A pilot study for development of a pulmonary function test induction jacket to automate effort in performing the forced vital capacity manoeuvre

The pulmonary function test (PFT) induction jacket was invented to make the process of performing the forced vital capacity (FVC) manoeuvre with a computerized spirometer effortless and productive for both the patient and the medical practitioner. The jacket is composed of three layers of PVC material sealed together to form a single jacket with two chambers. The inner chamber is formed between the inner layer and the middle layer, in which cold water at a temperature of 10 °C is circulated using a connected water unit when triggered. Similarly, the outer chamber is formed between the middle layer and the outer layer, in which air is pressurized using a connected air unit. Thirty volunteers performed the FVC manoeuvre with and without wearing the jacket. There was no difference between the results in spirometry parameters in the participants without a jacket and those with a jacket. However, use of the jacket significantly reduced the number of trials the participants had to undergo to perform spirometry. The jacket automated the FVC manoeuvre by triggering a physiological inspiratory gasp using cold water and circumscribing pressurized air for expiration. Additionally, subsequent advancements in the jacket have been suggested.

Prognostic implications of clinical phenotype and severity of cardiac involvement in patients presenting with immunoglobulin light chain amyloidosis

Background

Patients with systemic immunoglobulin light chain (AL) amyloidosis may present with a wide array of signs and symptoms due to the multi-systemic organ involved. The presence of cardiac involvement is the key determinant of survival. Cardiac magnetic resonance (CMR) has the unique ability to measure the continuum of cardiac amyloidosis (CA) infiltration providing a deep characterisation from early CA involvement to severe degree of CA burden.

Purpose

The aim of this study was to characterise the clinical profiles and the severity of organ involvement in patients presenting with AL amyloidosis and to investigate implications for long-term outcome.

Methods

Patients newly diagnosed with AL amyloidosis at the National Amyloidosis Centre underwent comprehensive clinical, laboratory and instrumental work up, including CMR imaging with left ventricular (LV) mass, late gadolinium enhancement (LGE) and extracellular volume (ECV). The clinical phenotypes were classified in cardiac, renal and other according to the symptoms at presentation. The degree of CA was investigated by CMR: 0= no features of CA (normal LV mass, no LGE and normal ECV); 1=early cardiac amyloid infiltration (normal LV mass, raised ECV no LGE); 2= characteristic of CA with normal mass (diffuse subendocardial or transmural LGE, altered gadolinium kinetics and raised ECV); 3= characteristic of CA with elevated mass (diffuse subendocardial or transmural LGE and raised ECV). The study outcome was all-cause mortality.

Results

The study population included 241 AL patients presenting with cardiac and renal (22.8%, n=55), cardiac (28.2%, n=68), renal (33.2%, n=80) and other (15.8% n=38) phenotypes. During a median follow up of 33 (IQR 7–52) months, cardiac phenotype either in isolation or in combination with renal phenotype was associated with a higher rate of all-cause mortality compared to the others (p<0.001) (Figure). On CMR imaging, 43.2% of patients without cardiac phenotype (49%, n=118/241) had characteristic scans of CA (CMR grade 2 and 3) whilst 13.8% of patients with cardiac phenotype (51%, n=123/241) had no features of CA on CMR images (CMR grade 0) in (p<0.001). With Kaplan Meier analysis, the risk of all-cause death increased in patients with characteristic features of CA on CMR scan (Figure 1) and in patients with cardiac phenotype and features of CA on CMR scans compared to the others (both p<0.001) (Figure). At multivariable analysis, age at diagnosis (hazard ratio [HR] 1.03, p=0.009), clinical phenotype at presentation (HR 1.35, p=0.014) and ECV measured by CMR (HR 56, p<0.001) emerged as independent prognostic parameters.

Conclusions

Patients with newly diagnosed AL amyloidosis present most frequently with renal and cardiac phenotypes. CMR detects CA in >40% of patients with non-cardiac phenotype. ECV is an independent predictor of all-cause mortality across the full clinical spectrum of AL amyloidosis.

Funding Acknowledgement

Type of funding sources: None.

Myocardial ischaemia in cardiac amyloidosis: a change of perspective

Introduction

Cardiac involvement is the main driver of clinical outcomes in systemic amyloidosis; however many clinical observations are not explained by the concept of replacement of the interstitium by amyloid material. Preliminary studies support the hypothesis that myocardial ischaemia contributes to cellular damage.

Purpose

This study assesses the presence and mechanisms of myocardial ischaemia using cardiovascular magnetic resonance (CMR) with multiparametric mapping and histopathological assessment.

Methods

Ninety-two patients with cardiac amyloidosis (CA) (AL = 41, ATTR = 51) and 97 without CA (3-vessel coronary disease (3VD) = 47, unobstructed coronary arteries = 26, healthy volunteers (HV) = 24) underwent quantitative stress perfusion CMR with myocardial blood flow (MBF) mapping. Twenty-six myocardial biopsies and 3 explanted hearts with CA were analysed histopathologically.

Results

Stress MBF was severely reduced in patients with CA with lower values than patients with 3VD, unobstructed coronary arteries and HV (CA = 1.03±0.51 ml/min/g, 3VD = 1.35±0.50 ml/min/g, Unobstructed coronaries = 2.92±0.52 ml/min/g, HV = 3.14±0.69 ml/min/g; CA vs 3VD p=0.008, CA vs Unobstructed coronaries p<0.001, CA vs HV p<0.001). After adjustment for intracellular volume the MBF in patients with CA remained significantly lower than in HV (stress MBF/ICV: AL = 2.24±1.12, ATTR = 2.22±0.93, HV = 4.38±1.06; AL vs. ATTR p=1.000, AL vs HV p<0.001, ATTR vs. HV p<0.001). Myocardial perfusion reserve (MPR) was severely reduced in CA patients, compared to HV and patients with unobstructed coronary arteries, with the degree of reduction being comparable only to patients with 3VD (CA = 1.55±0.60, 3VD = 1.54±0.51, unobstructed coronaries = 2.78±0.70, HV = 4.08±0.86; CA vs 3VD p=1.000, CA vs unobstructed coronary arteries p<0.001, CA vs. HV p<0.001). Myocardial perfusion abnormalities correlated with amyloid burden, systolic and diastolic function, structural parameters and blood biomarkers (p<0.05). Biopsies demonstrated diffuse hypoxia with abnormal VEGF staining in cardiomyocytes and endothelial cells. Amyloid infiltration in intramural arteries was associated with severe lumen reduction in 20% of vessels, and severe reduction in capillary density.

Conclusion

CA is associated with severe myocardial ischaemia demonstrable by histology and CMR stress perfusion mapping. Histological evaluation indicates a complex pathophysiology, where systolic and diastolic dysfunction, amyloid infiltration of the epicardial arteries and disruption and rarefaction of the capillaries play a role in contributing to myocardial ischaemia.

