Clinical and Radiological Review of a Semi-Constrained Cervical Disc Replacement with a Ceramic-Ceramic Articulation with a Minimum Seven Years Follow-Up.

PURPOSE OF THE STUDY Artificial cervical disc replacement (CDR) has emerged as a viable treatment alternative to fusion for the management of symptomatic compressive radiculopathy and potentially for cervical myelopathy. The aim of our study was to evaluate the clinical and radiological outcomes of patients treated with a second generation semi-constrained CDR with a ceramicceramic articulation. MATERIAL AND METHODS A prospective cohort study of all patients undergoing a cervical disc replacement for cervical disc pathology, during the period from April 2007 to April 2011 using a ceramic-ceramic disc replacement comprised the study group. 52 patients were available for final clinical and radiological follow-up. Both, clinical and radiological evaluation were performed at each clinical visit at 6 weeks, 6 months, 12 months, 2 years, 5 years and 7 years. RESULTS There were a total of 52 patients, with 44 single level cases and 8 two level cases. The NDI improved significantly (p < 0.05) from a mean preoperative score of 56 % to a score of 20% at final follow-up. The mean preoperative mobility at the index level unit was 12.2 ± 4.5°, this decreased to 7.9 ± 3.2° at six weeks, but slightly increased to 12.9 ± 2.9° at final follow-up (gain not significant). Heterotrophic ossification (HO) was noted in 13 (25%) patients. CONCLUSIONS Cervical disc replacement with a ceramic-ceramic bearing surface is a viable option in the treatment of variety of cervical pathologies. This ceramic-ceramic interface may eliminate the potential problems of metallosis and poly-wear but further longer-term results should be studied. Key words: Cervical spine; disc replacement; ceramic articulation; neck disability; heterotrophic ossification.

Augmenting cognitive behaviour therapy for post-traumatic stress disorder with emotion tolerance training: a randomized controlled trial.

BACKGROUND: Many patients do not adhere to or benefit from cognitive behaviour therapy (CBT) for post-traumatic stress disorder (PTSD). This randomized controlled trial evaluates the extent to which preparing patients with emotion regulation skills prior to CBT enhances treatment outcome. METHOD: A total of 70 adult civilian patients with PTSD were randomized to 12 sessions of either supportive counselling followed by CBT (Support/CBT) or emotion regulation training followed by CBT (Skills/CBT). RESULTS: Skills/CBT resulted in fewer treatment drop-outs, less PTSD and anxiety, and fewer negative appraisals at 6 months follow-up than Support/CBT. Between-condition effect size was moderate for PTSD severity (0.43, 95% confidence interval x0.04 to 0.90). More Skills/CBT (31%) patients achieved high end-state functioning at follow-up than patients in Support/CBT (12%) [Χ2(n=70)=3.67, p<0.05]. CONCLUSIONS: This evidence suggests that response to CBT may be enhanced in PTSD patients by preparing them with emotion regulation skills. High attrition of participants during the study limits conclusions from this study.

Noradrenergic modulation of serotonin release in rat dorsal and median raphé nuclei via alpha(1) and alpha(2A) adrenoceptors.

The rat rostral raphé nuclei receive catecholaminergic innervation from the locus coeruleus and other areas. In the present study, we investigated noradrenergic modulation of 5-HT release in rat dorsal and median raphé nuclei (DRN and MRN) slices (350 microm thick) superfused with artificial cerebrospinal fluid (aCSF). The raphé was locally stimulated (0.1 ms pulses, 10 mA) and 5-HT release was monitored at carbon fibre microelectrodes using fast cyclic voltammetry. The selective noradrenaline reuptake inhibitor desipramine (50 nM) did not increase stimulated (20 pulses, 100 Hz) 5-HT release but significantly slowed 5-HT reuptake in both DRN and MRN. On short stimulus trains (10 pulses, 200 Hz), the alpha(2)-selective agonist dexmedetomidine (10nM) decreased evoked 5-HT release in DRN and MRN (to 44+/-3 and 43+/-7% of pre-drug values, respectively, at minimum). In both nuclei, this response was antagonised by the selective alpha(2A)-antagonist BRL 44408 (1 microM: P<0.001 vs. dexmedetomidine) but not by the selective alpha(2B/C)-adrenoceptor antagonist ARC 239 (500 nM), the selective 5-HT(1A) antagonist WAY 100635 (100 nM) or the alpha(1)-selective antagonist prazosin (1 microM), suggesting that the effect of dexmedetomidine is wholly attributable to alpha(2A)-receptor activation. The alpha(1)-adrenoceptor agonist phenylephrine (5 microM) significantly decreased 5-HT release (to 49+/-7 and 41+/-4% of pre-drug values in DRN and MRN, respectively). The response was blocked by prazosin (P<0.001) and BRL 44408 (P<0.01) in DRN and by prazosin, BRL 44408 and WAY 100635 (all P<0.05) in MRN, suggesting that the effect of phenylephrine is, under these conditions, only partly mediated via alpha(1)-adrenoceptors. On long stimuli (30 pulses, 10 Hz), BRL 44408 (1 microM) increased evoked 5-HT efflux to 187+/-17 and 178+/-2% of pre-drug values in DRN and MRN, respectively (both P<0.001 vs. vehicle). Collectively, these data show that activation of both alpha(1) and alpha(2A)-adrenoceptors can decrease stimulated 5-HT release in the rostral raphé nuclei. Since the effect of dexmedetomidine was not antagonised by prazosin, we suggest that its effect was mediated directly, possibly through alpha(2A) receptors located on 5-HT cell elements, and not transduced indirectly through alpha(1)-adrenoceptor activation, as previously suggested by others.

