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Treatment of acromioclavicular joint (ACJ) dislocation is not encoded uniquely. Type I and II injuries are usually treated conservatively, while types IV, V and VI surgically. Controversy still exists over the treatment of type III injuries. In the operative approach, there is no agreement on the best surgical technique. Our purpose is to compare the mini-open and arthroscopic approach focusing on the evaluation of the anatomical precision of the coracoid drilling. This is a controlled laboratory study. Ten fresh-frozen cadaveric shoulders were randomly assigned to the two techniques in order to compare them. We performed essential surgical gestures to drill the tunnel using MINAR® System (mini-open) and Dog-Bone® (ARTHREX, arthroscopic). The anatomical specimens were then subjected to CT-scan investigation. We statistically evaluated the precision of these two techniques analyzing DICOM files using two parameters. Parameter 1 evaluates the tunnel entry area on the superior side of the coracoid. Parameter 2 describes the orientation of the tunnel. There are no statistically significant differences (95% confidence level) between arthroscopic and mini-open approach about the precision in the location of the coracoid hole, regarding the entry area (p = 1.00) and the orientation (p = 0.196). The evidences collected enable the orthopedic surgeon to choose equally between the two techniques in the treatment of AC joint dislocation toward precision.

There is growing interest in oxytocin as a putative treatment for various psychiatric disorders including major depressive disorder, bipolar disorder and schizophrenia/schizoaffective disorder. However, potential alterations in the endogenous brain oxytocin system in these disorders are poorly characterized. Brain expression of oxytocin and its receptor genes in patients with these psychiatric disorders has not been well studied outside the hypothalamus. We measured expression of mRNA for oxytocin and its receptor in the dorsolateral prefrontal cortex of postmortem brains using quantitative polymerase chain reaction in a total of 581 individuals. These individuals either were diagnosed with major depressive disorder ( n = 135), bipolar disorder ( n = 57), schizophrenia/schizoaffective disorder ( n = 169), or were control subjects, defined as individuals with no lifetime history of any of these disorders ( n = 220). Diagnoses of major depressive disorder and bipolar disorder were associated with significantly increased oxytocin receptor mRNA levels in the dorsolateral prefrontal cortex. This finding is discussed in light of the extant literature on the dysregulation of oxytocin signaling in individuals with major psychiatric disorders.

Background The rate of acute infection after surgery for proximal humeral fractures is not known. The aims of this study were to report the incidence and to analyze the risk factors for infection after proximal humeral fracture treatment. Materials and methods We report a retrospective multicenter study of 452 proximal humeral fractures. Data were modeled by use of univariate and/or linear regression analyses to determine the odds ratio (OR). A logistic regression analysis was used to check for demographic and other characteristics with the potential to confound a true association between risk factors and infection. Results The mean age was 62.1 years, and 314 patients were female patients. Of the patients, 18 (4%) had an acute infection. The factors that correlated with infection were length of surgery (OR, 1.009; P = .05), preoperative skin preparation with chlorhexidine gluconate (OR, 0.13; P = .008), and prophylactic antibiotic (OR, 10.73; P = .03). The delay to surgery was close to achieving significance (OR, 1.71; P = .06). Conclusion This study suggests that washing the shoulder with chlorhexidine gluconate and avoiding the use of first-generation cephalosporin in favor of more effective prophylactic therapy are effective at reducing the risk of infection after treatment for proximal humeral fractures.