Funding Acknowledgement

Type of funding sources: None.

Changes in referral pathway and phenotypic status of patients diagnosed with ATTR cardiac amyloidosis during the past 20 years

Background

Diagnostic and therapeutic advances have led to much increased awareness of transthyretin (ATTR) cardiac amyloidosis (CA).

Purpose

We sought to characterise the impact of this on referral practice, cardiac phenotype at diagnosis and specifically to determine whether patients are now being diagnosed at an earlier stage in their disease process.

Methods

We studied 1845 patients diagnosed with ATTR-CA at the National Amyloidosis Centre (NAC) from 2002–2021, all of whom underwent deep clinical phenotyping and follow-up.

Results

Analysis by 5-year quartiles revealed a substantial incremental increase in patients diagnosed with ATTR-CA (35 vs 260 vs 704 vs 846), which was associated with greater proportions of patients referred following advanced cardiac imaging (referrals following cardiac magnetic resonance and bone scintigraphy: 3% vs 44% vs 67% vs 76%; P<0.001). Over time, median duration of symptoms prior to diagnosis diminished from 36-months between 2002–2006 to 12-months between 2017–2021 (P<0.001) and a greater proportion of patients presented with milder disease across the 5-yearly quartiles (NAC stage 1: 40% vs 43% vs 44% vs 57%; P<0.001). The latter was associated with more favourable echocardiographic parameters of structure and function, including an incremental reduction in maximal left ventricular wall thickness (18.26mm vs 17.41mm vs 17.09mm vs 16.68mm; P=0.017). This was associated with improved survival in the overall population (2007–2011 vs 2012–2016: HR=1.65, 95% CI [1.33–2.06]; P<0.001 and 2012–2016 vs 2017–2021: HR =1.83, 95% CI [1.45–2.31]; P<0.001) and in each genotype (wtATTR, T60A and V122I). Despite a significant increase in the proportion of patients enrolled into clinical trials (0.0% vs 0.0% vs 2.6% vs 23.9%; P<0.001) and prescribed disease modifying therapy (5.7% vs 0.4% vs 4.8% vs 13.5%; P<0.001); the improved survival remained significant even after adjusting for clinical trials and disease modifying therapy (2012–2016 vs. 2017–2021: HR=1.65 95% CI [1.29–2.11], P<0.001).

Conclusion

Increased awareness and advances in cardiac imaging have been associated with a substantial increase in the diagnosis of ATTR-CA and at a progressively earlier stage of the disease, which has contributed to improved survival in recent years. These changes may have important implications for initiation and outcome of therapy. Given that ATTR-CA is now being diagnosed earlier, more data are needed to guide decisions on in whom and when to initiate treatment, and which treatments should be used at each disease stage. Furthermore, the changes in ATTR-CA phenotype at diagnosis urgently need to be factored into clinical trial design, given that pre-determined end-points based on trials performed in the past may no longer be appropriate, or at least sufficiently powered, or of adequate duration to evaluate efficacy of novel agents.

Funding Acknowledgement

Type of funding sources: None.

Multi-imaging characterisation of cardiac phenotype in different types of amyloidosis

Background

Bone scintigraphy is extremely valuable when assessing patients with suspected cardiac amyloidosis (CA), but the clinical significance and associated phenotype of different degrees of myocardial tracer uptake across different types of amyloidosis is yet to be defined.

Purpose

We sought to define the phenotypes of patients with varying degrees of cardiac uptake on bone scintigraphy, across multiple types of systemic amyloidosis using extensive characterisation comprising of biomarkers, echocardiographic and cardiac magnetic resonance (CMR) imaging.

Methods

A total of 296 patients (117 immunoglobulin light-chain [AL] amyloidosis, 165 transthyretin [ATTR] amyloidosis, 7 apolipoprotein-A1-amyloidosis [AApoAI],and 7 apolipoprotein-A4-amyloidosis [AApoA4]) underwent deep characterisation of their cardiac phenotype.

Results

AL-amyloidosis patients with grade 0 myocardial radiotracer uptake spanned the spectrum of CMR findings from no evidence of CA to characteristic features of CA, while AL-amyloidosis patients with grade 1–3 always produced characteristic CMR features. In ATTR-amyloidosis the CA burden strongly correlated with myocardial tracer uptake (correlation between bone scintigraphy cardiac uptake and CMR derived extracellular volume: R=0.88, 95% CI [0.84–0.91], P<0.001), except in patients with the Ser77Tyr variant. AApoAI-amyloidosis presented with grade 0–1 myocardial tracer uptake, and unique features of disproportionate right sided involvement such as disproportionate right ventricular (RV) and right atrial uptake on bone scintigraphy, RV free wall thickening, and tricuspid valve thickening and dysfunction. Within our cohort, AApoAIV-amyloidosis always presented with grade 0 myocardial tracer uptake, and characteristic features of CA on CMR. All AL-amyloidosis patients with grade 1 myocardial tracer uptake had characteristic CMR features of CA (n=48, 100%), while only ATTR-amyloidosis grade 1 patients with the Ser77Tyr variant had characteristic features of CA on CMR (n=5, 11.4%). Following the exclusion of Ser77Tyr and AApoAI, a CMR showing characteristic features of CA or an extracellular volume >0.40 in a patient with grade 1 myocardial tracer uptake had a sensitivity and specificity of 100% for diagnosing AL-amyloidosis.

Conclusion

Deep characterisation of the cardiac phenotype in different types of amyloidosis, across a range of bone scintigraphy cardiac uptake grades has identified clear differences between each amyloidosis type. The distinctive characteristics in each cohort has allowed the development of a diagnostic pathway to help define the diagnostic differentials and the clinical phenotype in each individual patient, following comprehensive assessment with bone scintigraphy and CMR.

Funding Acknowledgement

Type of funding sources: None.

0816 Sleep Correlates Of Nightmares Among Veterans

Introduction

There is an increased prevalence of Nightmare disorder (ND) among patients with obstructive sleep apnea (OSA). A further investigation of objectively measured sleep parameters among patients with and without ND could inform on potential comorbidities. We hypothesize ND correlates with Epworth sleepiness scale (ESS), apnea hypopnea index (AHI), Trough 02% (Sp02 nadir), and periodic limb movement (PLM) index.

Methods

Data presented herein are interim results from an IRB approved study to determine correlates and sequelae of nightmares. A cohort of all patients with ND visiting James A Haley Veterans Hospital between 2007 and 2011 was defined along with a random cohort of control patients. Demographic and outpatient visit data between January 2006 and April 2016 was pulled from VISTA for both the ND and control cohorts, and patients who had undergone a sleep study were identified. To date, sleep summary data has been individually extracted for 111 ND patients and 835 control patients. Logistic regression (SAS 9.4) was used to compare ESS, AHI, Sp02 nadir, and PLM Index.

