Long-term outcome after surgical treatment of Scheuermann's Kyphosis (SK).

STUDY DESIGN: A retrospective observational cohort study with a minimum follow-up of 10 years of patients who underwent surgery for Scheurmann Kyphosis (SK). OBJECTIVE: Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior-posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature. METHODS: 51 patients (30 M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed. RESULTS: The mean age at surgery for 51 patients was 20.6 years who were followed up for a minimum of 10 years (mean: 14 years; range 10-16 years). The mean age was 18.5 ± 2.2 years and 21.9 ± 4.8 years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p < 0.0001) and 30.7 ± 11.7 and 6.4 ± 5.7, respectively, in group 2 (p < 0.0001). The final SRS-22 scores in group 1 and 2 were 4.1 ± 0.4 and 4.0 ± 0.35, respectively (p = 0.88). The preoperative flexibility index was 49.2 ± 4.2 and 43 ± 5.6 in groups 1 and 2, respectively (p < 0.0001). The mean TKs were 81.4° ± 3.8° and 86.1° ± 6.0° for groups 1 and 2, respectively, which corrected to 45.1° ± 2.6° and 47.3° ± 4.8°, respectively, at final follow-up (p < 0.0001). The mean pre-operative LL angle was 60.0° ± 5.0° and 62.4° ± 7.6° in groups 1 and 2, respectively, which at final follow-up was 45.1° ± 4.4° and 48.1° ± 4.8°, respectively (p < 0.0001). The mean pre-operative and final follow-up Voustinas index (VI) in group 1 were 22.9 ± 2.9 and 11.2 ± 1.2, respectively, and in group 2 was 25.9 ± 3.5 and 14.0 ± 2.3, respectively. The mean pre-operative and final follow-up SI angle were 43.6° ± 3.3° and 31.2° ± 2.5° in group 1, respectively, and 44.3° ± 3.5° and 32.1° ± 3.5° in group 2, respectively (p < 0.0001). The pre-operative and final follow-up SVA in group 1 were - 3.3 ± 1.0 cms and - 1.3 ± 0.5 cms, respectively, and in group 2 was - 4.0 ± 1.3cms and - 1.9 ± 1.1cms, respectively (p < 0.0001). Though the magnitude of curve correction in the groups 1 and 2 was significant 36° vs 39° (p = 0.05), there was no significant difference in correction between the two groups. Proximal JK was seen in seven and distal JK in five patients were observed in the whole cohort. CONCLUSION: The long-term clinical outcomes for both PSF and AF/PSF are comparable with reproducible results. No difference was noted in loss of correction and outcome scores between the two groups. The correction of thoracic kyphosis (TK) had a good correlation with ODI. AF/PSF had much higher complications than PSF group. The objective of correcting the sagittal profile and balancing the whole spinal segment on the pelvis can be achieved through single posterior approach with fewer complications.

TOWARD NATIONAL CT DIAGNOSTIC REFERENCE LEVELS IN THE UNITED ARAB EMIRATES: A MULTICENTER REVIEW OF CT DOSE INDEX AND DOSE LENGTH PRODUCT.

This multicenter study evaluated computed tomography dose index volume (CTDIvol) and dose length product (DLP) to contribute to establishing computed tomography (CT) national diagnostic reference levels (NDRLs) in the United Arab Emirates (UAE). Data from 240 patients, who underwent CT head, chest, abdomen-pelvis and urography examinations, were analyzed, including patient age, sex and weight, CTDIvol (mGy) and DLP (mGy cm). The proposed DRLs for each examination were calculated as the third quartile. DRLs are proposed using CTDIvol (mGy) and DLP (mGy cm) for CT head (67 and 1189, respectively), chest (8 and 302, respectively), abdomen-pelvis (28 and 1122, respectively) and urography (20 and 714, respectively). These values are comparable with the initial NDRLs and published international DRLs. Baseline values for International Radiology Center (IRC) CT DRLs were calculated on frequently performed CT examinations. Implementation of DRL values improves dose optimization based on procedures, scanner type and patient characteristics while maintaining acceptable image quality and diagnostic confidence.

Could musculo-skeletal radiograph interpretation by radiographers be a source of support to Australian medical interns: A quantitative evaluation.

