The role of central hypersensitivity in the determination of intradiscal mechanical hyperalgesia in discogenic pain

OBJECTIVE: The primary aim of the present study was to investigate whether there is a relationship between central hypersensitivity (assessed by pressure pain thresholds of uninjured tissues) and intradiscal pain threshold during discography. The secondary aim was to test the hypothesis that peripheral noxious stimulation dynamically modulates central hypersensitivity. PATIENTS: Twenty-four patients with positive provocation discography were tested for central hypersensitivity by pressure algometry before and after the intervention with assessments of pressure pain detection and tolerance thresholds. Intradiscal pain threshold was assessed by measuring intradiscal pressure at the moment of pain provocation during discography. Correlation analyses between intradiscal pain threshold and pressure algometry were made. For the secondary aim, pressure algometry data before and after discography were compared. RESULTS: Significant correlation with intradiscal pain threshold was found for pressure pain detection threshold at the toe (regression coefficient: 0.03, P = 0.05) and pressure pain tolerance thresholds at the nonpainful point at the back (0.02, P = 0.024). Tolerance threshold at the toe was a significant predictor for intradiscal pain threshold only in multiple linear regression (0.036, P = 0.027). Detection as well as tolerance thresholds significantly decreased after discography at the painful and the nonpainful point at the back, but not at the toe. CONCLUSIONS: Central hypersensitivity may influence intradiscal pain threshold, but with a modest quantitative impact. The diagnostic value of provocation discography is therefore not substantially impaired. Regional, but not generalized central hypersensitivity is dynamically modulated by ongoing peripheral nociceptive input.

Prevalence of burnout among surgical residents and surgeons in Switzerland

Burnout is a pathologic reaction in response to long-term work-related stress. The aim of this study was 2-fold: first, to assess the prevalence and degree of burnout among surgical residents and surgeons in Switzerland and, second, to identify predictors of burnout in the surgical community. Four hundred five of 618 anonymous questionnaires (65.5%) were returned. Among respondents, 3.7% and 35.1% showed high and moderate degrees of burnout, respectively. Respondents with high and moderate degrees of burnout had higher summary scores of perceived stress (P < .001). In multiple logistic regression analysis, the strongest predictors of burnout were poor interaction with nurses, disturbances due to telephone consultations, and high overall workload. To reduce burnout, new work models should be sought, in addition to decreasing work intensity and workload rather than restricting work hours alone.

Echocardiogram versus cardiac magnetic resonance imaging for assessing systolic function of subaortic right ventricle in adults with complete transposition of great arteries and previous atrial switch operation

In adults with congenital heart disease and a systemic right ventricle, subaortic ventricular systolic dysfunction is common. Echocardiographic assessment of systolic right ventricular (RV) function in these patients is important but challenging. The aim of the present study was to assess the reliability of conventional echocardiographic RV functional parameters to quantify the systolic performance of a subaortic right ventricle. We compared 56 contemporary echocardiograms and cardiac magnetic resonance studies in 37 adults, aged 26.9 ± 7.4 years, with complete transposition and a subaortic right ventricle. The fractional area change (FAC), lateral tricuspid annular plane systolic excursion, lateral RV systolic motion velocities by tissue Doppler, RV myocardial performance index, and the rate of systolic RV pressure increase (dp/dt) measured across the tricuspid regurgitant jet were assessed by echocardiography and correlated with the cardiac magnetic resonance-derived RV ejection fraction (EF). The mean RVEF was 48.0 ± 7.8%. FAC (r(2) = 0.206, p = 0.001) and dp/dt (r(2) = 0.173, p = 0.009) significantly correlated with RVEF, and the other nongeometric echocardiographic parameters failed to show a significant correlation with RVEF by linear regression analysis. FAC <33% and dp/dt <1,000 mm Hg/s identified a RVEF of <50% with a sensitivity of 77% and 69% and a specificity of 58% and 87%, respectively. In conclusion, in patients with a systemic right ventricle, routine nongeometric echocardiographic parameters of RV function correlated weakly with cardiac magnetic resonance-derived EF. RV FAC and the measurement of the rate of systolic RV pressure increase (dp/dt) should be preferentially used to assess systemic systolic function in adult patients with a subaortic right ventricle.