Results

Mean age for ND was significantly lower at 49.7 ± 14, compared to 58.4 ± 12 for controls. Other demographic measures were similar including gender, race, and marital status. PLM index was significantly lower in ND compared to controls, however this relationship disappeared after adjusting for age. There were neither significant differences between other polysomnographic (PSG) variables, specifically AHI and Sp02 nadir, nor did OSA severity significantly different between ND and controls.

Conclusion

Among veterans undergoing a PSG, there were no significant differences between measured sleep parameters. Our results contradict our hypothesis that ND correlates with ESS, AHI, Sp02 nadir, and PLM index.

Support

This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

Evaluation of variation of interfraction doses to organs at risk during brachytherapy of cervical cancer

Background

Two-dimensional treatment planning using radiographs or simulator films was the standard in planning brachytherapy for patients with cervical cancer. Three-dimensional (3D) treatment planning has improved treatment efficacy. This retrospective study compares conventional and 3D treatment planning of brachytherapy in patients with cervical cancer and interfraction dose variation to bladder and rectum (D2cc).

Methods

The mean doses to bladder and rectum (D2cc) were computed by computed tomography (CT)-based planning during 100 sessions of intracavitary brachytherapy for carcinoma cervix with the same source configuration as generated for conventional planning, and these estimates were compared with the doses at International Commission on Radiation Units and measurements (ICRU) rectal, bladder points and point A. Interfraction variation of doses to bladder and rectum during various sessions was also analysed.

Result

The mean ICRU bladder dose and D2cc of the bladder for all patients was 3.7 Gy and 7.4 Gy, respectively (p < 0.001). The mean ICRU rectal dose from conventional plan was 4.3Gy and with CT planning, 4.45 Gy (p = 0.04). Interfraction dose variations for D2cc of the bladder were min -5.3 Gy and max 4.8 Gy and those of the rectum were min -1.8 Gy and max 1.72Gy.

Conclusion

Dosimetric evaluation of conventional and 3D CT-based treatment planning for the same brachytherapy sessions demonstrated underestimation of ICRU bladder dose points (p < 0.001) and the rectal ICRU point dose and D2cc (p=0.04). The doses to organs at risk did not show a statistically significant variation between the fractions. However, large variation was noted between the interfractional maximum and minimum doses to bladder and rectum.

The perils of inhibiting deficient factors

Essentials Anticoagulation in patients with factor X deficiency is an evidence-poor area. A patient with factor X deficiency was anticoagulated with warfarin followed by rivaroxaban. Warfarin may be a safer anticoagulant option than rivaroxaban in hereditary factor X deficiency. A baseline coagulation screen should be performed prior to commencement of anticoagulation.

SUMMARY

We report a case of a previously undiagnosed factor X deficiency in an 83-year-old man who had no previous bleeding history despite multiple hemostatic challenges. He was anticoagulated with warfarin for atrial fibrillation without bleeding complications; however, major hemorrhage occurred soon after a switch to rivaroxaban.

Dark chocolate supplementation reduces the oxygen cost of moderate intensity cycling

Background

Dark chocolate (DC) is abundant in flavanols which have been reported to increase the bioavailability and bioactivity of nitric oxide (NO). Increasing NO bioavailability has often demonstrated reduced oxygen cost and performance enhancement during submaximal exercise.

Methods

Nine moderately-trained male participants volunteered to undertake baseline (BL) measurements that comprised a cycle \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \overset{.}{V}{O}_{2 max} $$\end{document}V.O2max test followed by cycling at 80 % of their established gas exchange threshold (GET) for 20-min and then immediately followed by a two-minute time-trial (TT). Using a randomised crossover design participants performed two further trials, two weeks apart, with either 40 g of DC or white chocolate (WC) being consumed daily. Oxygen consumption, RER, heart rate and blood lactate (BLa) were measured during each trial.

Results

DC consumption increased GET and TT performance compared to both BL and WC (P < 0.05). DC consumption increased \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \overset{.}{V}{O}_{2 max} $$\end{document}V.O2max by 6 % compared to BL (P < 0.05), but did not reach statistical significance compared to WC. There were no differences in the moderate-intensity cycling for \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \overset{.}{V}{O}_2 $$\end{document}V.O2_, RER, BLa and heart rate between conditions, although, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \overset{.}{V}{O}_2 $$\end{document}V.O2 and RER exhibited consistently lower trends following DC consumption compared to BL and WC, these did not reach statistical significance.

Conclusion

Chronic supplementation with DC resulted in a higher GET and enhanced TT performance. Consequently, ingestion of DC reduced the oxygen cost of moderate intensity exercise and may be an effective ergogenic aid for short-duration moderate intensity exercise.

Perineal hernia formation following extralevator abdominoperineal excision

AIM

Extralevator abdominoperineal excision (ELAPE) has become increasingly used because of some evidence of improved oncological outcome. It is, however, thought to be associated with a higher incidence of perineal hernia formation, although the exact incidence is not known. The aim of this study was to identify the incidence of perineal hernia after ELAPE.

METHOD

The case notes of patients over a 54-month period were reviewed. The perineal closure technique, perineal complications and management plan were recorded.

RESULTS

During the study period, 56 patients underwent ELAPE, of whom 24 (44%) developed a perineal wound complication. Primary perineal closure was performed with (eight patients) and without (32 patients) insertion of a biological mesh or myocutaneous flap. Perineal hernia was the commonest complication (26%) and occurred in nine (45%) of 20 patients who had a laparoscopic ELAPE.

CONCLUSION

Perineal hernia formation was the commonest perineal complication of ELAPE and occurred in nearly half of patients having a laparoscopic ELAPE.

Simultaneous analysis and quantification of markers of manjisthadi churna using high performance thin layer chromatography

Manjisthadi churna has been traditionally used in the Ayurvedic system of medicine and by traditional medical practices of India to treat hyperlipidemia. A rapid, simple and accurate method with high performance thin layer chromatography has been developed to standardised Manjisthadi churna using rubiadin, sennoside and ellagic acid as markers. Methanol extract of Manjisthadi churna were used for high performance thin layer chromatography on silica gel plates. The Rf of rubiadin, sennoside-A and ellagic acid were found to 0.48, 0.23 and 0.72, respectively with densitometric scanning at 280 nm and the calibration plot were linear in the range of 100-600 ng of markers. The correlation coefficients were higher than 0.99 were indicative of good linear dependence of peaks area on concentration. The rubiadin, sennoside-A and ellagic acid contents in Manjisthadi churna were found to be 0.014, 0.038 and 0.534% w/w, respectively. This method permits reliable quantification of rubiadin, sennoside-A and ellagic acid with good resolution and separation of the same from other constitutes of the extract of Manjisthadi churna. Recovery value from 95.66-102.33% showed the reliability and reproducibility of the method. The proposed high performance thin layer chromatography method for simultaneous quantification of markers in Manjisthadi churna can be used for routine quality testing.