To evaluate granulocyte colony-stimulating factor (G-CSF) efficacy in accelerating bone regeneration following opening-wedge high tibial valgus osteotomy for genu varum. A phase II trial was conducted for evaluating the preoperative administration of G-CSF given at 10 μg/kg/day for 3 consecutive days with an additional half-dose 4 h before the opening-wedge high tibial valgus osteotomy. Overall, 12 patients (Group A) received G-CSF treatment, and the subsequent 12 patients (Group B) underwent surgery without G-CSF. The osteotomy gap was filled by a bone graft substitute. Bone marrow cell (BMC) mobilization was monitored by CD34+ve cell and clonogenic progenitor cell analysis. All patients underwent a clinical (Lysholm Knee Scale and SF-36) and radiographic evaluation preoperatively, as well as at given intervals postsurgery. All patients completed the treatment program without major side effects; G-CSF was well tolerated. BMC mobilization occurred in all Group A patients, with median peak values of circulating CD34+ve cells of 110/μL (range 29–256). Circulating clonogenic progenitors paralleled CD34+ve cell levels. A significant improvement in Lysholm Knee Scale was recorded at follow-up in Group A compared to Group B. At the radiographic evaluation, there was a significant increase in osseointegration at the bone-graft junction in Group A at 1, 2, 3 and 6 months postsurgery compared to Group B. The computerized tomography scan of the grafted area at 2 months postsurgery showed no significant difference in the quality of the newly formed bone between the two Groups. Although the limited number of patients does not allow firm conclusions, the study suggests that G-CSF can be safely administered preoperatively in subjects undergoing opening-wedge high tibial valgus osteotomy; in addition, the clinical, radiographic and CT monitoring indicate that G-CSF and/or mobilized BMCs may hasten bone graft substitute osseointegration. I.

The aim of this study was to investigate regional cerebral blood flow parameters during the postacute phase of unilateral ischemic stroke and to correlate them with clinical data. Regional cerebral blood flow was measured in 187 patients in the stabilized phase of stroke by the xenon-133 inhalation method with 32 extracranial detectors. Thirty-eight patients were reexamined after a mean +/- SD time of 32 +/- 21.4 months. The overall detection of hypoperfusion was 92.0%, with asymmetries as the most sensitive index, especially for patients with a lesser degree of neurological disability. Neurological disability score was strongly associated with regional cerebral blood flow in the affected hemisphere (p < 0.0001) and with asymmetries (p < 0.0001). The presence of carotid obstruction further decreased the regional cerebral blood flow in the affected hemisphere and significantly increased asymmetry (p < 0.0001). Subjects who had no hypoperfusion at absolute values analysis were more frequently free of carotid disease and had less severe disability than those who had bilateral or unilateral regional absolute cerebral blood flow reduction. In 38 patients without new cerebrovascular events, a significant (p = 0.005) reduction of hemispheric regional cerebral blood flow asymmetries was found on a follow-up examination. These data confirm the value of regional cerebral blood flow asymmetries in stroke detection and point out that important clinical information is also contained in absolute values analysis.

Regional cerebral blood flow (rCBF) asymmetries were studied in 189 subjects (96 males and 93 females) at rest with the 133Xenon inhalation method using a fixed detector system. rCBF asymmetries in the resting condition were very small, nevertheless a significant (p less than 0.001) effect for their topographical distribution was present, reflecting higher rCBF in the right fronto-temporal and left parieto-occipital regions. rCBF asymmetries were not correlated with age, and there were no significant differences between males and females. Asymmetries are therefore useful from a statistical point of view in detecting rCBF abnormalities in the resting condition: they are more stable than absolute values in normal subjects and no matching according to age or sex is required when statistical comparisons are performed.

Udgivelsesdato: 1996-May-28 Dopamine (DA) deficiency has been implicated in Lesch-Nyhan disease (LND), a genetic disorder that is characterized by hyperuricemia, choreoathetosis, dystonia, and compulsive self-injury. To establish that DA deficiency is present in LND, the ligand WIN-35,428, which binds to DA transporters, was used to estimate the density of DA-containing neurons in the caudate and putamen of six patients with classic LND. Comparisons were made with 10 control subjects and 3 patients with Rett syndrome. Three methods were used to quantify the binding of the DA transporter so that its density could be estimated by a single dynamic positron emission tomography study. These approaches included the caudate- or putamen-to-cerebellum ratio of ligand at 80-90 min postinjection, kinetic analysis of the binding potential [Bmax/(Kd x Vd)] using the assumption of equal partition coefficients in the striatum and the cerebellum, and graphical analysis of the binding potential. Depending on the method of analysis, a 50-63% reduction of the binding to DA transporters in the caudate, and a 64-75% reduction in the putamen of the LND patients was observed compared to the normal control group. When LND patients were compared to Rett syndrome patients, similar reductions were found in the caudate (53-61%) and putamen (67-72%) in LND patients. Transporter binding in Rett syndrome patients was not significantly different from the normal controls. Finally, volumetric magnetic resonance imaging studies detected a 30% reduction in the caudate volume of LND patients. To ensure that a reduction in the caudate volume would not confound the results, a rigorous partial volume correction of the caudate time activity curve was performed. This correction resulted in an even greater decrease in the caudate-cerebellar ratio in LND patients when contrasted to controls. To our knowledge, these findings provide the first in vivo documentation of a dopaminergic reduction in LND and illustrate the role of positron emission tomography imaging in investigating neurodevelopmental disorders.

