Poor visualization limits diagnosis of proximal junctional kyphosis in adolescent idiopathic scoliosis

BACKGROUND CONTEXT

Multiple methods are used to measure proximal junctional angle (PJA) and diagnose proximal junctional kyphosis (PJK) after fusion for adolescent idiopathic scoliosis (AIS); however, there is no gold standard. Previous studies using the three most common measurement methods, upper-instrumented vertebra (UIV)+1, UIV+2, and UIV to T2, have minimized the difficulty in obtaining these measurements, and often exclude patients for which measurements cannot be recorded.

PURPOSE

The purpose of this study is to assess the technical feasibility of measuring PJA and PJK in a series of AIS patients who have undergone posterior instrumented fusion and to assess the variability in results depending on the measurement technique used.

STUDY DESIGN/SETTING

A retrospective cohort study was carried out.

PATIENT SAMPLE

There were 460 radiographs from 98 patients with AIS who underwent posterior spinal fusion at a single institution from 2006 through 2012.

OUTCOME MEASURES

The outcomes for this study were the ability to obtain a PJA measurement for each method, the ability to diagnose PJK, and the inter- and intra-rater reliability of these measurements.

METHODS

Proximal junctional angle was determined by measuring the sagittal Cobb angle on preoperative and postoperative lateral upright films using the three most common methods (UIV+1, UIV+2, and UIV to T2). The ability to obtain a PJA measurement, the ability to assess PJK, and the total number of patients with a PJK diagnosis were tabulated for each method based on established definitions. Intra- and inter-rater reliability of each measurement method was assessed using intra-class correlation coefficients (ICCs).

RESULTS

A total of 460 radiographs from 98 patients were evaluated. The average number of radiographs per patient was 5.3±1.7 (mean±standard deviation), with an average follow-up of 2.1 years (780±562 days). A PJA measurement was only readable on 13%-18% of preoperative filmsand 31%-49% of postoperative films (range based on measurement technique). Only 12%-31% of films were able to be assessed for PJK based on established definitions. The rate of PJK diagnosis ranged from 1% to 29%. Of these diagnoses, 21%-100% disappeared on at least one subsequent film for the given patient. ICC ranges for intra-rater and inter-rater reliability were 0.730-0.799 and 0.794-0.836, respectively.

CONCLUSIONS

This study suggests significant limitations of the three most common methods of measuring and diagnosing PJK. The results of studies using these methods can be significantly affected based on the exclusion of patients for whom measurements cannot be made and choice of measurement technique.

Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures

BACKGROUND

There has been an increasing use of national databases to conduct orthopaedic research. Questions regarding the validity and consistency of these studies have not been fully addressed. The purpose of this study was to test for similarity in reported measures between two national databases commonly used for orthopaedic research.

METHODS

A retrospective cohort study of patients undergoing lumbar spinal fusion procedures during 2009 to 2011 was performed in two national databases: the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program. Demographic characteristics, comorbidities, and inpatient adverse events were directly compared between databases.

RESULTS

The total numbers of patients included were 144,098 from the Nationwide Inpatient Sample and 8434 from the National Surgical Quality Improvement Program. There were only small differences in demographic characteristics between the two databases. There were large differences between databases in the rates at which specific comorbidities were documented. Non-morbid obesity was documented at rates of 9.33% in the Nationwide Inpatient Sample and 36.93% in the National Surgical Quality Improvement Program (relative risk, 0.25; p < 0.05). Peripheral vascular disease was documented at rates of 2.35% in the Nationwide Inpatient Sample and 0.60% in the National Surgical Quality Improvement Program (relative risk, 3.89; p < 0.05). Similarly, there were large differences between databases in the rates at which specific inpatient adverse events were documented. Sepsis was documented at rates of 0.38% in the Nationwide Inpatient Sample and 0.81% in the National Surgical Quality Improvement Program (relative risk, 0.47; p < 0.05). Acute kidney injury was documented at rates of 1.79% in the Nationwide Inpatient Sample and 0.21% in the National Surgical Quality Improvement Program (relative risk, 8.54; p < 0.05).