Effects of chronic tramadol on pre- and post-synaptic measures of monoamine function.

The atypical analgesic tramadol has strong structural similarities to the antidepressant venlafaxine and is a mixed noradrenaline (NA) and serotonin (5-HT) uptake inhibitor. Because tramadol has been found active in the forced swim test, a common predictor of antidepressant efficacy, we therefore examined the effects of chronic tramadol on various pre- and post-synaptic monoamine measures. Male Wistar rats (150-200 g) received tramadol (20 mg/kg i.p.) or vehicle for 21 days and were sacrificed 24 h after the last dose. Quantitative autoradiography revealed that specific frontocortical [3H]dihydroalprenolol and [3H]ketanserin binding was lower in the chronic tramadol group than controls (beta: 37+/-8 and 217+/-56 fmol/mg; 5-HT2A: 23+/-3 and 44+/-7 fmol/mg, respectively, p < 0.05). Chronic tramadol had no effect on the magnitude of electrically stimulated noradrenaline (NA) efflux or uptake in locus coeruleus (LC) slices. Although dexmedetomidine (10 nM) decreased LC NA efflux equally (by approximately 60%) in chronic tramadol and vehicle groups, desipramine (50 nM) increased LC NA efflux more in vehicle (to 164+/-7%) than tramadol-treated rats (144+/-6%; p < 0.05). Chronic tramadol had no effect on dorsal raphé (DRN) or median raphé (MRN) 5-HT efflux. However, 5-HT uptake in tramadol-treated rats was slower (p < 0.05) in MRN and nearly so (p = 0.055) in DRN. The selective 5-HT1A agonist 8-OH-DPAT reduced 5-HT efflux in both DRN and MRN. Its effect in DRN was greater in rats given chronic tramadol than in vehicle controls (54+/-2 versus 32+/-6% reduction in 5-HT efflux, respectively). In conclusion, we suggest that tramadol has many of the pre- and postsynaptic neurochemical features of a conventional antidepressant, as might be predicted from its pharmacology.

Multiple 5-HT(1) autoreceptor subtypes govern serotonin release in dorsal and median raphé nuclei.

The present study investigated the possibility of multiple 5-HT(1) autoreceptor subtypes in the rostral raphé nuclei. Slices (350 microm) of rat dorsal or median raphé nucleus (DRN/MRN) were taken from male Wistar rats and superfused with artificial cerebrospinal fluid at 32 degrees C. Fast cyclic voltammetry at carbon fibre microelectrodes was used to monitor serotonin (5-HT) release following local electrical stimulation. In both DRN and MRN, 5-HT release on short trains was reduced by the selective 5-HT(1A) agonist 8-OH-DPAT (1 microM), an effect blocked by the selective 5-HT(1A) antagonist WAY 100635 (0.1 microM) but not by SB 216641 (0.05 and 0.2 microM) or BRL 15572 (0.5 microM), selective antagonists at the 5-HT(1B) and 5-HT(1D) receptors respectively. The selective 5-HT(1B) agonist CP 93129 (0.3 microM) also reduced 5-HT release in both nuclei. Its effect was blocked by SB 216641 but not by WAY 100635 or BRL 15572. The 5-HT(1D/1B) agonist sumatriptan (0.5 microM) decreased 5-HT release in both DRN and MRN. In DRN, the effect of sumatriptan was blocked by BRL 15572 but not by WAY 100635 or SB 216641. In MRN, the effect of sumatriptan was not blocked by any of the above antagonists. BRL 15572 increased 5-HT release on long stimulations in DRN and MRN while WAY 100635 had no effect. SB 216641 increased 5-HT release in MRN but not DRN. WAY 100635 potentiated the effect of SB 216641 in DRN but not MRN. The data suggest that 5-HT release in DRN is controlled by 5-HT(1A), 5-HT(1B) and 5-HT(1D) autoreceptors. 5-HT release in MRN is controlled by 5-HT(1A) and 5-HT(1B) autoreceptors and another, as yet unidentified mechanism.