INTRODUCTION: Public expectations regarding access to the emergency department (ED) challenges providers and policy makers with finite resources being stretched beyond capacity. To enable education of a greater numbers of doctors the format of the medical internship in Australia has changed and assumes that sufficient supervision is provided to interns to enable image interpretation skills development. Furthermore this assumes that appropriate foundational skills are established during undergraduate education. METHODS: A mixed methods approach using a convenience, self selecting sample population of radiographers and final year medical students was adopted. The study measured the interpretive ability of final year medical students and radiographers in musculo-skeletal trauma (MSK) plain radiographic images. An image test bank based upon radiologist consensual agreement was corrected for prevalence and bias. Performance across a range of measurements was completed and compared for statistical significance using Mann-Whitney U. RESULTS: Results were divided to enable analysis across age ranges and types of skeletal presentation. Radiographer performance was better numerically and demonstrated statistically significant difference in several areas. CONCLUSION: Radiographers have the knowledge base to assist junior doctors to clinically interpret the musculo-skeletal radiographic image. To meet the requirements of AMC and the Medical Board of Australia (MBA), a tailored clinically based educational system could be developed and provided by an accredited radiographer. Australian radiographers could also be employed to provide a safety net to avoid misinterpretation, such as seen in the UK commenting system, operating as an interprofessional team.

A Method for Continuous (239)Pu Determinations in Arctic and Antarctic Ice Cores.

Atmospheric nuclear weapons testing (NWT) resulted in the injection of plutonium (Pu) into the atmosphere and subsequent global deposition. We present a new method for continuous semiquantitative measurement of (239)Pu in ice cores, which was used to develop annual records of fallout from NWT in ten ice cores from Greenland and Antarctica. The (239)Pu was measured directly using an inductively coupled plasma-sector field mass spectrometer, thereby reducing analysis time and increasing depth-resolution with respect to previous methods. To validate this method, we compared our one year averaged results to published (239)Pu records and other records of NWT. The (239)Pu profiles from the Arctic ice cores reflected global trends in NWT and were in agreement with discrete Pu profiles from lower latitude ice cores. The (239)Pu measurements in the Antarctic ice cores tracked low latitude NWT, consistent with previously published discrete records from Antarctica. Advantages of the continuous (239)Pu measurement method are (1) reduced sample preparation and analysis time; (2) no requirement for additional ice samples for NWT fallout determinations; (3) measurements are exactly coregistered with all other chemical, elemental, isotopic, and gas measurements from the continuous analytical system; and (4) the long half-life means the (239)Pu record is stable through time.

Timing and climate forcing of volcanic eruptions for the past 2,500 years.

Volcanic eruptions contribute to climate variability, but quantifying these contributions has been limited by inconsistencies in the timing of atmospheric volcanic aerosol loading determined from ice cores and subsequent cooling from climate proxies such as tree rings. Here we resolve these inconsistencies and show that large eruptions in the tropics and high latitudes were primary drivers of interannual-to-decadal temperature variability in the Northern Hemisphere during the past 2,500 years. Our results are based on new records of atmospheric aerosol loading developed from high-resolution, multi-parameter measurements from an array of Greenland and Antarctic ice cores as well as distinctive age markers to constrain chronologies. Overall, cooling was proportional to the magnitude of volcanic forcing and persisted for up to ten years after some of the largest eruptive episodes. Our revised timescale more firmly implicates volcanic eruptions as catalysts in the major sixth-century pandemics, famines, and socioeconomic disruptions in Eurasia and Mesoamerica while allowing multi-millennium quantification of climate response to volcanic forcing.

Antarctic-wide array of high-resolution ice core records reveals pervasive lead pollution began in 1889 and persists today.

Interior Antarctica is among the most remote places on Earth and was thought to be beyond the reach of human impacts when Amundsen and Scott raced to the South Pole in 1911. Here we show detailed measurements from an extensive array of 16 ice cores quantifying substantial toxic heavy metal lead pollution at South Pole and throughout Antarctica by 1889 - beating polar explorers by more than 22 years. Unlike the Arctic where lead pollution peaked in the 1970s, lead pollution in Antarctica was as high in the early 20(th) century as at any time since industrialization. The similar timing and magnitude of changes in lead deposition across Antarctica, as well as the characteristic isotopic signature of Broken Hill lead found throughout the continent, suggest that this single emission source in southern Australia was responsible for the introduction of lead pollution into Antarctica at the end of the 19(th) century and remains a significant source today. An estimated 660 t of industrial lead have been deposited over Antarctica during the past 130 years as a result of mid-latitude industrial emissions, with regional-to-global scale circulation likely modulating aerosol concentrations. Despite abatement efforts, significant lead pollution in Antarctica persists into the 21(st) century.

