Comparison between semiquantitative and quantitative methods for the assessment of knee synovitis in osteoarthritis using non-enhanced and gadolinium-enhanced MRI

OBJECTIVE

To compare different semiquantitative and quantitative methods using both non-enhanced and gadolinium-enhanced MRI techniques for the assessment of synovitis in knee osteoarthritis (OA).

METHODS

Knees with end-stage clinical OA in patients undergoing total knee replacement surgery were included in this cross-sectional study. MRI was performed on all knees. Standard non-enhanced and gadolinium-enhanced sequences were acquired. Using non-enhanced MRI, we semiquantitatively assessed two features widely used as surrogates for synovitis: effusion-synovitis and Hoffa-synovitis. Using gadolinium-enhanced sequences, we semiquantitatively assessed synovial thickness. We quantitatively evaluated the total synovial volume on the gadolinium-enhanced sequences as well. We assessed the correlations of effusion-synovitis and Hoffa-synovitis with synovial thickness and volume, applying Spearman correlation analysis. The diagnostic performance of both synovitis features on non-enhanced MRI was assessed using synovial thickness on gadolinium-enhanced MRI as the reference.

RESULTS

A total of 104 subjects (one knee per subject) were included. Correlations of effusion-synovitis with synovial thickness and volume were r = 0.41 and r = 0.43 (P < .001) r = 0.32 and r = 0.39 (P < .0001).

CONCLUSION

Using synovial thickness assessed on gadolinium-enhanced sequences as the reference, effusion-synovitis showed superior correlations and sensitivity. Effusion-synovitis should be preferred over Hoffa-synovitis as a surrogate marker for synovial thickening, in studies of knee OA for which gadolinium-enhanced sequences are not available.

EPIDEMIC KERATOCONJUNCTIVITIS : I. ISOLATION AND IDENTIFICATION OF A FILTERABLE VIRUS

1. A virus has been isolated from two patients suffering with epidemic keratoconjunctivitis. 2. At first the virus could be maintained only by the inoculation of tissue cultures (serum ultrafiltrate and embryonic mouse brain) with conjunctival scrapings or with emulsified mouse brains from early passage animals. Later it caused a fatal disease in every mouse into which it was inoculated, and could, then be readily maintained in mice. 3. The virus proved pathogenic for unweaned white Swiss mice by the intranasal, intraperitoneal, and intracerebral routes; for adult mice by the intranasal and intracerebral routes, and for rabbits by only the intracerebral route. 4. Although the titer of tissue cultures rarely exceeded 10^–2 or 10^–3, the virus, once established in mice, increased in potency until titers of 10^–5 and 10^–6 were attained. Mice injected with either the emulsion of mouse brain tissue or with the tissue culture material in these dilutions developed symptoms within a definite incubation period; once the disease was initiated, it followed a characteristic course for a period of a few to 24 hours, and consistently terminated in death. 5. The pathological changes in mice were limited to the central nervous system, and were not particularly distinctive. The neurotropic character of the virus is further shown by the fact that only the brain tissue was consistently pathogenic for mice. 6. Serial tissue cultures could be maintained only at room temperature, and when the inoculum from virus-infected cultures into fresh tissue cultures contained ground-up cells. 7. The highest level of potency in cultures occurred on about the 6th day at room temperature. 8. The virus passed without difficulty through an E-K Seitz filter (double pads) and through all grades of Berkefeld filters. 9. The virus passed consistently through graded collodion membranes with an A.P.D. of 75 to 100 millimicrons and to a lesser extent through those with an A.P.D. of 50 to 75 millimicrons. Membranes with an A.P.D. of less than 50 millimicrons retained the virus. 10. The mouse virus was not neutralized by anti-lymphocytic choriomeningitis serum, antiherpes serum, normal human serum, or serum from cases of non-specific conjunctivitis or keratitis. 11. Mice hyperimmunized to Theiler's virus were susceptible to the mouse keratoconjunctivitis virus. The latter virus was also not neutralized by hyperimmune Theiler rabbit serum. 12. The mouse virus could be neutralized by serum from the two patients from whom the virus had been isolated, and also by that from the three patients convalescing from epidemic keratoconjunctivitis in California and the serum of a convalescent in New York. The neutralization data were confirmed by tests on 15 additional convalescent serums (unpublished data). 13. A mild but characteristic picture of epidemic keratoconjunctivitis was reproduced in a human volunteer following inoculation with the mouse virus. 14. The serum of the human volunteer, while not neutralizing the mouse virus before infection, contained neutralizing antibodies 1 month after infection. 15. Development of antibodies was demonstrated in one patient (R.H.) in the present series, and in six other patients of another series (unpublished data).

