Association between Bone marrow lesions & synovitis and symptoms in symptomatic knee osteoarthritis

OBJECTIVE

Bone marrow lesions (BMLs) on MRI are typically subchondral in location, however, a proportion occur at knee ligament attachments and also include a cyst-like component. Our aim was to determine whether the volume of BML subtypes and synovial tissue volume (STV) was associated with symptoms in symptomatic knee OA.

METHOD

Images were acquired in a sub-sample who had taken part in a randomised trial of vitamin D therapy in knee OA (UK-VIDEO). Contrast-enhanced (CE) MRI was performed annually. In those who had ≥1 follow-up and a baseline scan (N = 50), STV and BML volume was assessed. BMLs were categorised by location and by the presence/absence of a cyst-like component. WOMAC was assessed annually. We used fixed-effects panel-regression modelling to examine the association between volume and symptoms.

RESULTS

There was no association between knee pain and total subchondral BML volume (b = 0.3 WOMAC units, 95% CI -0.3 to 1.0) or total ligament-based BML volume (b = 1.9, 95% CI -1.6 to 5.3). The volume of subchondral BMLs with a cyst-like component was not associated with pain (b = 0.8, 95% CI -0.5 to 2.1) however, the volume of the cyst-like component itself was associated with pain (b = 51.8, 95% CI 14.2 to 89.3). STV was associated with pain (b = 2.2, 95% CI 0.6 to 3.7).

CONCLUSION

The volume of the cyst-like component from subchondral BMLs with a cyst-like component was associated with knee pain. BML location, however, did not influence symptoms. STV was also associated with knee symptoms.

Plantar plate pathology is associated with erosive disease in the painful forefoot of patients with rheumatoid arthritis

Background

Disease-related foot pathology is recognised to have a significant impact on mobility and functional capacity in the majority of patients with rheumatoid arthritis (RA). The forefoot is widely affected and the metatarsophalangeal (MTP) joints are the most common site of symptoms. The plantar plates are the fibrocartilaginous distal attachments of the plantar fascia inserting into the five proximal phalanges. Together with the transverse metatarsal ligament they prevent splaying of the forefoot and subluxation of the MTP joints. Damage to the plantar plates is a plausible mechanism therefore, through which the forefoot presentation, commonly described as ‘walking on pebbles’, may develop in patients with RA.

The aims of this study were to investigate the relationship between plantar plate pathology and clinical, biomechanical and plain radiography findings in the painful forefoot of patients with RA. Secondly, to compare plantar plate pathology at the symptomatic lesser (2nd-5th) MTP joints in patients with RA, with a group of healthy age and gender matched control subjects without foot pain.

Methods

In 41 patients with RA and ten control subjects the forefoot was imaged using 3T MRI. Intermediate weighted fat-suppressed sagittal and short axis sequences were acquired through the lesser MTP joints. Images were read prospectively by two radiologists and consensus reached. Plantar plate pathology in patients with RA was compared with control subjects. Multivariable multilevel modelling was used to assess the association between plantar plate pathology and the clinical, biomechanical and plain radiography findings.

Results

There were significant differences between control subjects and patients with RA in the presence of plantar plate pathology at the lesser MTP joints. No substantive or statistically significant associations were found between plantar plate pathology and clinical and biomechanical findings. The presence of plantar plate pathology was independently associated with an increase in the odds of erosion (OR = 52.50 [8.38–326.97], p < 0.001).

Conclusion

The distribution of plantar plate pathology at the lesser MTP joints in healthy control subjects differs to that seen in patients with RA who have the consequence of inflammatory disease in the forefoot. Longitudinal follow-up is required to determine the mechanism and presentation of plantar plate pathology in the painful forefoot of patients with RA.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1668-0) contains supplementary material, which is available to authorized users.

MRI appearances of the femur following bone graft harvesting using the Reamer-Irrigator-Aspirator

The reamer-irrigator-aspirator is increasingly being used to harvest autologous bone graft from the femur. The purpose of this study was to investigate the extent of neo-vascularisation and new bone formation that occurs within the medulla following the procedure, and determine if new bone formation would potentially allow a repeat bone harvest in those individuals subsequently requiring further bone graft. Eleven patients who had undergone femoral bone harvest were examined with MRI. The nature of the tissue within the medulla and the extent of neo-vascularisation were assessed. MRI was performed between 3 months and 28 months following bone graft harvest, mean 14 months. Intense vascularisation of the endostial cortical surface and neo-vascularisation of the haematoma within the canal occurred as soon as 3 months following bone harvest. From as early as 14 months the tissue was replaced by normal intramedullary bone. The formation of new bone within the medullary canal gives the potential for a repeat reaming, should further bone graft be required at a later date.

Role of vascular channels as a novel mechanism for subchondral bone damage at cruciate ligament entheses in osteoarthritis and inflammatory arthritis

OBJECTIVES

The purpose of this work was to test whether normal peri-entheseal vascular anatomy at anterior and posterior cruciate ligaments (ACL and PCL) was associated with distribution of peri-entheseal bone erosion/bone marrow lesions (BMLs) in inflammatory arthritis (IA) and osteoarthritis (OA).

METHODS

Normal microanatomy was defined histologically in mice and by 3 T MRI and histology in 21 cadaveric knees. MRI of 89 patients from the Osteoarthritis Initiative and 27 patients with IA was evaluated for BMLs at ACL and PCL entheses. Antigen-induced arthritis (AIA) in mice was evaluated to ascertain whether putative peri-entheseal vascular regions influenced osteitis and bone erosion.

RESULTS

Vascular channels penetrating cortical bone were identified in knees of non-arthritic mice adjacent to the cruciate ligaments. On MRI of normal cadavers, vascular channels adjacent to the ACL (64% of cases) and PCL (71%) entheses were observed. Histology of 10 macroscopically normal cadaveric specimens confirmed the location of vascular channels and associated subclinical changes including subchondral bone damage (80% of cases) and micro-cyst formation (50%). In the AIA model, vascular channels clearly provided a site for inflammatory tissue entry and osteoclast activation. MRI showed BMLs in the same topographic locations in both patients with early OA (41% ACL, 59% PCL) and IA (44%, 33%).

CONCLUSION

The findings show that normal ACL and PCL entheses have immediately adjacent vascular channels which are common sites of subtle bone marrow pathology in non-arthritic joints. These channels appear to be key determinants in bone damage in inflammatory and degenerative arthritis.

Anatomical location of erosions at the metatarsophalangeal joints in patients with rheumatoid arthritis

OBJECTIVE

The aim of this study was to identify the anatomical location of erosions at the MTP joints in patients with RA using high-resolution 3T MRI.