Genome-wide identification of quantitative trait loci in a cross between Hampshire and Landrace I: carcass traits

We report the identification of quantitative trait loci (QTL) affecting carcass composition, carcass length, fat deposition and lean meat content using a genome scan across 462 animals from a combined intercross and backcross between Hampshire and Landrace pigs. Data were analysed using multiple linear regression fitting additive and dominance effects. This model was compared with a model including a parent-of-origin effect to spot evidence of imprinting. Several precisely defined muscle phenotypes were measured in order to dissect body composition in more detail. Three significant QTL were detected in the study at the 1% genome-wide level, and twelve significant QTL were detected at the 5% genome-wide level. These QTL comprise loci affecting fat deposition and lean meat content on SSC1, 4, 9, 10, 13 and 16, a locus on SSC2 affecting the ratio between weight of meat and bone in back and weight of meat and bone in ham and two loci affecting carcass length on SSC12 and 17. The well-defined phenotypes in this study enabled us to detect QTL for sizes of individual muscles and to obtain information of relevance for the description of the complexity underlying other carcass traits.

Collateral-flow measurements in humans by myocardial contrast echocardiography: validation of coronary pressure-derived collateral-flow assessment

AIMS: Myocardial blood flow (MBF) is the gold standard to assess myocardial blood supply and, as recently shown, can be obtained by myocardial contrast echocardiography (MCE). The aims of this human study are (i) to test whether measurements of collateral-derived MBF by MCE are feasible during elective angioplasty and (ii) to validate the concept of pressure-derived collateral-flow assessment. METHODS AND RESULTS: Thirty patients with stable coronary artery disease underwent MCE of the collateral-receiving territory during and after angioplasty of 37 stenoses. MCE perfusion analysis was successful in 32 cases. MBF during and after angioplasty varied between 0.060-0.876 mL min(-1) g(-1) (0.304+/-0.196 mL min(-1) g(-1)) and 0.676-1.773 mL min(-1) g(-1) (1.207+/-0.327 mL min(-1) g(-1)), respectively. Collateral-perfusion index (CPI) is defined as the rate of MBF during and after angioplasty varied between 0.05 and 0.67 (0.26+/-0.15). During angioplasty, simultaneous measurements of mean aortic pressure, coronary wedge pressure, and central venous pressure determined the pressure-derived collateral-flow index (CFI(p)), which varied between 0.04 and 0.61 (0.23+/-0.14). Linear-regression analysis demonstrated an excellent agreement between CFI(p) and CPI (y=0.88 x +0.01; r(2)=0.92; P<0.0001). CONCLUSION: Collateral-derived MBF measurements by MCE during angioplasty are feasible and proved that the pressure-derived CFI exactly reflects collateral relative to normal myocardial perfusion in humans.

Estimation of pelvic tilt on anteroposterior X-rays--a comparison of six parameters

OBJECTIVE: To compare six different parameters described in literature for estimation of pelvic tilt on an anteroposterior pelvic radiograph and to create a simple nomogram for tilt correction of prosthetic cup version in total hip arthroplasty. DESIGN: Simultaneous anteroposterior and lateral pelvic radiographs are taken routinely in our institution and were analyzed prospectively. The different parameters (including three distances and three ratios) were measured and compared to the actual pelvic tilt on the lateral radiograph using simple linear regression analysis. PATIENTS: One hundred and four consecutive patients (41 men, 63 women with a mean age of 31.7 years, SD 9.2 years, range 15.7-59.1 years) were studied. RESULTS: The strongest correlation between pelvic tilt and one of the six parameters for both men and women was the distance between the upper border of the symphysis and the sacrococcygeal joint. The correlation coefficient was 0.68 for men (P<0.001) and 0.61 for women (P<0.001). Based on this linear correlation, a nomogram was created that enables fast, tilt-corrected cup version measurements in clinical routine use. CONCLUSION: This simple method for correcting variations in pelvic tilt on plain radiographs can potentially improve the radiologist's ability to diagnose and interpret malformations of the acetabulum (particularly acetabular retroversion and excessive acetabular overcoverage) and post-operative orientation of the prosthetic acetabulum.