Biosorption of arsenic (III) from aqueous solution by living cells of Bacillus cereus

In this work, removal of arsenic (III) from aqueous solution by living cells (Bacillus cereus), biosorption mechanism, and characterization studies have been reported. B. cereus cell surface was characterized using SEM-EDX and FTIR. Dependence of biosorption on pH of the solution, biosorbent dose, initial arsenic (III) concentration, contact time, and temperature had been studied to achieve optimum condition. The maximum biosorption capacity of living cells of B. cereus for arsenic (III) was found to be 32.42 mg/g at pH 7.5, at optimum conditions of contact time of 30 min, biomass dosage of 6 g/L, and temperature of 30 ± 2 °C. Biosorption data of arsenic (III) are fitted to linearly transformed Langmuir isotherm with R (2) (correlation coefficient) >0.99. The pseudo-second-order model description of the kinetics of arsenic (III) is successfully applied to predict the rate constant of biosorption. Thermodynamic parameters reveal the endothermic, spontaneous, and feasible nature of sorption process of arsenic (III) onto B. cereus biomass. The arsenic (III) ions are desorbed from B. cereus using both 1 M HCl and 1 M HNO(3).

Women's views on and adherence to low-molecular-weight heparin therapy during pregnancy and the puerperium

BACKGROUND

Non-adherence to prescribed medication represents a significant factor associated with treatment failure. Pregnant women identified at risk of venous thromboembolism are increasingly being prescribed low-molecular-weight heparin (LMWH) during pregnancy and the puerperium. It is important to understand women's views on and adherence to LMWH during pregnancy and the puerperium, so that women gain maximum benefit from the treatment.

OBJECTIVES

To monitor women's adherence to enoxaparin, when prescribed during pregnancy and the puerperium, and explore their beliefs about the enoxaparin therapy prescribed.

PATIENTS/METHODS

A prospective cohort study involving 95 nullparous and multiparous women prescribed enoxaparin for recognized antenatal indications. Adherence to enoxaparin was assessed through self-completion of a diary, additionally verified through laboratory tests. An adapted beliefs about medication questionnaire was administered to women during their pregnancy.

RESULTS

Women were highly adherent to enoxaparin: antenatally, mean percentage adherence 97.92%; postnatally, mean percentage adherence 93.37% (paired t-test, P = 0.000). In the cohort of women we followed, their perceived necessity for enoxaparin therapy outweighed any concerns they had regarding enoxaparin antenatally, necessity-concerns differential 2.20. In some women, however, this perceived necessity does decrease postnatally.

CONCLUSIONS

Our results suggest that most women prescribed enoxaparin are highly adherent to their therapy during the antenatal period and that women's antenatal beliefs about enoxaparin are able to predict a decrease in postnatal adherence. Our results have important clinical implications, particularly when women are initiated on LMWH just during the postnatal period.

Hydrogeochemical processes controlling the high fluoride concentration in groundwater: a case study at the Boden block area, Orissa, India

The present investigation reports the assessment of hydrochemical/geochemical processes controlling the concentration of fluoride in groundwater of a village in India (Boden block, Orissa). Boden block is one of the severely affected fluoride-contaminated areas in the state of Orissa (India). The sampling and subsequent analysis of water samples of the study area was carried out following standard prescribed methods. The results of the analysis indicate that 36.60% groundwater F(-) concentration exceeds the limit prescribed by the World Health Organization for drinking water. The rock interaction with groundwater containing high concentration of HCO(3)(-) and Na(+) at a higher pH value of the medium could be one of the important reasons for the release of F(-) from the aquatic matrix into groundwater. Geochemical classification of groundwater based on Chadha rectangular diagram shows that most of the groundwater samples having fluoride concentration more than 1.5 mg L(-1) belongs to the Na-K-HCO(3) type. The saturation index values evaluated for the groundwater of the study area indicated that it is oversaturated with respect to calcite, whereas the same is undersaturated with respect to fluorite content. The deficiency of calcium ion concentration in the groundwater from calcite precipitation favors fluorite dissolution leading to excess of fluoride concentration. The risk index was calculated as a function of fluoride level in drinking water and morbidity of fluorosis categorizes high risk for villages of Amera and Karlakote panchayat of Boden block.

Biosorption of As(V) from aqueous solutions by living cells of Bacillus cereus

In this work, the biosorption of As(V) from aqueous solutions by living cells of Bacillus cereus has been reported. The batch biosorption experiments were conducted with respect to biosorbent dosage 0.5 to 15 g/L, pH 2 to 9, contact time 5 to 90 min, initial concentration 1 to 10 mg/L and temperature 10 to 40 °C. The maximum biosorption capacity of B. cereus for As(V) was found to be 30.04 at pH 7.0, at optimum conditions of contact time of 30 min, biomass dosage of 6 g/L, and temperature of 30 ± 2 °C. Biosorption data were fitted to linearly transformed Langmuir isotherms with R(2) (correlation coefficient) >0.99. Bacillus cereus cell surface was characterized using AFM and FTIR. The metal ions were desorbed from B. cereus using both 1 M HCl and 1 M HNO(3). The pseudo-second-order model was successfully applied to predict the rate constant of biosorption.

P3-07-22: Combined Approach for Staging the Axilla in Breast Cancer Patients with Clinically (−)Nodes Versus Sentinel Node Biopsy Alone

Background

Prognostic information and local control for managing the majority of clinically node (−) breast cancer patients may be achieved by sentinel node biopsy (SNB) alone and/or limited axillary dissections (LAD). Currently, 20 - 30% of clinically node (−) patients have unnecessary surgery. This study compares the results from staging the axilla using SNB alone versus using the combined approach shown below.

Methods: Clinically node (−) patients (n=176) were subclassified according to their primary tumor histology, axillary ultrasound (US) data, and US guided Fine Needle Aspiration (US-FNA) results, as follows: Low Risk (LR) for axillary metastasis (n = 62); High Risk (HR) with normal axillary US (n = 17); HR with US suggesting minimal N1a disease (n = 23); HR with US suggesting N1a disease (n = 52); HR with US suggesting N2-3 disease (n = 22). All patients with (+) SNB or (+) US-FNA had Axillary Lymph Node Dissections (ALND). The number of (+) Sentinel Nodes (SN), Non Sentinel Nodes (NSN) and (+) LN after a (+) US-FNA from each patient category was correlated with corresponding preoperative data. HR patients were defined as having grade II tumors ≥ 1.5 cm and grade III tumors &gt; 1.0 cm. US abnormalities in the axilla were interpreted as follows: minimal N1a disease equivalent to cortical defects &lt; 5mm in 1–3 LN; N1a disease, cortical defects &gt; 5mm in 1–3 LN and N2-3 disease, complete nodal replacement in ≥ 1 LN. LAD refers to level I dissections (1-5 LN).

