Errors in Patient Positioning for Bone Mineral Density Assessment by Dual X-Ray Absorptiometry: Effect of Technologist Retraining

Improper positioning is one of the factors that can lead to incorrect bone mineral density (BMD) results. This study aimed to assess the frequencies of erroneous positioning during three periods: before retraining of the technologists (BR), after retraining (AR), and at the current timepoint 8 years after retraining (C). The BMD images of the first 150 consecutive patients who underwent DXA of the lumbar spine and hip during each of the three periods were retrospectively reviewed. Patients were excluded if they had severe scoliosis, rendering proper positioning impossible. Each BMD image was assessed by an International Society of Clinical Densitometry certified clinical densitometrist who was blinded to the date of the initial examination. For the lumbar spine in the BR group, the criteria frequently not met were inclusion of both iliac crests (33.8%), straightness (30.3%), and midline positioning (20.4%); the respective frequencies were significantly reduced to 0.8%?5.6%, 2.1%?3.0%, and 0%?2.8% in the AR and C groups (p < 0.05). For the hip in the BR group, the criteria frequently not met were straightness (52.8%) and internal rotation (21.8%); the respective frequencies were significantly reduced to 0%?4.2% and 8.3%?8.4% in the AR and C groups (p < 0.05). Overall improper positioning in the BR group was 49.3% and 57.3% at the lumbar spine and the hip, respectively; the respective frequencies were reduced to 9.3% and 12.7% in the AR group, and to 2.7% and 7.3% in the C group. The least significant change values for the lumbar spine, femoral neck, and total hip also became smaller after retraining. Retraining the technologists improved patient positioning, as evidenced by the decreased frequencies of erroneous positioning and the improved least significant change values after the retraining.     

The lowest effective dose of botulinum A toxin in adult patients with upper limb spasticity

Objective: To define the lowest effective dose of botulinum toxin type A (Dysport®) and safety in the treatment of adult patients with upper limb spasticity.

Design: This was a prospective, randomized, double-blind, dose-ranging study. Patients received either a placebo or one of three doses of Dysport® (350, 500, 1000 U) into five muscles of affected arm by anatomical and electromyography guidance. Efficacy was assessed periodically throughout the 6-month study period by the Modified Ashworth Scale (MAS), the Action Research Arm Test (ARA), the Barthel Index (BI) and the Visual Analogue Pain Scale (VAS).

Results: Fifty patients were recruited. The four study groups were comparable at baseline with respect to their demographical characteristics and severity of spasticity. All doses of Dysport® studied showed a significant reduction from baseline of muscle tone and pain compared to placebo. However, the effect of functional disability was best at a dose of 500 U and the peak improvement was at week 8 after injection. A dose of 1000 U Dysport produced such an excess degree of muscle weakening that the number of randomized patients was reduced to five. BI and ARA of all patients were decrease after injection. No other adverse event was considered related to the study medication.

Conclusion: This study suggests that treatment with Dysport® reduces muscle tone in adult patients with upper limb spasticity. The optimal dose for treatment of patients with residual voluntary movement in the upper limb appears to be 500 U.     

Molecular Evolution of Genetic Susceptibility to Hepatocellular Carcinoma

Background

Hepatocellular carcinoma (HCC) is a leading cancer-related cause of death worldwide. There are widespread global differences in HCC risk. Although the impact of geographic prevalence of specific causes of chronic liver disease on HCC is recognized, the contribution of the underlying genetic architecture to the risk of HCC remains undefined. Our aim was to characterize evolutionary trends in genetic susceptibility to HCC.

Methods

We examined the genetic risk associated with HCC risk alleles identified from genome-wide association studies and correlated these with geographic location and temporal and spatial patterns of human migration.

Results

A moderate increase in differentiation was noted for rs2596542 (F _st = 0.106) and rs17401966 (F _st = 0.116), single nucleotide polymorphisms (SNPs) associated with an increased risk of HCC in patients with chronic HCV and HBV, respectively. Both of these SNPs show a recent increase in allelic frequency with the most recent human migrations into East Asia, Oceania and the Americas. In contrast another SNP associated with an increased risk of HCC, rs9275572, showed a lack of differentiation (F _st = 0.09) with stable allelic expression across populations. The genetic risk score for HCC, based on the allelic frequency and risk odds ratio of five SNPs associated with increased risk of HCC, was greatest in populations from Africa and decreased with subsequent migration into Europe and Asia. However, a major increase was noted with the most recent migrations into Oceania and the Americas.

