Atorvastatin Rapidly Reduces Hepatitis B Viral Load in Combination with Tenofovir: A Prospective Clinical Trial.

Method: In this single-blind clinical trial, 40 patients with active chronic hepatitis B were randomly allocated to treatment or control groups. The treatment group received the standard treatment for chronic HBV (300 mg tenofovir twice a day) along with 40 mg/day atorvastatin for 12 months, while the control group received a placebo once daily in addition to the standard tenofovir regimen. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and HBV DNA copy numbers were measured at the beginning of the treatment and 1, 3, 6, 9, 12 months later. Results: One month after starting the treatment, the HBV copy number in the atorvastatin + tenofovir-treated group was significantly lower, by 200×, compared with the control group. After three months of the treatment, there was no detectable HBV DNA in 50% of the atorvastatin + tenofovir-treated group compared with 30% in the control group. The half-life of plasma viral load was 2.03 and 3.32 months in the atorvastatin + tenofovir-treated and control groups, respectively. No adverse events due to taking atorvastatin were observed. Conclusions: The combination of atorvastatin with tenofovir increased antiviral activity and led to a faster recovery from viral infection. Therefore, this modality can be recommended as a safe combination therapy for chronic hepatitis B patients.

Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h.

BACKGROUND: Over-aggressive intravenous fluid therapy with crystalloids has adverse effects in trauma patients. We assessed the role of large-volume (≥5l) administration of crystalloids within 24h of injury as an independent risk-factor for mortality, in-hospital complications, and prolonged mechanical ventilation. METHODS: A retrospective cohort analysis of adult trauma patients admitted to a level 1-trauma center between December 2011 and December 2012. Patient demographics, clinical and laboratory values, and total resuscitation fluid administered within the first 24h of injury were obtained. Outcomes included mortality, in-hospital complications and ventilator-days. Multivariable logistic regression and Poisson regression analyses were performed to investigate any association between the administration of ≥5L crystalloids with the aforementioned outcomes while controlling for selected clinical variables. RESULTS: A total of 970 patients were included in the analysis. 264 (27%) received ≥5L of crystalloids in the first 24h of injury. 118 (12%) had in-hospital complications and 337 (35%) required mechanical ventilation. The median age was 46 years (interquartile range (IQR) 27-65) years and 73% (n = 708) were males. The median injury severity score (ISS) was 17 (IQR 9-25). Overall mortality rate was 7% (n = 67). Multivariable logistic regression analysis showed several variables independently associated with mortality (p < 0.05), including resuscitation with ≥5L crystalloid in the first 24h (adjusted odds ratio (aOR) 2.55), older age (aOR 1.03), higher ISS (aOR 1.09), and lower temperature (aOR 0.68). The variables independently associated with in-hospital complications (p < 0.05) were older age, longer ICU stay, and platelet transfusion within 24h of the injury. Need for mechanical ventilation was more common in patients who received ≥5L crystalloids (RR 2.31) had higher ISS (RR 1.02), developed in-hospital complications (RR 1.91) and had lower presenting temperature (RR 0.87). CONCLUSION: Large-volume crystalloid resuscitation is associated with increased mortality and longer time ventilated, but not with in-hospital complications such as pneumonia and sepsis. Based on this data, we recommend judicious use of crystalloids in the resuscitation of trauma patients.

Co-transplantation of autologous bone marrow mesenchymal stem cells and Schwann cells through cerebral spinal fluid for the treatment of patients with chronic spinal cord injury: safety and possible outcome.