METHODS

In 24 patients with RA, the more symptomatic forefoot was imaged using 3T MRI. T1-weighted, intermediate-weighted and T2-weighted fat-suppressed sequences were acquired through the MTP joints, together with three-dimensional volumetric interpolated breath-hold examination (3D VIBE) and T1-weighted fat-suppressed post-gadolinium contrast sequences. Images were scored for bone erosion in the distal and proximal part of the MTP joints using the RA MRI scoring (RAMRIS) system. The base of the proximal phalanx and the head of the metatarsal were divided into quadrants to determine the location of erosions (octants) in the dorsal-medial, dorsal-lateral, plantar-medial and plantar-lateral regions.

RESULTS

Seventeen females and seven males with a mean age of 55.5 years and disease duration of 10.6 years (range 0.6-36) were included. Eighteen patients were RF positive, the mean 44-joint DAS for CRP and ESR (DAS44CRP and DAS44ESR) were 2.5 (s.d. 0.8) and 2.6 (s.d. 0.9), respectively. In this cohort of patients with RA, irrespective of MTP joint location, octants located in the proximal part (metatarsal) of the joint and the plantar aspect of the joint were more eroded.

CONCLUSION

This is the first study to report the anatomical location of erosions at the MTP joints in patients with RA. We noted that erosions were more commonly seen on the plantar aspect of the metatarsal head in RA, supporting the hypothesis of a relationship between biomechanical demands and bone changes in the forefoot.

Quantitative parametric MRI of articular cartilage: a review of progress and open challenges

With increasing life expectancies and the desire to maintain active lifestyles well into old age, the impact of the debilitating disease osteoarthritis (OA) and its burden on healthcare services is mounting. Emerging regenerative therapies could deliver significant advances in the effective treatment of OA but rely upon the ability to identify the initial signs of tissue damage and will also benefit from quantitative assessment of tissue repair in vivo. Continued development in the field of quantitative MRI in recent years has seen the emergence of techniques able to probe the earliest biochemical changes linked with the onset of OA. Quantitative MRI measurements including T(1), T(2) and T(1ρ) relaxometry, diffusion weighted imaging and magnetisation transfer have been studied and linked to the macromolecular structure of cartilage. Delayed gadolinium-enhanced MRI of cartilage, sodium MRI and glycosaminoglycan chemical exchange saturation transfer techniques are sensitive to depletion of cartilage glycosaminoglycans and may allow detection of the earliest stages of OA. We review these current and emerging techniques for the diagnosis of early OA, evaluate the progress that has been made towards their implementation in the clinic and identify future challenges in the field.

Contrast-enhanced MRI of the subdeltoid, subacromial bursa in painful and painless rotator cuff tears

OBJECTIVE

Although shoulder pain is often associated with rotator cuff tears, many tears are asymptomatic and are not the cause of the patient's pain. This may explain the persistence of symptoms in some patients despite technically successful rotator cuff repair. It has been proposed that rotator cuff tears cause pain through subdeltoid/subacromial bursal inflammation. The aim of this study was to determine whether bursal inflammation seen on MRI is associated with pain in patients with rotator cuff tears of the shoulder.

METHODS

The shoulders of 255 patients were screened with ultrasound. 33 full-thickness rotator cuff tears (18 with shoulder pain and 15 without pain) were identified and subsequently studied using contrast-enhanced MRI of the shoulder. Enhancement of the subacromial bursa was scored independently by two musculoskeletal radiologists. Logistic regression was used to determine whether bursal enhancement was independently associated with pain.

RESULTS

There was a significant association between pain and age, with greater likelihood of pain in younger patients. Bursal enhancement was common in both painful and painless tears. No statistically significant link between pain and bursal enhancement was seen, even after accounting for age.

CONCLUSION

Although enhancement of the subdeltoid/subacromial bursa was common, no evidence was found to support the hypothesis that bursal enhancement is associated with pain in rotator cuff tears. It is therefore unlikely to determine reliably which patients would benefit from rotator cuff repair. Advances in knowledge Bursal enhancement and thickening does not reliably correlate with symptoms or presence of rotator cuff tear.

Quantitative MRI measurements of the Achilles tendon in spondyloarthritis using ultrashort echo times

OBJECTIVES

Tendon involvement is common in spondyloarthritis. The MRI signal from the Achilles tendon has been used to quantify mechanical tendinopathy; however, conventional MRI is limited by the short T(2) of normal tendon. Short and ultrashort echo time (UTE) MRI have the potential to better measure signal intensity reflecting changes in T(2) or gadolinium enhancement. Furthermore, UTE images could be used for normalisation to reduce variability. The aim of this work was to investigate such techniques in patients with spondyloarthritis (SpA).

METHODS

The Achilles tendons of 14 healthy volunteers and 24 patients with symptomatic spondyloarthritis were studied. Combined UTE (TE=0.07 ms) and gradient echo (TE=4.9 ms) images were acquired before and after intravenous gadolinium together with pre-contrast gradient echo images (TE=2 ms). The signal intensity from a region of interest in the Achilles tendon above the calcaneus was measured. The relative enhancement at echo times of 0.07 ms (RE(0.1)) and 4.9 ms (RE(5)) were calculated. The ratios of the signal intensities from both 4.9 ms and 2 ms gradient echo images to the signal intensity from the UTE image were calculated (RTE(5) and RTE(2) respectively).

RESULTS

Interobserver intraclass correlation coefficients were excellent (≥0.97). The contrast-to-noise ratio was higher for enhancement on UTE images than on gradient echo images. RE(0.1), RTE(5) and RTE(2) were significantly higher in SpA patients than controls.

CONCLUSION

Signal intensity ratios using UTE images allow quantitative measurements to be made which are sensitive to tendon T(2) or contrast enhancement and which are increased in spondyloarthritis. They therefore have the potential for use as measures of tendon disease in spondyloarthritis.

Magnetic resonance arthrography of lesser metatarsophalangeal joints in patients with rheumatoid arthritis: relationship to clinical, biomechanical, and radiographic variables

OBJECTIVE

Our exploratory study of painful lesser metatarsophalangeal (MTP) joints in patients with rheumatoid arthritis (RA) primarily aimed to compare the clinical, biomechanical, and plain radiography findings with magnetic resonance (MR) arthrography findings. Our secondary aim was to compare standard unenhanced MR with MR arthrography in imaging the lesser MTP joints in RA.

METHODS

In 15 patients with RA, the more symptomatic forefoot was imaged using 3T MR imaging. Proton density fat-suppressed images were acquired through the lesser MTP joints prior to arthrography. Under ultrasound guidance, contrast agent was injected into 2 lesser MTP joints. T1-weighted fat-suppressed sequences were subsequently acquired. The MR images were read by 2 musculoskeletal radiologists and consensus was reached. Spearman's correlation coefficient was used to assess the association between abnormalities seen on MR arthrography and the clinical, biomechanical, and plain radiography findings.