Conclusions

There are differences in directional differentiation of HCC risk alleles across human populations that can contribute to population-based differences in HCC prevalence.     

Endoscopic Management of Recalcitrant Marginal Ulcers by Covering the Ulcer Bed

Background

Management options for marginal ulcers (MU) vary from medical therapy to revision surgery. Medical therapy is often ineffective and revision surgery is associated with a high morbidity and possible recurrence.

Aims

To evaluate technical feasibility, efficacy, and safety of endoscopic management of MU by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent (FCSEMS).

Methods

Medical records of consecutive patients who underwent endoscopic suturing and/or FCSEMS deployment for recalcitrant MU between August 2016 and June 2017 at a single academic center were reviewed. Recalcitrant MU was defined as an ulcer that persists after 6 to 8 weeks despite maximal medical therapy (open capsule PPI, 40 mg bid as well as sucralfate qid), cessation of smoking and nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori eradication.

Results

Eleven patients (age range 31–60; all females) with mean BMI of 27.72 ±?5.93 kg/m² underwent endoscopic suturing and/or stent deployment for recalcitrant MU with abdominal pain at a median of 50 months (range 3–120) post-Roux-en-Y gastric bypass (RYGB). Seven patients were managed by oversewing, two were managed by FCSEMS, and two patients required both. Technical success was 100%. All patients reported resolution of abdominal pain at 1 week. Surveillance endoscopy performed in 10/11 (90.9%) patients at 8 weeks revealed complete ulcer healing in 9/10 (90%). No adverse events were reported.

Conclusion

Endoscopic management is an effective and safe method to treat MU and should be considered an alternative to surgical revision. It appears effective for perforated and recalcitrant MU.

     

Karyotypic evolution in squamate reptiles: comparative gene mapping revealed highly conserved linkage homology between the butterfly lizard (Leiolepis reevesii rubritaeniata, Agamidae, Lacertilia) and the Japanese four-striped rat snake (Elaphe quadrivirgata, Colubridae, Serpentes)

The butterfly lizard (Leiolepis reevesii rubritaeniata) has the diploid chromosome number of 2n = 36, comprising two distinctive components, macrochromosomes and microchromosomes. To clarify the conserved linkage homology between lizard and snake chromosomes and to delineate the process of karyotypic evolution in Squamata, we constructed a cytogenetic map of L. reevesii rubritaeniata with 54 functional genes and compared it with that of the Japanese four-striped rat snake (E. quadrivirgata, 2n = 36). Six pairs of the lizard macrochromosomes were homologous to eight pairs of the snake macrochromosomes. The lizard chromosomes 1, 2, 4, and 6 corresponded to the snake chromosomes 1, 2, 3, and Z, respectively. LRE3p and LRE3q showed the homology with EQU5 and EQU4, respectively, and LRE5p and LRE5q corresponded to EQU7 and EQU6, respectively. These results suggest that the genetic linkages have been highly conserved between the two species and that their karyotypic difference might be caused by the telomere-to-telomere fusion events followed by inactivation of one of two centromeres on the derived dicentric chromosomes in the lineage of L. reevesii rubritaeniata or the centric fission events of the bi-armed macrochromosomes and subsequent centromere repositioning in the lineage of E. quadrivirgata. The homology with L. reevesii rubritaeniata microchromosomes were also identified in the distal regions of EQU1p and 1q, indicating the occurrence of telomere-to-telomere fusions of microchromosomes to the p and q arms of EQU1.     

Protective effects of quercetin against phenylhydrazine-induced vascular dysfunction and oxidative stress in rats.