CONCLUSIONS

As database studies become more prevalent in orthopaedic surgery, authors, reviewers, and readers should view these studies with caution. This study shows that two commonly used databases can identify demographically similar patients undergoing a common orthopaedic procedure; however, the databases document markedly different rates of comorbidities and inpatient adverse events. The differences are likely the result of the very different mechanisms through which the databases collect their comorbidity and adverse event data. Findings highlight concerns regarding the validity of orthopaedic database research.

Interrater and intrarater agreements of magnetic resonance imaging findings in the lumbar spine: significant variability across degenerative conditions

BACKGROUND CONTEXT

Magnetic resonance imaging (MRI) is frequently used in the evaluation of degenerative conditions in the lumbar spine. The relative interrater and intrarater agreements of MRI findings across different pathologic conditions are underexplored, as most studies are focused on specific findings.

PURPOSE

The purpose of this study was to characterize the interrater and intrarater agreements of MRI findings used to assess the degenerative lumbar spine.

STUDY DESIGN

A retrospective diagnostic study at a large academic medical center was undertaken with a panel of orthopedic surgeons and musculoskeletal radiologists to assess lumbar MRIs using standardized criteria.

PATIENT SAMPLE

Seventy-five subjects who underwent routine lumbar spine MRI at our institution were included.

OUTCOME MEASURES

Each MRI study was assessed for 10 lumbar degenerative findings using standardized criteria. Lumbar vertebral levels were assessed independently, where applicable, for a total of 52 data points collected per study.

METHODS

T2-weighted axial and sagittal MRI sequences were presented in random order to the four reviewers (two orthopedic spine surgeons and two musculoskeletal radiologists) independently to determine interrater agreement. The first 10 studies were reevaluated at the end to determine intrarater agreement. Images were assessed using standardized and pilot-tested criteria to assess disc degeneration, stenosis, and other degenerative changes. Interrater and intrarater absolute percent agreements were calculated. To highlight the most clinically important MRI disagreements, a modified agreement analysis was also performed (in which disagreements between the lowest two severity grades for applicable conditions were ignored). Fleiss kappa coefficients for interrater agreement were determined.

RESULTS

The overall absolute and modified interrater agreements were 76.9% and 93.5%, respectively. The absolute and modified intrarater agreements were 81.3% and 92.7%, respectively. Average Fleiss kappa coefficient was 0.431, suggesting moderate overall agreement. However, when stratified by condition, absolute interrater agreement ranged from 65.1% to 92.0%. Disc hydration, disc space height, and bone marrow changes exhibited the lowest absolute interrater agreements. The absolute intrarater agreement had a narrower range, from 74.5% to 91.5%. Fleiss kappa coefficients ranged from fair-to-substantial agreement (0.282-0.618).

CONCLUSIONS

Even in a study using standardized evaluation criteria, there was significant variability in the interrater and intrarater agreements of MRI in assessing different degenerative conditions of the lumbar spine. Clinicians should be aware of the condition-specific diagnostic limitations of MRI interpretation.

Obese Class III patients at significantly greater risk of multiple complications after lumbar surgery: an analysis of 10,387 patients in the ACS NSQIP database

BACKGROUND CONTEXT

Prior studies on the impact of obesity on spine surgery outcomes have focused mostly on lumbar fusions, do not examine lumbar discectomies or decompressions, and have shown mixed results regarding complications. Differences in sample sizes and body mass index (BMI) thresholds for the definition of the obese versus comparison cohorts could account for the inconsistencies in the literature.

PURPOSE

The purpose of the study was to analyze whether different degrees of obesity influence the complication rates in patients undergoing lumbar spine surgery.

STUDY DESIGN/SETTING

This was a retrospective cohort analysis of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2010.

PATIENT SAMPLE

Patients in the de-identified, risk-adjusted, and multi-institutional ACS NSQIP database undergoing lumbar anterior fusion, posterior fusion, transforaminal lumbar interbody fusion/posterior lumbar interbody fusion (TLIF/PLIF), discectomy, or decompression were included.