Results: Three subgroups of patients were identified: Group A, patients not requiring ALND (128/176 = 72%); Group B, patients requiring ALND bypassing SNB (22/176 =13%) and Group C, patients requiring LAD (26/176 = 15%). Preoperatively these 3 groups were categorized as follows: Group A included patients at LR for axillary metastasis, HR patients with normal axillary US, HR patients with axillary US suggesting minimal N1a disease and HR patients with axillary US suggesting N1a disease with (−) US-FNA; Group B included HR patients with axillary US suggesting N2-3 disease and (+) US-FNA; Group C included HR patients with axillary US suggesting N1a disease and (+) US-FNA. The post ALND characteristics for these 3 groups are summarized as follows: all Group A patients had N1a disease represented by ≤ 2 (+) LN, 94% (17/18) were SN (+) only, 85% (15/18) with 1 (+) LN and 15% with 2 (+) LN; in Group B, 20 patients had N2-3 disease and 2 patients had N1a disease, all Group B patients had &gt; 2 (+) LN; in group C, 20 patients had N1a disease and 2 patients had N2 disease, and 77% had single (+) node disease.

Conclusion: By following this approach a more patient oriented method for staging the axilla can be implemented as follows: 1. SNB alone for LR patients and for HR patients with axillary US findings suggesting no axillary disease, minimal N1a disease and/or N1a disease with (−) US-FNA; 2. ALND for HR patients with axillary findings suggesting N2-3 disease and a (+) US-FNA; 3. LAD for HR patients with US findings suggesting N1a disease and (+) US-FNA. This approach would result in a 38% (48/176) reduction in the number of SNB and a 30% (22/66) reduction in the number of ALND. This translates in to $200,000 (30-40%) in procedure-associated savings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-22.

Studies on the removal of arsenic (III) from water by a novel hybrid material

The present work provides a method for removal of the arsenic (III) from water. An ion-exchanger hybrid material zirconium (IV) oxide-ethanolamine (ZrO-EA) is synthesized and characterized which is subsequently used for the removal of selective arsenic (III) from water containing 10,50,100mg/L of arsenic (III) solution. The probable practical application for arsenic removal from water by this material has also been studied. The various parameters affecting the removal process like initial concentration of As (III), adsorbent dose, contact time, temperature, ionic strength, and pH are investigated. From the data of results, it is indicated that, the adsorbent dose of 0.7mg/L, contact time 50min after which the adsorption process comes to equilibrium, temperature (25±2), solution pH (5-7), which are the optimum conditions for adsorption. The typical adsorption isotherms are calculated to know the suitability of the process. The column studies showed 98% recovery of arsenic from water especially at low concentration of arsenic in water samples.

Serum phosphate and outcome at one year after deceased donor renal transplantation

Traditional risk factors do not adequately explain the increased prevalence of cardiovascular disease in renal patients. This study considered a "non-traditional" risk factor, serum phosphate and outcome in renal transplant recipients. Data from 377 patients who received a first deceased donor renal transplant between January 1, 1999, and December 31, 2008, were recorded; 10% (n=38) had diabetes, 16.7% (n=63) were smokers, and 18.8% (n=71) had a history of vascular disease. Three hundred and thirty-three patients were alive at the time of the analysis. Survivors were significantly younger, less likely to be smokers or diabetic, and had a higher estimated glomerular filtration rate at one yr post-transplantation. Serum phosphate was significantly lower in these patients (0.95 ± 0.23 vs. 1.04 ± 0.26, p = 0.031). Analysis of recipient survival, stratified by serum phosphate at one yr post-transplant, revealed that serum phosphate > 1.11 mMol/L was a significant predictor of all-cause mortality (p=0.006). Serum phosphate between 0.9 and 1.11 mMol/L afforded the best outcome. In multivariate analysis, serum phosphate remained a significant predictor of mortality (p=0.016). Serum phosphate at one yr after transplant seems to have a J-shaped relationship with mortality, and this effect is independent of traditional cardiovascular risk factors.

Toxicity and bioaccumulation potential of Cr (VI) and Hg (II) on differential concentration by Eichhornia crassipes in hydroponic culture

In this work, the phytoremediation of Cr (VI) and Hg (II) ion from water by an aquatic plant Eichhornia crassipes has been studied. Plants were cultured in a double distillated water with modified Hoagland's nutrient solution at pH 6.8 supplemented with 0, 0.75, 1.50, 2.50, and 4 mg Cr/L as potassium dichromate (K(2)Cr(2)O(7)) and 0, 5, 10, 15, and 20 mg Hg/L as mercuric chloride (HgCl(2)). They were separately harvested after 3, 6 and 9 days. Plants treated with 4 mg/L of Cr (VI) accumulated the highest concentration of metal in roots (1.22 mg/g, dry weight) and shoots (0.24 mg/g, dry weight) after 9 days; while those treated with 20 mg/L of Hg (II) accumulated the highest concentration of metal in roots (4.22 mg/g, dry weight) and shoots (2.43 mg/g, dry weight) after 9 days. Eichhornia crassipes biomass was characterised using AAS, SEM and FTIR. The accumulation and relative growth of metal ions at different concentrations of chromium and mercury solution significantly increased (P<0.05) with the passage of time. The maximum values of bio-concentration factor (BCF) for Cr (VI) and Hg (II) were found to be 413.33 and 502.40 L/kg respectively.

The effect of estrone on thrombin generation may explain the different thrombotic risk between oral and transdermal hormone replacement therapy

BACKGROUND

The metabolism of estrogen contained within hormone replacement therapy (HRT) is influenced by the route of administration, and this may affect the risk of venous thromboembolism. Thrombin generation, a global coagulation assay, is a marker of hypercoagulability and is of potential use in determining the thrombotic risk associated with particular HRT administration routes.

OBJECTIVES

To determine whether any effect of oral and transdermal HRT on thrombin generation is related to the plasma estrogen profile.

METHODS

We investigated the effects of oral, transdermal and no HRT (controls) in 52, 39 and 52 postmenopausal women, respectively, on thrombin generation, standard markers of thrombophilia, estradiol level and estrone level.

RESULTS

All parameters of thrombin generation were altered in women using oral HRT as compared with controls (P<0.001 for all comparisons). No such differences were found in women using transdermal HRT. Estrone levels correlated with peak thrombin generation (R=0.451, P<0.001) in women using oral HRT, but there was no correlation in women using the transdermal route.

