Radioactive bone cement for the treatment of spinal metastases: a dosimetric analysis of simulated clinical scenarios.

Vertebral metastases are a common manifestation of many cancers, potentially leading to vertebral collapse and neurological complications. Conventional treatment often involves percutaneous vertebroplasty/kyphoplasty followed by external beam radiation therapy. As a more convenient alternative, we have introduced radioactive bone cement, i.e. bone cement incorporating a radionuclide. In this study, we used a previously developed Monte Carlo radiation transport modeling method to evaluate dose distributions from phosphorus-32 radioactive cement in simulated clinical scenarios. Isodose curves were generally concentric about the surface of bone cement injected into cadaveric vertebrae, indicating that dose distributions are relatively predictable, thus facilitating treatment planning (cement formulation and dosimetry method are patent pending). Model results indicated that a therapeutic dose could be delivered to tumor/bone within ∼4 mm of the cement surface while maintaining a safe dose to radiosensitive tissue beyond this distance. This therapeutic range should be sufficient to treat target volumes within the vertebral body when tumor ablation or other techniques are used to create a cavity into which the radioactive cement can be injected. With further development, treating spinal metastases with radioactive bone cement may become a clinically useful and convenient alternative to the conventional two-step approach of percutaneous strength restoration followed by radiotherapy.

Evaluation of a radiation transport modeling method for radioactive bone cement.

Spinal metastases are a common and serious manifestation of cancer, and are often treated with vertebroplasty/kyphoplasty followed by external beam radiation therapy (EBRT). As an alternative, we have introduced radioactive bone cement, i.e. bone cement incorporated with a radionuclide. In this study, we present a Monte Carlo radiation transport modeling method to calculate dose distributions within vertebrae containing radioactive cement. Model accuracy was evaluated by comparing model-predicted depth-dose curves to those measured experimentally in eight cadaveric vertebrae using radiochromic film. The high-gradient regions of the depth-dose curves differed by radial distances of 0.3-0.9 mm, an improvement over EBRT dosimetry accuracy. The low-gradient regions differed by 0.033-0.055 Gy/h/mCi, which may be important in situations involving prior spinal cord irradiation. Using a more rigorous evaluation of model accuracy, four models predicted the measured dose distribution within the experimental uncertainty, as represented by the 95% confidence interval of the measured log-linear depth-dose curve. The remaining four models required modification to account for marrow lost from the vertebrae during specimen preparation. However, the accuracy of the modified model results indicated that, when this source of uncertainty is accounted for, this modeling method can be used to predict dose distributions in vertebrae containing radioactive cement.

Effect of force direction on femoral fracture load for two types of loading conditions.

Identifying the loading conditions under which the femur is most likely to fracture may aid the prevention of hip fracture. This study quantified the effect of force direction on fracture load, a factor inherently associated with fracture risk. Finite element (FE) models of four femora were used to determine the force directions associated with the lowest fracture loads. Force directions were varied three-dimensionally for two types of loading, one representing impact from a fall and one similar to joint loading during daily activities (atraumatic loading). For the fall configuration, the force direction with lowest fracture load corresponded to an impact onto the posterolateral aspect of the greater trochanter. For atraumatic loading, the lowest fracture loads for the force directions analyzed occurred when posterior force components were relatively large or when posterior and lateral components were both small, similar to conditions while standing on one leg or climbing stairs. When both fall and atraumatic configurations are considered, the type of loading associated with greatest fracture risk, i.e., with the greatest applied force and lowest fracture load, is impact from a fall onto the posterolateral aspect of the greater trochanter. Therefore, evaluation of hip fracture risk and development of fracture prevention technologies should focus on this high-risk loading condition.

The Schizosaccharomyces pombe spo20(+) gene encoding a homologue of Saccharomyces cerevisiae Sec14 plays an important role in forespore membrane formation.