American Academy of Pediatrics. Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and review of unexpected infant and child deaths

Although there is a continuing need for timely review of child deaths, no uniform system exists for investigation in the United States. Investigation of a death that is traumatic, unexpected, obscure, suspicious, or otherwise unexplained in a child younger than 18 years requires a scene investigation and an autopsy. Review of these deaths requires the participation of pediatricians and other professionals, usually as a child death review team. An appropriately constituted team should evaluate the death investigation process, review difficult cases, and compile child death statistics.

Recombinant retrovirus vectors for the expression of MHC class II heterodimers

Class II antigens are critical in determining the fate of vascularized allografts across major histocompatibility differences. We have recently developed a new approach to induce transplantation tolerance in miniature swine by creating MHC class II antigen "molecular chimerism" in bone marrow cells of potential recipients through retrovirus-mediated gene transfer. As part of this project, the ability of a recombinant double-expression vector (ZQ32N) to express MHC class II DQA and DQB was investigated. Flow cytometry analyses of ZQ32N transfected virus-producer cells demonstrated the cell surface expression of DQa/DQb heterodimers, thus suggesting a correct transcription, translation, and transport of the swine polypeptides to the cell surface. The analyses of RNA isolated from virus particles produced from ZQ32N transfected virus-producer cells indicated the DQ sequences to be correctly packaged. However, the DQ-negative cells transduced with the ZQ32N retrovirus did not show any DQ-retrovirus surface expression. Southern and Northern blot analyses of ZQ32N transfected and transduced cells strongly suggested DNA rearrangements and deletions which could account for transgene expression loss. An analysis of transduced cell genomes suggested DNA recombinations targeted to homologous sequences within the recombinant provirus. The implications of the sequence instability in designing vectors for gene therapy of organ transplantation are discussed.

Changing patterns of illicit substance use among schizophrenic patients: 1984-1996

Over 1,700 psychiatric emergency room visits of schizophrenic and schizoaffective patients between 1984 and 1996 were reviewed, and urine drug screens (UDS) were recorded. Illicit drug use increased significantly over the 12-year period, with a large increase for cocaine (0% to 73% of positive UDS), a decline for amphetamines (60% to 0%), and a small increase for marijuana (0% to 27%). Opiate and sedative use remained unchanged. The results support the impression that cocaine use increased dramatically among urban schizophrenic patients beginning in 1988 and continuing to the present. Furthermore, cocaine seems to have replaced amphetamines as the preferred drug of abuse among schizophrenic persons following the crack epidemic.

Schizencephaly associated with psychosis

Schizencephaly is a rare disorder of brain development resulting in the formation of abnormal unilateral or bilateral clefts in the cerebral hemispheres. It is often accompanied by partial seizures, mental retardation, and hemiparesis. Two patients are described with clear psychotic symptoms with either unilateral or bilateral schizencephaly. The implications of the association between schizencephaly and psychosis in these patients for understanding the biology of the psychoses are discussed.

Failure to detect Borna disease virus infection in peripheral blood leukocytes from humans with psychiatric disorders

The presence of antibodies reactive with Borna disease virus (BDV) in the sera of some patients with certain psychiatric illnesses has been taken as evidence that this veterinary neurotrophic virus may occasionally infect and cause psychiatric disorders in humans. In this paper, we report the results of our studies concerning the detection of BDV-specific RNA in blood cells from patients with psychiatric diseases. Contrary to the results obtained by others, we have found no evidence for the presence of BDV-RNA in such cells. Prior work with BDV sequences in the assay environment, together with the exquisite sensitivity of RT-PCR, may account for the sporadic appearance of false positive evidence that BDV-specific RNA is present in human blood cells.