RESULTS

MR arthrography demonstrated pathology at 18 of 28 lesser MTP joints (64%) examined in patients with RA. MR arthrography abnormalities were associated with RA disease duration, forefoot deformity, Larsen score, subluxation, and peak plantar pressure. Unenhanced MR had a sensitivity of 78% and specificity of 90% for detecting pathology compared to MR arthrography.

CONCLUSION

Capsule and plantar plate pathology occurs in the painful forefoot of patients with RA and is associated with features of disease and deformity at the lesser MTP joints. Compared with MR arthrography, standard MR imaging was highly specific and moderately sensitive for diagnosing lesser MTP joint pathology in patients with RA.

Tendon and ligament imaging

MRI and ultrasound are now widely used for the assessment of tendon and ligament abnormalities. Healthy tendons and ligaments contain high levels of collagen with a structured orientation, which gives rise to their characteristic normal imaging appearances as well as causing particular imaging artefacts. Changes to ligaments and tendons as a result of disease and injury can be demonstrated using both ultrasound and MRI. These have been validated against surgical and histological findings. Novel imaging techniques are being developed that may improve the ability of MRI and ultrasound to assess tendon and ligament disease.

MRI identifies plantar plate pathology in the forefoot of patients with rheumatoid arthritis

Previous cadaveric studies have suggested that forefoot deformities at the metatarsophalangeal (MTP) joints in patients with rheumatoid arthritis (RA) might result from the failure of the ligamentous system and displacement of the plantar plates. This study aimed to examine the relationship between plantar plate pathology and the rheumatoid arthritis magnetic resonance imaging score (RAMRIS) of the lesser (second to fifth) MTP joints in patients with RA using high-resolution 3 T magnetic resonance imaging (MRI). In 24 patients with RA, the forefoot was imaged using 3 T MRI. Proton density fat-suppressed, T2-weighted fat-suppressed and T1-weighted post gadolinium sequences were acquired through 96 lesser MTP joints. Images were scored for synovitis, bone marrow oedema and bone erosion using the RAMRIS system and the plantar plates were assessed for pathology. Seventeen females and 7 males with a mean age of 55.5 years (range 37–71) and disease duration of 10.6 years (range 0.6–36) took part in the study. Plantar plate pathology was most frequently demonstrated on MRI at the fifth MTP joint. An association was demonstrated between plantar plate pathology and RAMRIS-reported synovitis, bone marrow oedema and bone erosion at the fourth and fifth MTP joints. In patients with RA, 3 T MRI demonstrates that plantar plate pathology at the lesser MTP joints is associated with features of disease severity. Plantar plate pathology is more common at the fourth and fifth MTP joints in subjects with RA in contrast to the predilection for the second MTP reported previously in subjects without RA.

Imaging of the Achilles tendon in spondyloarthritis: a comparison of ultrasound and conventional, short and ultrashort echo time MRI with and without intravenous contrast

OBJECTIVES

To compare conventional MRI, ultrashort echo time MRI and ultrasound for assessing the extent of tendon abnormalities in spondyloarthritis.

METHODS

25 patients with spondyloarthritis and Achilles symptoms were studied with MRI and ultrasound. MR images of the Achilles tendon were acquired using T1-weighted spin echo, gradient echo and ultrashort echo time (UTE) sequences with echo times (TE) between 0.07 and 16 ms, before and after intravenous contrast medium. Greyscale and power Doppler ultrasound were also performed. The craniocaudal extent of imaging abnormalities measured by a consultant musculoskeletal radiologist was compared between the different techniques.

RESULTS

Abnormalities were most extensive on spoiled gradient echo images with TE = 2 ms. Contrast enhancement after intravenous gadolinium was greatest on the UTE images (TE = 0.07 ms). Fewer abnormalities were demonstrated using unenhanced UTE. Abnormalities were more extensive on MRI than ultrasound. Contrast enhancement was more extensive than power Doppler signal.

CONCLUSIONS

3D spoiled gradient echo images with an echo time of 2 ms demonstrate more extensive tendon abnormalities than the other techniques in spondyloarthritis. Abnormalities of vascularity are best demonstrated on enhanced ultrashort echo time images.

MRI for the assessment and monitoring of RA--what can it tell us?

The past 15 years has seen an exponential rise in the use of MRI for the assessment of rheumatoid arthritis (RA). In this Perspectives article, we review the current and potential future role of MRI in the diagnosis, prognosis and monitoring of RA. We also review the impact of MRI research on the understanding of disease mechanisms. In our view, the pivotal role of synovitis in RA and its predilection for sonographically accessible joints makes it likely that MRI will be used diagnostically in joints that are inaccessible to ultrasonography or where the differential diagnosis is unclear. Additionally, MRI will probably assume an even more prominent role in clinical trials where the aim of therapy is the complete ablation of synovitis. Given the ever-increasing sophistication of MRI, we anticipate that it will continue to be a key research tool in the coming years.

Optimization of multilayer mirrors at 13.4 nm with more than two materials

The design of multilayer mirrors with more than two materials is one of the key technologies for investigating lithography. We study a new procedure for optimizing multilayer mirrors of different combinations of materials at a wavelength of 13.4 nm. By adding Be and C layers in different orders to a Si/Mo stack, we have observed enhancement of the reflectivity and a reduction in the number of layers. The Luus-Jaakola optimization procedure has been implemented for the global optimization of the multilayer mirrors. With this algorithm it is not necessary to specify initially the number of layers present in a given design.

MRI of rheumatoid arthritis image quantitation for the assessment of disease activity, progression and response to therapy

Magnetic resonance imaging (MRI) allows the direct visualization of many bone and soft tissue changes in rheumatoid arthritis. Synovitis volume, bone marrow oedema and bone erosions are suitable for serial measurement. The outcome measures in rheumatoid arthritis clinical trials (OMERACT) rheumatoid arthritis magnetic resonance imaging (RAMRIS) system is designed to allow straightforward, reproducible scoring of all these features. Alternatively, synovial volumes may be directly and quickly measured using semi-automated techniques. There is the potential for similar systems for measuring erosions. Dynamic contrast enhanced MRI depends on the rate of enhancement of the synovium after intravenous contrast agent. Measurements depend on the underlying physiology of the inflamed synovium, in particular the vascularity and capillary permeability which are expected to closely mirror inflammatory activity in the joint. Measurements from MRI have been shown to correlate with clinical, laboratory, imaging and histological measures of inflammation, predict erosive progression and respond rapidly to various types of treatment. They are, therefore, expected to be good measures of disease activity, progression and response to therapy.