Control of dorsal raphé 5-HT function by multiple 5-HT(1) autoreceptors: parallel purposes or pointless plurality?

The serotonergic cells of the dorsal raphé nucleus innervate much of the forebrain and are thought to be involved in the mechanism of action of antidepressants. Dysfunction of these cells might be involved in the neural mechanisms underlying depression and suicide. The traffic in pathways emanating from the dorsal raphé nucleus is controlled by 5-HT(1) autoreceptors. Until recently it was thought that the autoreceptors in the dorsal raphé nucleus were solely of the 5-HT(1A) subtype. In this article, we discuss evidence that the situation is more complex and that multiple 5-HT(1) subtypes govern different aspects of 5-HT function in the dorsal raphé nucleus presenting new therapeutic opportunities.

Effects of dizocilpine (MK 801) on noradrenaline, serotonin and dopamine release and uptake.

In the present study, we examined the actions of the NMDA antagonist dizocilpine (MK801) on electrically evoked release and uptake of noradrenaline (NA) in the locus coeruleus (LC), serotonin (5-HT) in the dorsal raphe nucleus (DRN) and dopamine (DA) in the nucleus accumbens (NAc), measured by fast cyclic voltammetry (FCV) in rat brain slices. Dizocilpine (10 microM) significantly increased NA (to 248 +/- 15%) and 5-HT release (to 184 +/- 29%) and slowed monoamine uptake in the LC (t1/2 = 853 +/- 129%) and the DRN (t1/2 = 387 +/- 70%), respectively. However, dizocilpine had no effect on DA release or uptake in NAc. Actions on monoamines are thus likely and should be considered in the interpretation of data regarding dizocilpine.

Effects of tramadol stereoisomers on norepinephrine efflux and uptake in the rat locus coeruleus measured by real time voltammetry.

Despite its structural similarity to codeine, tramadol is an unusual analgesic whose antinociceptive efficacy is not solely a result of opioid actions but also of its apparent capacity to block monoamine uptake. Tramadol is a mixture of stereoisomers. In this study, we have examined the actions of racemic, (+)- and (-)-tramadol, in addition to O-desmethyltramadol (the main human metabolite), on electrically evoked norepinephrine efflux and uptake in the locus coeruleus brain slice, measured by fast cyclic voltammetry. Racemic tramadol and its (+)- and (-)-enantiomers (all at 5 mumol litre-1) significantly increased stimulated norepinephrine efflux (P < 0.01) by mean 66 (SEM 10)%, 57 (7)% and 64 (13)%, respectively. However, only (-)-tramadol blocked norepinephrine reuptake (P < 0.01), increasing the reuptake half-time to 499 (63)% of pre-drug values. The metabolite O-desmethyl tramadol was inactive at the concentration tested (5 mumol litre-1). In the case of (-)-tramadol, the effect on norepinephrine efflux was directly proportional to, but significantly smaller than, the effect on norepinephrine uptake (P < 0.01). This appeared to be a result of compensatory alpha 2A autoreceptor tone as the selective alpha 2A autoreceptor antagonist BRL 44408 (1 mumol litre-1) eliminated this difference when its own effects on norepinephrine reuptake were taken into account. The efficacy of (-)-tramadol on norepinephrine uptake, at clinically relevant concentrations, may contribute to its antinociceptive efficacy.

Plasma sialyltransferase levels in psychiatric disorders as a possible indicator of HPA axis function.

A dysfunction in the regulation of the hypothalamic-pituitary-adrenal (HPA) axis, possibly attributed to a change in glucocorticoid receptor (GR) functionality, has been implicated in depression. We have measured both lymphocyte GR receptor binding parameters and plasma sialyltransferase activity, as a biochemical marker of GR function, in two groups of patients suffering from depression or schizophrenia and in a group of age- and sex-matched controls. While there was a significant increase in plasma cortisol levels in the depressed group, there were no changes in the lymphocyte GR binding parameters (K(m) and Bmax). There was, however, a significant decrease in the plasma sialyltransferase: cortisol ratio in the depressed group suggesting an inability of the raised cortisol levels to induce enzyme expression and this ratio may provide a useful biochemical marker of cortisol receptor function. Although there was an increase in the plasma activity of the alpha 2,6 sialyltransferase isozyme in the schizophrenic group, no other changes were determined. Therefore, while the total plasma sialyltransferase:cortisol ratio reflects HPA axis function, alterations in specific isozyme activity may also be associated with other CNS disease states.