OUTCOME MEASURES

Primary outcome measures were 30-day postsurgical complications, including pulmonary embolism and deep vein thrombosis, death, system-specific complications (wound, pulmonary, urinary, central nervous system, and cardiac), septic complications, and having one or more complications overall. Secondary outcomes were time spent in the operating room, blood transfusions, length of stay, and reoperation within 30 days.

METHODS

Patients undergoing lumbar anterior fusion, posterior fusion, TLIF/PLIF, discectomy, or decompression in the ACS NSQIP, 2005 to 2010, were categorized into four BMI groups: nonobese (18.5-29.9 kg/m(2)), Obese I (30-34.9 kg/m(2)), Obese II (35-39.9 kg/m(2)), and Obese III (greater than or equal to 40 kg/m(2)). Obese I to III patients were compared with patients in the nonobese category using chi-square test and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative risk factors.

RESULTS

Data were available for 10,387 patients undergoing lumbar surgery. Of these, 4.5% underwent anterior fusion, 17.9% posterior fusion, 6.3% TLIF/PLIF, 40.7% discectomy, and 30.5% decompression. Among all patients, 25.6% were in the Obese I group, 11.5% Obese II, and 6.9% Obese III. On multivariate analysis, Obese I and III had a significantly increased risk of urinary complications, and Obese II and III patients had a significantly increased risk of wound complications. Only Obese III patients, however, had a statistically increased risk of having increased time spent in the operating room, an extended length of stay, pulmonary complications, and having one or more complications (all p<.05).

CONCLUSIONS

Patients with high BMI appear to have higher complication rates after lumbar surgery than patients who are nonobese. However, the complication rates seem to increase substantially for Obese III patients. These patients have longer times spent in the operating room, extended hospitals stays, and an increased risk for wound, urinary, and pulmonary complications and for having at least one or more complications overall. Surgeons should be aware of the increased risk of multiple complications for patients with BMI greater than or equal to 40 kg/m(2).

Do presence and location of annular tear influence clinical outcome after lumbar total disc arthroplasty? A prospective 1-year follow-up study

BACKGROUND

Lumbar total disc arthroplasty is often performed in patients with axial back pain. There are multiple etiologies for axial back pain, including disc degeneration and annular tears. The location of these annular tears can vary, producing differing preoperative symptomatology. Intraoperatively, disruptions in the annulus are identifiable, and it has been suggested that patients with discrete annular tears may have better clinical outcomes after surgery. The purpose of this study was to investigate whether the presence and location of annular tears have an effect on clinical outcomes after lumbar total disc arthroplasty.

METHODS

Patients undergoing a single-level anterior disc replacement from L3-S1 at a single site by a single surgeon were evaluated preoperatively for the presence or absence of annular tears with magnetic resonance imaging. All patients were part of either the ProDisc (n = 41) (Synthes, Paoli, Pennsylvania) or Activ-L (n = 19) (Aesculap [B. Braun Melsungen AG], Tuttlingen, Germany) lumbar prospective clinical trials. In those patients with annular tears, the location of the tear (central, paracentral, or lateral) was documented. Patients were assessed at 6 and 12 months after lumbar total disc arthroplasty with the Oswestry Disability Index (ODI), visual analog scale (VAS) score for back pain, VAS score for leg pain, and radiographic imaging. All radiographic evaluations were conducted by an attending neuroradiologist and an attending spinal surgeon, and reliability testing was performed. An analysis of variance was performed among the 3 anatomic locations of annular tears.