STUDY DESIGN: This is a clinical trial (phase 1). OBJECTIVES: The objective of this study was to asses the safety and feasibility of bone marrow mesenchymal stem cell (MSC) and Schwann cell (SC) co-injection through cerebral spinal fluid (CSF) for the treatment of patients with chronic spinal cord injury. METHODS: Six subjects with complete spinal cord injury due to trauma according to International Standard of Neurological Classification for Spinal Cord Injury (ISNCSCI) developed by the American Spinal Injury Association were enrolled. They received autologous co-transplantation of MSC and SC through lumbar puncture. Neurological status of the patients was determined by ISNCSCI, as well as by assessment of functional status by Spinal Cord Independent Measure. Before and after cell transplantation, magnetic resonance imaging (MRI) was performed for all the patients. Before the procedure, all the patients underwent electromyography, urodynamic study (UDS) and MRI tractograghy. After transplantation, these assessments were performed in special cases when the patients reported any changes in motor function or any changes in urinary sensation. RESULTS: Over the mean 30 months of follow-up, the radiological findings were unchanged without any evidence of neoplastic tissue overgrowth. American Spinal Injury Association class in one patient was changed from A to B, in addition to the improvement in indexes of UDS, especially bladder compliance, which was congruous with axonal regeneration detected in MRI tractography. No motor score improvement was observed among the patients. CONCLUSION: No adverse findings were detected at a mean of 30 months after autologous transplantation of the combination of MSCs and SCs through CSF. It may suggest the safety of this combination of cells for spinal cord regeneration.

A Unified Framework for Brain Segmentation in MR Images.

Brain MRI segmentation is an important issue for discovering the brain structure and diagnosis of subtle anatomical changes in different brain diseases. However, due to several artifacts brain tissue segmentation remains a challenging task. The aim of this paper is to improve the automatic segmentation of brain into gray matter, white matter, and cerebrospinal fluid in magnetic resonance images (MRI). We proposed an automatic hybrid image segmentation method that integrates the modified statistical expectation-maximization (EM) method and the spatial information combined with support vector machine (SVM). The combined method has more accurate results than what can be achieved with its individual techniques that is demonstrated through experiments on both real data and simulated images. Experiments are carried out on both synthetic and real MRI. The results of proposed technique are evaluated against manual segmentation results and other methods based on real T1-weighted scans from Internet Brain Segmentation Repository (IBSR) and simulated images from BrainWeb. The Kappa index is calculated to assess the performance of the proposed framework relative to the ground truth and expert segmentations. The results demonstrate that the proposed combined method has satisfactory results on both simulated MRI and real brain datasets.

Tortuosity of coronary bifurcation as a potential local risk factor for atherosclerosis: CFD steady state study based on in vivo dynamic CT measurements.

The purpose of the present study was to determine whether in vivo bifurcation geometric factors would permit prediction of the risk of atherosclerosis. It is worldwide accepted that low or oscillatory wall shear stress (WSS) is a robust hemodynamic factor in the development of atherosclerotic plaque and has a strong correlation with the local site of plaque deposition. However, it still remains unclear how coronary bifurcation geometries are correlated with such hemodynamic forces. Computational fluid dynamics simulations were performed on left main (LM) coronary bifurcation geometries derived from CT of eight patients without significant atherosclerosis. WSS amplitudes were accurately quantified at two high risk zones of atherosclerosis, namely at proximal left anterior descending artery (LAD) and at proximal left circumflex artery (LCx), and also at three high WSS concentration sites near the bifurcation. Statistical analysis was used to highlight relationships between WSS amplitudes calculated at these five zones of interest and various geometric factors. The tortuosity index of the LM-LAD segment appears to be an emergent geometric factor in determining the low WSS amplitude at proximal LAD. Strong correlations were found between the high WSS amplitudes calculated at the endothelial regions close to the flow divider. This study not only demonstrated that CT imaging studies of local risk factor for atherosclerosis could be clinically performed, but also showed that tortuosity of LM-LAD coronary branch could be used as a surrogate marker for the onset of atherosclerosis.

Framework for assessing stewardship of the oral health system in Islamic Republic of Iran.

