The Correlation of Epidural Fibrosis with Epiduroscopic and Radiologic Imaging for Chronic Pain after Back Surgery.

BACKGROUND: Chronic low back pain is observed frequently after lumbar spinal surgery. Epidural fibrosis has been implicated in the etiology of persistent pain after back surgery. The incidence of epidural fibrosis increases as the number and extent of spinal surgery increases. Epidural fibrosis can be detected by conventional radiologic methods [e.g., lumbosacral magnetic resonance imaging (MRI) with gadolinium], but these methods are insufficient to reveal the presence of epidural adhesions. Imaging of the epidural cavity using an epiduroscope is one of the best methods for visualizing the spinal cavity without damaging anatomic structures. OBJECTIVES: To evaluate the correlation between the type and number of surgery and the degree of epidural fibrosis and to compare epidural fibrosis in epiduroscopic and MRI findings in patients with failed back surgery syndrome (FBSS). STUDY DESIGN: A prospective trial. SETTING: A university hospital. METHODS: This study included 61 patients with persistent low back pain and/or radicular pain for at least 6 months, despite lumbar surgery and conservative treatment, and who accepted epiduroscopic imaging. All patients were evaluated in a physical examination using a visual analog scale (VAS) per the elapsed time after surgery. The patients were divided into 3 groups according to the number and type of surgeries. Epidural fibrosis was rated using MRI with gadolinium and epiduroscopy. RESULTS: When the relationship between admission symptoms and epidural fibrosis was evaluated, MRI findings of fibrosis were found to be significantly higher in all patients with both lumbar and radicular pain symptoms at the confidence level of 95% (P = 0.001). The degree of fibrosis detected using epiduroscopy was grade 1 and 2 in almost all patients who presented with low back pain only, only radicular pain, or only distal paresthesia (P = 0.001). In the correlation analysis between the duration of the postoperative period (4.13 ± 2.97 years) and the degree of fibrosis detected using MRI and epiduroscopy, a statistically significant relationship was found at the confidence level of 95% (P < 0.05). As the number and extent of spinal surgeries increased, the incidence of MRI fibrosis increased, which is compatible with the literature (P = 0.001) There was a statistically significant relationship between the degree of fibrosis as detected using MRI and epiduroscopy at the confidence level of 95% (P < 0.05). Differently, we observed that 6 patients had grade 1 fibrosis as diagnosed using epiduroscopy, whereas none had fibrosis on MRI. LIMITATIONS: We did not have a control group. Further studies are required to demonstrate the relevance of these 2 imaging techniques (epiduroscopy and MRI) in terms of detecting epidural fibrosis in patients with FBSS.  CONCLUSIONS: Epiduroscopic imaging seems to be more sensitive than MRI in detecting grade I epidural fibrosis in patients with FBSS. Thus, the possibility of low-grade epidural fibrosis as a source of pain after back surgery, should be kept in mind in normally reported MRIs. Treatment should be planned accordingly.

Prenatal Diagnosis of Organic Acidemias at a Tertiary Center.

The aim of this study was to share our experience in the prenatal diagnosis (PND) of organic acidemias (OAs) in our clinic. This study consisted of 10 cases in whom an invasive prenatal diagnostic test (IPNDT) was performed by a single physician for the PND of OAs. Median maternal age, parity, gestational week of IPNDT, prenatal test indications, OA types, method of IPNDT, IPNDT results and gestational outcomes were evaluated. Targeted mutation analysis was performed in fetal DNA for the specific mutations by using polymerase chain reaction (PCR) and direct Sanger sequencing. The diagnosis was confirmed by genetic targeted mutation analysis after birth. Median maternal age, parity and gestational week of IPNDT values were 30 (range 21-35), one (range 0-4) and 11.5 (range 11-17), respectively. Indications for IPNDT were mother being a carrier of the disease for one case (10.0%) and at least one child with OA in the family for nine cases (90.0%). Organic acidemia types investigated were maple syrup urine disease (MSUD), methylmalonic acidemia (MMA) and isovaleric acidemia (IVA) in five (50.0%), three (30.0%) and two (20.0%) patients, respectively. Chorion villus sampling (CVS) was done in seven (70.0%) patients and amniocentesis was performed in three (30.0%) patients. Eight fetuses (80.0%) were found to be healthy and two fetuses (20.0%) were found to be affected (one case with IVA and one case with MMA). The two pregnancies (20.0%) with affected fetuses were terminated. Prenatal diagnosis of OAs is critical. Appropriate prenatal counseling should be given to families with known risk factors.

Sleep quality, pain, anxiety, depression and quality of life in patients with frozen shoulder1.