Oxidative stress is a major contributor to the development of vascular dysfunction found in various pathological conditions. Quercetin, one of the potent antioxidant bioflavonoid compounds, has been shown to alleviate oxidative injury by modulation of gene expression leading to suppression of production of reactive oxygen and nitrogen species and conferring an antiapoptotic activity. The aim of the present study was to investigate the protective effects of quercetin in a model of phenylhydrazine (PHZ)-induced oxidant stress, vascular dysfunction and hemodynamic disturbance in rats. Male Sprague-Dawley rats were administered quercetin orally (25 or 50mg/kg/day) for 6 days. On day four, all animals except those in the normal control group, were administered PHZ intraperitoneally. The results showed that PHZ induced severe hemolysis. The mean arterial pressure and hindlimb vascular resistance of PHZ-control rats were markedly decreased compared to normal controls. Treatment with quercetin significantly improved arterial blood pressure and peripheral vascular resistance. Vascular responsiveness to bradykinin, acetylcholine, and phenylephrine in PHZ-control rats was dramatically suppressed and quercetin restored these responses in a dose-dependent manner. Quercetin partially protected blood glutathione, suppressed plasma malondialdehyde levels, and largely suppressed nitric oxide metabolites and superoxide anion production. These results provide the first evidence for the role of the flavonoid, quercetin, in the alleviation of vascular dysfunction in an animal model of PHZ-induced oxidant stress.     

Significance of tubulointerstitial fibrosis in paediatric IgM nephropathy

Summary: The significance of tubulointerstitial fibrosis in paediatric patients with primary diffuse mesangial proliferative glomerulonephritis and IgM deposition (IgM nephropathy) has not been well documented. the clinical course, therapeutic response and final outcome of 35 patients in whom renal biopsies showed IgM nephropathy are reported. They have been subdivided into two groups according to the absence (19 patients: group I) or presence (16 patients: group II) of superimposed lesion of tubulointerstitial fibrosis. Clinical presentation was similar in both groups but the patients in group I were male predominant (2.8:1 vs 1: 1). 6/19 (31.6%) of the patients in group I and 1/16 (6.3%) in group II responded to corticosteroid, 11/19 (57.9%) in group I and 8/16 (50.0%) in group II had steroid dependent, whereas 2/19 (10.5%) in group I and 7/16 (43.7%) in group II had steroid resistant. About 42% of the patients in group I and 94% in group II required cyclophosphamide therapy by which similar response in both groups (approximately 75%) were observed. the steroid non-responders and cyclophosphosphamide therapy among patients in group II were significantly higher ( P <0.05) than the group I. At the latest assessment, 5/16 (31.3%) in group I and 7/14 (50%) in group II had impaired renal function. the follow-up period in both groups were 3.1 ± 2.8 and 3.4 ± 2.9 years, respectively. In conclusion, the finding of tubulointerstitial fibrosis in a paediatric IgM nephropathy indicates an unfavourable therapeutic response.     

Local botulinum toxin type A injections in the treatment of spastic toes

OBJECTIVE: To investigate the efficacy and safety of botulinum toxin type A treatment of spastic toes using varying doses based on the degree of spasticity (Modified Ashworth Scale). DESIGN: Single-center, open-label, prospective study. Hemiplegic patients with either hitchhiker's great toes (persistent extension of the great toes) or toe flexor spasms with pain during walking were treated with local intramuscular injections of botulinum toxin type A. Initial botulinum toxin type A dose per muscle was 25 units for patients with a baseline Ashworth score of 2, 50 units for a score of 3, and 75 units for a score of 4. Additional botulinum toxin type A injections were allowed if there was an insufficient clinical response to initial treatment. The muscles injected included flexor digitorum, extensor hallucis longus, and/or flexor hallucis longus. All injections were made using electromyographic guidance. Outcome measures were the Modified Ashworth Scale, a visual pain scale, a visual percentage of function scale, and adverse effects. RESULTS: Twenty patients were enrolled. The dose of botulinum toxin type A used ranged from 25 to 35 units per muscle for an Ashworth score of 2, from 50 to 70 units per muscle for a score of 3, and from 75 to 95 units per muscle for a score of 4. There were improvements in all outcome measures. In most patients, the benefits lasted 5-6 mo, with a few patients exhibiting benefits for > or =2 yr. There were no adverse effects. CONCLUSIONS: Botulinum toxin type A treatment using doses based on spasticity severity seems to be safe and effective in the treatment of spastic toes, and further study is warranted.