This study designed a framework for assessing the stewardship function of the oral health system in Islamic Republic of Iran. The modified RAND Corporation/University of California Los Angeles (RAND-UCLA) Appropriateness Method was used in a 2-step process that combined literature evidence and the collective judgement of experts. After a comprehensive literature review, policy instruments related to stewardship components were extracted as candidate standards and categorized according to the 6 sub-functions of stewardship (accountability; defining strategic direction; alignment of policy objectives and organizational structure; regulation; intersectoral leadership; and generation of intelligence). Five key informants then rated the appropriateness of the 85 standards on a 5-point Likert scale. The 38 highest ranked standards, including at least 2 standards in each of the 6 sub-functions, formed a set of proposed standards for evaluating the current stewardship of oral health system. Piloting of the instrument will be reported separately.

Framework for assessing stewardship of the oral health system in Islamic Republic of Iran

This study designed a framework for assessing the stewardship function of the oral health system in Islamic Republic of Iran.The modified RAND Corporation/University of California Los Angeles [RAND-UCLA]Appropriateness Method was used in a 2-step process that combined literature evidence and the collective judgement of experts.After a comprehensive literature review, policy instruments related to stewardship components were extracted as candidate standards and categorized according to the 6 sub-functions of stewardship (accountability; defining strategic direction; alignment of policy objectives and organizational structure; regulation; intersectoral leadership; and generation of intelligence). Five key informants then rated the appropriateness of the 85 standards on a 5-point Likert scale.The 38 highest ranked standards, including at least 2 standards in each of the 6 sub-functions, formed a set of proposed standards for evaluating the current stewardship of oral health system.Piloting of the instrument will be reported separately

وضعت هذه الدراسة إطار عمل لتقييم وظيفة القوامة في نظام صحة الفم في جمهورية إيران الإسلامية. وتم استخدام الطريقة المعدلة لمؤسسة البحث والتقييم التابعة لجامعة كاليفورنيا في لوس أنجلوس على خطوتين للربط بين البينات المنشورة والرأي الجماعي للخبراء. وبعد إجراء مراجعة شاملة للنشريات، تم استخلاص النصوص الخاصة بالسياسات المتعلقة بعنصر القوامة كمقاييس مقترحة، وتم تصنيفها وفقا للوظائف الفرعية الست للقوامة [المساءلة، والتوجهات الاستراتيجية المحددة؛ وترتيب أهداف السياسيات؛ والهيكل التنظيمي؛ والتنظيم، والقيادة المشتركة بين القطاعات، وإنتاج المعلومات]. ثم قام خمسة مبلغين رئيسيين بتقييم مدى ملاءمة المعايير البالغ عددها 85 مقياسا وفقا لمقياس ليكرت ذي النقاط الخمس. وقد شكلت المقاييس التي حصلت على أعلى ترتيب والبالغ عددها 38 مقياسا، بما فيها مقياسان على الأقل في كل من الوظائف الفرعية الست، مجموعة من المقاييس المقترحة لتقييم القوامة الحالية لنظام صحة الفم. وسيتم تقديم تقرير عن هذه الأداة بشكل منفصل

La présente étude a conçu un cadre d'évaluation de la fonction de gouvernance du système de santé bucco-dentaire en République islamique d'Iran.La Méthode modifiée de détermination de la pertinence des indications de la Rand Corporation et de l'Université de Californie Los Angeles [Rand/UCIA]a été utilisée, dans un processus en deux étapes, combinant les données probantes de la littérature et le point de vue collectif d'experts.Après un examen exhaustif de la littérature, des instruments de politiques liés aux composantes de gouvernance ont été extraits en tant que normes candidates puis classés en catégories selon les six sous-fonctions de gouvernance [responsabilisation, définition d'une orientation stratégique, harmonisation des objectifs politiques et de la structure organisationnelle, réglementation, direction intersectorielle et production de données]. Cinq informateurs clés ont ensuite attribué une note à la pertinence de 85 normes sur l'échelle de Likert en cinq points.Les 38 normes les mieux notées, dont au moins deux normes dans chacune des six sous-fonctions, ont formé un ensemble propose pour l'évaluation de la gouvernance actuelle du système de santé bucco-dentaire.Le pilotage de l'instrument fera l'objet d'un rapport distinct

Developing a policy guidance for financing dental care in Iran using the RAND Appropriateness Method.

