Determinants of patients' expectations about total knee arthroplasty outcomes

Knee osteoarthritis (OA) is the most prevalent form of arthritis in the US, affecting approximately 37% of adults. Approximately 300,000 total knee arthroplasty (TKA) procedures take place in the United States each year. Total knee arthroplasty is an elective procedure available to patients as an irreversible treatment after failure of previous medical treatments. Some patients sacrifice quality of life and endure many years of pain before making the decision to undergo total knee replacement. In making their decision, it is therefore imperative for patients to understand the procedure, risks and surgical outcomes to create realistic expectations and increase outcome satisfaction. ^ From 2004-2007, 236 OA patients who underwent TKA participated in the PEAKS (Patient Expectations About Knee Surgery) study, an observational longitudinal cohort study, completed baseline and 6 month follow-up questionnaires after the surgery. We performed a secondary data analysis of the PEAKS study to: (1) determine the specific presurgical patient characteristics associated with patients’ presurgical expectations of time to functional recovery; and (2) determine the association between presurgical expectations of time to functional recovery and postsurgical patient capabilities (6 months after TKA). We utilized the WOMAC to measure knee pain and function, the SF-36 to measure health-related quality of life, and the DASS and MOS-SSS to measure psychosocial quality of life variables. Expectation and capability measures were generated from panel of experts. A list of 10 activities was used for this analysis to measure functional expectations and postoperative functional capabilities. ^ The final cohort consisted of 236 individuals, was predominately White with 154 women and 82 men. The mean age was 65 years. Patients were optimistic about their time to functional recovery. Expectation time of being able to perform the list activities per patient had a median of less than 3 months. Patients who expected to be able to perform the functional activities by 3 months had better knee function, less pain and better overall health-related quality of life. Despite expectation differences, all patients showed significant improvement 6 months after surgery. Participant expectation of time to functional recovery was not an independent predictor of capability to perform functional activities at 6 months. Better presurgical patient characteristics were, however, associated with a higher likelihood of being able to perform all activities at 6 months. ^ This study gave us initial insight on the relationship between presurgical patient characteristics and their expectations of functional recovery after total knee replacement. Future studies clarifying the relationship between patient presurgical characteristics and postsurgical functional capabilities are needed.^

Imaging of pulmonary embolism and t-PA therapy effects using MDCT and liposomal iohexol blood pool agent – preliminary results in a rabbit model

Hypothesis and Objectives PEGylated liposomal blood pool contrast agents maintain contrast enhancement over several hours. This study aimed to evaluate (long-term) imaging of pulmonary arteries, comparing conventional iodinated contrast with a liposomal blood pool contrast agent. Secondly, visualization of the (real-time) therapeutic effects of tissue-Plasminogen Activator (t-PA) on pulmonary embolism (PE) was attempted. Materials and Methods Six rabbits (approximate 4 kg weight) had autologous blood clots injected through the superior vena cava. Imaging was performed using conventional contrast (iohexol, 350 mg I/ml, GE HealthCare, Princeton, NJ) at a dose of 1400 mgI per animal and after wash-out, animals were imaged using an iodinated liposomal blood pool agent (88 mg I/mL, dose 900 mgI/animal). Subsequently, five animals were injected with 2mg t-PA and imaging continued for up to 4 ½ hours. Results Both contrast agents identified PE in the pulmonary trunk and main pulmonary arteries in all rabbits. Liposomal blood pool agent yielded uniform enhancement, which remained relatively constant throughout the experiments. Conventional agents exhibited non uniform opacification and rapid clearance post injection. Three out of six rabbits had mistimed bolus injections, requiring repeat injections. Following t-PA, Pulmonary embolus volume (central to segmental) decreased in four of five treated rabbits (range 10–57%, mean 42%). One animal showed no response to t-PA. Conclusions Liposomal blood pool agents effectively identified acute PE without need for re-injection. PE resolution following t-PA was quantifiable over several hours. Blood pool agents offer the potential for repeated imaging procedures without need for repeated (nephrotoxic) contrast injections

Imaging of pulmonary embolism and t-PA therapy effects using MDCT and liposomal iohexol blood pool agent: preliminary results in a rabbit model.