A two-year double-blind crossover trial of the prophylactic effect of methylene blue in manic-depressive psychosis.

A 2-year prophylactic trial was carried out in 31 bipolar manic-depressive subjects, comparing 300 mg/day methylene blue on a double-blind crossover basis with 15 mg/day. All patients were also maintained on lithium. Seventeen patients completed the 2-year trial. During the year the patients were treated with methylene blue at 300 mg/day, they were significantly less depressed than during the year on 15 mg/day. No significant difference in the severity of manic symptoms was shown. The trial had obvious limitations, e.g., a small number of subjects, a relatively large number of dropouts, relatively simple rating scales, doubts about blindness, and uncertainty as to whether or not 15 mg methylene blue per day could be considered a placebo. However, the results suggest that methylene blue may be a useful addition to lithium in the long-term treatment of manic-depressive psychosis and warrants further investigation.

Comparison of the prophylactic action of flupenthixol with placebo in lithium treated manic-depressive patients.

A double-blind cross-over trial of depot flupenthixol in recurrent manic depressive psychosis was carried out. All patients continued on lithium. Eleven patients completed the two-year trial. Flupenthixol appeared to have no prophylactic effect.

The influence of age on lithium efficacy and side-effects in out-patients.

One hundred and sixty-six unipolar and bipolar out-patients (21-78 years) on long-term lithium treatment were studied on a prospective basis. Although there was a possible tendency for manic attacks to increase in prevalence and severity with age, it was difficult to demonstrate a general age-related decline in lithium efficacy. There was a tendency for the prevalence and severity of fine hand tremor to increase with age. This was not seen with polydipsia/polyuria, the other typical lithium side-effect.

Prediction of clinical course of bipolar manic depressive illness treated with lithium.

A group of bipolar manic depressive patients attending a routine lithium clinic were investigated. The results suggest that, when on treatment with lithium, manic depressive patients with a good prognosis tend to have a higher erythrocyte Na-K ATPase and higher plasma and erythrocyte lithium concentrations than those with a poor prognosis. There was no evidence to suggest that the erythrocyte: plasma lithium ratio was useful in predicting clinical response to lithium therapy. There was also a positive correlation between plasma lithium concentration and Na-K ATPase activity, confirming that in manic depressive subjects lithium produces a rise in erythrocyte Na-K ATPase activity.

Physical growth and development of urban native Americans: a study in urbanization and its implications for nutritional status.

Anthropometric measurements and hematocrits are reported on a mixed longitudinal sample of 1309 urban native Americans from Minneapolis from 22 days through 19 years of age (the sample size for each measurement varied from 276 to 1309). The results are compared to the United States national probability samples from the National Center for Health Statistics (HANES and HES), as well as, from 6 through 12 years, to a sample of related American Indians from a reservation in northern Minnesota. Compared to the United States standards, the urban sample is slightly shorter and, in general, consistently heavier. The skinfold thicknesses (triceps and subcapular) varied by site, sex, and age, relative to the standard. In general, the native Americans had thicker skinfolds except for males below 6 years of age, and for the subcapsular in female at all ages. Relative to the sample from the reservation, the urban natives are taller, heavier, with thicker skinfolds and greater weights-for-height. The potentially greater risk for obesity associated with urbanization is discussed. While the mean hematocrits were very close to accepted standards, 35% of infants and children less then 6 years of age had values less than 34.

Age as a factor affecting lithium therapy.

1 We examined the case notes of 82 psychiatric out-patients (aged 21-84 years) receiving lithium prophylaxis and with steady-state plasma lithium levels. 2 The mean weight-related daily dose of lithium prescribed decreased by about 50% between the third and eight decades. 3 The corresponding steady-state plasma lithium levels showed a less marked tendency to decrease, this only being seen in the seventh and eighth decades. 4 In patients aged 50 years or over the daily lithium dose required to give a plasma level of 1 mmol l-1 (0.50 mmol kg-1) was significantly lower than that (0.65 mmol kg-1) in patients aged under 50 years (P less than 0¿5, Student's t-test). In patients aged 70-79 years this dose was 31% lower than in patients under 50 years. However, interindividual variation was great and it was estimated that age only contributed about 14% to the total interpatient variation. 5 Of the 36 patients under 50 years of age, 42% had minor lithium side-effects and 17% were not optimally controlled with lithium. The corresponding figures for the 46 'older' patients were 46% and 28%. 6 Generally the 50% dosage reduction seemed necessary to compensate for an age-related decrease in lithium excretion and to reduce lithium side effects to a level comparable to that acceptable in younger patients.