Evolving phenotype of systemic lupus erythematosus in Caucasians: low incidence of lupus nephritis, high burden of neuropsychiatric disease and increased rates of late-onset lupus in the 'Attikon' cohort.

OBJECTIVE: This study aimed to analyse the phenotype of systemic lupus erythematosus (SLE) at first presentation and during follow-up in a newly established SLE cohort based at 'Attikon' University Hospital. The hospital combines primary, secondary and tertiary care for the region of Western Attica, Greece. METHODS: This study comprised a mixed prevalent and incident cohort of 555 Caucasian patients diagnosed with SLE according to American College of Rheumatology 1997 criteria and/or the Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) 2012 criteria. Demographic and clinical characteristics, patterns of severity, treatments and SLICC damage index were recorded for each patient at the time of diagnosis and at last evaluation. RESULTS: The mean age at lupus diagnosis was 38.3 years (standard deviation = 15.6 years), with a median disease duration at last follow-up of two years (interquartile range 1-11). At initial presentation, the most common 'classification' manifestations were arthritis (73.3%), acute cutaneous lupus (65%) and unexplained fever (25%), while among symptoms not included in any criteria set, Raynaud's phenomenon (33%) was the most common. Kidney and neuropsychiatric involvement as presenting manifestations were present in 10.3% and 11.5% cases, respectively. Irreversible damage accrual was present in 17.8% within six months of disease diagnosis, attributed mainly to thrombotic and neuropsychiatric disease. At last evaluation, 202 (36.4%) patients had developed severe disease, of whom more than half were treated with pulse cyclophosphamide. CONCLUSION: In this cohort of Caucasian patients, lupus nephritis is not as common as in older cohorts, while neuropsychiatric disease is emerging as a major frontier in lupus prevention and care. These data may help to document changes in the natural history and treatment of SLE over time and may have implications for its early recognition and management.

Sex-specific structural and functional leaf traits and sun-shade acclimation in the dioecious tree Pistacia vera (Anacardiaceae).

In dioecious species, sex-related adaptive strategies, influenced by natural and sexual selection, allow each sex to meet the specific demands of reproduction. Differences in ecophysiological traits between males and females may rely on innate differences in secondary sex traits such as structural and functional leaf traits. We tested structural sexual leaf dimorphism in Pistacia vera L. and the intersexual differences in sun-shade acclimation processes expected from the different adaptive strategies of males and females. Fifteen structural and functional leaf traits were compared in 50-year-old trees between females with low fruit load and males under sun and shade conditions. Despite the low additional energy investment in reproduction in females, remarkable sex effects in leaf structure and function were observed. Male trees had smaller leaves with significantly lower total conducting petiole area (TCA) and higher stomatal density, water use efficiency and concentration of phenolic compounds; females had larger leaves with greater thickness, leaf mass per area, TCA and maximum photosynthetic capacity per area (Amax,a). The higher Amax,a and stomatal conductance of female leaves were associated with their ~20-fold higher TCA compared with male trees. Females seem to invest more in high xylem efficiency and rates of C gain; males invest more in defence-protection. Sun-shade plastic responses were sex- and trait-specific, but the plasticity assessment indicated that both sexes have evolved an almost equal degree of phenotypic plasticity that allows them to perform optimally under varying environmental conditions. However, the trait-specific differences indicate that each sex displays a different strategy of optimisation.

How does long-term drought acclimation modify structure-function relationships? A quantitative approach to leaf phenotypic plasticity of barley.

Under drought conditions the growth and survival of a plant depend on its adaptive characteristics and acclimation ability. Adaptation refers to inherent morpho-physiological characters providing protection against water losses. Acclimation, however, is a special case of phenotypic plasticity: environment-dependent phenotypic expression resulting to a 'new' phenotype through drought-induced modulations in leaf morphology, anatomy and physiology. Given that phenotypic plasticity influences environmental tolerance, a multi-trait plasticity index could be of great importance. Therefore, we examined the acclimation processes of three different barley genotypes using a multi-trait plasticity assessment with emphasis on the leaf water economy-related traits. Our results showed that (i) the structure-function co-ordination during long-term drought acclimation follows the trade-off between carbon gain and water saving as well as the competition between investments in photosynthesis vs synthesis of protective compounds; (ii) the genotypes with smaller leaf area, narrower and denser veins, as well as smaller and denser stomata i.e. traits providing tolerance, exhibited less drastic adjustments under stress conditions, suggesting a trade-off between acclimation and tolerance-adaptation; and (iii) the slope values of a multi-trait 'reaction norm' based on regression analysis of PCA scores were indicative of the degree of plasticity for each genotype, providing an accurate representation of a complex set of data with single numeric results easily comparable.