Quantitative trait loci contributing to phencyclidine-induced and amphetamine-induced locomotor behavior in inbred mice

Phencyclidine (PCP) and amphetamine (AMP) can induce psychotic syndromes in humans, whereas administration of these drugs to mice results in behavioral activation that is influenced by genetic factors. Quantitative trait loci (QTL) underlying genetic differences in response to PCP and AMP in mice were provisionally identified by correlating allelic variation at known marker loci in the BXD series of recombinant inbred (RI) mice and its progenitors (C57BL/6J and DBA/2J inbred strains) with the locomotor response of each strain to PCP and AMP. Total distance traveled for individual mice from each of the 26 BXD RI and two progenitor strains was measured after injections of normal saline and 7.5 mg/kg i.p. injection of PCP. This procedure was repeated after 1 week, using 5.0 mg/kg of AMP, instead of PCP. Markers significantly (p < .01) correlated with response to PCP map to murine chromosomes 1, 14, and 15. Response to amphetamine was correlated with markers mapping to chromosomes 4, 5, 6, 8, 14, and 18. Identification of the QTL underlying PCP-induced and AMP-induced behavior in mice may provide clues into the complicated genetics of psychosis in humans.

Current and emerging concepts in child abuse

Within the three decades since Henry Kempe first popularized the concept of "the battered child syndrome," much has been learned not only about physical abuse but also neglect and sexual abuse. More recently, physicians with an interest in child abuse have expanded their focus to include child death review and other prevention strategies. Despite the increasing specialization of child abuse evaluation and management, all physicians working with children are likely to encounter child abuse in their practice. In 1994, more than 3.1 million reports of child abuse were made, of which more than 1 million had enough evidence to substantiate the allegations. Approximately one-half of all substantiated child abuse reports were for neglect. Physical abuse was involved in 21% and sexual abuse in about 11%. In 3% of the cases, the newer category of mental injury (emotional abuse/neglect) also was present. Despite the increase in the reporting of child abuse, the percentage of adults who have experienced child maltreatment (approximately 25% to 33%) probably has not changed significantly during this century. Most people who are victims of child abuse still never come to the overt attention of physicians, social workers, or other professionals, but the hidden emotional consequences have a considerable impact on the mental and medical health care systems. This article will briefly review the following three major categories of child abuse to highlight some of the thinking behind recent advances: Neglect; Physical Abuse; and Sexual Abuse. We will also discuss Prevention.

Minor physical anomalies in schizophrenia

Using the Waldrop scale, minor physical anomalies were studied in 82 Caucasian subjects, including 41 schizophrenic and 8 bipolar adults, as well as 14 normal and 19 mentally retarded adults. An increased incidence of minor physical anomalies was found in the mentally retarded adults relative to the other groups. Consistent with previous studies, there was a trend for the total mean Waldrop score of the schizophrenic group to be higher than the mean score of the normal group. Minor physical anomalies (assessed by the Waldrop scale), however, appear to be of questionable utility in identifying "congenital" schizophrenia, at least as this putative subgroup of schizophrenia is currently conceptualized.

Quantitative trait loci mapping of three loci controlling morphine preference using inbred mouse strains

Quantitative trait loci mapping was used to identify the chromosomal location of genes which contribute to oral morphine preference (in a two-bottle choice paradigm) of C57BL/6J mice, compared to DBA/2J mice. An F2 intercross of these two strains (606 mice) was phenotyped for morphine preference and those mice demonstrating extreme values for morphine consumption (the highest and lowest 7.7%) were genotyped for 157 murine microsatellite polymorphisms. Maximum likelihood methods revealed three loci on murine chromosomes 1, 6 and 10 which are responsible for nearly 85% of the genetic variance observed between the two parental strains.

Search for evidence of herpes simplex virus, type 1, or varicella-zoster virus infection in postmortem brain tissue from schizophrenic patients

The highly sensitive polymerase chain reaction (PCR) was used to search for herpes simplex virus type 1 (HSV-I) or varicella-zoster virus (VZV) in the DNA extracted from postmortem temporal cortex samples of 8 schizophrenic subjects, 8 nonschizophrenic suicide victims and 8 normal controls. HSV-I or VZV-specific DNA amplification was not detected in any of the samples studied.

