Detection of dynamic stability deficits in subjects with functional ankle instability

PURPOSE: To determine which combination of landing protocol and analysis technique would be the most effective at detecting differences in dynamic stability between healthy subjects and subjects with functional ankle instability (FAI). METHODS: Fifty-eight subjects participated in this investigation: 29 healthy individuals and 29 individuals with FAI. Subjects were assessed during a single test session for time to stabilization (TTS) in the anterior/posterior, medial/lateral, and vertical directions from two protocols: a step down and jump protocol. The step down protocol started with each subject atop a 20-cm-high platform, and the jump protocol started with subjects in a standing position 70 cm from the center of a force plate and required each subject to jump off both legs and touch a designated marker placed at a position equivalent to 50% of the subject's maximum vertical leap. TTS scores in the anterior/posterior, medial/lateral, and vertical direction were compared between group, protocol, and type of analysis. RESULTS: A significant protocol by analysis by group interaction (F(1,56) = 6.9, P = 0.011) was observed for anterior/posterior TTS. Likewise, protocol by group (F(1,56) = 4.4, P = 0.042) and protocol by analysis (F(1,56) = 14.1, P < 0.001) interactions were also noted in anterior/posterior TTS. The jump protocol (2381.7 +/- 36.5 ms) produced significantly greater TTS scores in the vertical direction than the step protocol (1533.5 +/- 71.8 ms), whereas the unbounded third order polynomial (UTOP) method (2554.4 +/- 68.7 ms) produced significant greater TTS scores as compared with the sequential estimation (SE) method (1360.8 +/- 52.1 ms). CONCLUSIONS: The jump protocol and UTOP method of analysis are the most effective TTS combination in detecting differences between healthy and FAI groups.     

MDCT of abdominal wall hernias: is there a role for valsalva's maneuver?

OBJECTIVE: Our objective was to evaluate the role of Valsalva's maneuver during MDCT for the diagnosis and characterization of abdominal wall hernias. SUBJECTS AND METHODS: From September 2002 to May 2003, 100 consecutive patients (37 men and 63 women; mean age, 53 years) with suspected anterior abdominal wall hernias underwent 4-, 8-, or 16-MDCT with and without Valsalva's maneuver. Patients received both oral and IV contrast material. On a workstation, three independent reviewers evaluated each scan obtained during rest and during Valsalva's maneuver for the following parameters: anteroposterior (AP) diameter of the abdomen; presence, location, and contents of the hernia; and transverse diameter of the fascial defect. The scans were compared to assess for changes in hernia size and contents and to determine whether the hernia would have been overlooked without Valsalva's maneuver. Fisher's exact test, the McNemar test, and Cohen's kappa coefficient were used to assess for significant differences. RESULTS: The three reviewers identified a mean of 72 abdominal wall hernias (72%). The reviewers agreed (kappa = 0.723) with respect to the presence of a hernia. AP diameters increased an average of 1.33 cm during Valsalva's maneuver (p < 0.001). The transverse diameter of the fascial defect increased an average of 0.66 cm and the AP diameter of the hernia sac increased an average of 0.79 cm during Valsalva's maneuver (p < 0.001). Fifty percent of the hernias became more apparent with Valsalva's maneuver. Ten percent of the hernias could be detected only on the scan obtained during Valsalva's maneuver. Conversely, in no patients was the hernia detected only on the rest scan. CONCLUSION: As opposed to scans obtained at rest, scans obtained during Valsalva's maneuver aid in the detection and characterization of suspected abdominal wall hernias. A single scan obtained during Valsalva's maneuver is sufficient to detect 100% of anterior abdominal wall hernias identified on CT.     