Fracture at the stem-condylar junction of a modular femoral prosthesis in a varus-valgus constrained total knee arthroplasty.

UNLABELLED: We present a rare case of fracture of the modular femoral component in a varus-valgus constrained total knee arthroplasty (TKA) prosthesis which occurred 2 years after implantation. Both femoral and tibial components underwent a second revision using a constrained hinged TKA. Laboratory analysis revealed insufficient metaphyseal bone stock in association with inadequate cement mantle incorporation which made implant fixation solely reliant on the intramedullary stem construct. It was therefore hypothesized that high repetitive stresses over the junction of the modular component led to the fracture. LEVEL OF EVIDENCE: Case report, Level IV.

Total knee arthroplasty in severe valgus knee deformity: comparison of a standard medial parapatellar approach combined with tibial tubercle osteotomy.

PURPOSE: Primary TKA in valgus knees with a deformity of more than ten degrees may prove challenging, since bone and soft tissue abnormalities make accurate axis restoration, component orientation and joint stability attainment a difficult task. The purpose of this study was to determine which approach is optimal in these patients, by comparing the standard medial parapatellar approach to a lateral parapatellar combined with a tibial tubercle osteotomy (TTO). METHODS: Forty-four valgus knees--with an axis deviation ranging from 15 to 36 degrees (mean 24°)--were dealt with primary TKA and followed up for a minimum period of 7 years. Lateral parapatellar arthrotomy combined with TTO was performed in 22 individuals (Group A) and a standard medial parapatellar capsulotomy in the remaining patients (Group B). The International Knee Society System Score (IKSS) was used for clinical evaluation. Radiological assessment was performed yearly postoperatively using long films for assessment of the anatomical axis. RESULTS: The postoperative IKSS scores showed no significant statistical difference between groups A and B (P < 0.05). In the alignment parameter, however, residual valgus deviation occurred in 9% of patients from Group A and in 32% from Group B. No late-onset instability was displayed. CONCLUSION: Lateral parapatellar approach combined with TTO may prove highly beneficial in significant valgus deformities, as the anatomical axis is restored accurately and soft tissue release of the lateral contracted structures facilitated to an important extent.

Total knee arthroplasty in severe valgus deformity: interest of combining a lateral approach with a tibial tubercle osteotomy.

INTRODUCTION: Among the patients requiring total knee arthroplasty (TKA), approximately 10-15% presents with a valgus deformity (VD). Severely deformed valgus knees represent a surgical challenge. The purpose of this study is to evaluate the results of TKA in grade II and III valgus knee deformities (Ranawat classification), focusing on axis correction, by using a lateral parapatellar capsulotomy combined with tibial tubercle osteotomy. HYPOTHESIS: The lateral approach in combination with a tibial tuberosity osteotomy is highly beneficial in the treatment of severe valgus knees in patients undergoing primary TKA, for correction of anatomical axis. PATIENTS AND METHODS: Between January 1995 and December 2001, 33 patients with severe VD, grade II and III, were treated with TKA by one surgeon. Twenty-six patients (19 male, seven female) with mean age of 72 years (57-79) were dealt with a resurfacing posterior stabilized design; whereas in seven cases, a constrained type implant was used. These seven patients were excluded from the study. Two more patients were lost for follow-up and were also excluded. The axis deviation of the remaining 24 patients ranged from 15 to 35 degrees, (average 23°). A lateral parapatellar arthrotomy, in combination with tibial tubercle osteotomy was used. Patients' clinical evaluation - using the International Knee Society (IKS) score - with simultaneous radiological assessment was performed yearly after the operation; and for a mean follow-up time of 11.5 years (8 to 15 years). RESULTS: The mean IKS score improved from 44 points (34 to 52) preoperatively, to 91 points (68 to 100) postoperatively, at the last follow-up. In terms of alignment parameter, only two knees had a residual valgus deviation greater than 7° (ideal range : 3-7°). One knee exhibited a 9° valgus, and another one 10°, according to anatomical axis measurments. In one case, there was a 5mm proximal migration of the osteotomised tuberosity fragment, due to breakage of the screw. However, the final outcome was not affected. There were no cases of tibial tubercle's non-union; neither of delayed instability. CONCLUSION: The lateral approach is a useful approach in the treatment of severe valgus knee deformity in patients undergoing primary TKA. Anatomical axis restoration is facilitated, as the contracted structures are easily accessed and, in severe cases, the patellar alignment may be achieved by displacing the osteotomised tubercle. However, careful fixation of the tuberosity is mandatory. LEVEL OF EVIDENCE: Level IV, prospective study of case series.

