by case study design and used a longitudinal faculty development programme as a case offering an opportunity to study how participants in faculty development work with change in practice. The study applied activity theory and its concept of activity systems in a thematic analysis of focus group interviews with 14 programme attendees. Participants represented two teaching hospitals, five clinical departments and five different health professions.

RESULTS

We present the activity systems involved in the integration process and the contradiction that arose between them as the innovations were introduced in the workplace. The findings depict how the faculty development participants and the clinicians teaching in the workplace interacted to overcome this contradiction through iterative processes of negotiating a mandate for change, reconceptualising the innovation in response to workplace reactions, and reconciliation as temporary equilibria between the systems.

CONCLUSION

The study depicts the complexities of how educational change is brought about in the workplace after faculty development. Based on our findings and the activity theoretical concept of knotworking, we suggest that these complex processes may be understood as collaborative knotworking between faculty development participants and workplace staff through which both the output from faculty development and the workplace practices are transformed. Increasing our awareness of these intricate processes is important for enhancing our ability to make faculty development reach its full potential in bringing educational change in practice.

Grounding judgement in context: A conceptual learning model of clinical reasoning

CONTEXT

Contemporary research on clinical reasoning focuses on cognitive problem-solving processes. However, the decisive role that clinical context plays in clinical reasoning is often overlooked. We explored how novice learners make sense of the patient encounter in the clinical situation. In particular, we examined medical students' own judgements concerning diagnostic and management decisions and how the clinical context impacts on this. We aimed to produce a conceptual model of how students learn clinical reasoning in the clinical environment.

METHOD

We used grounded theory methodology to develop a conceptual learning model. A total of 23 medical students in their third academic year were recruited. Qualitative data were gathered from semi-structured interviews, participant observations and field interviews, during clinical clerkships.

RESULTS

Learners participating in the clinical environment experienced tensions, called 'Disjunctions.' These disjunctions emerged in the context of the student-patient encounter and in particular in situations where an element from the interaction with the patient was perceived as being inconsistent with existing frames of reference. We categorised the sources of disjunctions into four subcategories: (a) observing the manifestations of clinical signs in reality; (b) fitting the symptoms to a diagnosis; (c) considering management decisions, and (d) communicating a medical decision to the patient. Disjunctions involved an affective component and were associated with feelings of uncertainty. These tensions provoked reactions from the learners, leading them to reassess and modify held assumptions in order to accommodate the encountered inconsistent elements. This facilitated changes in judgement. When making a judgement, participants learned to take into consideration situational elements.

CONCLUSIONS

Students experience disjunctions in the clinical environment as they encounter situations that challenge their frames of reference. These disjunctions carry significant learning potential. This study can contribute to knowledge concerning the role of the patient encounter in advancing clinical reasoning by transforming problematic habits of the mind.

Contradictions in clinical teachers' engagement in educational development: an activity theory analysis

Many medical universities offer educational development activities to support clinical teachers in their teaching role. Research has focused on the scope and effectiveness of such activities and on why individual teachers attend. However, systemic perspectives that go beyond a focus on individual participants are scarce in the existing literature. Employing activity theory, we explored how clinical teachers' engagement in educational development was affected by the systems they act within. Three focus groups were held with clinical teachers from different professions. A thematic analysis was used to map the contradictions between the systems that the participants were part of and the manifestations of these contradictions in the system of education. In our model, clinical teachers were part of three activity systems directed by the objects of patient care, research and education respectively. Contradictions arose between these systems as their objects were not aligned. This manifested through the enacted values of the academic hospital, difficulties establishing educational discussions in the clinical workplace, the transient nature of educational employments, and impediments to developing a teacher identity. These findings offer insights into the complexities of engaging in educational development as clinical teachers' priorities interact with the practices and values of the academic hospital, suggesting that attention needs to shift from individual teachers to developing the systems in which they work.

Trends in the Incidence, Etiology, Treatment, and Outcomes of Pleural Infections in Adults Over a Decade in a Finnish University Hospital

BACKGROUND AND AIMS

The aim of the study was to ascertain changes in the incidence, etiology, treatment, and outcomes of pleural infections over a decade in a Finnish University Hospital.