Results of hemivertebrectomy and fusion for symptomatic thoracic disc herniation.

We retrospectively analysed ten consecutive patients (age range 32-77 years) treated surgically from 1994 to 1999 for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. Clinically, eight patients had varying grades of back pain and eight patients had paraparesis. Radiography showed calcification in 50% of the herniated discs. Two patients had two-level thoracic disc herniation. Hemivertebrectomy followed by discectomy and fusion was carried out in all patients. Instrumentation with cages was performed in eight patients and bone grafting alone in two patients. The average follow-up was 24 months (range 13-36 months). Six patients had an excellent or good outcome, three had a fair outcome and one had a poor outcome. One patient had atelectasis, which recovered within 2 days of surgery. Another patient had developed complete paraplegia, detected at surgery by SSEPs, and underwent resurgery following magnetic resonance (MR) scan with complete corpectomy and instrumented fusion. At 2 years, she had a functional recovery. The patient with poor outcome had undergone a previous discectomy at T9/10. He developed severe back pain and generalised hyper-reflexia following corpectomy and fusion for disc herniation at T10/11. We advocate anterior transthoracic discectomy following partial corpectomy for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. This procedure offers improved access to the thoracic disc for an instrumented fusion, which is likely to decrease the risk of iatrogenic injury to the spinal cord.

Neutrophils from systemic lupus erythematosus patients demonstrate increased nuclear DNA damage.

OBJECTIVE: (i) To determine the levels of nuclear DNA damage in freshly isolated and cultured neutrophils from SLE patients (SLE), rheumatoid arthritis patients (RA) and healthy individuals and relate these to the percentage of apoptotic neutrophils. (ii) To assess rates of repair of neutrophil oxidative DNA damage. METHODS: The comet assay was used to quantify nuclear DNA damage in neutrophils from SLE patients (n = 20), control subjects (n = 15) and RA patients (n = 15). Levels of DNA damage were related to apoptosis as assessed by annexin V binding and morphology. Rates of repair of neutrophil oxidative DNA damage was measured by incorporating formamidopyrimidine-DNA glycosylase (FPG) into the comet assay. RESULTS: Nuclear DNA damage in freshly isolated and cultured (20 h) neutrophils was significantly greater in SLE patients (median = 12.5%, 27.3%; respectively) compared with RA patients (median = 9.4%, p = 0.002; 19.3%, p = 0.002; respectively) and control subjects (median = 8.2%, p = 0.003; 18.7%, p = 0.01, respectively). Significantly higher levels of circulating apoptotic neutrophils were demonstrated in SLE patients compared to RA and control subjects. Similar findings were observed following 20 h cultured neutrophil preparations. However, no significant direct correlation between neutrophil apoptosis and DNA damage was observed. Neutrophils from 3 of 5 SLE patients demonstrated an impaired ability to repair oxidatively modified DNA. CONCLUSION: Neutrophils from SLE patients display increased DNA damage and, additionally, may demonstrate defective repair of oxidative DNA damage. These features, in addition to increased rates of neutrophil apoptosis, may act as contributing factors to autoantigen excess and immune activation.

Reduced expression of CD44 on monocytes and neutrophils in systemic lupus erythematosus: relations with apoptotic neutrophils and disease activity.

BACKGROUND: Increased numbers of apoptotic neutrophils, and impaired monocyte/macrophage clearance of apoptotic cells, have been demonstrated in systemic lupus erythematosus (SLE). CD44 is implicated in the clearance of apoptotic neutrophils. OBJECTIVE: To determine the expression of CD44 on peripheral blood monocytes and neutrophils in SLE, and examine the relations with disease activity and numbers of circulating apoptotic neutrophils. METHODS: Peripheral blood was sampled from 31 patients with SLE, 19 healthy normal subjects, and 19 patients with rheumatoid arthritis (RA). Monocyte and neutrophil density of surface CD44 expression was determined by immunofluorescence labelling and flow cytometry, and results expressed as mean channel fluorescence (MCF) values. Neutrophil apoptosis was measured by morphology in 15 patients with SLE, nine with RA, and six normal subjects. RESULTS: Monocyte CD44 expression was significantly lower in SLE (median MCF 4.71) than in healthy normal subjects (median MCF 5.61) and controls with RA (median MCF 5.39). Neutrophil CD44 expression was also significantly lower in SLE (median MCF 1.95) than in healthy normal subjects (median MCF 2.37) and controls with RA (median MCF 2.60). Monocyte, but not neutrophil, CD44 expression correlated negatively with the percentage of apoptotic neutrophils. There was no significant correlation of monocyte or neutrophil CD44 expression in SLE with disease activity or damage. CONCLUSIONS: Monocyte and neutrophil CD44 expression is reduced in SLE, and this may contribute to the impaired recognition and clearance of apoptotic neutrophils by monocyte derived macrophages.