RATIONALE AND OBJECTIVES: Polyethylene glycol-coated liposomal blood pool contrast agents maintain contrast enhancement over several hours. This study aimed to evaluate (long-term) imaging of pulmonary arteries, comparing conventional iodinated contrast with a liposomal blood pool contrast agent. Also, visualization of the (real-time) therapeutic effects of tissue plasminogen activator (t-PA) on pulmonary embolism (PE) was attempted. MATERIALS AND METHODS: Six rabbits (weight approximately 4 kg) had autologous blood clots injected through the superior vena cava. Imaging was performed using conventional contrast (iohexol, 350 mg I/ml; GE HealthCare, Princeton, NJ) at a dose of 1400 mg I per animal, and after wash-out, animals were imaged using an iodinated liposomal blood pool agent (88 mg I/mL, dose 900 mg I/animal). Subsequently, five animals were injected with 2 mg of t-PA and imaging continued for up to 4(1/2) hours. RESULTS: Both contrast agents identified PE in the pulmonary trunk and main pulmonary arteries in all rabbits. Liposomal blood pool agent yielded uniform enhancement, which remained relatively constant throughout the experiments. Conventional agents exhibited nonuniform opacification and rapid clearance postinjection. Three of six rabbits had mistimed bolus injections, requiring repeat injections. Following t-PA, pulmonary embolus volume (central to segmental) decreased in four of five treated rabbits (range 10-57%, mean 42%). One animal showed no response to t-PA. CONCLUSIONS: Liposomal blood pool agents effectively identified acute PE without need for reinjection. PE resolution following t-PA was quantifiable over several hours. Blood pool agents offer the potential for repeated imaging procedures without need for repeated (nephrotoxic) contrast injections.

DIRECT INPUTS TO OFF Α AND G9 GANGLION CELLS FROM AII AMACRINE CELLS IN RABBIT RETINA

In the mammalian retina, AII amacrine cells are essential in the rod pathway for dark-adapted vision. But they also have a “day job”, to provide inhibitory inputs to certain OFF ganglion cells in photopic conditions. This is known as crossover inhibition. Physiological evidence from several different labs implies that AII amacrine cells provide direct input to certain OFF ganglion cells. However, previous EM analysis of the rabbit retina suggests that the dominant output of the AII amacrine cell in sublamina a goes to OFF cone bipolar cells (Strettoi et al., 1992). Two OFF ganglion cell types in the rabbit retina, OFF α and G9, were identified by a combination of morphological criteria such as dendritic field size, dye coupling, mosaic properties and stratification depth. The AII amacrine cells (AIIs) were labeled with an antibody against calretinin and glycine receptors were marked with an antibody against the α1 subunit. This material was analyzed by triple-label confocal microscopy. We found the lobules of AIIs made close contacts at many points along the dendrites of individual OFF α and G9 ganglion cells. At these potential synaptic sites, we also found punctate labeling for the glycine receptor α1 subunit. The presence of a post-synaptic marker such as the α1 glycine receptor at contact points between AII lobules and OFF ganglion cells supports a direct inhibitory input from AIIs. This pathway provides for crossover inhibition in the rabbit retina whereby light onset provides an inhibitory signal to OFF α and G9 ganglion cells. Thus, these two OFF ganglion cell types receive a mixed excitatory and inhibitory drive in response to light stimulation.

Stratification of alpha ganglion cells and ON/OFF directionally selective ganglion cells in the rabbit retina.