Nerve-sparing open radical retropubic prostatectomy

INTRODUCTION: In recent years, the surgical technique for open radical prostatectomy has evolved and increasing attention is paid to preserving anatomic structures and the impact on outcome and quality of life. METHODS: Technical aspects of nerve-sparing open radical retropubic prostatectomy (RRP) are described. Patient selection criteria and functional results are discussed, focusing on postoperative urinary continence. RESULTS: The video demonstrates the nerve-sparing open RRP and important steps are elucidated with schematic drawings. The value of nerve sparing, not only for preserving erectile function, but also for preserving urinary continence is discussed and results from our institution are presented. In our series, urinary incontinence was present in 1 of 71 patients (1%) with attempted bilateral nerve-sparing, 11 of 322 (3%) with attempted unilateral nerve-sparing, or 19 of 139 (14%) without attempted nerve-sparing surgery. In multiple logistic regression analysis, the only statistically significant factor influencing urinary continence after open RRP was attempted nerve sparing (odds ratio, 4.77; 95% confidence interval, 2.18-10.44; p=0.0001). CONCLUSIONS: Nerve-sparing surgery has a significant impact on erectile function and urinary continence and should be performed in all patients provided radical tumour resection is not compromised. For successful nerve preservation we advocate a lateral approach to the prostate to improve visualisation and simplify separation of the neurovascular bundles from the dorsolateral prostatic capsule. Bunching, ligating, and incising Santorini's plexus over the prostate and not over the sphincter ensures a bloodless surgical field. Mucosa-to-mucosa adaptation of the reconstructed bladder neck and the urethra is another important factor to be observed.

Nerve sparing open radical retropubic prostatectomy--does it have an impact on urinary continence?

PURPOSE: We prospectively assessed the role of nerve sparing surgery on urinary continence after open radical retropubic prostatectomy. MATERIALS AND METHODS: We evaluated a consecutive series of 536 patients who underwent open radical retropubic prostatectomy with attempted bilateral, unilateral or no nerve sparing, as defined by the surgeon, without prior radiotherapy at a minimum followup of 1 year with documented assessment of urinary continence status. Because outlet obstruction may influence continence rates, its incidence and management was also evaluated. RESULTS: One year after surgery 505 of 536 patients (94.2%) were continent, 27 (5%) had grade I stress incontinence and 4 (0.8%) had grade II stress incontinence. Incontinence was found in 1 of 75 (1.3%), 11 of 322 (3.4%) and 19 of 139 patients (13.7%) with attempted bilateral, attempted unilateral and without attempted nerve sparing, respectively. The proportional differences were highly significant, favoring a nerve sparing technique (p <0.0001). On multiple logistic regression analysis attempted nerve sparing was the only statistically significant factor influencing urinary continence after open radical retropubic prostatectomy (OR 4.77, 95% CI 2.18 to 10.44, p = 0.0001). Outlet obstruction at the anastomotic site in 33 of the 536 men (6.2%) developed at a median of 8 weeks (IQR 4 to 12) and was managed by dilation or an endoscopic procedure. CONCLUSIONS: The incidence of incontinence after open radical retropubic prostatectomy is low and continence is highly associated with a nerve sparing technique. Therefore, nerve sparing should be attempted in all patients if the principles of oncological surgery are not compromised.