RESULTS

A total of 60 patients were included and had complete 12-month follow-up. The prevalence of annular tears among all patients was 42% (n = 25). Outcome data in patients without annular tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 8.0 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 2.9 preoperatively and 1.2 postoperatively. Among those patients with tears, the prevalence of central tears was 80%, the prevalence of paracentral tears was 12%, and the prevalence of lateral tears was 8%. Outcome data in patients with central tears were as follows: ODI, 66% preoperatively and 26% postoperatively; VAS score for back pain, 7.8 preoperatively and 2.6 postoperatively; and VAS score for leg pain, 5.2 preoperatively and 0.5 postoperatively. Outcome data in patients with paracentral tears were as follows: ODI, 86% preoperatively and 59% postoperatively; VAS score for back pain, 8.8 preoperatively and 3.3 postoperatively; and VAS score for leg pain, 5.0 preoperatively and 5.4 postoperatively. Outcome data in patients with lateral tears were as follows: ODI, 6.5 preoperatively and 2.6 postoperatively; VAS score for back pain, 9.2 preoperatively and 0.2 postoperatively; and VAS score for leg pain, 1.4 preoperatively and 0.7 postoperatively. In those patients with paracentral tears, there was a significantly higher incidence of postoperative radicular symptoms both from an intensity standpoint and from a duration standpoint. Other complications did not vary among those patients with or without annular tears.

CONCLUSIONS

Although patients with annular tears and patients without annular tears improve after lumbar artificial disc replacement, those with central annular tears or without tears have significantly lower disability scores than those with paracentral tears or lateral tears, whose outcome scores showed significantly less improvement (P ≤ .03). In particular, patients with central tears have less postoperative leg pain than those with paracentral annular tears. In this study the presence or absence of an annular tear on magnetic resonance imaging was not a significant predictive factor for clinical outcome. Further investigation regarding the effects of paracentral annular tears and surgical techniques should be explored.

Atmospheric chemistry of dichlorvos

Dichlorvos [2,2-dichlorovinyl dimethyl phosphate, (CH(3)O)(2)P(O)OCH═CCl(2)] is a relatively volatile in-use insecticide. Rate constants for its reaction with OH radicals have been measured over the temperature range 296-348 K and atmospheric pressure of air using a relative rate method. The rate expression obtained was 3.53 × 10(-13) e((1367±239)/T) cm(3) molecule(-1) s(-1), with a 298 K rate constant of (3.5 ± 0.7) × 10(-11) cm(3) molecule(-1) s(-1), where the error in the 298 K rate constant is the estimated overall uncertainty. In addition, rate constants for the reactions of NO(3) radicals and O(3) with dichlorvos, of (2.5 ± 0.5) × 10(-13) cm(3) molecule(-1) s(-1) and (1.7 ± 1.0) × 10(-19) cm(3) molecule(-1) s(-1), respectively, were measured at 296 ± 2 K. Products of the OH and NO(3) radical-initiated reactions were investigated using in situ atmospheric pressure ionization mass spectrometry (API-MS) and (OH radical reaction only) in situ Fourier transform infrared (FT-IR) spectroscopy. For the OH radical reaction, the major initial products were CO, phosgene [C(O)Cl(2)] and dimethyl phosphate [(CH(3)O)(2)P(O)OH], with equal (to within ±10%) formation yields of CO and C(O)Cl(2). The API-MS analyses were consistent with formation of (CH(3)O)(2)P(O)OH from both the OH and NO(3) radical-initiated reactions. In the atmosphere, the dominant chemical loss processes for dichlorvos will be daytime reaction with OH radicals and nighttime reaction with NO(3) radicals, with an estimated lifetime of a few hours.

Pancreatic VIPomas: subject review and one institutional experience

VIPomas are rare pancreatic endocrine tumors associated with a well-defined clinical syndrome characterized by watery diarrhea, hypokalemia, and metabolic acidosis. The objective of this study was to review a single institution's experience with VIPomas, as well as to review the English literature. A retrospective review of the Johns Hopkins pancreatic database revealed four cases of VIPoma, with three patients being male. All patients presented with watery diarrhea, hypokalemia, hypercalcemia, and acidosis. All patients had no family history of multiple endocrine neoplasia. Computed tomography revealed the primary pancreatic tumor in all patients, with three tumors located in the tail of the pancreas. One tumor involved the entire pancreas. Computed tomography and/or octreotide radionuclide scans identified hepatic metastasis in three patients. Mean serum vasoactive intestinal polypeptide levels were 683 pg/ml (range 293 to 1,500 pg/ml). All patients underwent resection of the pancreatic primary tumor. Two patients also had simultaneous liver resections. All patients had evidence of malignancy as defined by the presence of metastatic lymph nodes and/or hepatic metastases. Two patients had complete resolution of symptoms after surgical resection. One patient required radioablation of liver metastases and adjuvant octreotide therapy for control of symptoms. One patient died of progressive metastatic disease 96 months after surgery, whereas the other three remain alive. Extended, meaningful survival can be achieved for VIPoma patients, combining an aggressive surgical approach with additional strategies for treatment of unresected disease.