BACKGROUND: Nocturnal shoulder pain could play an essential role in frozen shoulder (FS) and can lead to disturbed sleep, anxiety, depression and reduced quality of life (QoL). OBJECTIVE: The aim of this study was to examine anxiety, depression, sleep quality and quality of life in patients with FS and compare these to healthy controls. METHODS: We prospectively evaluated 148 participants (76 FS patients and 72 healthy controls). We obtained Visual Analogue Scale (VAS) pain score, Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI) and World Health Organization Quality of Life Scale short form (WHOQoL-BREF). RESULTS: FS patients had significantly higher scores for VAS and BAI (p< 0.001) than the control group. There was no significant difference between the BDI scores of the groups (p= 0.067). The WHOQoL-BREF scale of the physical, mental and environmental fields were significantly lower in the FS group (p< 0.001). FS patients had significantly lower sleep efficiency, and sleep disorders in terms of PSQI section scores (p< 0.001). CONCLUSION: Our study demonstrated that there is a high prevalence and close relationships of pain, anxiety and sleep disturbance in patients with FS. Adding a psychiatric evaluation to the treatment of patients with FS may be beneficial.

Relationship between fragmented QRS complexes and left ventricular systolic and diastolic functions.

BACKGROUND: Fragmented QRS complexes (fQRS) have been associated with increased morbidity and mortality, sudden cardiac death, and recurrent cardiovascular events. The association between left ventricular systolic and diastolic functions and presence of fragmented QRS has not been comprehensively studied to date. We tested the hypothesis that the presence of fragmented QRS is associated with left ventricular systolic and diastolic dysfunction. METHODS: The study included 259 patients who were consecutively admitted to our outpatient clinic for cardiovascular risk factor management. Extensive echocardiographic parameters were obtained from all patients and these were compared with the presence and number of fQRS. RESULTS: Patients with fQRS were of older age (58 ± 12 vs. 55 ± 13 years, p = 0.03) and had prolonged QRS time (105 ± 12 vs. 93 ± 10 ms, p < 0.001) and a higher rate of Q waves on ECG (36% vs. 11%, p < 0.001). In addition, they had worse systolic (lower LVEF%, 44 ± 17 vs. 61 ± 12, p < 0.001) and diastolic functions (DT, 177 ± 77 vs. 211 ± 59 ms, p < 0.001; IVRT, 81 ± 27 vs. 92 ± 22 ms, p = 0.001; Em, 9 ± 4 vs. 10 ± 4 cm/s, p = 0.008; E/Em ratio, 11 ± 5 vs. 8 ± 4, p < 0.001) in comparison to patients with nonfragmented QRS. There was a significant negative correlation between the number of fQRS and left ventricle systolic functions (for LVEF%, r = - 0.595, p < 0.001). After adjustment for age and gender, the number of fQRS remained significantly negatively associated with left ventricular systolic and diastolic functions. CONCLUSION: We found that fQRS is related to left ventricular systolic dysfunction and diastolic dysfunction. fQRS, which may be the result of myocardial ischemia or scar on myocardial electrical parameters at the cellular level, may represent inadequate systolic and diastolic functions.

Effects of propylthiouracil, propranolol, and vitamin E on lipid peroxidation and antioxidant status in hyperthyroid patients.

OBJECTIVE: The purpose of this study was to examine lipid peroxidation and antioxidant states during hyperthyroidism states and after given different treatments. DESIGN AND METHODS: We examined 44 hyperthyroid patients and 19 euthyroid healthy controls. Patients were divided into three groups according to the treatment: Propylthiouracil (PTU) group, PTU + propranolol (PRP) group, PTU + PRP + vitamin E (vitE) group. RESULTS: In the hyperthyroid patients plasma malondialdehyde (MDA) levels were significantly high as compared to the control group (p < 0,001). There was a significant decrease in the MDA levels post-treatment (p < 0.001 in the PTU + PRP group and PTU + PRP + vitE group, p < 0.01 in the PTU group). In the hyperthyroidism, blood reduced glutathione (GSH) levels were lower, erythrocyte superoxide dismutase (SOD) and catalase (CAT) activities were higher than in the control group, but these changes were not significant. Post-treatment in each of the three groups the GSH levels were increased significantly as compared to the pretreatment levels (p < 0.001). There was significant decrease in the SOD activity post treatment (p < 0.01 in all three groups). Post-treatment CAT activity was decreased (p < 0.05 in the PTU group, p < 0.001 in the other two groups). The erythrocyte glutathione peroxidase (Gpx) activity was lower significantly in the hyperthyroidism as compared to the control group (p < 0.001). Post-treatment, in the three groups Gpx activity increased significantly as compared to the pretreatment levels (p < 0.05 in the PTU group, p < 0.001 in the PTU + PRP group and PTU + PRP + vitE group). CONCLUSION: We considered that giving all three treatments would be useful to the prevention of oxidative stress in the hyperthyroidism states.