Curing capability of halogen and LED light curing units in deep class II cavities in extracted human molars

Class II cavities were prepared in extracted lower molars filled and cured in three 2-mm increments using a metal matrix. Three composites (Spectrum TPH A4, Ceram X mono M7 and Tetric Ceram A4) were cured with both the SmartLite PS LED LCU and the Spectrum 800 continuous cure halogen LCU using curing cycles of 10, 20 and 40 seconds. Each increment was cured before adding the next. After a seven-day incubation period, the composite specimens were removed from the teeth, embedded in self-curing resin and ground to half the orofacial width. Knoop microhardness was determined 100, 200, 500, 1000, 1500, 2500, 3500, 4500 and 5500 microm from the occlusal surface at a distance of 150 microm and 1000 microm from the metal matrix. The total degree of polymerization of a composite specimen for any given curing time and curing light was determined by calculating the area under the hardness curve. Hardness values 150 microm from the metal matrix never reached maximum values and were generally lower than those 1000 microm from the matrix. The hardest composite was usually encountered between 200 microm and 1000 microm from the occlusal surface. For every composite-curing time combination, there was an increase in microhardness at the top of each increment (measurements at 500, 2500 and 4500 microm) and a decrease towards the bottom of each increment (measurements at 1500, 3500 and 5500 microm). Longer curing times were usually combined with harder composite samples. Spectrum TPH composite was the only composite showing a satisfactory degree of polymerization for all three curing times and both LCUs. Multiple linear regression showed that only the curing time (p < 0.001) and composite material (p < 0.001) had a significant association with the degree of polymerization. The degree of polymerization achieved by the LED LCU was not significantly different from that achieved by the halogen LCU (p = 0.54).

Immunologic response to antiretroviral therapy in hepatitis C virus-coinfected adults in a population-based HIV/AIDS treatment program

BACKGROUND: We sought to characterize the impact that hepatitis C virus (HCV) infection has on CD4 cells during the first 48 weeks of antiretroviral therapy (ART) in previously ART-naive human immunodeficiency virus (HIV)-infected patients. METHODS: The HIV/AIDS Drug Treatment Programme at the British Columbia Centre for Excellence in HIV/AIDS distributes all ART in this Canadian province. Eligible individuals were those whose first-ever ART included 2 nucleoside reverse transcriptase inhibitors and either a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor and who had a documented positive result for HCV antibody testing. Outcomes were binary events (time to an increase of > or = 75 CD4 cells/mm3 or an increase of > or = 10% in the percentage of CD4 cells in the total T cell population [CD4 cell fraction]) and continuous repeated measures. Statistical analyses used parametric and nonparametric methods, including multivariate mixed-effects linear regression analysis and Cox proportional hazards analysis. RESULTS: Of 1186 eligible patients, 606 (51%) were positive and 580 (49%) were negative for HCV antibodies. HCV antibody-positive patients were slower to have an absolute (P<.001) and a fraction (P = .02) CD4 cell event. In adjusted Cox proportional hazards analysis (controlling for age, sex, baseline absolute CD4 cell count, baseline pVL, type of ART initiated, AIDS diagnosis at baseline, adherence to ART regimen, and number of CD4 cell measurements), HCV antibody-positive patients were less likely to have an absolute CD4 cell event (adjusted hazard ratio [AHR], 0.84 [95% confidence interval [CI], 0.72-0.98]) and somewhat less likely to have a CD4 cell fraction event (AHR, 0.89 [95% CI, 0.70-1.14]) than HCV antibody-negative patients. In multivariate mixed-effects linear regression analysis, HCV antibody-negative patients had increases of an average of 75 cells in the absolute CD4 cell count and 4.4% in the CD4 cell fraction, compared with 20 cells and 1.1% in HCV antibody-positive patients, during the first 48 weeks of ART, after adjustment for time-updated pVL, number of CD4 cell measurements, and other factors. CONCLUSION: HCV antibody-positive HIV-infected patients may have an altered immunologic response to ART.