The correlation between cholinergic sensitivity and the level of stratification for ganglion cells was examined in the rabbit retina. As examples, we have used ON or OFF alpha ganglion cells and ON/OFF directionally selective (DS) ganglion cells. Nicotine, a cholinergic agonist, depolarized ON/OFF DS ganglion cells and greatly enhanced their firing rates but it had modest excitatory effects on ON or OFF alpha ganglion cells. As previously reported, we conclude that DS ganglion cells are the most sensitive to cholinergic drugs. Confocal imaging showed that ON/OFF DS ganglion cells ramify precisely at the level of the cholinergic amacrine cell dendrites, and co-fasciculate with the cholinergic matrix of starburst amacrine cells. However, neither ON or OFF alpha ganglion cells have more than a chance association with the cholinergic matrix. Z -axis reconstruction showed that OFF alpha ganglion cells stratify just below the cholinergic band in sublamina a while ON alpha ganglion cells stratify just below cholinergic b . The latter is at the same level as the terminals of calbindin bipolar cells. Thus, the calbindin bipolar cell appears to be a prime candidate to provide the bipolar cell input to ON alpha ganglion cells in the rabbit retina. We conclude that the precise level of stratification is correlated with the strength of cholinergic input. Alpha ganglion cells receive a weak cholinergic input and they are narrowly stratified just below the cholinergic bands.

Screening of gap junction antagonists on dye coupling in the rabbit retina.

Many cell types in the retina are coupled via gap junctions and so there is a pressing need for a potent and reversible gap junction antagonist. We screened a series of potential gap junction antagonists by evaluating their effects on dye coupling in the network of A-type horizontal cells. We evaluated the following compounds: meclofenamic acid (MFA), mefloquine, 2-aminoethyldiphenyl borate (2-APB), 18-alpha-glycyrrhetinic acid, 18-beta-glycyrrhetinic acid (18-beta-GA), retinoic acid, flufenamic acid, niflumic acid, and carbenoxolone. The efficacy of each drug was determined by measuring the diffusion coefficient for Neurobiotin (Mills & Massey, 1998). MFA, 18-beta-GA, 2-APB and mefloquine were the most effective antagonists, completely eliminating A-type horizontal cell coupling at a concentration of 200 muM. Niflumic acid, flufenamic acid, and carbenoxolone were less potent. Additionally, carbenoxolone was difficult to wash out and also may be harmful, as the retina became opaque and swollen. MFA, 18-beta-GA, 2-APB and mefloquine also blocked coupling in B-type horizontal cells and AII amacrine cells. Because these cell types express different connexins, this suggests that the antagonists were relatively non-selective across several different types of gap junction. It should be emphasized that MFA was water-soluble and its effects on dye coupling were easily reversible. In contrast, the other gap junction antagonists, except carbenoxolone, required DMSO to make stock solutions and were difficult to wash out of the preparation at the doses required to block coupling in A-type HCs. The combination of potency, water solubility and reversibility suggest that MFA may be a useful compound to manipulate gap junction coupling.

Multiple GABA receptors in rabbit retina

The task of encoding and processing complex sensory input requires many types of transsynaptic signals. This requirement is served in part by an extensive group of neurotransmitter substances which may include thirty or more different compounds. At the next level of information processing, the existence of multiple receptors for a given neurotransmitter appears to be a widely used mechanism to generate multiple responses to a given first messenger (Snyder and Goodman, 1980). Despite the wealth of published data on GABA receptors, the existence of more than one GABA receptor was in doubt until the mid 1980's. Presently there is still disagreement on the number of types of GABA receptors, estimates for which range from two to four (DeFeudis, 1983; Johnston, 1985). Part of the problem in evaluating data concerning multiple receptor types is the lack of information on the number of gene products and their subsequent supramolecular organization in different neurons. In order to evaluate the question concerning the diversity of GABA receptors in the nervous system, we must rely on indirect information derived from a wide variety of experimental techniques. These include pharmacological binding studies to membrane fractions, electrophysiological studies, localization studies, purification studies, and functional assays. Almost all parts of the central and peripheral nervous system use GABA as a neurotransmitter, and these experimental techniques have therefore been applied to many different parts of the nervous system for the analysis of GABA receptor characteristics. We are left with a large amount of data from a wide variety of techniques derived from many parts of the nervous system. When this project was initiated in 1983, there were only a handful of pharmacological tools to assess the question of multiple GABA receptors. The approach adopted was to focus on a single model system, using a variety of experimental techniques, in order to evaluate the existence of multiple forms of GABA receptors. Using the in vitro rabbit retina, a combination of pharmacological binding studies, functional release studies and partial purification studies were undertaken to examine the GABA receptor composition of this tissue. Three types of GABA receptors were observed: Al receptors coupled to benzodiazepine and barbiturate modulation, and A2 or uncoupled GABA-A receptors, and GABA-B receptors. These results are evaluated and discussed in light of recent findings by others concerning the number and subtypes of GABA receptors in the nervous system. ^