MATERIALS AND METHODS

All patients treated for pleural infections in Tampere University Hospital during 2000-2008 and 2012-2016 were included. The incidence rates and the epidemiologic data and medical history of patients, etiology of infection, and treatment trends and outcomes were compared between the cohorts.

RESULTS

The incidence of pleural infections increased from 4.4 during 2000-2008 to 9.9 during 2012-2016 per 100.000 patient-years, p < 0.001. The patients in the latter group were older, 63 versus 57 years, p = 0.001, and the prevalence of chronic lung disease, hypertension, heart failure, dyslipidemia, and immunosuppressive medication were higher. The causes of infection remained similar and pneumonia accounted for 70% of all cases. The identification rate of the microbe pathogens increased from 49% to 64%, p = 0.002, while the distribution of identified pathogens was unchanged. More patients in the latter cohort were treated operatively, 88.3% versus 80.9%, p = 0.005, and, in these, the proportion of thoracoscopic surgery was higher, 57.4% versus 8.0%, p < 0.001, and the delay to surgery shorter, 5 versus 7 days, p < 0.001. Radiologic outcomes were similar. The 30-day mortality rate was 3.1% during 2000-2008 and 5.1% during 2012-2016, p = 0.293.

CONCLUSION

The overall incidence of pleural infections has increased significantly while the causes of pleural infections and the distribution of pathogens remain unchanged. Contemporary patients are older with higher prevalence of comorbidities and more frequently undergo thoracoscopic surgery.

How do tutors intervene when conflicts on knowledge arise in tutorial groups?

Recent research on problem-based learning (PBL) has shown that students need support when dealing with conflicting ideas in PBL-tutorial discussions. In the present study, we examined tutor facilitation during tutorial discussions, and particularly how the facilitation helped students to collaboratively resolve conflicts on knowledge. The study involved four PBL-tutorial sessions that included altogether 33 first-year medical and dental students. The sessions were videotaped and analysed using qualitative interaction analysis. Our aim was to find out how the tutor interventions encouraged students to elaborate on conflicting ideas, and how the interventions differed between conflict and non-conflict situations. We also examined how the tutors intervened during conflicts about factual or conceptual knowledge. The tutorial discussions included 92 tutor intervention episodes and 43 conflict episodes. The tutors intervened during 24 of the conflict episodes and resolved 13 of these episodes. Generally, the tutors often intervened by confirming what the students had said or by giving explanations, but they rarely asked questions that would stimulate the elaboration of knowledge. During conflicts on knowledge the tutors gave more explanations, but did little to encourage the students to deal with conflicting ideas. The tutors more often resolved conflicts on factual knowledge than conceptual knowledge. The findings suggest that tutor training should focus on promoting tutors' understanding on when to give direct explanations, and when and how to encourage students to collaboratively elaborate on conflicting ideas.

Orthopaedic reconstruction of complex pelvic bone defects. Evaluation of various treatment methods

Despite major developments in the field of revision surgery in recent decades, the management of severe acetabular deficiency at revision arthroplasty, complex primary total hip replacement or after pelvic tumour resection remains a complex problem. The options available for the management of severe bone loss include the use of uncemented press-fit cups with or without metal augments, impaction allografts, allograft-prosthesis composites, custom-made triflange cups, hip transposition, reconstruction prostheses or various combinations of these. This paper describes defect classification, various treatment options, clinical outcomes, survival of reconstruction, and typical complications in relation to treatment.

Dealing with conflicts on knowledge in tutorial groups

The aim of our study was to gain understanding of different types of conflicts on knowledge in the discussions of problem-based learning tutorial groups, and how such conflicts are dealt with. We examined first-year medical and dental students' (N = 33) conflicts on knowledge in four videotaped reporting phase tutorials. A coding scheme was created for analysing verbatim transcripts of 43 conflict episodes in order to find out whether the conflict episodes were about factual or conceptual knowledge and how the students elaborated the knowledge. Conflict episodes were relatively rare (taking up 7.6 % of the time) in the videotaped groups. Conflict episodes were more frequently about factual knowledge (58 %) than conceptual knowledge (42 %), but conflicts on conceptual knowledge lasted longer and were more often elaborated. Elaboration was, however, more frequently done individually than collaboratively. Conflict episodes were generally fairly short (mean duration 28 s). This was due to a lack of thorough argumentation and collaborative elaboration of conflicting ideas. The results suggest that students' skills to bring out differences in each other's conceptual thinking, the depth of argumentation and the use of questions that elicit elaboration need to be improved. Tutors' skills to facilitate the collaborative resolving of conflicts on knowledge call for further study.