Inhibitor screening using immobilized enzyme reactor chromatography/mass spectrometry

We describe the coupling of capillary-scale monolithic enzyme reactor columns directly to a tandem mass spectrometer for screening of enzyme inhibitors. A two-channel nanoLC system is used to continuously infuse substrate or substrate/inhibitor mixtures through the column, allowing continuous variation of inhibitor concentration by simply altering the ratio of flow from the two pumps. In the absence of inhibitor, infusion of substrate leads to formation of product, and both substrate and product ions can be simultaneously monitored in a quantitative manner by MS/MS. The presence of inhibitor leads to a decrease in product and an increase in substrate concentration in the column eluent. Knowing the product/substrate ratio and the total analyte concentration (P + S), the concentration of product eluting, and hence the relative enzyme activity, can be determined. Both IC50 and KI values can then be obtained by direct MS detection of the effect of inhibitors on relative activity. Inhibitor screening is demonstrated using reusable, sol-gel derived, monolithic capillary columns containing adenosine deaminase, directly interfaced to ESI-MS/MS. On-column enzyme activity was assessed by monitoring inosine and adenosine elution. It is shown that the method can be used for automated screening of the effects of compound mixtures on ADA activity and to determine the KI value of the known inhibitor, erythro-9-(2-hydroxy-3-nonyl)adenine, even when the compound is present within a mixture.

Capillary-scale frontal affinity chromatography/MALDI tandem mass spectrometry using protein-doped monolithic silica columns

Frontal affinity chromatography (FAC) interfaced with electrospray mass spectrometry (ESI-MS) has been reported as a potential method for screening of compound mixtures against immobilized target proteins. However, the interfacing of bioaffinity columns to ESI-MS requires that the eluent that passes through the protein-loaded column have a relatively low ionic strength to produce a stable spray. Such low ionic strength solvents can cause serious problems with protein stability and may also affect binding constants and lead to high nonspecific binding to the column. Herein, we report on the interfacing of bioaffinity columns to matrix-assisted laser desorption/ionization (MALDI) MS/MS as a new platform for FAC/MS studies. Capillary columns containing a monolithic silica material with entrapped dihydrofolate reductase were used for frontal affinity chromatography of small-molecule mixtures. The output from the column was combined with a second stream containing alpha-cyano-hydoxycinnamic acid in methanol and was deposited using a nebulizer-assisted electrospray method onto a conventional MALDI plate that moved relative to the column via a computer-controlled x-y stage, creating a semipermanent record of the FAC run. The use of MALDI MS/MS allowed for buffers with significantly higher ionic strength to be used for FAC studies, which reduced nonspecific binding of ionic compounds and allowed for better retention of protein activity over multiple runs. Following deposition, MALDI analysis required only a fraction of the chromatographic run time, and the deposited track could be rerun multiple times to optimize ionization parameters and allow signal averaging to improve the signal-to-noise ratio. Furthermore, high levels of potential inhibitors could be detected via MALDI with limited ion suppression effects. Both MALDI- and ESI-based analysis showed similar retention of inhibitors present in compound mixtures when using identical ionic strength conditions. The results show that FAC/MALDI-MS should provide advantages over FAC/ESI-MS for high-throughput screening of compound mixtures.

Pharmacokinetic modeling of dynamic contrast-enhanced MRI of the hand and wrist in rheumatoid arthritis and the response to anti-tumor necrosis factor-α therapy

Dynamic contrast-enhanced MRI (DCE-MRI) of the hand and wrist was performed in 11 patients with rheumatoid arthritis twice before and once 2 weeks after treatment with anti-tumor necrosis factor (TNF)-alpha therapy. A rapid, T1-weighted 3D spoiled gradient echo (SPGR) sequence was used for the dynamic imaging. T1 estimation was performed using similar images obtained at different flip angles. The relative radiofrequency field was estimated from the known T1 of the periarticular fatty marrow. The arterial input function (AIF) was measured at each examination, and normalized to the expected plasma concentration to reduce partial volume effects. Synovial enhancement was modeled to yield values for Ktrans, ve, and vp. Ktrans and ve showed good reproducibility. There was a significant decrease of about 20% in Ktrans after 2 weeks of treatment. This study demonstrates the potential of DCE-MRI and pharmacokinetic modeling to study early changes in inflammatory activity in rheumatoid arthritis following treatment.

Immobilized enzyme reactor chromatography: Optimization of protein retention and enzyme activity in monolithic silica stationary phases

Our group recently reported on the application of protein-doped monolithic silica columns for immobilized enzyme reactor chromatography, which allowed screening of enzyme inhibitors present in mixtures using mass spectrometry for detection. The enzyme was immobilized by entrapment within a bimodal meso/macroporous silica material prepared by a biocompatible sol-gel processing route. While such columns proved to be useful for applications such as screening of protein-ligand interactions, significant amounts of entrapped proteins leached from the columns owing to the high proportion of macropores within the materials. Herein, we describe a detailed study of factors affecting the morphology of protein-doped bioaffinity columns and demonstrate that specific pH values and concentrations of poly(ethylene glycol) can be used to prepare essentially mesoporous columns that retain over 80% of initially loaded enzyme in an active and accessible form and yet still retain sufficient porosity to allow pressure-driven flow in the low muL/min range. Using the enzyme gamma-glutamyl transpeptidase (gamma-GT), we further evaluated the catalytic constants of the enzyme entrapped in capillary columns with different silica morphologies as a function of flowrate and backpressure using the enzyme reactor assay mode. It was found that the apparent activity of the enzyme was highest in mesoporous columns that retained high levels of enzyme. In such columns, enzyme activity increased by approximately 2-fold with increases in both flowrate (from 250 to 1000 nL/min) and backpressure generated (from 500 to 2100 psi) during the chromatographic activity assay owing to increases in k(cat) and decreases in K(M), switching from diffusion controlled to reaction controlled conditions at ca. 2000 psi. These results suggest that columns with minimal macropore volumes (<5%) are advantageous for the entrapment of soluble proteins for bioaffinity and bioreactor chromatography.

Capillary-Scale Monolithic Immunoaffinity Columns for Immunoextraction with In-Line Laser-Induced Fluorescence Detection

A bimodal meso/macroporous monolithic silica capillary column containing an entrapped antibody was prepared by a biocompatible sol-gel process and used for nanoflow immunoaffinity chromatography and immunoextraction studies. Stationary phases were prepared by combining the protein-compatible silane precursor diglycerylsilane with an aqueous solution containing 10,000 Da poly(ethylene glycol) and the antibody. An analytical method was developed that was capable of determining both the dissociation constant and binding site content for the anti-fluorescein antibody within the stationary phase. The assay showed that while the antibody residing in macropores was easily removed, approximately 20% of initially loaded antibody remained active and accessible after several washes, consistent with the antibody being entrapped within the mesopores of the sol-gel matrix. The dissociation constants for fluorescein binding to the anti-fluorescein antibody were similar in solution and in the meso/macroporous silica, indicating that the entrapped antibody retained its native conformation within such a matrix. The mixture was loaded into a 250-microm-i.d. fused-silica capillary where the polymer phase separated from the silica followed by gelation of the silica. The capillary-scale immunoaffinity columns could be operated at low back pressure using a syringe pump and were capable of performing chromatographic separations that were dependent on the presence of the antibody within the stationary phase. Such columns could also be operated using in-line laser-induced fluorescence detection. The use of the capillary-scale monolithic columns for on-column immunoextraction and preconcentration is also demonstrated.