Characterization of neurotransmitter inputs to cholinergic amacrine cells of the rabbit retina: Analysis of ACh release

The cholinergic amacrine cells of the rabbit retinal are the only neurons which accumulate choline and also synthesize acetylcholine (ACh). It is widely accepted that the physiologically evoked release of acetylcholine can be taken as a measure of the activity of the entire cholinergic population. Initially, we examined the possibility that these cells receive excitatory input via glutamate receptors from glutamatergic neurons. Glutamate analogs were found to cause massive ACh release from the rabbit retina. Glutamate was found to activate several different receptor subtypes. Selective glutamate antagonists were used to separate the responses evoked by the different glutamate receptor subtypes. The kainate receptor was determined pharmacologically to be the subtype activated physiologically. Since bipolar cells make direct contact with cholinergic amacrine cells, our results support the hypothesis the bipolar cell neurotransmitter is glutamate. Although NMDA receptors can be activated by NMDA analogs, they are not activated during the physiologically evoked release of ACh. A separate study examined the possibility that L-homocysteate could be the bipolar cell neurotransmitter and the results placed serious constraints on this possibility.^ GABA$\sb{\rm A}$ agonists and antagonists are known to have powerful effects on ACh release from the rabbit retina. By pharmacologically blocking the excitatory input from bipolar cells, we attempted to determine the site of GABA$\sb{\rm A}$ input. Our results suggest that the predominant site of GABA$\sb{\rm A}$ input is onto the bipolar cells presynaptic to cholinergic amacrine cells. In a separate study, we found SR-95531 to be a potent and selective GABA$\sb{\rm A}$ receptor antagonist. In addition, GABA$\sb{\rm B}$ agonists and antagonists were found to have minor or no effects on ACh release. Glycine was also examined, its inhibitory effects were found to be very similar to GABA$\sb{\rm A}$ agonists. In contrast, strychnine was found to increase basal but inhibit light evoked ACh release. Additional results indicated that the predominant site of glycinergic input is onto the presynaptic bipolar cells. Our results suggest a different role for glycine compared to GABA in shaping the light evoked release of ACh from the rabbit retina. ^

Glutamate and nitric oxide as regulatory transmitters in developing rabbit retina

Glutamate is the major excitatory neurotransmitter in the retina and serves as the synaptic messenger for the three classes of neurons which constitute the vertical pathway--the photoreceptors, bipolar cells and ganglion cells. In addition, the glutamate system has been localized morphologically, pharmacologically as well as molecularly during the first postnatal week of development before synaptogenesis occurs. The role which glutamate plays in the maturing visual system is complex but ranges from mediating developmental neurotoxicity to inducing neurite outgrowth.^ Nitric oxide/cGMP is a novel intercellular messenger which is thought to act in concert with the glutamate system in regulating a variety of cellular processes in the brain as well as retina, most notably neurotoxicity. Several developmental activities including programmed cell death, synapse elimination and synaptic reorganization are possible functions of cellular regulation modulated by nitric oxide as well as glutamate.^ The purpose of this thesis is to (1) biochemically characterize the endogenous pools of glutamate and determine what fraction exists extracellularly; (2) examine the morphological expression of NO producing cells in developing retina; (3) test the functional coupling of the NMDA subtype of glutamate receptor to the NO system by examining neurotoxicity which has roles in both the maturing and adult retina.^ Biochemical sampling of perfusates collected from the photoreceptor surface of ex vivo retina demonstrated that although the total pool of glutamate present at birth is relatively modest, a high percentage resides in extracellular pools. As a result, immature neurons without significant synaptic connections survive and develop in a highly glutamatergic environment which has been shown to be toxic in the adult retina.^ The interaction of the glutamate system with the NO system has been postulated to regulate neuronal survival. We therefore examined the developmental expression of the enzyme responsible for producing NO, nitric oxide synthase (NOS), using an antibody to the constitutive form of NOS found in the brain. The neurons thought to produce the majority of NO in the adult retina, a subpopulation of widefield amacrine cells, were not immunoreactive until the end of the second postnatal week. However, a unique developmental expression was observed in the ganglion cell layer and developing outer nuclear layer of the retina during the first postnatal week. We postulate NO producing neurons may not be present in a mature configuration therefore permitting neuronal survival in a highly glutamatergic microenvironment and allowing NO to play a development-specific role at this time.^ The next set of experiments constituted a functional test of the hypothesis that the absence of the prototypic NO producing cells in developing retina protects immature neurons against glutamate toxicity. An explant culture system developed in order to examine cellular responses of immature and adult neurons to glutamate toxicity showed that immature neurons were affected by NMDA but were less responsive to NMDA and NO mediated toxicity. In contrast, adult explants exhibited significant NMDA toxicity which was attenuated by NMDA antagonists, 2-amino-5-phosphonovaleric acid (APV), dextromethorphan (Dex) and N$\rm\sp{G}$-D-methyl arginine (metARG). These results indicated that pan-retinal neurotoxicity via the NMDA receptor and/or NO activation occurred in the adult retina but was not significant in the neonate. (Abstract shortened by UMI.) ^