Motivating medical students to learn teamwork skills

BACKGROUND

This study examined teaching teamwork skills to first-year medical students. Teamwork skills focused on verbal communication in PBL-tutorial sessions and in healthcare teams.

AIMS

The aim was to find out how to teach teamwork skills to first-year medical students and how to motivate them to learn these skills.

METHOD

Three consecutive classes of first-year medical students (N = 342) participated in teamwork skills module in the years 2006, 2007 and 2008. After the first year, the introduction to the topic was revised in order to be more motivating to medical students. After each module data were collected with a feedback questionnaire containing numerical and open questions. By analyzing the students' numerical answers and the content of students' open answers regarding the module, we examined how the revised introduction affected students' perceptions of the usefulness of the module.

RESULTS

Medical students' feedback in the years 1 (n = 81), 2 (n = 99) and 3 (n = 95) showed that the students found the module in the second and third years significantly more useful than in the first year. These results support earlier findings that clearly stated clinical relevance motivates medical students.

CONCLUSIONS

When introducing multidisciplinary subjects to medical students, it is important to think through the clinical relevance of the topic and how it is introduced to medical students.

MED NORD--A tool for measuring medical students' well-being and study orientations

BACKGROUND

The relationship between medical students' well-being, motivation, and their conceptions of learning and knowledge has not been previously explored.

AIMS

This study aimed to validate a research instrument intending to measure medical students' (n = 280) (1) experiences of stress, anxiety and disinterest, (2) motivational (thinking) strategies, (3) conceptions of learning and knowledge (epistemologies), and (4) approaches to learning.

METHODS

We developed an instrument, MED NORD, which is a composition of scales measuring different theoretical constructs that previously have shown good predictive value, validity and reliability. A principal component analysis with Varimax-rotation was performed in order to see how the scales related to each other.

RESULTS

The internal consistency reliability was found to be satisfactory or good for each scale. The results showed five factors: Dysfunctional Orientation, Collaborative Knowledge Building Orientation, Cookbook Orientation, Social Orientation, and Individual Abilities Orientation. These study orientations were related to how medical students perceived their learning environment.

CONCLUSIONS

The new tool showed consistency and validity and was judged appropriate for future use in measuring medical students' well-being and study orientations.

On the relationship between group functioning and study success in problem-based learning

INTRODUCTION

In problem-based learning (PBL), discussion in the tutorial group plays a central role in stimulating student learning. Problems are the principal input for stimulating discussion. The quality of discussion is assumed to influence student learning and, in the end, study success.

AIMS

To investigate the relationships between aspects of group functioning and study success.

METHODS

First-year medical students (n = 116), forming 12 PBL groups, completed a 21-item questionnaire on various aspects of a PBL session. At the end of the unit, a course examination was administered. Scales were constructed and reliability analyses conducted.

RESULTS

Group functioning and case quality were strongly correlated with students' grades in a course examination. Further, students' perceptions of group functioning, case quality and the quality of their own contribution were linked strongly with each other.

CONCLUSIONS

Group functioning, case quality and study success are associated with each other in PBL. The interaction between these aspects of PBL in promoting learning calls for further investigation.

Randomized clinical trial of Lichtenstein patch or Prolene Hernia System® for inguinal hernia repair

Background

In this randomized prospective study the short- and long-term outcomes of patients undergoing inguinal hernia repair with either Lichtenstein mesh or the Prolene Hernia System® (PHS) were evaluated.