The Schizosaccharomyces pombe spo20-KC104 mutation was originally isolated in a screen for sporulation-deficient mutants, and the spo20-KC104 mutant exhibits temperature-sensitive growth. Herein, we report that S. pombe, spo20(+) is essential for fission yeast cell viability and is constitutively expressed throughout the life cycle. We also demonstrate that the spo20(+) gene product is structurally homologous to Saccharomyces cerevisiae Sec14, the major phosphatidylinositol transfer protein of budding yeast. This structural homology translates to a significant degree of functional relatedness because reciprocal complementation experiments demonstrate that each protein is able to fulfill the essential function of the other. Moreover, biochemical experiments show that, like Sec14, Spo20 is a phosphatidylinositol/phosphatidylcholine-transfer protein. That Spo20 is required for Golgi secretory function in vegetative cells is indicated by our demonstration that the spo20-KC104 mutant accumulates aberrant Golgi cisternae at restrictive temperatures. However, a second phenotype observed in Spo20-deficient fission yeast is arrest of cell division before completion of cell separation. Consistent with a direct role for Spo20 in controlling cell septation in vegetatively growing cells, localization experiments reveal that Spo20 preferentially localizes to the cell poles and to sites of septation of fission yeast cells. We also report that, when fission yeasts are challenged with nitrogen starvation, Spo20 translocates to the nucleus. This nuclear localization persists during conjugation and meiosis. On completion of meiosis, Spo20 translocates to forespore membranes, and it is the assembly of forespore membranes that is abnormal in spo20-KC104 cells. In such mutants, a considerable fraction of forming prespores fail to encapsulate the haploid nucleus. Our results indicate that Spo20 regulates the formation of specialized membrane structures in addition to its recognized role in regulating Golgi secretory function.

Prediction of fracture location in the proximal femur using finite element models.

Finite element (FE) models of the proximal femur are often used to study hip fracture. To interpret the results of these models, it is important to know whether the models accurately predict fracture location and/or type. This study evaluated the ability of automatically generated, CT scan-based linear FE models of the proximal femur to predict fracture location and fracture type. Fracture location was defined as the specific location of the fracture. Fracture type was a categorical variable defined as either a cervical or a trochanteric fracture. FE modeling and mechanical testing of 18 pairs of human femora were performed under two loading conditions, one similar to joint loading during single-limb stance and one simulating impact from a fall. For the stance condition, the predicted and actual fracture locations agreed in 13 of the 18 cases (72% agreement). For the fall condition, the predicted and actual fracture locations agreed in 10 of the 15 cases where the actual fractures could be identified (67% agreement). The FE models correctly predicted that only cervical fractures occurred in the stance configuration. For the fall configuration, FE-predicted and actual fracture types agreed in 11 of the 14 cases that could be compared (9 trochanteric, 2 cervical; 79% agreement). These results provide evidence that CT scan-based FE models of the proximal femur can predict fracture location and fracture type with moderate accuracy.

Knock-out mouse for Canavan disease: a model for gene transfer to the central nervous system.

BACKGROUND: Canavan disease (CD) is an autosomal recessive leukodystrophy characterized by deficiency of aspartoacylase (ASPA) and increased levels of N-acetylaspartic acid (NAA) in brain and body fluids, severe mental retardation and early death. Gene therapy has been attempted in a number of children with CD. The lack of an animal model has been a limiting factor in developing vectors for the treatment of CD. This paper reports the successful creation of a knock-out mouse for Canavan disease that can be used for gene transfer. METHODS: Genomic library lambda knock-out shuttle (lambdaKOS) was screened and a specific pKOS/Aspa clone was isolated and used to create a plasmid with 10 base pair (bp) deletion of exon four of the murine aspa. Following linearization, the plasmid was electroporated to ES cells. Correctly targeted ES clones were identified following positive and negative selection and confirmed by Southern analysis. Chimeras were generated by injection of ES cells to blastocysts. Germ line transmission was achieved by the birth of heterozygous mice as confirmed by Southern analysis. RESULTS: Heterozygous mice born following these experiments have no overt phenotype. The homozygous mice display neurological impairment, macrocephaly, generalized white matter disease, deficient ASPA activity and high levels of NAA in urine. Magnetic resonance imaging (MRI) and spectroscopy (MRS) of the brain of the homozygous mice show white matter changes characteristic of Canavan disease and elevated NAA levels. CONCLUSION: The newly created ASPA deficient mouse establishes an important animal model of Canavan disease. This model should be useful for developing gene transfer vectors to treat Canavan disease. Vectors for the central nervous system (CNS) and modulation of NAA levels in the brain should further add to the understanding of the pathophysiology of Canavan disease. Data generated from this animal model will be useful for developing strategies for gene therapy in other neurodegenerative diseases.