Pressure dependence of pentyl nitrate formation from the OH Radical-initiated reaction of n-pentane in the presence of NO

The formation yields of 2- and 3-pentyl nitrate from the reactions of 2- and 3-pentyl peroxy radicals with NO have been measured at room temperature over the pressure range 51-744 Torr of N2 + O2, using the OH radical-initiated reaction of n-pentane to generate the pentyl peroxy radicals. The influence of 2- and 3-pentyl nitrate formation from the reaction of 2- and 3-pentoxy radicals with NO2 was investigated by conducting experiments with the initial CH3ONO (the OH radical precursor) and NO concentrations being varied by a factor of 5-10. From experiments carried out with low initial CH3ONO and NO concentrations, the measured yields of 2-pentyl nitrate and 3-pentyl nitrate, defined as ([pentyl nitrate] formed)/([n-pentane] reacted), each increase with increasing total pressure, from 1.10 +/- 0.09% and 1.11 +/- 0.10%, respectively, at 51 +/- 1 Torr of O2 to 5.48 +/- 0.51% and 4.07 +/- 0.31%, respectively, at 737 +/- 4 Torr of N2 + O2.

Temperature-Dependent Rate Constants for the Gas-Phase Reactions of OH Radicals with 1,3,5-Trimethylbenzene, Triethyl Phosphate, and a Series of Alkylphosphonates

Rate constants for the reactions of OH radicals with dimethyl methylphosphonate [DMMP, (CH3O)2P(O)CH3], dimethyl ethylphosphonate [DMEP, (CH3O)2P(O)C2H5], diethyl methylphosphonate [DEMP, (C2H5O)2P(O)CH3], diethyl ethylphosphonate [DEEP, (C2H5O)2P(O)C2H5], triethyl phosphate [TEP, (C2H5O)3PO] and 1,3,5-trimethylbenzene have been measured over the temperature range 278-348 K at atmospheric pressure of air using a relative rate method. alpha-Pinene (for DEMP, DEEP, TEP and 1,3,5-trimethylbenzene) and di-n-butyl ether (for DMMP and DMEP) were used as the reference compounds, and rate constants for the reaction of OH radicals with di-n-butyl ether were also measured over the same temperature range using alpha-pinene and n-decane as the reference compounds. The Arrhenius expressions obtained for these OH radical reactions (in cm3 molecule(-1) s(-1) units) are 8.00 x 10(-14)e(1470+/-132)/T for DMMP (296-348 K), 9.76 x 10(-14)e(1520+/-14)/T for DMEP (296-348 K), 4.20 x 10(-13)e(1456+/-227)/T for DEMP (296-348 K), 6.46 x 10(-13)e(1339+/-376)/T for DEEP (296-348 K), 4.29 x 10(-13)e(1428+/-219)/T for TEP (296-347 K), and 4.40 x 10(-12)e(738+/-176)/T for 1,3,5-trimethylbenzene (278-347 K), where the indicated errors are two least-squares standard deviations and do not include the uncertainties in the rate constants for the reference compounds. The measured rate constants for di-n-butyl ether are in good agreement with literature data over the temperature range studied (278-348 K).