OBJECTIVE: This study aimed to provide recommendations on health care financing with special emphasis on dental care. METHODS: The RAND Appropriateness Method was employed to obtain the collective opinion of a multidisciplinary panel of experts on a set of recommendation statements regarding Iranian dental care financing. An initial set of recommendations were identified from a literature review. Panel members, selected purposively and by peer nomination, each rated the appropriateness and necessity of the recommendations in a structured process of two rounds. Each recommendation was classified as inappropriate, uncertain, appropriate but not necessary, or appropriate and necessary according to the median rating score and the level of disagreement among the panellists. RESULTS: Of 28 initial recommendations, 25 were agreed on as appropriate, of which 22 were considered as necessary. Altogether, these recommendations provide a holistic picture of an oral health system's financing in three domains: revenue collection, pooling of revenues and purchasing of dental services. CONCLUSION: The policy guidance recommendations are intended to provide the Iranian oral health authorities with an evidence-base for financing dental care. The recommendations may be transferrable, at least in part, particularly to developing countries with similar hybrid health system structures. Finally, the method used to develop the recommendations can serve as a model for use elsewhere.

Ex vivo and preclinical assessment of an endothelial progenitor cell capturing bioengineered stent.

Although drug-eluting stents (DES) have significantly reduced the rates of restenosis as compared to bare metal stents, late stent thrombosis remains a major drawback, especially for "off-label" use. Delayed arterial healing, characterized by persistent fibrin deposition and poor endothelialization, has been shown to correlate with late DES thrombosis. To overcome these limitations, a "pro-healing" approach has been developed to capture circulating endothelial progenitor cells (EPC) to enhance endothelialization of the stent surface. EPC have the ability to migrate to sites of vascular injury and aid the regeneration of damaged and dysfunctional endothelium. Clinically, the safety of EPC-capture stent has been proven in numerous clinical trials with low incidence of late stent thrombosis. The focus of this review is to demonstrate the efficacy of the Genous stent in preclinical studies, specifically to show the effectiveness of the anti-CD34+ coating in promoting endothelialization and reducing thrombogenicity.

Effects of vaginal versus oral misoprostol to terminate second-trimester pregnancy.

OBJECTIVES: Using surgical methods compared to medical methods, such as misoprostol for termination of pregnancy, has several side effects. This study was performed in order to compare the effect of vaginal and oral misoprostol in second-trimester pregnancy termination (14-24 weeks). MATERIALS AND METHODS: The authors performed a clinical trial study in 40 pregnant women at 14 to 24 weeks of gestation and candidates for medical interruption of pregnancy. All patients received 600 microg of vaginal misoprostol as primary dosage and then, were placed randomly in two groups consisting of 20 patients that received 400 microg of vaginal or oral misoprostol, every four hours, up to three doses. If the abortion was incomplete, oxytocin was used. Twenty-four hours after the procedure, uterine sonography was performed in all patients and if residue was found, the patients were then candidates for curettage. RESULTS: Seventeen patients (85%) in the vaginal group and 17 patients (85%) in the oral group had successful pregnancy interruption. The mean interval until the discharge of pregnancy products in the vaginal group (15/42 +/- 10/84) showed no significant difference compared to the oral group (12/65 +/- 7/8) and no significant differences in side-effects were found between the two groups. CONCLUSION: Oral misoprostol is as effective as vaginal misoprostol in performing second-trimester abortion. It appears that the vaginal misoprostol primary dose together with the continuation of oral dose is not more effective compared to the vaginal misoprostol method alone.

Reducing the absorbed dose in analogue radiography of infant chest images by improving the image quality, using image processing techniques.