Ceramic bearing surfaces.

Despite more than 25 years of clinical experience with ceramic materials as bearing surfaces, their role in modern joint replacement surgery remains to be clearly defined. The two primary materials are alumina and zirconia. The application of these materials is primarily as a femoral head bearing surface against polyethylene, but alumina also is used as a femoral head and an acetabulum to provide a polyethylene-free bearing surface. Important issues that must be clarified for these materials to gain wide acceptance are the material properties, wear rates against polyethylene and alumina, the biologic response to ceramic wear debris, and cost in relation to indications. The bulk materials are biocompatible, hard, wettable, high-strength, and can yield good surface finishes. Linear polyethylene wear against alumina heads is reported to be as much as a factor of 5 to 10 lower than metal versus polyethylene. Thus, the ceramic femoral head may be a good choice for the younger patient in whom it seems necessary to use a larger head for stability reasons with a polyethylene cup. Ceramic-on-ceramic wear rates are in the range of 0.003 mm/year, a factor of 10 less than the lowest polyethylene wear rates. These costly materials are limited in head and neck sizes because of statistical variation in strength that can lead to fracture. Occasional reports of high alumina-on-alumina wear have appeared. Many of the problems of the past have been design, manufacture, or application related, and have been improved or eliminated. Proper clinical technique in the use of ceramic femoral heads is crucial to prevent fracture. The materials hold high promise and should continue to be used so that additional experience can help define the clinical indications for components made of these materials.

Identifying structural hip and knee problems. Patient age, history, and limited examination may be all that's needed.

A likely identification of a given structural disorder of the hip or knee can be suggested by the patient's age. In the hip, developmental dysplasia is usually found in infants, Legg-Calvé-Perthes disease in children of 4 to 10 years, slipped capital femoral epiphysis in somewhat older children, osteonecrosis in young to middle-aged adults, and degenerative joint disease and hip fracture in older adults. In the knee, Blount's disease is usually found in children aged 3 to 8, patellofemoral disease during the teens and early 20s, meniscal tears from the early teens through the mid-50s, ligament injuries from the teens to the 40s, and osteoarthritis throughout adulthood. With relatively little additional information, a useful diagnosis can be made so appropriate therapy can be started or referral made.

Cloning, chromosomal location, and expression analysis of murine Smarce1-related, a new member of the high-mobility 365 group gene family.

Proteins containing high-mobility group (HMG) domains are segregated into two major groups. Members of one group are identified by the presence of more than one HMG domain that binds to DNA without sequence specificity, and they are usually ubiquitously expressed. In contrast, members of the other group possess a single HMG domain with high affinity to specific DNA sequences. Generally, members of the second group resemble classic tissue-specific transcriptional regulators. In contrast, Smarce1/BAF-57 is a ubiquitously expressed, novel protein with a single HMG domain that displays nonspecific DNA-binding characteristics. Additionally, as a core subunit of the mammalian SWI/SNF-like transcriptional activator complex, Smarce1/BAF-57 is also the first member of the HMG protein family that was reported to contain a kinesin-like coiled-coil (KLCC) domain. Here we report the cloning, as well as the chromosomal and phylogenetic analysis, of a novel mammalian protein that is structurally related to Smarce1, termed Smarce1-related (Smarce1r). The unique arrangement of an HMG with a KLCC domain shared with Smarce1/BAF-57 suggests a similar, albeit still unknown, function in chromatin assembly as part of a mammalian SWI/SNF-like complex. The linkage of a single nonspecific DNA-binding HMG domain with a KLCC domain makes both proteins the founding members of a third group of HMG proteins.