The addition of a psychological intervention to a home detoxification programme

AIMS

Home detoxification is a recognized method of treating problem drinkers within their own home environment. The aim of this research is to determine whether a relatively brief psychological intervention adds to its effectiveness.

METHODS

A pragmatic trial with 91 participants randomly assigned to either the psychological intervention or treatment as usual. Community Psychiatric Nurses were trained to administer the brief psychological intervention involving motivational interviewing, coping skills training and social support. A manual was developed in order to standardize the training and implementation.

RESULTS

At the 3 month and 12 month follow-up the psychological intervention resulted in significant positive changes in alcohol consumption, abstinent days, social satisfaction, self-esteem and alcohol-related problems. Further, a cost analysis confirmed that the psychological intervention was a ninth of the cost of inpatient treatment.

CONCLUSIONS

Adding a psychological intervention to a home detoxification programme was successful and cost-effective.

Protein-Doped Monolithic Silica Columns for Capillary Liquid Chromatography Prepared by the Sol−Gel Method: Applications to Frontal Affinity Chromatography

The development of bioaffinity chromatography columns that are based on the entrapment of biomolecules within the pores of sol-gel-derived monolithic silica is reported. Monolithic nanoflow columns are formed by mixing the protein-compatible silica precursor diglycerylsilane with a buffered aqueous solution containing poly(ethylene oxide) (PEO, MW 10,000) and the protein of interest and then loading this mixture into a fused-silica capillary (150-250-microm i.d.). Spinodal decomposition of the PEO-doped sol into two distinct phases prior to the gelation of the silica results in a bimodal pore distribution that produces large macropores (>0.1 microm), to allow good flow of eluent with minimal back pressure, and mesopores (approximately 3-5-nm diameter) that retain a significant fraction of the entrapped protein. Addition of low levels of (3-aminopropyl)triethoxysilane is shown to minimize nonselective interactions of analytes with the column material, resulting in a column that is able to retain small molecules by virtue of their interaction with the entrapped biomolecules. Such columns are shown to be suitable for pressure-driven liquid chromatography and can be operated at relatively high flow rates (up to 500 microL x min(-1)) or with low back pressures (<100 psi) when used at flow rates of 5-10 microL x min(-1). The clinically relevant enzyme dihydrofolate reductase was entrapped within the bioaffinity columns and was used to screen mixtures of small molecules using frontal affinity chromatography with mass spectrometric detection. Inhibitors present in compound mixtures were retained via bioaffinity interactions, with the retention time being dependent on both the ligand concentration and the affinity of the ligand for the protein. The results suggest that such columns may find use in high-throughput screening of compound mixtures.

A randomized controlled trial of a brief intervention after alcohol-related facial injury

AIM

To evaluate the effectiveness of a brief motivational intervention on alcohol consumption and misuse in young males with alcohol-related face injury.

DESIGN

Randomized controlled trial.

SETTING

Oral and maxillofacial surgery out-patient clinic in an urban teaching hospital.

PARTICIPANTS

One hundred and fifty-one participants were randomized to motivational intervention and control conditions.

INTERVENTIONS

Control was treatment as usual. The intervention was treatment as usual plus a one-session brief motivational intervention administered by a nurse.

MEASUREMENTS

Three sets of measurements were taken at baseline, 3-month and 1-year follow-up. Collateral measurements were also taken at 1-year follow-up. Primary outcome measures were total alcohol consumption, typical weeks consumption and days abstinent in preceding 3 months. Other outcome measures included the Alcohol Use Disorders Identification Test, a short form of the Alcohol Problems Questionnaire, and a measure of satisfaction with social relationships.

RESULTS

There was a significant decrease in 84-day total alcohol consumption across the year (P < 0.006) and further, a significant effect for the motivational intervention was demonstrated (P < 0.029). This pattern was repeated for days abstinent and alcohol consumption in a typical week as well as alcohol-related problems. There was a significantly greater reduction in the percentage of hazardous drinkers in the motivational intervention group (from 60% to 27%, P < 0.009) compared to the control group (from 54% to 51%, NS).

CONCLUSION

A proportion of young men change their alcohol consumption following alcohol-related injury. A nurse-led psychological intervention adds significantly to the proportion and magnitude of response.

Effects of glucose and fluoride on competition and metabolism within in vitro dental bacterial communities and biofilms

Antimicrobial effects of fluoride in vivo remain contentious. Previous studies suggested that 1 mM NaF reduced acid production from glucose, and prevented the enrichment of bacteria associated with caries in a chemostat model. The present study examines the effects of a lower fluoride concentration (0.53 mM, 10 ppm NaF) in both biofilm and planktonic microbial communities. Nine oral species were grown at pH 7.0 and pulsed on 10 successive days with glucose; bacterial metabolism was allowed to reduce the pH for 6 h before being returned to neutrality, either in the presence or absence of NaF. In addition, 10-day-old mixed culture biofilms were overlaid with glucose, with or without NaF, and the pH change followed by microelectrode. After 10 days, chemostat pH dropped to ca. pH 4.5 following glucose pulses, and the community was dominated by Streptococcus mutans (rising from 4 to 23% of total CFU) and Veillonella dispar (16 to 73%). In comparison, after 10 days pulsing with glucose + fluoride, the final pH was significantly higher (ca. pH 4.9) (paired t test, p < 0.0001). The culture was predominated by V. dispar (70%) and Actinomyces naeslundii (13%), whereas S. mutans proportions were significantly lower (t test, p = 0.04), remaining <3% of the total flora, compared to the culture without fluoride. Biofilm pH fell to only pH 5.55 1 h after glucose/fluoride overlay, compared to 4.55 with glucose alone (paired t test, p < 0.000001). Analysis of the data suggests that fluoride exerts dual antimicrobial modes of action. Fluoride prevents enrichment of S. mutans by inhibiting critical metabolic processes (direct effect) and, in an inter-related way, by reducing environmental acidification (indirect effect) in biofilms.

A continuous culture biofilm model of cariogenic responses

AIMS

To validate an in vitro model for the analysis of physiological and ecological responses to sugar challenge in bacterial populations, and subsequent changes in enamel mineralization.