Effects of pentoxifylline and coenzyme Q10 in hepatic ischemia/reperfusion injury.

OBJECTIVES: We examined whether pentoxifylline (PTX) and coenzyme Q10 (Q) pretreatment affect ischemia-reperfusion damage in the rat liver. DESIGN AND METHODS: Twenty minutes of reflow following 30 min of ischemia was performed. Before the experiment, rats were treated PTX 50 mg/kg, IP or PTX 50 mg/kg IP + Q10 mg/kg, intragastric, or untreated. Rats were divided into four groups: control (C), ischemia-reperfusion (IR), PTX-treated (P), and Q+PTX-treated (QP) groups. Hepatic glutathione (GSH) and malondialdehyde (MDA) levels and catalase, superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and reductase (GSSGR) activities were measured. RESULTS: In IR group GSH levels decreased (p<0.01), conversely MDA levels increased (p<0.01). PTX pretreatment did not affect GSH and MDA values, but Q+PTX pretreatment improved of those (p<0.01). It was shown that catalase and GSH-Px activities increased during ischemia-reperfusion (p<0.01, both of), but PTX pretreatment did not significantly ameliorate those activities. GSSGR activity was higher in IR group than in basal levels (p<0.01). The decrease GSSGR activity that was observed in P group was not significant compared to IR group. During ischemia/reperfusion also SOD activity increased as compared with controls (p<0.05). In PTX-treated group, SOD activity was significantly higher than control and ischemia/reperfusion groups (p<0.01, both of). Q+PTX treatment ameliorated those enzyme activities to the control values. CONCLUSIONS: Short-term hepatic ischemia-reperfusion diminished GSH, increased MDA levels and induced some antioxidant enzyme activities. Q+PTX pretreatment was useful in hepatic ischemia-reperfusion injury, but treatment of PTX alone did not cause beneficial effect in the present study.

Comparison of fully three-dimensional optical, normally conducting, and superconducting interconnections.

Several approaches to three-dimensional integration of conventional electronic circuits have been pursued recently. To determine whether the advantages of optical interconnections are negated by these advances, we compare the limitations of fully three-dimensional systems interconnected with optical, normally conducting, repeatered normally conducting, and superconducting interconnections by showing how system-level parameters such as signal delay, bandwidth, and number of computing elements are related. In particular, we show that the duty ratio of pulses transmitted on terminated transmission lines is an important optimization parameter that can be used to trade off signal delay and bandwidth so as to optimize applicable measures of performance or cost, such as minimum message delay in parallel computation.

Pentoxifylline and N-acetylcysteine in hepatic ischemia/reperfusion injury.

This study was designed to clarify the effects of pentoxifylline (PTX) and N-acetylcysteine (NAC) on hepatic reperfusion injury in rats. Rats were pretreated with NAC, or PTX, or combination of the drugs. In each rat, liver was isolated after twenty minutes reperfusion following thirty minutes ischemia. Plasma alanine amino transferase (ALT) activity, liver tissue glutathione (GSH) and malondialdehyde (MDA) levels, glutathione peroxidase (GPx), glutathione reductase (GSSGR), superoxide dismutase (SOD) and catalase (CAT) activities were determined. Plasma ALT activity was higher in ischemia/reperfusion groups than in control. It was decreased in the groups given NAC. Administration of NAC maintained tissue GSH levels, whereas the levels were decreased in both the ischemia/reperfusion groups treated (P < 0.05) and untreated with PTX (P < 0.01). Increases in liver MDA concentration in ischemia/reperfusion (P < 0.01) and PTX-treated groups (P < 0.05) were mitigated by administration of NAC. GPx and CAT activities were increased in the ischemia/reperfusion (P < 0.01, P < 0.05) and PTX-treated groups (P < 0.05, P < 0.001). GSSGR activities were increased in the NAC (P < 0.001) and NAC-PTX-treated groups (P < 0.01). SOD activities were higher in the ischemia/reperfusion (P < 0.01) and the PTX-treated (P < 0.01) and the NAC-PTX-treated groups (P < 0.01 ). In conclusion, short-term liver ischemia/reperfusion diminished GSH, increased MDA and induced some antioxidant enzymes. While we could not find any useful effects with PTX as we expected, our findings indicate that NAC might be useful to prevent tissue damage in hepatic ischemia/reperfusion injury.

Space bandwidth-efficient realizations of linear systems.

One can obtain either exact realizations or useful approximations of linear systems or matrix-vector products that arise in many different applications by implementing them in the form of multistage or multichannel fractional Fourier-domain filters, resulting in space-bandwidth-efficient systems with acceptable decreases in accuracy. Varying the number and the configuration of filters enables one to trade off between accuracy and efficiency in a flexible manner. The proposed scheme constitutes a systematic way of exploiting the regularity or structure of a given linear system or matrix, even when that structure is not readily apparent.