High-dose intravenous immunoglobulin pulse therapy in patients with progressive immunoglobulin A nephropathy: a long-term follow-up

In progressive immunoglobulin A nephropathy (IgAN), intravenous immunoglobulin (IVIg) treatment has been used to delay disease progression, but the long-term efficacy is largely unknown. We report the clinical outcomes after IVIg therapy in six male patients with progressive IgAN [median glomerular filtration rate (GFR) 31 ml/min per 1.73 m(2)] followed for a median observation period of 8 years. In this single-arm, non-randomized study, IVIg was given monthly at a dose of 2 g/kg body weight for 6 months. The course of renal function was assessed by linear regression analysis of GFR and proteinuria, and was compared to eight patients with IgAN (median GFR 29 ml/min per 1.73 m(2)) without IVIg as a contemporaneous control group. IgAN disease progression was delayed after IVIg therapy on average for 3 years. The mean loss of renal function decreased from -1.05 ml/min per month to -0.15 ml/min per month (P = 0.024) and proteinuria decreased from 2.4 g/l to 1.0 g/l (P = 0.015). The primary end-point (GFR < 10 ml/min or relapse) occurred 5.2 years (median; range 0.4-8.8) after the first IVIg pulse, and after 1.3 years (median; range 0.8-2.4) in the control group (P = 0.043). In Kaplan-Meier analysis, the median renal survival time with IVIg was prolonged by 3.5 years (IVIg 4.7 years versus control 1.2 years; P = 0.006). IVIg pulse therapy may be considered as a treatment option to reduce the loss of renal function and improve proteinuria in patients with progressive IgAN.

Noninvasive Doppler-derived myocardial performance index in rats with myocardial infarction: validation and correlation by conductance catheter

The rodent model of myocardial infarction (MI) is extensively used in heart failure studies. However, long-term follow-up of echocardiographic left ventricular (LV) function parameters such as the myocardial performance index (MPI) and its ratio with the fractional shortening (LVFS/MPI) has not been validated in conjunction with invasive indexes, such as those derived from the conductance catheter (CC). Sprague-Dawley rats with left anterior descending coronary artery ligation (MI group, n = 9) were compared with a sham-operated control group (n = 10) without MI. Transthoracic echocardiography (TTE) was performed every 2 wk over an 8-wk period, after which classic TTE parameters, especially MPI and LVFS/MPI, were compared with invasive indexes obtained by using a CC. Serial TTE data showed significant alterations in the majority of the noninvasive functional and structural parameters (classic and novel) studied in the presence of MI. Both MPI and LVFS/MPI significantly (P < 0.05 for all reported values) correlated with body weight (r = -0.58 and 0.76 for MPI and LVFS/MPI, respectively), preload recruitable stroke work (r = -0.61 and 0.63), LV end-diastolic pressure (LVEDP) (r = 0.82 and -0.80), end-diastolic volume (r = 0.61 and -0.58), and end-systolic volume (r = 0.46 and -0.48). Forward stepwise linear regression analysis revealed that, of all variables tested, LVEDP was the only independent determinant of MPI (r = 0.84) and LVFS/MPI (r = 0.83). We conclude that MPI and LVFS/MPI correlate strongly and better than the classic noninvasive TTE parameters with established, invasively assessed indexes of contractility, preload, and volumetry. These findings support the use of these two new noninvasive indexes for long-term analysis of the post-MI LV remodeling.

Tooth loss over five years

Objectives: To assess the ability to predict tooth loss on the basis of clinical and radiographic parameters. Methods: Clinical and radiographic data from a five year prospective cohort were studied to identify cause of progressive tooth loss in older subjects. Results: 363 subjects with a baseline mean age of 67.1 years (S.D. + 4.7, range : 60-75), and 51.4% women were studied including 59.5% never smokers, and 33.0% current smokers. At baseline the subjects had, on average, 22.4 teeth (S.D. + 6.4). Self-assessed tooth loss risk was identified by 16.0 % of subjects while 34% of subjects lost teeth. Tooth loss due to caries was found in 24.7% (178 teeth), periodontitis in 15.4% (133 teeth), peri-apical lesions 5.9% (32 teeth), combined periodontal/peri-apical in 3.4% (18 teeth), and teeth irrational to treat in 7.5% (58 teeth) of the subjects. 122 of the extracted teeth (34%) should have been possible to save but were extracted. At year five severe caries, periodontitis, peri-apical lesions, periodontal/peri-apical, irrational to treat were found in 6.3%, 7.2%, 2.6%, 4.6%, and 1.2% of subjects, respectively. Signs of osteoporosis increased by 11.2 % (Klemetti index). Linear regression analysis failed to include smoking habits as being explanatory. Explanatory factors were researcher prediction of extraction needs, subject self assessment of risk and change in ostoporosis status (r2 = 0.39, ANOVA, F=22.6, p< 0.001). Conclusions: Caries and periodontitis are primary causes for extraction. Progressive osteoporosis is associated with tooth loss. Radiographs, and subjects self-assessment of risk for tooth loss are robust predictors.