CONCLUSIONS

Thrombin generation is significantly increased in women who use HRT administered by the oral route. This is probably mediated by the hepatic first-pass metabolism of estrone, the main metabolite of oral estradiol, which is avoided by the transdermal route. The effect of estrone on thrombin generation may provide the explanation for the higher thrombotic risk seen in women using oral rather than transdermal HRT.

The use of an exclusion-based risk-assessment model for venous thrombosis improves uptake of appropriate thromboprophylaxis in hospitalized medical patients

BACKGROUND

Venous thromboembolism is a common condition in hospitalized medical patients. Numerous studies have demonstrated that low molecular weight heparin significantly reduces this risk but, despite this, the use of thromboprophylaxis remains poor.

AIM

To evaluate the use of an exclusion based risk-assessment model (RAM) for venous thrombosis in improving the uptake of appropriate thromboprophylaxis in hospitalized medical patients.

DESIGN

A survey with a subsequent audit cycle of three separate audits over 36 months.

METHODS

497 hospitalized patients with acute medical conditions on general medical wards were audited at a secondary care centre in London, UK. The survey and subsequent audits were performed by reviewing the notes and medication charts of medical patients, prior to the launch of the RAM and at 12, 28 and 36 months following its introduction.

RESULTS

Prior to launching the RAM, 49% of hospitalized medical patients received appropriate thromboprophylaxis. This did not change 12 months after the RAM was introduced but increased significantly to 71% following formal education of the health care professionals involved in thromboprophylaxis prescription. This improvement was maintained as demonstrated by a subsequent audit 8 months later (75.9%).

CONCLUSION

The introduction of a simple exclusion-based RAM for venous thrombosis in medical patients significantly improved delivery of thromboprophylaxis. The successful uptake of the RAM appears to have been dependent on direct education of those health carers involved in its use. A similar exclusion-based model used nationally could have a significant impact on the burden of VTE currently experienced in the UK.

The prevalence of the activating JAK2 tyrosine kinase mutation in chronic porto-splenomesenteric venous thrombosis

BACKGROUND

Occult myeloproliferative disorders (MPD) are present in 25% of patients with chronic portal, splenic and mesenteric venous thrombosis (PSMVT). A somatic mutation of JAK2 (JAK2V617F) can be used to identify patients with latent MPD.

AIM

We evaluated the prevalence and clinical significance of JAK2V617F in patients with chronic PSMVT.

METHODS

Allele-specific polymerase chain reaction was performed to screen for JAK2V617F.

RESULTS

Thirty-five patients were tested for JAK2V617F. The underlying pro-coagulant condition was MPD in seven of 35 (20.0%) patients; other aetiologies included hereditary thrombophilia (n = 5), chronic pancreatitis (n = 2), liver abscess (n = 1) and umbilical vein sepsis (n = 3). The remainder were labelled idiopathic, i.e. 17/35 (48.6%) patients. JAK2V617F was detected in 16/35 (45.7%) patients: seven of seven (100%) with MPD, two of 11 (18.1%) with non-MPD acquired conditions and seven of 17 (41.2%) with 'idiopathic' chronic PSMVT. Mean haemoglobin concentration (P = 0.04), haematocrit (P = 0.04), white cell count (P = 0.002) and platelet count (P = 0.05) were significantly higher in patients with JAK2V617F. None of the seven patients with latent MPD have progressed to overt MPD over median follow-up of 85 months.

CONCLUSION

JAK2V617F occurs in 41% of patients with idiopathic chronic portal, splenic and mesenteric venous thrombosis, confirming the presence of latent myeloproliferative disorders, and should form part of the routine pro-coagulant screen.

Altered expression of signalling lymphocyte activation molecule (SLAM) family receptors CS1 (CD319) and 2B4 (CD244) in patients with systemic lupus erythematosus

CS1 (CRACC, CD319) and 2B4 (CD244), members of the signalling lymphocyte activation molecule (SLAM) family receptors, regulate various immune functions. Genes encoding SLAM family receptors are located at 1q23, implicated in systemic lupus erythematosus (SLE). In this study, we have investigated the expression and alternative splicing of CS1 and 2B4 in immune cells from SLE patients. The surface expression of CS1 and 2B4 on total peripheral blood mononuclear cells (PBMCs), T, B, natural killer (NK) cells and monocytes in 45 patients with SLE and 30 healthy individuals was analysed by flow cytometry. CS1-positive B cell population was increased significantly in SLE patients. Because CS1 is a self-ligand and homophilic interaction of CS1 induces B cell proliferation and autocrine cytokine secretion, this could account for autoreactive B cell proliferation in SLE. The proportion of NK cells and monocytes expressing 2B4 on their surface was significantly lower in patients with SLE compared to healthy controls. Our study demonstrated altered expression of splice variants of CS1 and 2B4 that mediate differential signalling in PBMC from patients with SLE.

Removal of lead and zinc ions from water by low cost adsorbents

In this study, activated carbon, kaolin, bentonite, blast furnace slag and fly ash were used as adsorbent with a particle size between 100 mesh and 200 mesh to remove the lead and zinc ions from water. The concentration of the solutions prepared was in the range of 50-100 mg/L for lead and zinc for single and binary systems which are diluted as required for batch experiments. The effect of contact time, pH and adsorbent dosage on removal of lead and zinc by adsorption was investigated. The equilibrium time was found to be 30 min for activated carbon and 3h for kaolin, bentonite, blast furnace slag and fly ash. The most effective pH value for lead and zinc removal was 6 for activated carbon. pH value did not effect lead and zinc removal significantly for other adsorbents. Adsorbent doses were varied from 5 g/L to 20 g/L for both lead and zinc solutions. An increase in adsorbent doses increases the percent removal of lead and zinc. A series of isotherm studies was undertaken and the data evaluated for compliance was found to match with the Langmuir and Freundlich isotherm models. To investigate the adsorption mechanism, the kinetic models were tested, and it follows second order kinetics. Kinetic studies reveals that blast furnace slag was not effective for lead and zinc removal. The bentonite and fly ash were effective for lead and zinc removal.

Use of agricultural waste for the removal of nitrate-nitrogen from aqueous medium

The effectiveness of wheat straw charcoal (WSC) and mustard straw charcoal (MSC) as adsorbents for the removal of nitrate-nitrogen from water has been investigated. Commercial activated carbon (CAC) was used as a standard for comparison. The adsorption effectiveness of MSC was highest followed by CAC and WSC irrespective of the concentration of nitrate-nitrogen in the range of 0-25mg/l. The effects of temperature in the range of 15-28 degrees C on adsorption by WSC and MSC have also been investigated. It was observed that the temperature dependence of the adsorption effectiveness of MSC was higher than that of WSC and CAC. It is concluded that the MSC can be used for the in situ treatment by adsorption of nitrate-nitrogen in underground and surface water.