Role of PHABULOSA and PHAVOLUTA in determining radial patterning in shoots.

The upper side of the angiosperm leaf is specialized for efficient capture of sunlight whereas the lower side is specialized for gas exchange. In Arabidopsis, the establishment of polarity in the leaf probably requires the generation and perception of positional information along the radial (adaxial versus abaxial or central versus peripheral) dimension of the plant. This is because the future upper (adaxial) side of the leaf develops from cells closer to the centre of the shoot, whereas the future under (abaxial) side develops from cells located more peripherally. Here we implicate the Arabidopsis PHABULOSA and PHAVOLUTA genes in the perception of radial positional information in the leaf primordium. Dominant phabulosa (phb) and phavoluta (phv) mutations cause a dramatic transformation of abaxial leaf fates into adaxial leaf fates. They do so by altering the predicted sterol/lipid-binding domains of ATHB14 and ATHB9, proteins of previously unknown function that also contain DNA-binding motifs. This change probably renders the protein constitutively active, implicating this domain as a central regulator of protein function and the PHB and PHV proteins as receptors for an adaxializing signal.

Improving radiographer highlighting of trauma films in the accident and emergency department with a short course of study--an evaluation.

The case for radiographer abnormality highlighting in the Accident and Emergency (A&E) department is well documented. Following evaluative feedback, 280 questionnaires were sent nationally to A&E radiology departments (excluding Northern Ireland). The intent of the survey was to ascertain the viability of constructing a short course in trauma plain film pattern recognition in the axial and appendicular skeleton. Following a highly positive response a course was designed and operated on a workshop basis, being lead primarily by reporting radiographers. The course was evaluated for effectiveness using three identical assessments of 42 films, including 12 positive for trauma. A sample of 22 radiographers who attended the pilot course and subsequent courses throughout 1998/99 undertook the assessment. The assessments themselves were performed at the start and end of the course and 6-10 weeks after completion. Results appear to indicate that a significant improvement in the specificity (p = 0.002) and accuracy (p = 0.005) was achieved following the course. In the light of continuing professional development, the course appears to address the needs of the majority of clinical radiographers working in A&E.

The ambiguity about death in Japan: an ethical implication for organ procurement.

In the latter half of the twentieth century, developed countries of the world have made tremendous strides in organ donation and transplantation. However, in this area of medicine, Japan has been slow to follow. Japanese ethics, deeply rooted in religion and tradition, have affected their outlook on life and death. Because the Japanese have only recently started to acknowledge the concept of brain death, transplantation of major organs has been hindered in that country. Currently, there is a dual definition of death in Japan, intended to satisfy both sides of the issue. This interesting paradox, which still stands to be fully resolved, illustrates the contentious conflict between medical ethics and medical progress in Japan.

Leaf polarity and meristem formation in Arabidopsis.

Shoot apical meristems (SAMs) of seed plants are small groups of pluripotent cells responsible for making leaves, stems and flowers. While the primary SAM forms during embryogenesis, new SAMs, called axillary SAMs, develop later on the body of the plant and give rise to branches. In Arabidopsis plants, axillary SAMs develop in close association with the adaxial leaf base at the junction of the leaf and stem (the leaf axil). We describe the phenotype caused by the Arabidopsis phabulosa-1d (phb-1d) mutation. phb-1d is a dominant mutation that causes altered leaf polarity such that adaxial characters develop in place of abaxial leaf characters. The adaxialized leaves fail to develop leaf blades. This supports a recently proposed model in which the juxtaposition of ad- and abaxial cell fates is required for blade outgrowth. In addition to the alteration in leaf polarity, phb-1d mutants develop ectopic SAMs on the undersides of their leaves. Also, the phb-1d mutation weakly suppresses the shoot meristemless (stm) mutant phenotype. These observations indicate an important role for adaxial cell fate in promoting the development of axiallary SAMs and suggest a cyclical model for shoot development: SAMs make leaves which in turn are responsible for generating new SAMs.