Radiographic inspection is one of the most widely employed techniques for medical testing methods. Because of poor contrast and high un-sharpness of radiographic image quality in films, converting radiographs to a digital format and using further digital image processing is the best method of enhancing the image quality and assisting the interpreter in their evaluation. In this research work, radiographic films of 70 infant chest images with different sizes of defects were selected. To digitise the chest images and employ image processing the two algorithms (i) spatial domain and (ii) frequency domain techniques were used. The MATLAB environment was selected for processing in the digital format. Our results showed that by using these two techniques, the defects with small dimensions are detectable. Therefore, these suggested techniques may help medical specialists to diagnose the defects in the primary stages and help to prevent more repeat X-ray examination of paediatric patients.

Psychomotor delay, a possible rare presentation of moyamoya disease.

Moyamoya disease is a rare, chronic cerebrovascular occlusive disease of unknown etiology. It is characterized by progressive stenosis of the arteries of the circle of Willis leading to ischemic strokes in young people and cerebral hemorrhage, which is more frequent in adults. Secondarily, an abnormal network of fine collateral vessels arises at the base of the brain. The term moyamoya refers to the angiographic appearance of the cerebral vasculature. We present such a disease in an 18-month-old Iranian girl with global developmental delay, which is a very rare presentation of moyamoya disease. She was diagnosed by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA).

Stomatal vs. genome size in angiosperms: the somatic tail wagging the genomic dog?

BACKGROUND AND AIMS: Genome size is a function, and the product, of cell volume. As such it is contingent on ecological circumstance. The nature of 'this ecological circumstance' is, however, hotly debated. Here, we investigate for angiosperms whether stomatal size may be this 'missing link': the primary determinant of genome size. Stomata are crucial for photosynthesis and their size affects functional efficiency. METHODS: Stomatal and leaf characteristics were measured for 1442 species from Argentina, Iran, Spain and the UK and, using PCA, some emergent ecological and taxonomic patterns identified. Subsequently, an assessment of the relationship between genome-size values obtained from the Plant DNA C-values database and measurements of stomatal size was carried out. KEY RESULTS: Stomatal size is an ecologically important attribute. It varies with life-history (woody species < herbaceous species < vernal geophytes) and contributes to ecologically and physiologically important axes of leaf specialization. Moreover, it is positively correlated with genome size across a wide range of major taxa. CONCLUSIONS: Stomatal size predicts genome size within angiosperms. Correlation is not, however, proof of causality and here our interpretation is hampered by unexpected deficiencies in the scientific literature. Firstly, there are discrepancies between our own observations and established ideas about the ecological significance of stomatal size; very large stomata, theoretically facilitating photosynthesis in deep shade, were, in this study (and in other studies), primarily associated with vernal geophytes of unshaded habitats. Secondly, the lower size limit at which stomata can function efficiently, and the ecological circumstances under which these minute stomata might occur, have not been satisfactorally resolved. Thus, our hypothesis, that the optimization of stomatal size for functional efficiency is a major ecological determinant of genome size, remains unproven.

Underreporting of major obstetric haemorrhage in the Netherlands.

Major obstetric haemorrhage (MOH) is the main cause of severe maternal morbidity, incidence being estimated at 4.5 per 1000 deliveries. Cases are not routinely registered in the Netherlands. The objective of this study is to quantify the degree of underreporting of MOH in a large nationwide survey of severe acute maternal morbidity in the Netherlands (LEMMoN) and to estimate the true incidence of MOH in the Netherlands. Retrospective cross-match of the LEMMoN-database with the databases of local blood transfusion laboratories in 65 of 98 hospitals in the Netherlands during a 20-month period, using the capture-recapture method was used. From 16 of 65 centres, the reported transfusion data could not be confirmed by a local obstetrician for logistical reasons. These centres were excluded leaving 49 hospitals available for final analysis. In both databases together, 1018 unique cases of MOH were identified. Underreporting to LEMMoN was 35%. Hence, the true incidence of MOH in the Netherlands is at least 6.1 instead of 4.5 per 1000 deliveries. The estimated underreporting of MOH of 35% is considerable. Underreporting is inherent to large observational multicentre studies and should be anticipated and quantified to facilitate fair comparison of epidemiologic data.

