Bilateral total knee arthroplasty in a patient with hemophilia A, high inhibitor titre and aneurysma spurium of the popliteal artery. A case report

The authors report on bilateral simultaneous knee arthroplasty in a 40-year-old male patient with haemophilia A, high inhibitor titre and an aneurysma spurium of the right popliteal artery. Both knees showed a fixed flexion deformity of 20 degrees. To build up haemostasis, treatment with activated prothrombin complex concentrate (APCC) and recombinant activated factor seven (rFVIIa) was initiated preoperatively. A tourniquet was used on both sides during the operation and factor VIII (FVIII) was administered to further correct coagulopathy. On the eleventh postoperative day the patient complained of increasing pain and pressure in the right knee. An ultrasound suggested aneurysm, which was confirmed by substraction angiography. Under the protection of rFVIIa the aneurysm could be coiled and further rehabilitation was uneventful. At one year post-op the patient presented a range of motion of 90/5/0 degrees for both knees and had returned to full time office work. This case indicates that haemophiliacs with high antibody titre and destruction of both knees can be operated on in one session in order to diminish the operative risk of two consecutive surgical procedures, thus allowing an effective rehabilitation programme. Because of the significant frequency of popliteal aneurysms, preoperative angiography is recommended.

A closer look at the high affinity benzodiazepine binding site on GABAA receptors

Ligands of the benzodiazepine binding site of the GABA(A) receptor come in three flavors: positive allosteric modulators, negative allosteric modulators and antagonists all of which can bind with high affinity. The GABA(A) receptor is a pentameric protein which forms a chloride selective ion channel and ligands of the benzodiazepine binding site stabilize three different conformations of this protein. Classical benzodiazepines exert a positive allosteric effect by increasing the apparent affinity of channel opening by the agonist γ-aminobutyric acid (GABA). We concentrate here on the major adult isoform, the α(1)β(2)γ(2) GABA(A) receptor. The classical binding pocket for benzodiazepines is located in a subunit cleft between α(1) and γ(2) subunits in a position homologous to the agonist binding site for GABA that is located between β(2) and α(1) subunits. We review here approaches to this picture. In particular, point mutations were performed in combination with subsequent analysis of the expressed mutant proteins using either electrophysiological techniques or radioactive ligand binding assays. The predictive power of these methods is assessed by comparing the results with the predictions that can be made on the basis of the recently published crystal structure of the acetylcholine binding protein that shows homology to the N-terminal, extracellular domain of the GABA(A) receptor. In addition, we review an approach to the question of how the benzodiazepine ligands are positioned in their binding pocket. We also discuss a newly postulated modulatory site for benzodiazepines at the α(1)/β(2) subunit interface, homologous to the classical benzodiazepine binding pocket.

Calibration of a portal imaging device for high-precision dosimetry: a Monte Carlo study

Today electronic portal imaging devices (EPID's) are used primarily to verify patient positioning. They have, however, also the potential as 2D-dosimeters and could be used as such for transit dosimetry or dose reconstruction. It has been proven that such devices, especially liquid filled ionization chambers, have a stable dose response relationship which can be described in terms of the physical properties of the EPID and the pulsed linac radiation. For absolute dosimetry however, an accurate method of calibration to an absolute dose is needed. In this work, we concentrate on calibration against dose in a homogeneous water phantom. Using a Monte Carlo model of the detector we calculated dose spread kernels in units of absolute dose per incident energy fluence and compared them to calculated dose spread kernels in water at different depths. The energy of the incident pencil beams varied between 0.5 and 18 MeV. At the depth of dose maximum in water for a 6 MV beam (1.5 cm) and for a 18 MV beam (3.0 cm) we observed large absolute differences between water and detector dose above an incident energy of 4 MeV but only small relative differences in the most frequent energy range of the beam energy spectra. It is shown that for a 6 MV beam the absolute reference dose measured at 1.5 cm water depth differs from the absolute detector dose by 3.8%. At depth 1.2 cm in water, however, the relative dose differences are almost constant between 2 and 6 MeV. The effects of changes in the energy spectrum of the beam on the dose responses in water and in the detector are also investigated. We show that differences larger than 2% can occur for different beam qualities of the incident photon beam behind water slabs of different thicknesses. It is therefore concluded that for high-precision dosimetry such effects have to be taken into account. Nevertheless, the precise information about the dose response of the detector provided in this Monte Carlo study forms the basis of extracting directly the basic radiometric quantities photon fluence and photon energy fluence from the detector's signal using a deconvolution algorithm. The results are therefore promising for future application in absolute transit dosimetry and absolute dose reconstruction.

High-resolution summer temperature reconstruction from Lake Silvaplana based on in-situ reflectance spectroscopy

Annually laminated (varved) sediments of proglacial Lake Silvaplana (46 ̊27’N, 9 ̊48’E, 1791 m a.s.l., Engadine, eastern Swiss Alps) provide an excellent archive for quantitative high-resolution (seasonal – annual) reconstruction of high- and lowfrequency climate signals back to AD 1580. The chronology of the core is based on varve counting, Cs-137, Pb-210 and event stratigraphy. In this study we present a reconstruction based on in-situ reflectance spectroscopy. In situ reflectance spectroscopy is known as a cost- and time-effective non destructtive method for semi-quantitative analysis of pigments (e.g., chlorines and carotenoids) and of lithoclastic sediment fractions. Reflectance-dependent absorption (RDA) was measured with a Gretac Macbeth spectrolino at 2 mm resolution. The spectral coverage ranges from 380 nm to 730 nm at 10 nm band resolution. In proglacial Lake Silvaplana, 99% of the sediment is lithoclastic prior to AD 1950. Therefore, we concentrate on absorption features that are characteristic for lithoclastic sediment fractions. In Lake Silvaplana, two significant correlations that are stable in time were found between RDA typical for lithoclastics and meteorological data: (1) the time series R 570 /R 630 (ratio between RDA at 570 nm and 630 nm) of varves in Lake Silvaplana and May to October temperatures at nearby station of Sils correlate highly significantly (calibration period AD 1864 – 1951, r = 0.74, p < 0.01 for 5ptsmoothed series; RMSE is 0.28 ̊C, RE = 0.41 and CE = 0.38), and (2) the minimum reflectance within the 690nm band (min690) data correlate with May to October (calibration period AD 1864 – 1951, r = 0.68, p < 0.01 for 5pt-smoothed series; RMSE = 0.22 ̊C, RE = 0.5, CE = 0.31). Both proxy series (min690nm and R 570 /R 630 values) are internally highly consistent (r = 0.8, p < 0.001). In proglacial Lake Silvaplana the largest amount of sediment is transported by glacial meltwater. The melting season spans approximately from May to October, which gives us a good understanding of the geophysical processes explaining the correlations between lithoclastic proxies and the meteorological data. The reconstructions were extended back to AD 1580 and show a broad corresponddence with fully independent reconstructions from tree rings and documentary data.