Blood-CSF barrier permeability and central nervous system immunoglobulin G in schizophrenia

The ratio of albumin in cerebrospinal fluid (CSF) to serum may serve as an index of the integrity of the blood-CSF barrier, with increases in this ratio indicating increased permeability. The ratio of immunoglobulin G (IgG) in CSF to serum (divided by the albumin ratio to correct for variance in blood-CSF permeability) represents an index of the endogenous production of IgG in the central nervous system (CNS), with increases reflecting a possible infectious and/or autoimmune process stimulating central IgG synthesis. We analyzed simultaneously collected CSF and serum samples from 46 schizophrenic subjects, 8 of whom were studied both on and off neuroleptic treatment, and samples from 20 normal controls. The data indicated increases in CSF/serum albumin ratios or CSF/serum IgG indices in 22% and 20%, respectively, of the schizophrenic patients. Only 3 patients showed elevations in both indices. Comparison of values on and off neuroleptics indicated no significant effect of neuroleptics on these indices.

Treatment of tardive dyskinesia with vitamin E

OBJECTIVE

Vitamin E (alpha-tocopherol), a free-radical scavenger, has been reported to improve symptoms of tardive dyskinesia. The authors attempted to replicate this finding under more controlled conditions in a larger study group.

METHOD

Fifteen inpatients and six outpatients with tardive dyskinesia received up to 1600 IU/day of vitamin E for 6 weeks in a double-blind, placebo-controlled crossover study. Abnormal Involuntary Movement Scale (AIMS) examinations of these patients were videotaped and rated independently by two trained raters. Levels of neuroleptic medication and vitamin E were measured during both treatment periods. Eighteen patients who demonstrated high blood levels of vitamin E were included in the data analysis.

RESULTS

Vitamin E levels were significantly higher while the patients were receiving vitamin E than while they were receiving placebo. For all 18 patients, there were no significant differences between AIMS scores after receiving vitamin E and AIMS scores after receiving placebo. In agreement with previous studies, however, the nine patients who had had tardive dyskinesia for 5 years or less had significantly lower AIMS scores after receiving vitamin E than after receiving placebo. There were no changes in neuroleptic levels during vitamin E treatment.

CONCLUSIONS

Vitamin E had a minor beneficial effect on tardive dyskinesia ratings in a selected group of patients who had had tardive dyskinesia for 5 years or less. This effect was not due to an increase in blood levels of neuroleptic medications.

Search for cytomegalovirus in the postmortem brains of schizophrenic patients using the polymerase chain reaction

Cytomegalovirus infection has a number of features that suggest a possible association between congenital infection and schizophrenia. Previous studies have investigated anticytomegalovirus antibody titers or attempted directly to identify viral antigens in body fluids or brain tissue from schizophrenic subjects but have been limited by the sensitivity of the available methods. The highly sensitive polymerase chain reaction, a newly developed technique for gene amplification, was used to search for cytomegalovirus in the DNA extracted from postmortem temporal cortex samples of eight schizophrenic subjects, eight nonschizophrenic suicide victims, and eight normal controls. Cytomegalovirus-specific DNA amplification was not detected in any of the samples. The implications of this finding for the viral hypothesis of schizophrenia are discussed.

DNA repair and mutant frequency in schizophrenia

The in vivo frequency of mutants resulting from mutation at the hprt locus in human T-lymphocytes was determined with a cloning assay. T-lymphocytes were obtained from 14 individuals diagnosed with schizophrenia and 5 controls. No significant difference in mutant frequency was observed between the 2 groups. In addition, DNA-repair capacity was measured with the unscheduled DNA synthesis technique in lymphocytes from 7 individuals diagnosed with schizophrenia and 7 controls. Repair capacity was determined following treatment with MMS, MNNG, and 20 J/m2 ultraviolet light. No significant differences in DNA repair were observed between the patient and control groups in response to any of the 3 DNA-damaging agents. These results argue against differences between normal and schizophrenic individuals with respect to in vivo mutant frequency or their capacity to repair DNA lesions induced by MMS, MNNG, or ultraviolet radiation.

The continued search for evidence of retroviral infection in schizophrenic patients

Retroviral infection has been proposed as an etiologic factor in schizophrenia. In an effort to unmask a latent retrovirus, short term cultures of peripheral lymphocytes from 15 schizophrenic subjects and nine normal controls were exposed to ionizing radiation and co-cultured with indicator cells. Reverse transcriptase activity, a marker of retroviral infection, could not be detected in any of the cultures. Our findings are further evidence against a role for retroviral infection in the etiology of schizophrenia.