Delayed transplantation of fibroblasts genetically modified to secrete BDNF and NT-3 into a spinal cord injury site is associated with limited recovery of function

Delivery of neurotrophic factors in acute models of spinal cord injury in adult rats can rescue axotomized neurons, promote axonal growth, and partially restore function. The extent to which repair and recovery of function can be achieved after chronic injury has received less attention. In the companion paper we show that transplanting fibroblasts genetically modified to produce neurotrophic factors into chronic (6-week) hemisection injuries results in sprouting, partial neuroprotection, but only limited regeneration. Here we describe functional consequences of this treatment using a series of behavioral tests. Adult rats received a complete unilateral C3/C4 hemisection and recovery from the injury was assessed over 5 weeks. At 6 weeks postoperative, the experimental group received grafts of a combination of fibroblasts modified to secrete BDNF or NT-3. The operated control groups received grafts of either gelfoam or gelfoam with fibroblasts expressing GFP into the lesion site. Behavioral recovery in the three groups was assessed over the next 10 weeks. Severe deficits with no recovery in any of the groups were observed in several tests (BBB, limb preference, narrow beam, horizontal rope test) that measure primarily motor function. Recovery was observed in the grid test, a measure of sensorimotor function, and the von Frey test, a measure of response to mechanical stimulation, but there were no differences between the operated control or experimental groups. Both groups also showed recovery from heat-induced hyperalgesia, with the experimental group exhibiting greater recovery than the operated control groups. In this test, delivery of neurotrophic factors from transplanted fibroblasts does not worsen responses to nociceptive stimuli and in fact appears to reduce hypersensitivity. Our data also demonstrate that additional damage to the spinal cord upon placement of a graft further compromises behavioral recovery for locomotor and postural function. Additional therapeutic interventions will be necessary to provide greater levels of recovery after chronic injuries.

Fetal testosterone surge: specific modulations induced in male rats by maternal stress and/or alcohol consumption

Plasma testosterone (T) was measured in control male and female rats on gestational days 16, 17, 18, 19, and 20 and on days 17-20 in males from dams who were fed ethanol and/or were stressed during pregnancy. Circulating T in control males showed an earlier rise, yielding a longer period of prenatal T elevation, than was reported previously (Endocrinology 106 (1980)306). Compared to control males, exposure to alcohol-alone augmented T on days 18 and 19, stress-alone attenuated prenatal T, and the combination of stress and alcohol completely blocked the normal rise in T between days 17 and 18. When these prenatal alterations in T are viewed along with effects these same treatments have on the postparturient T surge (Horm. Behav. 41 (2002) 229), a possible explanatory mechanism emerges for the uniquely different behavioral patterns of sexual behavior differentiation induced in males by prenatal exposure to alcohol, stress, or both factors. Whereas the potential for feminine behavior is retained to the extent that either the prenatal or the neonatal T surge is attenuated, the male potential is more sensitive to reductions in the fetal surge and is maximally disrupted if both the prenatal and the postparturitional T surges are suppressed.

Day to day variations in ocular surface staining of the bulbar conjunctiva

PURPOSE

The purpose of this study was to characterize the variability of bulbar conjunctival staining over time in response to a single application of fluorescein.

METHODS

Sixteen subjects were stained Monday through Friday for a 2-week period. Appointments were scheduled from 9:00 a.m. to 12:00 p.m. to minimize variance due to diurnal variation. Fluorescein stain was applied by touching a separate Ful-Glo strip wetted with nonpreserved saline to the lower palpebral conjunctiva of each eye, with the right eye being stained first. Immediately after application of the fluorescein, conjunctival staining was graded in a randomized order by two examiners, using cobalt blue illumination and a no. 15 Wratten enhancement filter. Conjunctival staining was assessed based upon a 0 to 4 grading scale with 0.5 grade increments. By evaluating the variability in staining over time for each subject, a representation of overall fluctuation for the group was obtained.

RESULTS

The average duration for an episode of staining graded higher than the group median (grade 0.5) was found to be 2.0 +/- 2.4 days. Overall, a mean staining grade of 0.5 for the right eye and 0.6 for the left eye was found. Right and left eyes were found to correlate well (r = 0.67, p < 0.01, Spearman's correlation) and the mean difference was not statistically significant [p = 0.73, multi-way, repeated measures analysis of variance (ANOVA)]. The mean difference in grading between the two examiners was 0.1 grades (p = 0.67, multi-way, repeated measures ANOVA), with a correlation coefficient of r = 0.68 (p < 0.01, Spearman's correlation).