Effects of distal cement voids on cement stress in total hip arthroplasty.

The purpose of this study was to determine whether voids in the distal cement mantle created during total hip arthroplasty increase cement stress at the distal tip of the femoral component. Using a three-dimensional finite element model of an idealized, cylindrical femoral shaft with implanted prosthesis, peak von Mises stress in the cement mantle was evaluated for five different air-bubble configurations and two cement mantle thicknesses, 2 mm and 5 mm. Results indicated that voids in the cement mantle increased peak cement stress at the medial tip of the prosthesis by 2% to 57%, with greater increases in stress being evident with larger bubble sizes. On the average, peak stresses were 53% greater in the models with the thinner cement mantle. Clinicians are encouraged to use a thicker cement mantle and to avoid bubble formation during total hip arthroplasty.

Adaptive gait responses to plantar heel pain.

Neuropathic foot ulcers in people with diabetes result from repetitive stress aggravated by a lack of protective sensation. Protective sensation causes individuals without this impairment to produce alterations in their gait in response to painful stimuli. This study evaluates the adaptive gait responses to pain in individuals with sensate feet. The gaits of 18 such control subjects were studied with a foot switch gait analyzer without painful stimuli. Each then had his or her gait analyzed with three successively larger painful stimuli (2, 3.3, and 4.6 mm beads) placed below the heel. This study showed that subjects compensated for the painful stimuli by reducing the single limb support duration of the affected side at bead sizes of 3.3 and 4.6 mm and by reducing the unaffected side's swing phase and single limb support as a percentage of the gait cycle at the 4.6-mm bead size only. Gait adaptations to painful stimuli may indicate another possible avenue, in addition to pressure redistribution, in the assessment of programs aimed at prevention and treatment of diabetic foot ulcers.

The relationship between gait parameters and pain in persons with transtibial amputation: a preliminary report.

This is a preliminary study of the potential relationship between pain and gait parameters in 11 persons with transtibial amputation who underwent gait analysis under both baseline and discomfort walking conditions. Gait analysis included measurement with a VA-Rancho Stride Analyzer of the following gait parameters: velocity, cadence, stride length, gait cycle, and support time. These data were correlated with pain intensity data determined with a standard Visual Analog Scale. Wide ranges of discomfort were reported and corresponding alterations in gait parameters varied greatly in both magnitude and quality. There was no obvious pattern in acclimation to discomfort. A significant correlation was found between pain intensity and the magnitude of change in velocity (p < 0.05). In addition, all subjects reporting significant pain (> 33% of maximum) slowed down, while gait alterations of others varied widely in response to the experience of pain. Further studies with a larger and more homogeneous subject pool to examine these relationships fully are recommended to follow this preliminary report.

Upregulation of xanthine oxidase by lipopolysaccharide, interleukin-1, and hypoxia. Role in acute lung injury.

LPS and selected cytokines upregulate xanthine dehydrogenase/xanthine oxidase (XDH/XO) in cellular systems. However, the effect of these factors on in vivo XDH/XO expression, and their contribution to lung injury, are poorly understood. Rats were exposed to normoxia or hypoxia for 24 h after treatment with LPS (1 mg/kg) and IL-1beta (100 microg/kg) or sterile saline. Lungs were then harvested for measurement of XDH/XO enzymatic activity and gene expression, and pulmonary edema was assessed by measurement of the wet/dry lung weight ratio (W/D). Although treatment with LPS + IL-1beta or hypoxia independently produced a 2-fold elevation (p < 0. 05 versus exposure to normoxia and treatment with saline) in lung XDH/XO activity and mRNA, the combination of LPS + IL-1beta and hypoxia caused a 4- and 3.5-fold increase in these values, respectively. XDH/XO protein expression was increased 2-fold by hypoxia alone and 1.3-fold by treatment with LPS + IL-1beta alone or combination treatment. Compared with normoxic lungs, W/D was significantly increased by exposure to hypoxia, LPS + IL-1beta, or combination treatment. This increase was prevented by treatment of the animals with tungsten, which abrogated lung XDH/XO activity. In conclusion, LPS, IL-1beta, and hypoxia significantly upregulate lung XDH/XO expression in vivo. The present data support a role for this enzyme in the pathogenesis of acute lung injury.