Education of the physician in child abuse

Child abuse training often mirrors the development of the field of child abuse by focusing on identification and reporting at the expense of other topics. Physical abuse, and recently sexual abuse, have been emphasized, although neglect is more often reported. The training approach should also include information on epidemiologies, treatment, and prevention. A high index of suspicion can be taught by learning to identify specific physical and behavioral patterns of abuse, and discrepancies between history and the child's condition, and developing better interview skills. Physicians need to know reporting laws, what happens to reports in their community, and how to challenge adverse decisions. Characteristics of child abuse treatment and prevention programs should be taught to residents and physicians providing primary care to children. Principles of learning can be used with various methods to present child abuse information and skills. Whether educating medical students, general physicians, or child abuse experts, their level of involvement with child abuse and the key concepts appropriate for that level should be identified before training methods can be selected. Pediatricians can play an active role in assuring that education in child abuse occurs for all physicians. Answers to first set of questions: STEP 1. Probably middle class or higher. 2. Probably at least 5 years old. 3. Children should have at least average verbal and intellectual skills; they may need to be formally tested. 4. Parents should have at least average verbal and intellectual skills. Answers to second set of questions: Childhood Comes First 1. Approximately 1 year in many cases. 2. It should not; it is an individualized program. 3. No, but it should be an emotionally stable individual with good interactive skills and willing to make a substantial time commitment. 4. A wide range can be tolerated, but the coach will have to read if the consumer cannot.

Failure to find interference between anti-HLA antibodies and chlorpromazine

Chlorpromazine has been reported to interfere with the action of alloantibodies directed against HLA-A1. We attempted to replicate this finding using peripheral blood lymphocytes from 3 healthy donors in a complement-mediated lymphocytotoxicity assay. We were unable to find evidence of interference between chlorpromazine and the anti-HLA sera tested. Possible reasons for the difference between our finding and the previous report, as well as the implications for schizophrenia, are discussed.

HLA antigens in schizophrenia

Human leukocyte antigen (HLA) typing was performed on 55 white schizophrenic patients, who were subdivided into groups on the basis of clinical subtype, response to neuroleptic treatment, enlargement of the lateral ventricles, presence of increased prefrontal or parieto-occipital markings, and presence of reversed frontal or occipital lobe asymmetry. No observed differences in antigen frequencies between the group as a whole and controls or between any subgroup and the remaining group or controls remained significant after correction for the number of antigens tested.

Head injury in child abuse: evaluation with MR imaging

To evaluate the usefulness of magnetic resonance (MR) imaging in the diagnosis of head injury in child abuse, the authors compared the findings at head MR imaging and computed tomography (CT) in 19 abused children. Subdural hematomas (15 cases), cortical contusions (six cases), and shearing injuries (five cases) were demonstrated to particular advantage with MR imaging. CT remained superior in the detection of subarachnoid hemorrhage. MR imaging appears to be valuable in the assessment of patients with suspected intracranial injury due to child abuse.

Fusiform bacterial sepsis. Metastases with osteomyelitis and hepatic abscess occurring in a chaotic family

Cases of fusiform bacteria sepsis have been reported infrequently in the pediatric literature. This case demonstrates the severe metastatic complications of fusiform bacterial sepsis including osteomyelitis, with multiple pathological fractures, sepsis, and abscesses of the liver. In the diagnostic evaluation of the etiology for this uncommon infection, child abuse was discovered in all children of this family. In children with uncommon infections and no underlying etiology, child abuse should be considered.

Schizophrenia, just the facts. What do we know, how well do we know it?

The basic facts of schizophrenia are subjectively reviewed in terms of their reproducibility and significance for understanding the disorder. Some of the facts that are either less well known or of greater importance for future investigation are discussed in more detail. The purpose of establishing what we know about schizophrenia is to develop firm ground for generating hypotheses. One attempt to synthesize these facts is outlined.