Methods

Postoperative pain and time to return to work, driving and sporting hobbies were recorded after 300 inguinal hernia repairs done by one of the two methods. Long-term sequelae and complications were assessed at follow-up visits 1 week, 1 month and 1 year after the operation.

Results

The median duration of operation for unilateral primary hernia was 37 min for the Lichtenstein operation and 27 min for the PHS procedure (P &lt; 0·001). Postoperative pain was similar after both operations. Median sick leave was 7 days in both groups. Time to driving a car was 4 versus 3 days, and time to return to sporting hobbies 13 versus 11 days, in the Lichtenstein and PHS groups, respectively. Apart from a residual femoral hernia after Lichtenstein repair, no recurrent inguinal hernias were detected.

Conclusion

Both Lichtenstein and PHS methods resulted in rapid recovery and low recurrence rates. The PHS operation was significantly quicker.

Abnormal response to physical activity in femurs after heterozygous inactivation of one allele of the Col2a1 gene for type II collagen in mice

The objective of this study was to evaluate the influence of heterozygous inactivation of one allele of the type II collagen gene (Col2a1) on biomechanical properties and mineral density of bone under physical loading conditions. C57BL/6-TGN mice with heterozygous knockout (HZK) inactivation of Col2a1 gene and their nontransgenic littermate controls were housed in individual cages with running wheels for 9 and 15 months. The running activity of each mouse was monitored continuously throughout the experiment. Bone mineral density (BMD) of mice femora was measured using dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computerized tomography (pQCT). Biomechanical properties were determined using three-point bending tests. Vertebral bone samples were prepared for quantitative polarized light microscopy and digital densitometry of proteoglycans. The concentration of total collagen and collagen cross-links were analyzed using high-performance liquid chromatograpy (HPLC). The average daily running distance was shorter for the HZK mice between the age of 4 and 15 months as compared with normal runners (P < 0.05). The ultimate breaking force was 14.8% and 23.6% (9 vs. 15 months) lower in HZK-runners than in wild-type runners. BMD of the femur was 6.1% lower in HZK-runners at the age of 9 months (P < 0.05). Physical activity increased cortical BMD in wild-type runners but not in the HZK runners at the age of 9 months. The collagen network of the HZK mice was less organized. There were only minor changes in BMD and mechanical and structural properties between sedentary HZK mice and their wild-type controls. Increased physical activity induced significantly lower bone density, mechanical properties, and organization of collagen fibers in male HZK mice. However, there were no major differences in biomechanical parameters between sedentary HZK and wild-type male mice. This suggests an important guiding role of collagen type II in bone remodelling and maturation.

Functional treatment of closed humeral shaft fractures

We treated 93 consecutive patients, average age 53 (16-90) years, with closed humeral shaft fractures applying a functional brace immediately after injury. Seventy-two (77%) fractures healed without problems. There were significantly more consolidation problems in fractures in the proximal third (46% consolidated) compared to those at the middle (81% consolidated) and distal third (86% consolidated) of the shaft. Logistic regression analysis revealed the only predictive factor in respect to successful brace treatment was fracture location. No significant difference was found in respect to healing between different AO-type fractures.

Premature vertebral endplate ossification and mild disc degeneration in mice after inactivation of one allele belonging to the Col2a1 gene for Type II collagen

STUDY DESIGN

Skeletal tissues of mice with an inactivated allele of the Col2a1 gene for Type II collagen ("heterozygous knockout") were studied.

OBJECTIVE

To determine whether a heterozygous inactivation of the Col2a1 gene has a role in the etiology of spine disorders such as disc degeneration.

SUMMARY OF BACKGROUND DATA

Mutations in the COL2A1, COL11A1, COL11A2, and COL9A2 genes have been linked to spine disorders. However, the mechanism by which genetic factors lead to disc degeneration still are largely unknown.

METHODS

Spine tissues were studied using radiograph analyses; conventional, quantitative, and polarized light microscopy; immunohistochemistry for the major extracellular components, and in situ hybridization for procollagens alpha1(I) and alpha1(II). Voluntary running activity also was monitored in half of the mice.