AN ELECTROPHYSIOLOGICAL ANALYSIS OF THE AMYGDALOID AND SUBICULAR PROJECTIONS TO THE VENTROMEDIAL NUCLEUS OF THE HYPOTHALAMUS IN THE RABBIT

Electrophysiological experiments were performed on 96 male New Zealand white rabbits, anesthetized with urethane. Glass electrodes, filled with 2M NaCl, were used for microstimulation of three fiber pathways projecting from "limbic" centers to the ventromedial nucleus of the hypothalamus (VMH). Unitary and field potential recordings were made in the VMH after stimulation.^ Stimulation of the lateral portion of the fimbria, which carries fibers from the ventral subiculum of the hippocampal formation, evokes predominantly an inhibition of neurons medially in the VMH, and excitation of neurons located laterally.^ Stimulation of the dorsal portion of the stria terminalis, which carries fibers from the cortical nucleus of the amygdala, also produces predominantly an inhibition of cells medially and excitation laterally.^ Stimulation of the ventral component of the stria terminalis, which carries fibers from the medial nucleus of the amygdala, evokes excitation of cell medially, with little or no response seen laterally.^ Cells recorded medially in the VMH received convergent inputs from each of the three fiber systems: inhibition from fimbria and dorsal stria stimulation, excitation from ventral stria stimulation.^ The excitatory unitary responses recorded medially to ventral stria stimulation and laterally to fimbria and dorsal stria stimulation were subjected to a series of threshold stimulus intensities. From these tests it was determined that each of these three projections terminates monosynaptically on VMH neurons.^ The evidence for convergence upon single VMH neurons of projections from the amygdala and the hippocampal formation suggests this area of the brain to be important for integration of information from these two limbic centers. The VMH has been implied in a number of behavioral states: eating, reproduction, defense and aggression; it has further been linked to control of the anterior pituitary. These data provide a functional circuit through which the amygdaloid complex and the hippocampal formation can channel information from higher cortical centers into a hypothalamic area capable of coordinating behavioral and hormonal responses. ^

THE SITE AND MECHANISM OF ACTION OF BENZODIAZEPINE IN RABBIT HIPPOCAMPUS

The purpose of this study was to determine the effects of benzodiazepine in area CA1 of the hippocampus, and to explore possible mechanisms of action for these agents in this brain area. Two distinctly different benzodiazepine-induced changes in hippocampal physiology have been identified. First, benzodiazepine depresses the population spike recorded in stratum pyramidale, indicating a decrease in action potential generation. Second, benzodiazepine decreases the magnitude of post-tetanic potentiation of the population EPSP recorded in stratum radiatum, and shortens the duration. The effect of benzodiazepine on pyramidal cell excitation was reversed by the GABA antagonis bicuculline, and mimicked by GABA itself. Thus the available evidence is consistent with the hypothesis that benzodiazepine acts by enhancing the effect of GABA in this area. In stratum radiatum, on the other hand, the effect of benzodiazepine on post tetanic potentiation of the population EPSP was not altered by bicuculline although bicuculline did antagonize GABA in this area. In addition, application of GABA, while it caused profound changes in the population EPSP,p, did not cause the same changes that were induced by benzodiazepine. Thus the evidence does not support the hypothesis that benzodiazepine is acting in stratum radiatum by enhancing the effects of GABA. ^