Microhardness and marginal adaptation of pre-warmed composites

Objectives: The aim of this study was to examine the effect of pre-warmed composite on the microhardness and marginal adaptation. Methods: Ninety six identical class II cavities were prepared in extracted human molars and filled/cured in three 2 mm increments using a metal matrix. Two composites (Tetric Evo Ceram (IvoclarVivadent) and ELS(Saremco)) were cured with a LED curing unit (Bluephase (IvoclarVivadent)) using curing cycles of 20 and 40 seconds. The composite was used at room temperature or pre-warmed at 54.5ºC (Calset(AdDent)). Twelve teeth were filled for every composite-curing time-composite temperature combination. The teeth were thermocycled (1000 cycles at 5º and 55ºC) and then stored at 37° C for seven days . Dye penetration (basic fuchsine 5% for 8 hours) was measured using a score scale. Knoop microhardness was determined 100, 200, 500, 1000, 1500, 2500, 3500, 4500 and 5500µm from the occlusal surface at a distance of 150 and 1000µm from the metal matrix. The total degree of polymerization of a composite specimen was determined by calculating the area under the hardness curve. Results: Statistical analyses showed no difference in marginal adaptation (p>0.05). Hardness values at 150µm from the matrix were lower than those at 1000µm. There was an increase of the microhardness at the top of each increment and decrease towards the bottom of each increment. Longer curing times resulted in harder composite samples. Multiple linear regression showed that only the curing time (p<0.001) and composite material (p<0.001) had a significant association with the degree of polymerization. The degree of polymerization was not influenced by pre-warming the composite at a temperature of 54.5ºC (p=4.86). Conclusion: Polymerization time can not be reduced by pre-warming the composite on a temperature of 54.5ºC. The marginal adaptation is not compromised by pre-warming the composite.

Sequential immunosuppressive therapy in progressive IgA nephropathy

BACKGROUNDS: Cyclophosphamide and high-dose steroids have been used as limited induction therapy in progressive IgA nephropathy (IgAN) to reduce the loss of renal function and proteinuria. We evaluated the effect of cyclophosphamide pulses (CyP) and mycophenolic acid (MPA) as sequential therapy on renal function in patients with progressive IgAN. METHODS: Twenty patients with progressive IgAN and advanced renal failure (median GFR 22 ml/min per 1.73 m2) and further disease activity (triangle downGFR -0.8 ml/min per month) after cyclophosphamide (CyP; n = 18) or steroid pulse therapy (n = 2) were treated with mycophenolate mofetil 1 g per day for a median of 27 months. RESULTS: The monthly loss of renal function was significantly reduced in linear regression analysis from -2.4 ml/min before CyP to -0.12 ml/min with CyP/MPA (p = 0.0009). Estimated renal survival time was significantly prolonged by a median of 65 months (p = 0.0014). Proteinuria decreased significantly from 1.7 to 0.4 g/l during MPA treatment (p = 0.015). In Cox regression analysis, only proteinuria >1.0 g/l was an independent risk factor for doubling of creatinine during CyP/MPA treatment (p = 0.03). CONCLUSION: A sequential therapy with CyP/MPA may arrest or slow down the loss of renal function and reduces proteinuria even in patients who passed the so called 'point of no return' with progressive IgAN.