RESULTS

As the findings showed, 1-month-old heterozygous knockout mice had shorter limb bones, skulls, and spines, as well as thicker and more irregular vertebral endplates, which calcified earlier than in the control mice. They also had a lower concentration of glycosaminoglycans in the anulus fibrosus, in the endplates, and in the vertebral bone than the controls. These features in the heterozygous knockout mice were compensated by the age of 15 months. However, the long bones and skulls of the mature heterozygous mice remained shorter than those of the controls. Gene-deficient mice used the running wheel less. However, physical exercise did not induce any marked structural changes in the skeleton.

CONCLUSION

Mice with heterozygous knockout of Col2a1 show subtle early skeletal manifestations that bear some resemblance to those of human spine disorders.

FT-IR breath test in the diagnosis and control of treatment of methanol intoxications

A portable Fourier transform infrared (FT-IR) multicomponent point-of-care analyzer was tested for the diagnosis of methanol intoxications. Breath analysis with FT-IR was fast and easy, and no sample preparation was needed. The analyzer was adequately sensitive and accurate in detecting and quantitating clinically relevant amounts of ethanol and methanol in the breath of seriously ill patients. FT-IR spectrometry was also suitable for nearly on-line monitoring of the exhaled ethanol and methanol during hemodialysis. The breath analysis results correlated well with blood samples. The FT-IR method used also has a traceable calibration to physical properties of the analyte, and the measured spectra can be saved for later analysis.

Efficacy and tolerability of fluticasone propionate nasal drops 400 microgram once daily compared with placebo for the treatment of bilateral polyposis in adults

BACKGROUND

Chronic eosinophilic rhinosinusitis underlies a range of respiratory disorders including nasal polyposis. Surgical and medical methods are used to control polyps, with topical steroids commonly being used for their anti-inflammatory properties. Fluticasone propionate nasal drops (FPND) is a formulation developed specifically for an effective and well tolerated corticosteroid treatment of nasal polyposis.

OBJECTIVES

To assess efficacy and tolerability of FPND in the treatment of bilateral nasal polyposis in adults.

METHODS

This multicentre, randomized, parallel-group study compared FPND 400 microgram once daily (o.d.) with placebo for 12 weeks in adult patients with mild to moderate bilateral polyposis. The primary efficacy endpoint was visual assessment of polyp size by the physician at monthly clinic visits. Nasal blockage, rhinitis, peak nasal inspiratory flow (PNIF), olfactory function and requirement for polypectomy were also assessed at visits. The patients kept diary card records of symptoms, PNIF, and use of rescue antihistamine. Additional safety data were provided by a 12-week open extension, when all patients received FPND 400 microgram o.d.

RESULTS

After 12 weeks double-blind treatment with FPND (n = 52) or placebo (n = 52), polyp size was reduced in 27% and 16% of patients, respectively; clinical reduction of nasal blockage significantly favoured FPND over placebo (55% vs 22%; P = 0.002), and clinic PNIF had increased significantly with FPND (by 52 L/min vs -3 L/min for placebo; P < 0.001). Diary card measurements showed significant benefits of FPND vs placebo for daily PNIF, nasal blockage, rhinitis and use of loratadine rescue medication. Both treatments were well tolerated and no serious adverse events occurred during randomized treatment. Epistaxis was more frequent with FPND than placebo but was generally mild and did not result in withdrawals. Mean serum cortisol levels did not change significantly with either treatment.

CONCLUSION

This study showed FPND 400 microgram o.d. to be an effective and well tolerated treatment for bilateral nasal polyposis in adults.

The use of low-resolution FT-IR spectrometry for the analysis of alcohols in breath

Fast and reliable diagnostic methods are needed for detection or exclusion of industrial solvents as a cause of intoxication. Analyzing human breath reveals the presence of any volatile substance. A portable Fourier transform infrared (FT-IR) multicomponent point-of-care analyzer was developed for exhaled breath. The analyzer proved to be accurate and precise in laboratory tests for simultaneous measurement of methanol and ethanol in water. Ethanol, in addition to normal contents of breath, was simultaneously analyzed in human experiments, and the results correlated well with blood samples. FT-IR method has a traceable calibration to physical properties of the analyte. The measured spectra can also be saved and analyzed later. Breath analysis with FT-IR is fast and easy, and no preparation of the sample is needed.