METHODS AND RESULTS

A seven-organism bacterial consortium was grown in a biofilm mode on enamel and hydroxyapatite (HA) surfaces in a continuous culture system and exposed to repeated sucrose challenges. This produced 'pH-cycling' conditions within the system. Populations on HA surfaces were enumerated. Changes in relative proportions of the different populations, and in the total viable count, were observed, between different treatments. Microradiography of the enamel sections showed increasing demineralization with increasing sucrose concentration. The lesions formed were similar to 'white-spot' lesions found in vivo. Differences in the quality of biofilms formed were also observed using Confocal Laser Scanning Microscopy.

CONCLUSION

An in vitro model has been validated for the analysis of both physiological and ecological responses to sucrose challenges in bacterial populations, and subsequent changes in enamel mineralization.

SIGNIFICANCE AND IMPACT OF THE STUDY

This model should facilitate the study of changes in bacterial populations in response to application of putative anticaries agents and concomitant changes in enamel mineralization.

Genetic Algorithm Approach to Particle Identification by Light Scattering

The inverse static light-scattering problem for spheres is treated numerically by employing genetic algorithms. Intensity functions are generated with variable amounts of noise and are used as input data in order to deduce both the refractive index and the radius of the particle. Both real and complex refractive indices are treated. Comparisons are made with a gradient-based minimization approach that requires fewer function evaluations but which often terminates in a local minimum. The genetic algorithm approach gives very good results for the parameters even in cases where the noise level in the data is relatively high. Copyright 2000 Academic Press.

Goonery in British clinical psychology: the Duracic spark

Stanley Rachman, known to his colleagues as Jack Durac, has had a powerful influence on British clinical psychology. It is hypothesised that Duracic goonery has played a major role in the development of new treatments, as well as in the training of new clinical psychologists. Objective, historical evidence is assembled to support the view that this Duracic spark should be brought out into the field of scientific discourse and should not be hidden behind more comfortable jargon.

Brief interventions for patients with alcohol-related trauma

Patients who have sustained alcohol-related injuries are frequently treated in departments of oral and maxillofacial surgery. Often, an alcohol intervention will not be possible in accident and emergency departments due to intoxication but, when attending out-patient clinics for follow-up, patients are usually sober. This presents a unique opportunity for encouraging patients to review their alcohol consumption at a time when their facial injury may make them more receptive to advice. This article reviews the convincing evidence of the effectiveness of advice and brief interventions designed to be incorporated into standard out-patient consultations and describes practical screening of patients for harmful drinking, the Stages of Change Model of behaviour change and motivational interviewing for facilitating behavioural change.

A fluorescence study of ligand-induced conformational changes in cytosolic fructose-1,6-bisphosphatase from germinating castor oil seeds

The intrinsic fluorescence of homogeneous castor oil seed cytosolic fructose-1,6-bisphosphatase (FBPasec) was used as an indicator of conformational changes due to ligand binding. Binding of the substrate and the inhibitor fructose-2,6-bisphosphate (F-2,6-P2) was quantitatively compared to their respective kinetic effects on enzymatic activity. There are two distinct types of substrate interaction with FBPasec, corresponding to catalytic and inhibitory binding, respectively. Inhibitory substrate binding shares several characteristics with F-2,6-P2 binding which indicates that both ligands bind at the same site. However, F-2,6-P2 does not prevent fluorescence transitions attributed to catalytic substrate binding. The marked synergistic inhibition of FBPasec by AMP and F-2,6-P2 appears to arise via AMP's promotion of F-2,6-P2 binding. Based on the X-ray crystal structure of porcine kidney FBPase our modelling studies suggest the existence of a distinct F-1,6-P2/F-2,6-P2 inhibitory binding site which partially overlaps with the enzyme's catalytic site. We propose that a pronounced allosteric transition mediated by AMP binding increases access of F-1,6-P2 and F-2,6-P2 to this common inhibitory binding site.

Purification and characterization of cytosolic fructose-1, 6-bisphosphate aldolase from endosperm of germinated castor oil seeds

Cytosolic fructose-1,6-bisphosphate (FBP) aldolase (ALDc) from the endosperm of 4- to 5-day germinated castor oil seeds (COS) has been purified 83-fold to electrophoretic homogeneity and a final specific activity of 2.5 micromol FBP cleaved/min/mg protein. SDS-PAGE and denaturing isoelectric focusing of the final preparation revealed a single protein-staining band of 40 kDa and pI value 7.2. The native Mr was determined by gel-filtration chromatography and multiangle laser light scattering to be 160-175 kDa, indicating that the enzyme is homotetrameric. The enzyme (a) is a class I aldolase, since EDTA or Mg2+ had no effect on its activity; and (b) was relatively heat stable and had an activation energy of 100 kJ/mol. It exhibited a broad pH-activity optima of 7.2, a relatively high affinity for FBP (Km = 0.16 microM), and a forward:reverse Vmax ratio of 0.77. Rabbit anti-(COS ALDc) antibodies cross-reacted with COS ALDc, but not with the corresponding plastidic isozyme. Time-course studies revealed that (a) the increase in total ALD activity that occurs during COS development and early germination coincides with an increase in ALDc concentration and (b) the latter stages of COS maturation and germination are accompanied by marked reductions in ALD activity and ALDc concentration. The most significant elevation in ALDc concentration occurred over the first 4 days of germination when COS initiates the gluconeogenic conversion of P-enolpyruvate and triose-P, derived from reserve triacylglycerols, into the sucrose required to support early seedling growth.

Magnetic resonance imaging, histology, and x-ray of three stages of damage to the knees of STR/ORT mice

RATIONALE AND OBJECTIVES

The authors develop a scoring system for assessing those features of degeneration of the STR/ORT mouse knee visualizable by magnetic resonance (MR) imaging, and to validate those MR scores by comparison with x-ray and histology.

METHOD

Magnetic resonance imaging, histology, and x-ray have been used in a cross-sectional study to visualize the anatomy and pathology of the knees of three pairs of male STR/ORT mice and their approximately age-matched female pairs. A scoring system was developed that distinguished the faster rate of damage of the males from the slower progressive changes seen in the females.

RESULTS

Changes in the patellar tendon were observed in MR imaging of the 5-month-old male knee. Sagittal images showed other degenerative features such as sclerosis and loss of signal from synovial fluid after 9 months; osteophytes and degeneration of the tibial plateau were better visualized in the coronal plane. Cysts were poorly correlated to the progression of the disease. Similar trends were observed for four features scored in x-rays (sclerosis, joint space narrowing, cysts, and osteophytes) and cartilage degradation assessed using histology. In contrast, the age-matched females were less affected.

CONCLUSIONS

Magnetic resonance imaging can identify joint degeneration in the knees of male mice, which develops more rapidly than in age-matched females. Those observations were validated by radiology and histology.