Prediction of femoral fracture load using automated finite element modeling.

Hip fracture is an important cause of morbidity and mortality among the elderly. Current methods of assessing a patient's risk of hip fracture involve local estimates of bone density (densitometry), and are limited by their inability to account for the complex structural features of the femur. In an effort to improve clinical and research tools for assessing hip fracture risk, this study investigated whether automatically generated, computed tomographic (CT) scan-based finite element (FE) models can be used to estimate femoral fracture load in vitro. Eighteen pairs of femora were examined under two loading conditions one similar to loading during the stance phase of gait, and one simulating impact from a fall. The femora were then mechanically tested to failure and regression analyses between measured fracture load and FE-predicted fracture load were performed. For comparison, densitometry measures were also examined. Significant relationships were found between measured fracture load and FE-predicted fracture load (r = 0.87, stance; r = 0.95, fall; r = 0.97, stance and fall data pooled) and between measured fracture load and densitometry data (r = 0.78, stance; r = 0.91, fall). These results indicate that this sophisticated technique, which is still early in its development, can achieve precision comparable to that of densitometry and can predict femoral fracture load to within -40% to +60% with 95% confidence. Therefore, clinical use of this approach, which would require additional X-ray exposure and expenditure for a CT scan, is not justified at this point. Even so, the potential advantages of this CT/FE technique support further research in this area.

Cementless implant composition and femoral stress. A finite element analysis.

Proximal atrophy and thigh pain are recognized problems with some cementless femoral stems in total hip arthroplasty. It is thought that reduced femoral stress from alterations in load transfer caused by an intramedullary stem contributes to proximal femoral atrophy. An increase in flexural rigidity and bone stress near the stem tip is thought to contribute to thigh pain. A three-dimensional finite element analysis study was performed to calculate stresses in the proximal femur and bone near the stem tip before and after implantation of a collared, proximally coated, cementless femoral prosthesis. The influence of prosthetic material was examined by changing implant composition from cobalt chrome to titanium alloy and leaving all other parameters constant. Femoral stress was increased twofold immediately below the collar with the titanium implant compared with the cobalt chrome. However, the proximal femoral stress in the titanium implanted model was still 1/10 that in the corresponding region of the unimplanted femur model. At the stem tip, as much as a 30% reduction in femoral stress was seen with the titanium stem compared with the cobalt chrome. These findings suggest biomechanical evidence of an advantage for titanium as an implant material compared with cobalt chrome for cementless femoral stems.

Free and protein-associated nitrotyrosine formation following rat liver preservation and transplantation.