Do more highly organized collagen fibrils increase bone mechanical strength in loss of mineral density after one-year running training?

The aim of this study was to evaluate the effects of long-term running training on the structural properties of bone. Ten beagle dogs ran according to a strenuous progressive program (up to 40 km/day) for 1 year. At the end of the training program, there was a significant reduction in bone mineral density (up to 9.7%) in the vertebrae of the runner dogs as compared with 10 sedentary control dogs. Polarized light microscopy of the vertebral trabecular bone, however, displayed proportionally higher retardation values of the collagen network of the runner dogs than of the sedentary dogs, suggesting a reorganization in a more parallel manner in the collagen fibrils. The concentration and cross-linking of collagen in the bones remained similar in both groups. No differences were observed in the force to failure of bones of the two groups nor in the histomorphometric analysis of the bones. We suggest that the collagen network in the bones accounted for the maintenance of the strength properties in the bones of the runner dogs despite the loss of mineral density.

Subchondral bone remodeling increases in early experimental osteoarthrosis in young beagle dogs

We evaluated subchondral bone remodeling and structure in the condyles of the femur and the patellar surface of the femur in early experimental osteoarthrosis of young female beagle dogs. 14 littermate (twin) dogs were divided into operation (n 7) and control groups (n 7). The dogs in the operation group underwent surgically a 30 degrees valgus angulation of the right tibia to induce osteoarthrotic articular cartilage lesions in the knee (stifle) joint. 7 months postoperatively, bone samples were harvested from both condyles and the patellar surface of the femur and evaluated by histomorphometry of subchondral bone. Cartilage samples from the same areas were taken for histology. In the operated dogs, subchondral bone remodeling increased strikingly in the patellar surface of the femur; osteoid thickness and osteoblast surface/bone surface increased up to 42% and 94% (p < 0.05), as compared to controls. Total and active erosion depths increased by 14% and 30% in the same area (p < 0.05). However, in bone structural parameters no significant difference could be observed between the groups. In the medial condyle of the femur, the trabecular number decreased in operated dogs, as compared to controls (p < 0.05). The lateral condyle of the femur in operated animals did not differ from controls in the parameters tested. In the operated dogs, histology from cartilage samples showed initial osteoarthrotic changes in the patellar surface and the medial condyle of the femur. Histologic changes were greatest in the patellar surface of the femur, as assessed by the Mankin scores. At the very onset of osteoarthrosis, subchondral bone remodeling increases, but the bone structural changes are indistinct. It seems that in this osteoarthrosis model, cartilage lesions precede major subchondral changes in the structure of the bone.

Estimation of spinal bone density using conventional MRI. Comparison between MRI and DXA in 32 subjects

We evaluated the usefulness of MRI T1 and T2 relaxation times in assessing bone mineral status. T1 and T2 relaxation times of L3 were measured in 16 pairs of identical twins (24 men, 8 women), aged 25-69 years. Bone mineral density (BMD), bone mineral content (BMC) and apparent volumetric bone mineral density (BMDvol) of L3 were measured from the same subjects using dual x-ray absorptiometry (DXA). T2 relaxation time correlated inversely with BMD and BMC (r -0.40 and r -0.47, respectively), whereas a significant positive correlation between T1 relaxation time and BMDvol was found (r 0.36). The measurement of T1 may give some information on bone mineral status in clinical MRI measurements when DXA is not available. It is possible that T1 and T2 reflect not only bone density, but also other factors related to bone structure.