CONCLUSIONS

Characterization of conjunctival staining over time may be useful in evaluating clinically suspect staining, and in determining its potential duration. The appearance and variability of the conjunctival staining patterns noted in this study indicate a potential relationship to normal physiological processes, such as desquamation. This study also demonstrated a low amount of variability between right and left eyes, supporting the use of contralateral studies in the assessment of conjunctival staining. It also demonstrated a good consistency between separate examiners despite not being standardized.

Corneal staining patterns in normal non-contact lens wearers

Corneal fluorescein staining was evaluated in 16 subjects over a 2-week period by 2 practitioners. Using a scale of 0 to 4 with 0.5 grade steps, the average duration for an episode of staining above the group median (grade 0.5) was found to be 1.2 +/- 0.4 days. For both eyes, the most prevalent location of staining was the inferior region (50%), followed by the nasal region (20%). Overall, a mean staining grade of 0.5 for the right eye and 0.6 for the left eye was found. Practitioners also demonstrated a difference in grading of 0.1 in the right and left eyes. These data may be most useful in determining the normality of suspect corneal fluorescein staining and its duration until resolution. This study demonstrated a low amount of variability between right and left eyes, and established a good consistency between separate examiners.

Characteristics of corneal staining in hydrogel contact lens wearers

Corneal fluorescein staining is widely used in clinical practice and research, but little information exists on the distribution of staining in a large group of asymptomatic contact lens wearers. This cross-sectional study took place at 3 centers, and investigated the pattern of corneal fluorescein staining in both eyes of 98 hydrogel contact lens wearers. We also investigated the strategies used by three experienced clinicians to grade corneal staining. Overall corneal staining was graded using a scale from 0 to 4 in one-half steps, and five corneal zones, superior, inferior, nasal, temporal, and central, were also graded. The average overall staining grade for both eyes of our subjects was 0.50, with an average of 0.57 for the right eye and 0.44 for the left. This difference between the eyes was statistically significant (p = 0.011). In addition, a comparison of the zones within each eye showed a significant difference (p = 0.0001) among the zones. Corneal staining between the two eyes was also positively and significantly correlated (r = 0.58; p = 0.0001). Grading strategies among clinical investigators were significantly different (p = 0.0001), indicating a potential source of bias in multi-centered studies. The difference in corneal staining between the eyes may represent a source of systematic bias, and could be due to grading the right eye before the left. The correlation in corneal staining between the eyes indicates that the two eyes of a subject cannot serve as independent data points. One-third of the subjects who participated in this study had notable corneal staining. This finding underlines the importance of regularly checking corneal staining in clinical practice.

Concurrent dissection and intracaval rupture of an abdominal aortic aneurysm: CT findings

The CT findings of a concurrent dissection and intracaval fistula of an arteriosclerotic aortic aneurysm are reported. Recognition of the CT features of this severe and unusual complication is important for planning effective surgical treatment.

Obsidian Hydration Dates Glacial Loading?

Three different groups of hydration rinds have been measured on thin sections of obsidian from Obsidian Cliff, Yellowstone National Park, Wyoming. The average thickness of the thickest (oldest) group of hydration rinds is 16.3 micrometers and can be related to the original emplacement of the flow 176,000 years ago (potassium-argon age). In addition to these original surfaces, most thin sections show cracks and surfaces which have average hydration rind thicknesses of 14.5 and 7.9 micrometers. These later two hydration rinds compare closely in thickness with those on obsidian pebbles in the Bull Lake and Pinedale terminal moraines in the West Yellowstone Basin, which are 14 to 15 and 7 to 8 micrometers thick, respectively. The later cracks are thought to have been formed by glacial loading during the Bull Lake and Pinedale glaciations, when an estimated 800 meters of ice covered the Obsidian Cliff flow.