High resolution magnetic resonance imaging of the proximal interphalangeal joints. Correlation with histology and production of a three-dimensional data set

The magnetic resonance imaging appearance of the proximal interphalangeal joints of cadavers was correlated with histology of the same specimen allowing many small-scale features to be identified that might otherwise have been misinterpreted. It enabled the magnetic resonance signal to be understood at a tissue and cellular level, allowing identification of synovial folds extending from the extensor tendon and volar plate, the entheses of the proper collateral ligament, the epitenon of the flexor tendons and the presence of osteophytes and sites of cartilage erosion. The main difficulties in matching two-dimensional magnetic resonance images with histology were the differing section thicknesses of the two methods and shrinkage of histological specimens. There are many advantages in producing high resolution three-dimensional datasets-the magnetic resonance section thickness is reduced and the individual components of the joint can be viewed simultaneously in two or more planes. A unique magnetic resonance atlas of three dimensional joint structure is presented.

Magnetic resonance imaging protocol optimization for evaluation of hyaline cartilage in the distal interphalangeal joint of fingers

RATIONALE AND OBJECTIVES

To identify a single magnetic resonance imaging (MRI) protocol that will provide optimal signal-to-noise ratio, resolution, and image contrast with minimal susceptibility artifacts and that will allow clear delineation and visualization of cartilage, fluid, bone, tendons, and ligaments within the distal interphalangeal (DIP) joint of the human hand.

METHODS

A highly optimized 2.4 T MRI system was constructed from a 31-cm horizontal bore magnet, using a solenoid radiofrequency coil. This was used to study the DIP joints of 16 healthy, asymptomatic volunteers.

RESULTS

A range of image contrast protocols were explored, including spin-echo T1 and T2, field echo, chemical shift suppression to give water only images, and magnetization transfer. Susceptibility variations were explored by changing the field strength from 0.6 to 2.4 T. A spin-echo protocol with TR = 1500 msec and TE = 30 msec can routinely produce images with resolution 0.075 x 0.150 for a slice thickness of 1 mm in 13 minutes. That protocol can visualize simultaneously compact and trabecular bone, two layers of cartilage, synovial fluid, and synovium within the joint, tendons and ligaments, and the volar plate.

CONCLUSIONS

Although the contrast is not fully optimized for any one tissue, the spin echo protocol (TR = 1500, TE = 30) provides sagittal MR images, which clearly delineate the major structures of interest within the DIP joint, and which will be used in future studies to compare changes in the DIP joint because of aging or osteoarthritis. Experience gained by applying the above methods to a total of 16 healthy, asymptomatic volunteers has enabled a single sequence to be identified, which although not optimized for any one tissue, nevertheless visualized simultaneously and clearly delineated compact and trabecular bone, two layers of cartilage, synovial fluid, and synovium within the joint.

Effect of polyethylene glycol on the activity, intrinsic fluorescence, and oligomeric structure of castor seed cytosolic fructose-1,6-bisphosphatase

The effect of polyethylene glycol (PEG) on the activity, intrinsic fluorescence, and oligomeric structure of homogeneous cytosolic fructose-1,6-bisphosphatase (FBPasec) from endosperm of germinating castor oil seeds has been examined. Increasing the PEG concentration in the FBPasec reaction mixture elicited a progressive 3-fold decrease in the enzyme's Km for fructose-1,6-P2. The presence of PEG also: (i) increased the extent of FBPasec inhibition by high levels of fructose-1,6-P2, (ii) enhanced the intensity of the enzyme's fluorescence emission spectra, and (iii) prevents dissociation of the active tetrameric native enzyme into inactive lower M(r) forms during gel filtration HPLC. It is concluded that the activity and structure of plant FBPasec is modified by extreme dilution, probably as a result of partial deaggregation of the native tetrameric enzyme.

Visualisation of subchondral erosion in rat monoarticular arthritis by magnetic resonance imaging

High-resolution magnetic resonance imaging (MRI) was used to investigate antigen-induced monoarticular arthritis (AIMA) in the rat. In sagittal, spin-echo images of the knee, characteristic parallel bands, in the order dark-light-dark, were consistently observed 5-8 days after arthritis induction; the bands ran concentric with, and just beneath, the femoral and tibial articular surfaces. Concurrent radiology, histology and MRI (chemical shift-selective imaging and contrast enhancement with magnetisation transfer and gadolinium) established that the phenomenon reflected subchondral erosion, not artefact. The outer hypointense band corresponded to calcified cartilage underlying the articular surface. The central hyperintense band reflected inflammatory matrix displacing normal haematopoietic tissue immediately subchondrally; here, trabecular bone had mostly disappeared, but adjacent articular cartilage, although under attack and lacking proteoglycan, appeared structurally normal. The inner hypointense band reflected deeper, truncated trabeculae within inflammatory matrix, layered with pallisading osteoblast-like cells. This study exemplifies the power of MRI for revealing localised joint pathology non-invasively, and shows that rat AIMA shares many pathological features with arthritis in human beings.

A combined analysis and magnetic resonance imaging technique for computerised automatic measurement of cartilage thickness in the distal interphalangeal joint

It is well known that magnetic resonance imaging (MRI) contrast can be controlled, albeit sometimes at the expense of image resolution and signal-to-noise ratio, and most studies of articular joints have used a single MRI protocol, which is optimised for subjective image analysis. Inevitably that single protocol frequently compromises the detection of one or another of the boundaries between which any measurement must be made. This paper describes an alternative approach in which the criteria for computerised edge detection necessary for fully automated measurement of cartilage thickness are used to define the MRI acquisition parameters. This necessitates the combined use of two MRI sequences, one optimised for the cartilage-bone boundary, and the other for cartilage-synovial fluid. This provides a highly effective combination and its efficacy is demonstrated for the distal interphalangeal joint of a range of asymptomatic adults.