Nitrotyrosine in human and animal tissues has been associated with pathologic conditions such as atherosclerosis, renal failure, and acute lung disease. In this study, free and protein-associated nitrotyrosine were determined in plasma and tissue samples using a dual-channel electrochemical detection method. Free nitrotyrosine was quantified in acetonitrile-extracted samples while protein-associated nitrotyrosine was determined in proteinase K-digested samples. In human plasma, total nitrotyrosine increased from 2.3 to 4.3 and 13.2 mumol/mol Tyr following addition of 0, 0.5, and 1 mM ONOO-. To determine if nitrotyrosine was produced during ex vivo hypothermic preservation, rat livers were stored in University of Wisconsin solution (UW) for 0, 6, or 8 h and reperfused for 3 h. Total nitro-tyrosine increased 359 and 908% after 6 and 8 h preservation compared to 0 h. To determine if nitrotyrosine was produced in vivo following hepatic ischemia, a rat preservation-transplantation model was utilized in which livers were flushed with cold UW (0-h group) or transplanted following 6 h hypothermic preservation in UW. Free nitrotyrosine increased from 15.7 +/- 0.3 in the 0-h group to 23.6 +/- 2.5 mumol/mol Tyr, 24 h posttransplant of 6-h preserved livers. Protein-associated nitrotyrosine increased from 9.5 +/- 1.1 in the 0-h group to 27.5 +/- 0.7 mumol/mol Tyr in the 6-h preservation-transplantation group. Protein-associated nitrotyrosine provides an integrative determination of nitration. Detection of free and protein-associated nitrotyrosine in biologic samples may allow insight into the role of .NO-derived oxidants in tissue injury associated with various pathologic conditions.

Postfailure compressive behavior of tibial trabecular bone in three anatomic directions.

To obtain information describing the postfailure behavior of human proximal tibial trabecular bone, cube specimens of bone were mechanically tested in compression beyond the point of failure. Tests were performed in the three anatomic directions, plots of stress versus strain were obtained, and measures to describe the stress-strain relations before, during, and after failure were defined. These measures included elastic modulus, strength, postfailure slope, strain during maximum stress, and first postfailure minimum stress. For each anatomic direction, analyses were performed to correlate these parameters with ash density. Each of these measures was significantly correlated with ash density at the p < 0.05 level for all test directions, except for postfailure slope, which was correlated in the mediolateral and superior-inferior directions, and strain during maximum stress, which was correlated only in the superior-inferior direction. The data from this study enable trilinear stress-strain relations to be estimated for proximal tibial trabecular bone of various densities, and can serve as a first step toward modeling the behavior of trabecular bone before, during, and after failure.

Medial compartment arthrosis of the knee.

When the resultant forces on the tibial plateau are displaced medially, compressive stresses cause apposition of bony tissue, thus thickening the dense subchondral bone underlying the medial plateau. Loss of the articular cartilage and an increase in subchondral bone density facilitate the progression of osteoarthrosis. Surgical management is dependent on the presence of a varus deformity; patients with medial compartment disease and varus alignment should be considered for high tibial osteotomy (HTO) or unicondylar or total knee arthroplasty (TKA), depending on their age and activity level. Patients without varus deformity and with mechanical symptoms, only mild joint-space narrowing, and pain less than 1 year are likely to benefit from arthroscopic débridement. Patients without varus alignment but with chronic pain associated with loading and more pronounced joint-space loss should be considered for HTO, or unicondylar or TKA.

Mutant rat phosphatidylinositol/phosphatidylcholine transfer proteins specifically defective in phosphatidylinositol transfer: implications for the regulation of phospholipid transfer activity.

The mammalian phosphatidylinositol/phosphatidylcholine transfer proteins (PI-TPs) catalyze exchange of phosphatidylinositol (PI) or phosphatidylcholine (PC) between membrane bilayers in vitro. We find that Ser-25, Thr-59, Pro-78, and Glu-248 make up a set of rat (r) PI-TP residues, substitution of which effected a dramatic reduction in the relative specific activity for PI transfer activity without significant effect on PC transfer activity. Thr-59 was of particular interest as it is a conserved residue in a highly conserved consensus protein kinase C phosphorylation motif in metazoan PI-TPs. Replacement of Thr-59 with Ser, Gln, Val, Ile, Asn, Asp, or Glu effectively abolished PI transfer capability but was essentially silent with respect to PC transfer activity. These findings identify rPI-TP residues that likely cooperate to form a PI head-group binding/recognition site or that lie adjacent to such a site. Finally, the selective sensitivity of the PI transfer activity of rPI-TP to alteration of Thr-59 suggests a mechanism for in vivo regulation of rPI-TP activity.