This chapter assesses the accuracy and precision of a in vivo correction method for partial volume effects using a multicavity basal ganglia (BG) brain phantom. Corrected activity was within 2% of the true activity for a BG to background ratio of 3.5:1 and with over 300 kcounts/slice. The intraregional noise amplification factor is

Cerebral hypoperfusion has occasionally been reported during essential hypertension. We explored regional cerebral blood flow in a large series of neurologically asymptomatic hypertensive patients to determine relations among cerebral blood flow, concomitant main vascular risk factors, and the most common signs of end-organ damage. Regional cerebral blood flow was measured by the 133Xe inhalation method in 101 hypertensive patients without clinically apparent central nervous system involvement, including 39 mild to moderate untreated and 62 mild to severe treated patients. Compared with age- and sex-matched normal control subjects, cerebral blood flow was significantly reduced in untreated hypertensive patients (P < .01) and to a lesser extent in treated patients (P = .047). Both regional and global cerebral blood flow reductions were observed in approximately one third of patients in both groups. Analysis of variance failed to show significant correlations between cerebral blood flow and total cholesterol concentration, mean arterial blood pressure, duration of disease, or the presence of retinopathy or left ventricular hypertrophy. In the treated group, the quality of control of hypertension significantly influenced both global cerebral blood flow (P = .007) and cerebrovascular resistance (P < .0001). Focal or diffuse cerebral hypoperfusion is present even in neurologically asymptomatic hypertensive patients, especially when untreated; good control of blood pressure may preserve cerebral perfusion and reduce cerebrovascular resistance. Regional cerebral blood flow examination represents a relatively simple and low-cost technique to explore the perfusional condition of the brain, one of the main target organs of hypertensive disease.

OBJECTIVE To investigate both rCBF and cerebrovascular reactivity, evaluated as pre- and post-ACZ rCBF differences in a group of IDDM patients with differences in duration of disease and severity of complications. RESEARCH DESIGN AND METHODS rCBF was measured by the 133Xenon inhalation method in 20 IDDM patients and in 15 healthy control subjects before and after an intravenous injection of ACZ, a carbonic anhydrase inhibitor commonly used to assess cerebrovascular reactivity. RESULTS Basal global CBF (the mean of 32 regional values) was within the normal range in all patients but 1, who showed slight hyperperfusion; moreover, in 3 patients with long-lasting disease, some hypoperfused regions were found. ANOVA showed an inverse correlation between basal global CBF (P < 0.01) and duration of diabetes, but no correlation with Hb, MABP, serum glucose concentration, or GHb. Compared with control subjects, the percentage of global CBF increment after ACZ administration was significantly impaired in 4 patients and gave a borderline response in 2 patients; 4 of these poor ACZ responders had retinopathy, and 1 had suffered from a TIA. Duration of diabetes, Hb, MABP, serum glucose concentration, and GHb did not correlate with the percentage of post-ACZ global CBF changes, and did not differ among the 6 poor ACZ responders and the other diabetic patients or control subjects. CONCLUSIONS These results confirm that global CBF is within the normal range in most IDDM patients, although it is significantly influenced by the duration of diabetes; pathophysiological correlates of the altered cerebrovascular reactivity need to be further investigated. rCBF measurements, before and after ACZ administration, seem to represent a safe and reliable tool for assessing cerebrovascular function in IDDM.