Idiopathic spinal accessory nerve palsy. A case report.

Spinal accessory nerve palsy may lead to dysfunction or paralysis of the trapezius muscle. Common causes are iatrogenic or secondary due to trauma, infection or tumour. Idiopathic palsy is considered extremely rare. We present the case of a 42-year-old Caucasian male suffering from a unilateral, isolated paralysis of his ipsilateral trapezius muscle. There was no related trauma, nor any past history of surgical procedures. An electromyographic study confirmed the idiopathic paralysis of the distal segment of the spinal accessory nerve.

Evidence for oxidative stress in lens epithelial cells in pseudoexfoliation syndrome.

PURPOSE: To investigate the oxidative status in lens epithelial cells of patients with pseudoexfoliation (PEX) syndrome. METHODS: Lens capsule samples obtained during cataract surgery of patients with PEX syndrome and normal age-matched control subjects were examined for changes in the levels of glutathione (GSH), glutathione disulphide (GSSG), protein concentration, and lipid peroxidation. Concentrations of GSH, GSSG, lipid peroxidation, and protein concentration were determined by specific fluorescent assays. RESULTS: This study shows a 2.2- and 2.0-fold decrease in GSH and GSSG levels, respectively, in PEX lens epithelial lens compared with non-PEX lens epithelial cells, as well as a 2.5-fold increase in lipid peroxidation product malondialdehyde (MDA) levels. CONCLUSION: The increased MDA and decreased GSH levels indicate high oxidative stress. On the other hand, GSSG usually increases in cases of high-oxidative stress, but this is not always the case, as it may not always accumulate in cells. Our findings suggest a role for oxidative stress in the pathogenesis and the progression of PEX syndrome.

A theoretical model evaluating the angular distribution of luminescence emission in X-ray scintillating screens.

The aim of this study was to examine the angular distribution of the light emitted from radiation-excited scintillators in medical imaging detectors. This distribution diverges from Lambert's cosine law and affects the light emission efficiency of scintillators, hence it also affects the dose burden to the patient. In the present study, the angular distribution was theoretically modeled and was used to fit experimental data on various scintillator materials. Results of calculations revealed that the angular distribution is more directional than that predicted by Lambert's law. Divergence from this law is more pronounced for high values of light attenuation coefficient and thick scintillator layers (screens). This type of divergence reduces light emission efficiency and hence it increases the incident X-ray flux required for a given level of image brightness.

Radon exposure in the thermal spas of Lesvos Island--Greece.

The aim of this work is to study the exposure due to radon to bathers and personnel in the spas of Lesvos Island under a specific use pattern. 222Rn concentrations in the supplying water were measured during a long time period. Variations in indoor 222Rn, attached and unattached progenies, and influence of the ambient atmosphere were thoroughly analysed during bath treatment for the purpose of investigating a consequent probable short-term health impact. Concentration peaks both for 222Rn and PAEC were found to appear during bathtubs filling. These peaks considered imposing an additional short-term radiation burden for spa users. The additional doses delivered to bathers during bath treatment were found to be very low and for personnel did not exceed the value of 5 mSv per year.

Study of a Greek area with enhanced indoor radon concentrations.

In this paper the focus is on Arnea Chalkidikis, an area in Greece with granitic geological background and indications of possible elevated radon concentration indoors. Data are reported of indoor radon measurements with etched track detectors and those are used for dosimetric estimations. Moreover, data are reported on soil gas and soil radon concentrations in Arnea, as well as radon and uranium concentrations in water samples. From the measured radon concentrations in water samples the contribution to the overall dose has been calculated. For a period of 1 month, indoor radon and progeny activity has also been monitored in the dwelling that has the maximum indoor radon concentration in Greece. This dwelling is in Arnea and the dose delivered to the inhabitants has been calculated. The mean annual effective dose due to indoor radon was 4.5 mSv and about 11% of this was due to the use of water. Mean soil gas concentration and soil radon concentration were (90 +/- 30) kBq m(-3) (p<0.05) and (30 +/- 5) kBq m(-3) (p<0.05) respectively. Mean uranium concentration of the water samples was (98 +/- 13) mBq l(-1) (p<0.05).