Prognostic value of cardiovascular screening in potential renal transplant recipients: a single-center prospective observational study

We assessed the outcome of pretransplant cardiac assessment in a single center. Three hundred patients with end-stage renal disease underwent electrocardiogram, Bruce exercise testing (ETT) and ventricular assessment by cardiac MRI. Patients with high index of suspicion of coronary artery disease (CAD) underwent coronary angiography and percutaneous coronary intervention (PCI) if indicated. Two hundred and twenty-two patients were accepted onto the renal transplant waiting list; 80 patients were transplanted during the follow-up period and 60 died (7 following transplantation). Successful transplantation was associated with improved survival (mean survival 4.5 +/- 0.6 years vs. listed not transplanted 4.1 +/- 1.4 years vs. not listed 3.1 +/- 1.7 years; p < 0.001). Ninety-nine patients underwent coronary angiography; 65 had normal or low-grade CAD and 34 obstructive CAD. Seventeen patients (5.6%) were treated by PCI. There was no apparent survival difference between patients who underwent PCI or coronary artery bypass graft compared to those who underwent angiography without intervention or no angiography (p = 0.67). Factors associated with nonlisting for renal transplantation included burden of preexisting cardiovascular disease, poor exercise tolerance and severity of CAD. Pretransplant cardiovascular screening provides prognostic information and information that can be used to restrict access to transplantation. However, if the aim is to identify and treat CAD, the benefits are far from clear.

Prognostic value of cardiovascular screening in potential renal transplant recipients: a single-center prospective observational study

We assessed the outcome of pretransplant cardiac assessment in a single center. Three hundred patients with end-stage renal disease underwent electrocardiogram, Bruce exercise testing (ETT) and ventricular assessment by cardiac MRI. Patients with high index of suspicion of coronary artery disease (CAD) underwent coronary angiography and percutaneous coronary intervention (PCI) if indicated. Two hundred and twenty-two patients were accepted onto the renal transplant waiting list; 80 patients were transplanted during the follow-up period and 60 died (7 following transplantation). Successful transplantation was associated with improved survival (mean survival 4.5 +/- 0.6 years vs. listed not transplanted 4.1 +/- 1.4 years vs. not listed 3.1 +/- 1.7 years; p < 0.001). Ninety-nine patients underwent coronary angiography; 65 had normal or low-grade CAD and 34 obstructive CAD. Seventeen patients (5.6%) were treated by PCI. There was no apparent survival difference between patients who underwent PCI or coronary artery bypass graft compared to those who underwent angiography without intervention or no angiography (p = 0.67). Factors associated with nonlisting for renal transplantation included burden of preexisting cardiovascular disease, poor exercise tolerance and severity of CAD. Pretransplant cardiovascular screening provides prognostic information and information that can be used to restrict access to transplantation. However, if the aim is to identify and treat CAD, the benefits are far from clear.

Acute renal infarction due to renal fibromuscular dyplasia: a case of mistaken identity

A 53 year old male presented with right sided loin pain in the absence of other distinguishing symptoms, past medical history or examination findings. Investigation, a week later, revealed a right sided renal mass. He underwent laparascopic nephrectomy for presumed renal malignancy. Surprisingly, the mass was an area of infarction and the renal artery had intimal-type fibromuscular dysplasia (FMD). This case demonstrates three important points. Firstly, renal infarction is a cause of acute loin pain. Secondly, delayed investigation can alter the radiological appearance of renal infarction. Lastly, FMD is a rare condition, particularly in men, and can cause renal infarction.

Removal of endosulfan by sal wood charcoal

The removal efficiency of endosulfan from water by two low cost adsorbents viz. sal wood (Shorea robusta, family-Diptero carpaceae) charcoal and sand along with activated charcoal as the reference was investigated. For the selection of the suitable adsorbent for endosulfan uptake, the maximum adsorption capacity (Q(max)) was chosen as the main parameter. Using linearized forms of equilibrium models like Langmuir, BET, Freundlich, the maximum adsorptive capacities were determined. It was observed that the efficiency for removal of pesticide is higher in activated charcoal with 94% followed by sand 90%. The efficiency of sal wood charcoal is moderately high with 87% which can be regenerated after treatment with dilute HCl and HNO(3). Though the efficiency of sand is better than sal wood charcoal, it cannot be regenerated.

Evaluation of removal efficiency of fluoride from aqueous solution using quick lime

Several methods are available to remove fluoride from the aqueous environment but they are not feasible in all places and conditions due to various reasons. In the present work, F(-) has been removed by using activated and ordinary quick lime. The removal of fluoride was 80.6% and the final concentration was 9.7 mg/L at optimum condition from the synthetic solution having initial fluoride concentration of 50 mg/L. Adsorption kinetic study revealed that the adsorption process followed first order kinetics. And the removal process followed Langmuir adsorption isotherm. The SEM micrographs and XRD studies revealed that the removal of fluoride was mainly due to chemi-sorption and precipitation. However, they can be suitably used to remove fluoride from industrial effluent where the concentration is high. But this method cannot be employed to treat water for domestic purpose, since it cannot bring fluoride within permissible limit and also increases the pH of treated water.

Novel cytogenetic finding: an unusual X;X-translocation in Mehsana buffalo (Bubalus bubalis)

Cytogenetic investigations of a phenotypically normal Mehsana river buffalo calf (Bubalusbubalis) revealed an XXY chromosome complement due to X;X-translocation in all screened metaphase plates. The chromosomal anomaly was identified by GTG-banding while CBG- and RBG-banding revealed two heterochromatin blocks and that one of the two X chromosomes was late replicating, respectively. The normal cytogenetic profiles of sire, dam and relatives of the calf suggest that the anomaly could have arisen spontaneously during oogenesis. This is the first report on a male river buffalo calf having an XXY chromosome complement with translocation between the two X chromosomes.