Image-directed color Doppler ultrasonography of kidney in systemic lupus nephritis.

We evaluated intrarenal arterial waveforms with image-directed color Doppler ultrasonography in 21 patients with systemic lupus erythematosus (SLE). The systolic-diastolic ratio, resistive index, and pulsatility index were compared with serum creatinine levels, creatinine clearance, and quantitation of urinary protein excretion, as well as with histopathologic scores of specimens obtained from 9 patients who underwent renal biopsy. Doppler parameters were in the normal ranges in all patients, without showing significant correlation with any of the histopathologic scores or laboratory parameters except creatinine levels. We conclude that image-directed color Doppler ultrasonography is of no practical value in the evaluation of lupus nephritis during the early stages of the disease.

Intrarenal Doppler findings of upstream renal artery stenosis: a preliminary report.

To diagnose 60% or greater diameter-reducing stenosis of the renal artery (RAS), color Doppler imaging (CDI) and angiography were performed on 44 hypertensive and 16 normotensive cases. In this prospective, double-blind study we evaluated the related intrarenal waveform changes. In both the right and left kidneys of normotensive cases, at the level of interlobar arteries, the results indicated a symmetric finding in peak systolic/end diastolic velocities (S/D), pulsatility index (PI) and resistive index (RI) ratios. The results in the stenotic kidneys among the hypertensive group indicated that index values were significantly lower in the stenotic kidneys than those of the contralateral kidneys, the kidneys of control and nonstenotic hypertensive cases. To quantify this observation we suggest "perfusion indexes," which require more studies on a greater number of hypertensive cases. It was concluded that measuring the index values of intrarenal arterial waveforms is easier and more accessible in diagnosing RAS than obtaining those of the main renal artery.

Color-Doppler imaging in acute scrotal disorders.

Eighteen patients who referred to our hospital with acute scrotal pain and swelling were evaluated with color-Doppler imaging (CDI) after the initial clinical examinations. Five of these subjects were considered to have testicular torsion as diagnosed with CDI. These diagnoses were surgically confirmed, and appropriate treatments were performed. CDI findings of 13 patients were in accordance with inflammatory pathologies (epididymitis and/or orchitis). These patients received medical treatment. The CDI diagnoses of all patients were in agreement with the final clinical diagnoses. We conclude that CDI, which is a practical, rapid and high-resolution technique, promises to be the leading and decisive scanning method in acute scrotal disorders.

Changes of hexose monophosphate pathway and methemoglobin reductase enzyme activity after radiation in guinea pigs.

HMP pathway activity changes occurring after exposure to ionizing radiation (LD50 dose) have been investigated. The study was carried out on 18 experimental guinea pigs subjected to 5 successive exposures of 150 rads 3 or 4 days apart. The control animals were sham radiated but were otherwise treated identically as those of the experimental groups. Blood samples were taken by cardiac puncture before radiation and 30 min after each exposure of 150 rads. The red cells were re-suspended in their own plasma and HMP pathway activity was measured in the suspension. The pathway activity showed a consistent but minor reduction in the experimental group, which became statistically significant after the total dose of 750 rads (P less than 0.020). In a separate study the changes induced by ionizing radiation in the erythrocyte enzyme NADH-methemoglobin reductase were measured using the same experimental protocol. The enzyme activity in the red cells of the experimental group varied between 34.90 +/- 2.17 to 161.95 +/- 5.34 I.U./ml erythrocyte pack. Its activity declined toward the initial value after reaching the peak by the 12th day of ionizing radiation with 600 rads (P less than 0.001).

Changes of reduced glutathion, glutathion reductase, and glutathione peroxidase after radiation in guinea pigs.

In this series of experiments the protective action of reduced glutathion due to ionizing radiation has been studied. In the experimental group 18 guinea pigs were exposed to successive radiations of 150 rad 3 or 4 days apart. Total dose given amounted to 750 rad which is the LD50 for guinea pigs. Blood samples were taken 30 min after each exposure. The control series were sham radiated but otherwise treated identically. The cells of the removed blood samples were separated by centrifugation and were subjected to the reduced glutathion stability test. GSSGR, GPer, and LDH enzyme activities were also measured of which the latter served as a marked enzyme. It was found that LDH did not show any alteration after radiation. The reduced glutathion stability test showed a consistent but minor reduction (P greater than 0.05), in the experimental group. GSSGR enzyme activity on the other hand was reduced significantly (from 176.48 +/- 11.32 to 41.34 +/- 1.17 IU/ml of packed erythrocytes, P less than 0.001) in the same group. GPer activity showed a consistent but minor elevation during the early phase of the experimental group. It was later increased significantly beginning after 600 rad total radiation on the fourth session (P less than 0.050).