Thallium-201 for detection of myocardial viability: comparison of early postexercise reinjection and imaging with 4 and 18-24 hours redistribution imaging.

To evaluate the efficacy of an early 201Tl reinjection and imaging protocol for reducing the need for conventional 4-hour or optimal 24-hour redistribution imaging (RI) and detecting of myocardial viability, we compared the results of early postexercise Tl reinjection and imaging with those of 4- and 24-hour RI in 74 consecutive patients aged 55 +/- 9 years (mean +/- SD) who were assessed for myocardial ischemia. One millicurie of Tl was injected promptly after completion of the initial postexercise imaging (PEX) and three additional sets of images were acquired 1, 4 and 18-24 h later. A total of 2,368 segments were evaluated. On PEX, 390 (17%) segments showed defects, of which 287 (74%) showed enhanced Tl uptake at 1-hour RI; 89 (23%) did not change and 14 (4%) showed reverse redistribution. Of the 103 persistent defects, only 27 (7%) showed further fill-in of Tl; 62 (16%) segments showed reverse redistribution at 4-hour RI while at 18- to 24-hour RI 17 (4%) and 47 (12%) segments showed further fill-in of Tl and reverse redistribution, respectively. Finally, after analysis of 4- and 18- to 24-hour RI, the diagnosis changed from myocardial necrosis to ischemia in only 2 (3%) patients. In conclusion, these results suggest that by eliminating the need for an additional delayed set of images for detection of myocardial viability, this protocol reduces the total investigation procedure, is more convenient for the patient, increases patient turnover and expedites the decision-making process.

Early postexercise thallium-201 reinjection after sublingual nitroglycerin augmentation: effects on detection of myocardial ischemia and/or viability.

BACKGROUND: Thallium-201 (201Tl) reinjection after conventional redistribution imaging is a standard procedure, resulting in enhanced 201Tl redistribution which is compatible with viable myocardium. Although this method significantly improves identification of viable myocardium, it increases the investigation time by approximately 1 h. Thus, this technique is suboptimal from the standpoint of patient convenience, since its routine performance may be impractical in a high-volume nuclear medicine laboratory. HYPOTHESIS: This study was undertaken to evaluate the efficacy of an early 201Tl reinjection and imaging protocol in combination with sublingual nitroglycerin, to detect myocardial ischemia and/or viability, and to reduce the need for conventional (4 h) redistribution imaging. MATERIALS AND METHODS: In this study, 62 consecutive coronary patients, referred for the detection of possible myocardial ischemia and/or viability, were involved (mean age 55 years, range 41-70). Of those, 50 had previous angina attacks, with 42 having a history of previous myocardial infarction; 10 patients had coronary artery bypass grafting; and the remaining 2 had atypical chest pain. Immediately after the completion of the initial postexer-cise imaging, 0.3 mg sublingual nitroglycerin followed by the reinjection of 1 m Ci of 201Tl were administered, and two further sets of images were acquired 1 h and 4 h later. RESULTS: In each set of images, a total of 496 segments were analyzed. On postexercise imaging, 305 (61%) segments demonstrated defects of which 198 (65%) showed enhanced thallium uptake, 97 (32%) did not change, and 10 (3%) showed reverse redistribution on 1 h reinjection imaging (IRI). Of the 97 persistent defects, only 17 (6%) showed fill-in of 201Tl on 4 h redistribution imaging (CRI), while 12 (4%) segments showed reverse redistribution. On the other hand, after analyzing the 62 patients of the 1 h IRI, 17 (27%) remained unchanged while in only 1 patient (6%) of 17 the diagnosis changed from myocardial necrosis to ischemia after analysis of the 4 h CRI. CONCLUSION: These results indicate that early postexercise reinjection of 201Tl in combination with sublingual nitroglycerin followed by 1 h image acquisition may prove useful for a comprehensive and convenient assessment of myocardial ischemia and/or viability.