Endovascular histologic effects of ultrathin gold- or vitronectin-coated platinum aneurysm coils in a rodent arterial occlusion model: a preliminary investigation.

BACKGROUND AND PURPOSE: Novel stratagems to improve the efficacy of platinum coils in occluding cerebral aneurysms have primarily involved coating coils with materials thought likely to provoke more desirable histologic reactions. No investigations to date, however, have evaluated the utility of gold or vitronectin coatings, despite known endovascular histologic effects of these agents, which may be favorable for treating cerebral aneurysms. This study was conducted to evaluate the degree of endovascular histologic change associated with ultrathin gold- or vitronectin-coated platinum coils. It was hypothesized that such coatings would increase intra-aneurysmal intimal hyperplasia and the degree of luminal occlusion compared with standard platinum coils. MATERIALS AND METHODS: The ligated carotid artery rat model was used to study 4 different aneurysm coil conditions: no coil (sham-surgery controls), uncoated platinum coil, and gold- or vitronectin-coated platinum coil. Two weeks postimplantation, the aneurysms were harvested and stained with hematoxylin-eosin. Slides were evaluated for the degree of neointimal response by a pathologist blinded to treatment. Additional quantitative evaluation was performed blindly by using the ratio of intimal-to-luminal cross-sectional area. RESULTS: A gold- or vitronectin-coated platinum aneurysm coil produced a statistically significant increase in neointimal response compared with a sham (no coil). Arterial segments treated with gold-coated platinum coils also demonstrated a statistically significant 100% increase in neointimal response compared with those treated with bare platinum coils. CONCLUSIONS: In concordance with our hypothesis, ultrathin coatings of gold provoked a neointimal response and degree of luminal occlusion greater than that of plain platinum aneurysm coils in a rat arterial occlusion model.

Preclinical assessment of the receptor-binding domain of Plasmodium vivax Duffy-binding protein as a vaccine candidate in rhesus macaques.

The receptor-binding domain of Plasmodium vivax Duffy-binding protein, region II (PvRII), is an attractive candidate for a vaccine against P. vivax malaria. Here, we have studied the safety and immunogenicity of recombinant PvRII in Macaca mulatta (rhesus monkeys). Recombinant PvRII with a C-terminal 6-histidine tag was expressed in E. coli, recovered from inclusion bodies, refolded into its functional conformation, purified to homogeneity and formulated with three adjuvants, namely, Alhydrogel, Montanide ISA 720 and the GSK proprietary Adjuvant System AS02A for use in immunogenicity studies. All the PvRII vaccine formulations tested were safe and highly immunogenic. The overall magnitude of the antibody response was significantly higher for both Montanide ISA 720 and AS02A formulations in comparison with Alhydrogel. Furthermore, there was a significant correlation between antibody recognition titers by ELISA and binding inhibition titers in in vitro binding assays. The PvRII vaccine formulations also induced IFN-gamma recall responses that were identified using ex vivo ELISPOT assays. These results provide support for further clinical development of a vaccine for P. vivax malaria based on recombinant PvRII.

Distinct patterns of DeltaFosB induction in brain by drugs of abuse.

The transcription factor DeltaFosB accumulates and persists in brain in response to chronic stimulation. This accumulation after chronic exposure to drugs of abuse has been demonstrated previously by Western blot most dramatically in striatal regions, including dorsal striatum (caudate/putamen) and nucleus accumbens. In the present study, we used immunohistochemistry to define with greater anatomical precision the induction of DeltaFosB throughout the rodent brain after chronic drug treatment. We also extended previous research involving cocaine, morphine, and nicotine to two additional drugs of abuse, ethanol and Delta(9)-tetrahydrocannabinol (Delta(9)-THC, the active ingredient in marijuana). We show here that chronic, but not acute, administration of each of four drugs of abuse, cocaine, morphine, ethanol, and Delta(9)-THC, robustly induces DeltaFosB in nucleus accumbens, although different patterns in the core vs. shell subregions of this nucleus were apparent for the different drugs. The drugs also differed in their degree of DeltaFosB induction in dorsal striatum. In addition, all four drugs induced DeltaFosB in prefrontal cortex, with the greatest effects observed with cocaine and ethanol, and all of the drugs induced DeltaFosB to a small extent in amygdala. Furthermore, all drugs induced DeltaFosB in the hippocampus, and, with the exception of ethanol, most of this induction was seen in the dentate. Lower levels of DeltaFosB induction were seen in other brain areas in response to a particular drug treatment. These findings provide further evidence that induction of DeltaFosB in nucleus accumbens is a common action of virtually all drugs of abuse and that, beyond nucleus accumbens, each drug induces DeltaFosB in a region-specific manner in brain.