Comparison of different models for interpreting bone mineral density measurements using DXA and MRI technology

Bone mineral density measurements using dual X-ray absorptiometry (DXA) are commonly expressed as areal density (g/cm2). However, areal BMD (BMDareal) is dependent on bone size and this can lead to erroneous interpretations of BMD values. We have previously presented a simple method for calculating apparent volumetric bone mineral density (BMDvol) using ancillary DXA-derived data. In the present study we tested the validity of our model using in vivo volumetric data obtained from magnetic resonance imaging (MRI) of lumbar vertebrae. BMDareal and BMDvol of L3 were measured from sixteen pairs of identical twins (24 men, 8 women), aged 25-69 years. The dimensions of the lumbar vertebra L3 were measured from MR images and BMD values were corrected for these dimensions. The DXA-derived apparent volumetric bone mineral density (BMDvol) correlated moderately with MRI-derived BMDs (r values from 0.665 to 0.822). In contrast to BMDareal, BMDvol and MRI-derived BMDs were not related to body size variables. All these volume-corrected BMDs diminished the erroneous effect of vertebral size on areal BMD. We conclude that the simple DXA-derived BMDvol can be used for normalization of bone mineral density values in subjects of different body sizes, and especially in growing children.

Long-distance running alters bone anthropometry, elemental composition and mineral density of young dogs

Ten young beagle dogs were run on a treadmill for 1 year, the last 15 weeks 40 km/day. Thereafter bone anthropometric variables, elemental composition, mineral density (BMD) and serum markers of bone metabolism were analyzed and compared with matched-paired control dogs. More osteophytes developed, weight-bearing bones grew larger and BMD of axial skeleton was reduced in the trained group. Zinc and sodium accumulated in bones of the runners. Zinc correlated negatively with BMD. Serum osteocalcin and C-terminal propeptide of type I procollagen did not correlate with the observed differences in BMD. This experiment implies that intensive endurance training in adolescence may reduce the peak bone mass and alter the structural properties of bone.

Endurance training associated with slightly lowered serum estradiol levels decreases mineral density of canine skeleton

The effects of long-term running exercise were studied in 20 beagle dogs. A total of 10 dogs ran from the age of 15 weeks to the age of 70 weeks in a progressive program for up to 40 km/day. A total of 10 sister dogs spent the study period in individual cages. When the dogs were 70 weeks old, bone mineral density of the vertebrae, hip, and radius was analyzed by dual-energy x-ray absorptiometry (DEXA; Lunar) and the vertebrae were also assessed by quantitative computed tomography (QCT; Siemens DR 1). Mineral density was lower in the running dogs than in the controls. The difference was greatest in the spine in the QCT analysis. Blood chemistry analyses revealed that the metabolism of the bone was significantly accelerated. The estradiol levels showed the trend to be reduced in the running group. The beneficial effect of exercise on mineral density has been shown in many earlier studies. However, in this study we demonstrate the possibility of adverse effects of long-term exercise on bone tissue. The change was associated with a decrease of serum estradiol level.

Effects of long-term running on spinal mineral content in dogs

The effects of long-term running were studied in 20 beagle dogs. Ten dogs ran from the age of 15 weeks to the age of 70 weeks in a progressive program for up to 40 km/day. Ten sister dogs spent the same time in individual cages. At the age of 70 weeks the spines of the dogs were studied with regard to mineral density using dual-energy X-ray absorptiometry and quantitative computed tomography. Mineral density was lower in the running dogs than in the controls.

Gonococcal perihepatitis in a surgical ward

Within a three-year period six female patients with gonococcal perihepatitis were encountered. In the acute stage they had clinical symptoms indistinguishable from acute cholecystitis. In all six patients the diagnosis was established by positive growth of Neisseria gonorrhoeae from cervix specimens. Evidence of previous gonococcal pelvic infection was disclosed in three of the patients. In two patients the gonococcal aetiology of the disease was suggested by papular skin lesion and arthritis. Of the annual mean number of patients admitted to the emergency ward with suspicion of acute cholecystitis within the same three year period, 2.6% presented with gonococcal perihepatitis. As the incidence of gonorrhoea is increasing, complications such as perihepatitis are seen more frequently among young female patients admitted to surgical emergency wards because of acute abdominal pains.

The results of operative and non-operative management of tibial fractures

A series of 160 fractures of the tibia in 155 patients is analysed. Eighty patients were operated on' intramedullary nails were used in 33, AO plates in 29 and screws in 18 cases. In the final evaluation the result was classified as good in 39, fair in 27, and poor in 14 cases in the non-operative group, and 40, 25 and 15 in the operative group. Fracture comminution had a significant effect on foot and ankle motion.