One-step purification and characterization of an alkaline protease from haloalkaliphilic Bacillus sp

An alkaline protease producer haloalkaliphilic bacteria (isolate Vel) was isolated from west coast of India. It was related to Bacillus pseudofirmus on the basis of 16S r RNA gene sequencing, lipid profile and other biochemical properties. The protease secreted by this bacteria was purified 10-fold with 82% yield by a single step method on Phenyl Sepharose 6 Fast Flow column. The apparent molecular mass based on the sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) was estimated to be 29 000 Da. The Km and Vmax towards caseinolytic activity were found to be 2 mg ml(-1) and 289.8 microg min(-1), respectively. The enzyme was active over the pH range of 8.5-12.0, the optimum being 10-11.0. The purified enzyme when kept at 45 degrees C and 50 degrees C for 40 min retained 92% and 85% protease activity, respectively. Effect of NaCl concentration on protease activity showed that the enzyme was slightly inhibited with high concentration of salt. The proteolytic activity was inhibited by PMSF, suggesting that the enzyme may belong to serine type protease. Interestingly, the activity was slightly enhanced with SDS (0.1%) and Triton X-100 (0.1%) but remained unaffected by Tween 80 (0.1%). The activity was affected by metal ions to varying extent. While Mn2+, Zn2+ and Mg2+ had no significant effect on protease activity, the enzyme was activated with Ca2+ (1 mM) and Cu2+ (5 mM). The stability of the enzyme in the presence of detergent components and surfactants is particularly attractive for its application in detergent industries.

Contamination of water due to major industries and open refuse dumping in the steel city of Orissa--a case study

Contamination of ground water is common in the areas surrounded by industrial refuse dumping sites and the probability of contamination is more where dumping is done in low lying areas and the rate of percolation through the soil is high. In order to assess the ground water pollution by leachate around the refuse dumping site, eighteen wells were selected for study. Few wells are nearer to the dumps, few are far away and others are in between. Also an attempt has been made to evaluate the effect of industrial effluents on the ground and surface water due to Integrated Rourkela Steel Plant and other major industries. From the analytical data of physico-chemical parameters, it is indicated that the river water is contaminated mainly due to the industrial and municipal effluents and the ground water of some of the analyzed areas is contaminated due to municipal and industrial solid waste dumping.

Quality of water for drinking and agriculture in and around a mines in Keonjhar District, Orissa

For optimum utilization of water resources, it is necessary to know both the quantity as well as quality of water. This paper describes the assessment of the quality of water of a mining area in the Keonjhar district of Orissa for drinking and agricultural purpose. The water quality for drinking purposes and for agricultural purposes was found to be suitable, however to give the final conclusion it requires the study of biological parameters.

Internal jugular vein thrombosis after assisted conception therapy

Superovulation therapy during assisted conception may result in a hypercoagulable state. Five cases of upper extremity venous thrombosis were identified in women who conceived after ovarian stimulation for in vitro fertilization (IVF). They presented between 7 and 10 weeks' gestation with neck pain and swelling. Three had been treated for ovarian hyperstimulation syndrome and two had evidence of inherited thrombophilia. Four patients received thromboprophylaxis before presentation. Although thrombosis is an uncommon complication of IVF, patients should be counselled before treatment. Thrombophilia screening may be considered for 'high-risk' patients, although current regimes for thromboprophylaxis remain suboptimal.

Metastatic prostate cancer to the spine and a PSA of 5666: a case report

Prostate cancer is the most commonly diagnosed cancer and the second most common cause of cancer death among American men. To our knowledge, the highest reported prostate specific antigen (PSA) level on initial presentation is 3280 ng/mL. In this case report, we discuss a 46-year-old African-American man with back pain of 1-month's duration. A magnetic resonance imaging study of the lumbar spine revealed numerous osseous metastatic lesions, and the PSA level was found to be 5666 ng/mL. He was treated with oral narcotics and a Duragesic patch to achieve analgesia and bicalutamide (Casodex) and leuprolide acetate (Lupron) therapy for androgen blockade. Later in his course, he required chemotherapy due to hormone-refractory prostate cancer. The patient has done well as shown at his latest follow-up at 48 months. The objective of this report is to discuss the first patient with metastatic prostate cancer to the spine with PSA level greater than 3,500 ng/mL.

Osseous stress reaction in a rower diagnosed with positron emission tomography (PET): a case report

Back injury is one of the most frequently encountered injuries in the collegiate rower. The differential diagnosis of back pain in the competitive rower includes muscle strain, ligament/tendon injury, stress reaction, stress fracture, and a tear in the annulus fibrosis. Endurance sports, such as rowing, have an increased frequency of stress injury The diagnosis of stress reaction cannot be made with plain radiographs. Many studies have firmly established the efficacy of single photon emission computed tomography (SPECT) bone scans and magnetic resonance imaging in establishing the diagnosis of a stress reaction We present a case of a collegiate rower with mid back pain secondary to a stress reaction of the endplates of the costotransverse articulation at the T8 level diagnosed by a positive positron emission tomogram study in the setting of a negative SPECT scan.

Persistent hiccup associated with thoracic epidural injection

Epidural steroid injections are commonly used to treat lumbosacral radicular and discogenic pain. When used in this manner, these agents can cause minor, transient systemic side effects and rarely result in any serious complications. Because adverse reactions are uncommon and transient, epidural injections are considered a safe therapeutic intervention. We describe the first case of persistent hiccups as a consequence of a thoracic epidural steroid injection in a patient with thoracic discogenic pain.

Side of symptomatic annular tear and site of low back pain: is there a correlation?

STUDY DESIGN

A retrospective chart review.

OBJECTIVES

To report the correlation between the side of a concordantly painful, post-discography computer tomography (CT) visualized, annular tear, and the side of a patients' low back pain.

SUMMARY OF BACKGROUND DATA

An annular fissure extending from the nucleus to the outer one-third of the annulus is thought to be the nociceptive source stimulated during provocative lumbar discography. To our knowledge, there are no studies that have attempted to delineate whether the side of the annular tear correlates with the side of the patient pain.

METHODS

One hundred and one post-discography CT scans, performed on patients with single level, concordantly painful, and fissured discs identified during lumbar discography, were randomly obtained from the archived and current files of the Penn Spine Center's film library. These were reviewed by both the lead author and a spine radiologist, both of who were blinded to the side of the patients pain, to determine which scans demonstrated clearly definable tears extending to the outer one-third of the annulus. Statistical analysis via the exact method was used to determine the correlation between the side of the patients tear and the side of the patients pain.

RESULTS

Forty post-discography CT scans met the inclusion criteria. There was a random correlation between the side of the patients concordantly painful annular tear and the side of the patients pain.

CONCLUSIONS

The results of this study raise several questions regarding the embryologic development of the intervertebral disc and its somite, neurologic transmission of discogenic pain, distribution of chemical inflammagens, validity of discography, technique of ESI, and technique and validity of IDET.

An unusual case of shoulder pain

Shoulder pain is a common musculoskeletal ailment. The process of determining the etiology of shoulder pain can be difficult. The differential diagnoses include: both intracapsular and extracapsular lesions; and neurologic, vascular, postural, and visceral causes. We present an unusual case of shoulder pain accompanied by loss of shoulder range of motion (ROM), initially thought to be caused by an intrinsic shoulder disorder. However, it ultimately was determined that a cervical radicular disorder caused both the impaired ROM and the patient's shoulder pain.