In vivo activation of gelatinase B/MMP-9 by trypsin in acute pancreatitis is a permissive factor in streptozotocin-induced diabetes

Matrix metalloproteinases, in particular gelatinase B/MMP-9, are key mediators in autoimmune diseases like multiple sclerosis and rheumatoid arthritis, but their pathogenic roles in diabetes are not well established. Gelatinase B has previously been shown to be upregulated in pancreas tissue from patients with acute and chronic pancreatitis and was suggested to exacerbate diabetes by cleaving insulin. In this study, the role of gelatinase B in diabetes was investigated using two streptozotocin-induced animal models of type I diabetes. In both a hyperacute and a subacute model, gelatinase B upregulation was found to be associated with disease activity. However, gelatinase B deficiency did not significantly protect against diabetes development, and wild-type and gelatinase B-deficient animals behaved similarly in terms of beta-cell apoptosis or necrosis. The fact that gelatinase B was found almost exclusively as the inactive pro-enzyme in most of the streptozotocin-induced diabetic animals may explain the lack of a gelatinase B effect. On the contrary, gelatinase B was completely activated in a minority (15%) of wild-type animals. This coincided with exocrine pancreatic inflammation, as revealed by the presence of active trypsin. The discovery of in vivo activation of progelatinase B by trypsin in acute pancreatitis is extended in a model of caerulein-induced pancreatitis. In the latter model, trypsinogen activation is systematically achieved and gelatinase B is found in its active form. In conclusion, gelatinase B itself is not a causative factor but, when activated by endogenous trypsin, is a permissive factor for insulin degradation and diabetes.     

Management of ovarian cysts

BACKGROUND: The treatment of an ovarian cyst relies on its nature, and accurate preoperative discrimination of benign and malignant cysts is therefore of crucial importance. This study was undertaken to review the literature concerning the preoperative diagnosis and treatment of ovarian cysts. METHODS: Articles concerning ovarian cysts from a medline literature search during the period 1985-2003 were included in addition to articles found as references in the initial publications. RESULTS: Different methods for discriminating between benign and malignant ovarian cysts are discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status, pregnancy, and whether the cyst is presumed to be benign or malignant. In general, expectant management is the choice in premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular, anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels of CA-125. Women with symptoms should be operated regardless of age, menopausal status, or ultrasound findings. CONCLUSIONS: The preoperative discrimination between benign and malignant ovarian cysts is a challenge. Multimodal methods improve the results of single modalities, but we still need improved preoperative diagnostic tools. Furthermore, these methods should be validated in consecutive patient populations large enough to give a reliable estimate of the method's sensitivity and specificity.     

Single-step maternal serum screening for trisomy 21 in the era of combined or integrated screening

Single-step maternal serum screening (MSS) in the first (1MSS) or second (2MSS) trimester at maternal age > or =35 years was evaluated in the North Belgian region Flanders, where difficulties are encountered in the general introduction of combined or integrated screening algorithms. The fetal aneuploidy screening database of General Medical Laboratory AML in Antwerp was searched for 2MSS tests between 1992 and 1999 (alpha-fetoprotein, beta-human chorionic gonadotropin (beta-HCG) and unconjugated estriol, cut-off 1:300) and for 1MSS tests between 1999 and 2003 (free beta-HCG and pregnancy-associated plasma protein A, cut-off 1:85). At > or =35 years, the detection rate for trisomy 21 (DR) was 93.8% (15/16) for 2MSS and the screen-positive rate (SPR) was 24.5% (504/2061). For 1MSS, these figures were 85.7% (6/7) and 17.7% (109/615) respectively. To detect one trisomy 21, missed by MSS at > or =35 years of age, an additional number of 1,557 and 506 primary invasive procedures would be needed for 2MMS and 1MSS respectively. We conclude that the performance of both single-step 1MSS and 2MSS at maternal age > or =35 years in Flanders is excellent, even without the combination with ultrasound parameters or integration of first and second trimester parameters. The simplicity of both methods allows to consider them valuable options for fetal aneuploidy screening at advanced maternal age, until high quality combined or integrated screening is accessible to all pregnant women in Belgium.