Copurification of cytosolic fructose-1,6-bisphosphatase and cytosolic aldolase from endosperm of germinating castor oil seeds

The cytosolic isozymes of fructose-1,6-bisphosphatase (FBPasec) and aldolase (ALDc) from germinating castor oil seed endosperm (COS) (Ricinus communis L.; cv Hale) were purified to homogeneity and final specific activities 49 and 2.8 (mumol product produced/min)/mg protein, respectively. Nondenaturing polyacrylamide gel electrophoresis of the final FBPasec preparation resolved a single protein-staining band which comigrated with FBPase activity. Two protein-staining bands of 41 and 39 kDa that occurred in an approximate 1:1 ratio were observed following sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the final FBPasec preparation. Rabbit anti-(FBPasec) immune serum immunoprecipitated the activities of FBPasec, but not that of the plastidic isozyme of FBPase from germinated COS. Immunoblot analysis utilizing affinity purified anti-(COS FBPasec) immunoglobulin G established that the 39-kDa subunit of FBP-asec did not arise via proteolytic cleavage of the 41-kDa subunit during tissue extraction and enzyme purification. However, FBPasec was susceptible to degradation by endogenous protease(s) during incubation of an acidic (pH 5.9) clarified COS extract at 25 degrees C. This proteolysis caused the production of a 32-kDa antigenic polypeptide and resulted in FBPase inactivation. Gel filtration indicated that purified FBPasec exists in at least 8 different oligomeric forms ranging in size from > 2 million to < 34 kDa. The majority of FBPasec, however, eluted as a 143-kDa heterotetramer. Sodium dodecyl sulfate gel electrophoresis of the final ALDc preparation yielded a single 40-kDa protein-staining polypeptide that cross-reacted with anti-(carrot ALDc) IgG. FBPasec copurified with ALDc through polyethylene glycol fractionation, Q-Sepharose, and phosphocellulose chromatographies, and the intensity of the fluorescence emission spectrum of ALDc was greatly reduced in the presence of COS FBPasec, but not rabbit muscle FBPase. These findings suggest that these two metabolically sequential enzymes might specifically interact in the cytosol of the highly gluconeogenic germinating COS. Our results also demonstrate that endogenous nonspecific acid phosphatase activity can interfere with the spectrophotometric assay for FBPase and can thus result in overestimations of FBPase activity in impure plant extracts.

High-resolution magnetic resonance imaging of arthritic pathology in the rat knee

High-resolution magnetic resonance imaging (MRI) has been used to visualise the changes that occur in both soft tissue and bone during antigen-induced, monoarticular arthritis (AIMA) of the rat knee. Extensive optimisation studies were performed in order to minimise the time of the experiments and to maximise both the signal-to-noise ratio and the contrast in the MR images. The study was cross-sectional rather than longitudinal and at each of the 13 time points studied during the progression of the disease, corresponding X-radiographs and histological sections were obtained. Interpretation of the spin echo MR images was aided by the use of chemical shift-selective imaging, magnetisation transfer contrast and relaxation time experiments, as well as by correlation with the histology and X-radiography data. The MR images clearly show invasion of the synovium by an inflammatory pannus which spreads over the articular cartilage and invades the bone, leading to erosion and later remodelling. Two distinct types of bony erosion were observed: focal erosions, especially at the margins of the joint, and subchondral erosions. It is concluded that MRI provides a sensitive, non-invasive method for investigating both early-stage inflammatory changes and late-stage bony changes in the knee joints of the arthritic rat.

Magnetic resonance imaging in a model of atherosclerosis: use of a collar around the rabbit carotid artery

Transverse cardiac-cycle gated high resolution magnetic resonance images have been obtained from the neck of the New Zealand white rabbit both in normal animals and from those in which a collar had been earlier positioned around one carotid artery. The study included animals fed on normal and on high cholesterol diets with the surgical modification having been demonstrated previously to cause a rapid and reproducible lesion resembling early atherosclerosis. The aim of the work was to investigate the attainable spatial resolution and sensitivity at a field strength of 2 T using a large radiofrequency transmitter system and a surface coil receiver with which spin-echo images have been obtained. Visualization was enhanced using a three-dimensional interpolation technique. An image resolution of 200 microns was readily obtained but was shown to be insufficient for delineating pathological features within the artery wall such as intimal layer thickening. The results have been compared with histopathological findings which confirmed that any morphological changes were within the pixel resolution of the image. Extensions to the methodology are proposed which should be able to detect atherosclerotic changes with a resolution of 50 microns within a feasible imaging time. In addition, the MRI study of how the surgical intervention alters the artery shape and curvature was carried out and the MRI demonstrated that collar implantation in general does not occlude the artery and causes only a slight and gradual degree of curvature to the vessel.

Resisting temptation: a psychological analysis

It is proposed that self control involves several related processes including vivid awareness of future consequences, overcoming learned helplessness and tunnel vision, developing commitment and accepting anxiety/frustration. Facing up to temptation and resisting the compulsive urge is considered to be a crucial therapeutic experience. Evidence is presented to support the view that cue exposure should therefore be a central component of treatments for compulsions and addictions.

Amelioration of chronic renal allograft dysfunction in cyclosporine-treated patients by addition of azathioprine

Management of chronic renal allograft dysfunction in cyclosporine-prednisone treated renal allograft recipients remains problematic. We therefore initiated a protocol of azathioprine addition (1.0-1.5 mg/kg/day) to ongoing CsA/Pred therapy. Three groups were treated. Group A (n = 21) had chronic progressive renal dysfunction (serum creatinine greater than or equal to 2.5 mg/dl or more than 15% above baseline) four or more months after transplantation. Group B (n = 8) had frequent or severe rejection episodes occurring despite adequate CsA levels. Group C (n = 7) had constitutional side effects of CsA with or without renal dysfunction persisting despite drug taper or financial difficulty in affording CsA. Aza was initiated 17.8 +/- 2.8 months after transplantation in group A, the mean serum creatinine having risen from 2.55 +/- 27 mg/dl to 3.04 +/- .20 mg/dl (P = .07) over the six months preceding Aza initiation, despite stable and low therapeutic range HPLC whole-blood CsA levels (118 +/- 10 ng/ml vs. 133 +/- 11 ng/ml, P = NS). Renal function declined at a rate of -0.20 +/- .06 Cr1/year in the six-month period before addition of Aza, and then improved at a rate of 0.09 +/- .04 Cr-1/year after addition of Aza (P = .002). These changes in renal function occurred without a decrease in CsA levels (118 +/- 10 six months before Aza vs. 126 +/- 26 six months after Aza, P = NS). In group B Aza was initiated at 58 +/- 8 days after transplantation when mean sCr was 3.56 +/- .29 mg/dl and mean CsA level was 222 +/- 17 ng/ml. At least follow-up 12.7 +/- 2.0 months after addition of Aza, all group B grafts were functioning, mean sCr was 2.69 +/- .31 mg/dl (P = .09 compared with baseline), and mean CsA level was 128 +/- 34 ng/ml (P = .07 compared with baseline). Group C patients had addition of Aza at 43 +/- 19 months after transplantation when mean sCr was 2.97 +/- .60 and mean CsA level was 125 +/- 30 ng/ml; addition of Aza had no influence on the rate of decline in renal function in this group. Of these 36 patients, 6 received therapy for acute rejection over the entire follow-up period of 12.3 +/- 1.4 months after addition of Aza; 4 of these retain graft function. Infectious complications consisted of 2 urinary tract infections, 1 bacterial pneumonia, and one case of otitis media.(ABSTRACT TRUNCATED AT 400 WORDS)