Characterization of healing tissue in a tooth extraction socket in a rabbit model

The histology of healing in a tooth extraction socket has been described in many studies. The focus of research in bone biology and healing is now centered on molecular events that regulate repair of injured tissue. Rapid progress in cellular and molecular biology has resulted in identification of many signaling molecules (growth factors and cytokines) associated with formation and repair of skeletal tissues. Some of these include members of the transforming growth factor-β superfamily (including the bone morphogenetic proteins), fibroblast growth factors, platelet derived growth factors and insulin like growth factors. ^ Healing of a tooth extraction socket is a complex process involving tissue repair and regeneration. It involves chemotaxis of appropriate cells into the wound, transformation of undifferentiated mesenchymal cells to osteoprogenitor cells, proliferation and differentiation of committed bone forming cells, extracellular matrix synthesis, mineralization of osteoid, maturation and remodeling of bone. Current data suggests that these cellular events are precisely controlled and regulated by specific signaling molecules. A plethora of cytokines; have been identified and studied in the past two decades. Some of these like transforming growth factor beta (TGF-β), vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF) and fibroblast growth factors (FGFs) are well conserved proteins involved in the initial response to injury and repair in soft and hard tissue. ^ The purpose of this study was to characterize the spatial and temporal localization of TGF-βl, VEGF, PDGF-A, FGF-2 and BMP-2, and secretory IgA in a tooth extraction socket model, and evaluate correlation of spatial and temporal changes of these growth factors to histological events. The results of this study showed positive correlation of histological events to spatial and temporal localization of TGF-β1, BMP-2, FGF-2, PDGF-A, and VEGF in a rabbit tooth extraction model. ^

Confocal analysis of synaptic connectivity of the rod pathway in the rabbit retina

The retina is a specialized neuronal structure that transforms the optical image into electrical signals which are transmitted to the brain via the optic nerve. As part of the strategy to cover a stimulus range as broad as 10 log units, from dim starlight to bright sunlight, retinal circuits are broadly divided into rod and cone pathways, responsible for dark and light-adapted vision, respectively. ^ In this dissertation, confocal microscopy and immunocytochemical methods were combined to study the synaptic connectivity of the rod pathway from the level of individual synapses to whole populations of neurons. The study was focused on synaptic interactions at the rod bipolar terminal. The purpose is to understand the synaptic structure of the dyad synapse made by rod bipolar terminals, including the synaptic components and connections, and their physiological functions in the rod pathway. In addition, some additional components and connections of the rod pathway were also studied in these experiments. The major results can be summarized as following: At the dyad synapse of rod bipolar terminals, three postsynaptic components—processes of All amacrine cells and the varicosities of S1 or S2 amacrine cells express different glutamate receptor subunits, which may underlie the functional diversity of these postsynaptic neurons. A reciprocal feedback system is formed by rod bipolar terminals and S1/S2 amacrine cells. Analysis showed these two wide-field GABA amacrine cells have stereotyped synaptic connections with the appropriate morphology and distribution to perform specific functions. In addition, S1 and S2 cells have different coupling patterns and, in general, there is no coupling between the two types. Besides the classic rod pathway though rod bipolar cells and All amacrine cells, the finding of direct connections between certain types of OFF cone bipolar cells and rods indicates the presence of an alternative rod pathway in the rabbit retina. ^ In summary, this dissertation presents a detailed view of the connection and receptors at rod bipolar terminals. Based on the morphology, distribution and coupling, different functional roles were identified for S1 and S2 amacrine cells. Finally, an alternative to the classic rod pathway was found in the rabbit retina. ^