Investigating sacroplasty: technical considerations and finite element analysis of polymethylmethacrylate infusion into cadaveric sacrum.

BACKGROUND AND PURPOSE: Sacroplasty is not as routinely performed as vertebroplasty, possibly due to technical challenges and the paucity of data regarding subsequent outcomes. The first goal of the present investigation was to describe a technique for sacroplasty that facilitates safe needle placement and polymethylmethacrylate (PMMA) extrusion. The second goal was to perform finite element analysis (FEA) by using a geometric model of sacral fracture to identify mechanical outcomes of sacroplasty. MATERIALS AND METHODS: Sacroplasty was performed on fresh pelvis specimens (n=4) under biplane fluoroscopy. Cadavers were imaged via CT before and after sacroplasty and volume rendered to examine needle placement and PMMA extrusion. The volume-rendered CT data were then used to generate geometric models of the intact, fractured, and cement-augmented fractured sacrum for comparison by using FEA. RESULTS: CT data demonstrate that safe injection needle placement and PMMA delivery may be facilitated by orienting the needle parallel to the L5-S1 interspace and ipsilateral sacroiliac joint, then targeting the superolateral sacral ala within an area bounded by a line lateral to the posterior foraminal openings and a line superimposed on the medial edge of the sacroiliac joint. FEA revealed that simulated sacroplasty decreased maximal principal stress at the point of sacral fracture propagation by 83% and fracture gap micromotion by 48%. CONCLUSION: Sacral landmarks can be used to place PMMA safely where sacral fractures occur. FEA suggests that sacroplasty may decrease fracture-associated mechanical stress and micromotion, which may contribute to patient reports of decreased pain and increased mobility postsacroplasty.

Optimal dosage of cyclopentolate 1% for complete cycloplegia: a randomized clinical trial.

PURPOSE: To determine the optimal dosage of cyclopentolate for adequate cycloplegia with minimal side effects. METHODS: A prospective randomized clinical trial of patients 3.5 to 20 years of age referred to a strabismus clinic during a 1-year period. Eligible patients were randomly divided into three groups. In Group 1, the cycloplegic effect of one drop of cyclopentolate was compared with two drops; in Group 2, the effect of two drops was compared with three drops; and in Group 3, the effect of one drop was compared with three drops. RESULTS: This study includes 192 eyes of 96 patients with a mean age of 11.0 +/- 5.7 years. Strabismus was present in 43 patients (44.8%). A total of 146 patients (76%) were hyperopic, 33 (17.2%) were myopic, and 13 (6.8%) were slightly hyperopic or myopic at the two stages of the study. Overall, only 16 eyes, including 9 eyes in Group 1 (16.4%), 2 eyes in Group 2 (3.2%), and 5 eyes in Group 3 (8.6%), had > or = 0.5 D difference in spherical equivalent refractive error at two stages of the study; however, intergroup differences were not statistically significant (p=0.16, chi-square test). Within each group, the percentage of eyes with <0.5 D difference was significantly greater than those with > or = 0.5 D difference (p<0.001 in all three groups, binomial test). Side effects were more prevalent using more frequent drops. CONCLUSIONS: A single drop of cyclopentolate 1% suffices for cycloplegic refraction. There were less frequent side effects using one drop of cyclopentolate, compared to two or three drops.