Rumination and vomiting in Prader-Willi syndrome

Inability to vomit has been cited as characteristic of Prader-Willi syndrome (PWS). Although post-prandial vomiting after gastric by-pass surgery has been reported, neither vomiting under "typical" circumstances or rumination have been described. Prompted by the discovery of several cases of vomiting and rumination, a questionnaire was sent to members of the PWS Association. Approximately 36% (113/313) of affected individuals reportedly experienced at least one episode of vomiting. Induced vomiting was unsuccessful in 9 of 14 cases in whom results were known. However, no complications of Ipecac were reported. We suggest that there is an alteration in the physiologic set-point at which vomiting occurs, leading to a decreased propensity to vomit. Liberal and strict definitions of rumination yielded 15.7% and 10.2% positive responses, respectively. Rumination was associated with a history of vomiting. Enamel deterioration consistent with rumination has been observed, and such changes should be looked for in all PWS children. In several instances, rumination was found to decrease when very strict weight control was lessened. Certain individuals may ruminate under too strict a weight control program, and weight control goals should be evaluated to achieve a reasonable compromise between ideal weight and obesity. Vomiting and rumination do not rule out the diagnosis of PWS.

Pulmonary infiltrates and hypoxemia in patients with the acquired immunodeficiency syndrome re-exposed to trimethoprim-sulfamethoxazole

Fever, hypotension, pulmonary infiltrates, and hypoxemia developed upon re-exposure to trimethoprim-sulfamethoxazole in 2 patients with the Acquired Immunodeficiency Syndrome. This reaction can mimic sepsis or the clinical worsening of underlying pulmonary opportunistic infection. The literature concerning adverse pulmonary effects of trimethoprim-sulfamethoxazole is reviewed.

Effects of microwave radiation on living tissues

Prompted by an alleged case of child abuse resulting from microwave oven burns and the discovery of one other case, an animal model was chosen to explore microwave burn characteristics upon living, perfusing tissue. Anesthetized piglets were exposed to radiation from a standard household microwave oven for varying lengths of time, sufficient to result in full-thickness skin and visceral burns. Characteristic burn patterns were grossly identified. Biopsies studied with both light and electron microscopy demonstrated a pattern of relative layered tissue sparing. Layered tissue sparing is characterized by burned skin and muscle, with relatively unburned subcutaneous fat between these two layers. These findings have important forensic and patient care implications.

Microwave oven burns to children: an unusual manifestation of child abuse

Two children sustained full-thickness burns as a result of being placed in microwave ovens. Well demarcated burns occurred on the skin surfaces closest to the microwave-emitting devices. Morbidity was limited to complications of direct thermal effects. One of the children sustained a distinctive pattern of relative sparing of tissue layers without electrical burn features, such as nuclear streaming and charring, at the entrance site. In both instances eventual identification of this unusual etiology was initiated by child abuse concerns.

Magnetic resonance imaging of intracranial injuries from child abuse

Magnetic resonance imaging (MRI) and computed tomography (CT) were compared in four children who had evidence of intracranial injury caused by shaking. All children had intracranial bleeding, neurologic impairment, and history or physical examination findings suggestive of child abuse. Three had bilateral retinal hemorrhages, and three had visual impairment. MRI revealed bilateral subdural hematomas in all four children, but CT showed this in only one. Skull fractures in one patient were visualized by CT alone. MRI alone demonstrated posterior fossa bleeding in one patient and intraparenchymal bleeding in another; an additional patient in whom CT showed relatively diffuse atrophy also had defined areas of focal atrophy apparent on MRI. Subarachnoid hemorrhages were equally well detected using CT or MRI. Overall, MRI was superior to CT for detection of intracranial injury caused by shaking, and may help to document milder instances of this form of child abuse.

Monoamine oxidase inhibitors and tricyclic antidepressants: comparison of their cardiovascular effects

The cardiovascular effects of monoamine oxidase inhibitors (MAOIs) are contrasted with those of the tricyclic antidepressants (TCAs). At therapeutic doses, MAOIs lower supine blood pressure and increase the postural fall in blood pressure, whereas TCAs have only the latter effect. MAOIs have little effect on heart rate and do not prolong cardiac conduction; TCAs increase heart rate and prolong cardiac conduction. Neither class of drugs appears to impair cardiac mechanical functioning. For patients with certain cardiac problems, MAOIs may have an advantage over TCAs.