Abstract 4773 Introduction. Bone substitutes are widely used to improve bone repair in orthopaedic surgical procedures. Osseointegration is a slow process that takes place both at bone-implant interface and inside the tridimensional structure. The process might benefit from the addition of bone marrow-derived cells (BMC). In order to exploit this possible effects, a study protocol has been designed including preoperative BMC mobilization induced by granulocyte-colony stimulating factor (G-CSF). Aim of the study was to verify feasibility, safety and efficacy of BMC-mobilization in patients undergoing high tibial valgus osteotomy (HTVO). Patients and Methods. Overall, 24 patients undergoing medial open wedge HTVO to treat genu varum were enrolled in a prospective phase II trial. The osteotomy gap was filled by hydroxyapatite and tricalciumphosphate bone graft substitute. Two consecutive cohorts of 12 patients were assigned to receive (GROUP A) or not receive (GROUP B) a daily dose of 10 μ g/kg of G-CSF for 3 consecutive days, with an additional dose 4 hours before surgery. BMC mobilization was monitored by White Blood Cell (WBC) count and flow cytometry analysis of circulating CD34+ cells. All patients underwent a clinical (Lysholm Score and SF-36) and X-ray evaluation preoperatively, and at 1, 3 and 6 months after surgery. Anteroposterior standard radiographs were analysed to compare bone structure of the osteotomy areas. The percentage of integration at the interface between host bone and bone substitute (“host bone-substitute interface”) was estimated by 2 blinded observers. A computed tomography (CT) evaluation of the host bone-substitute interface was performed at 2 months. The osseointegration at the host bone-substitute interface was estimated through a semiquantitative score by 2 blinded observers and through a measure of bone density. Results. Patients of Groups A and B were well balanced in terms of age and clinical presentation. All patients of both groups completed the study. The most common adverse events among patients assigned to G-CSF were mild to moderate bone pain and muscle discomfort, well controlled by oral analgesics. There were no severe adverse events in both Group A and B, all patients are presently alive and well. Mobilization of CD34+ve cells occurred in all patients receiving G-CSF: mean preoperative WBC and CD34+ values were 39,09 × 103/μ l (21,57-51,11) and 131,58/ƒnμ l (29.1 - 404) in Group A, and 6,77 (2,8-12-06) and 7,67/μ l (5,4-12) in Group B, respectively. At the post-surgery clinical evaluation, patients of Group A experienced pain and a slight impairment in overall performance at 1 month assessment, whereas they displayed a slight increase in overall performance at 3 and 6 months compared to Group B. Semi-quantitative radiographic evaluation revealed a higher rate of bone substitute osseointegration in Group A than in Group B at 1, 3 and 6 months post-surgery. Also semiquantitative CT evaluation at 2 months showed an overall improved osseointegration at the host bone-substitute interface in Group A patients. Bone density was measured at the host bone-substitute interface by the Hounsfield score: Group A patients scored lower values at the upper interface compared to Group B, accordingly with advanced stage bone remodelling. The differences between Group A and B on assessment of host bone-substitute interface reached a statistical significance (p< 0,05). Bone mineral density at the host bone-substitute interface as measured with DEXA (Dual-energy X-ray absorptiometry), was lower, although without statistical significance, in Group A than in Group B, again suggesting a more advanced stage of bone remodelling in the treated group compared to controls. Conclusions. G-CSF administration given to induce pre-operative mobilization of bone marrow-derived cells: i. is feasible and safe in patients undergoing orthopaedic surgery; ii. allows the peripheral blood circulation of high numbers of CD34+ve cells; iii. may hasten bone graft substitute integration as suggested by both clinical and radiographical and CT evaluations. The enhanced osseointegration might be the result of a direct activity of G-CSF or of a cellular effect mediated by either hematopoietic or endothelial progenitors mobilized by G-CSF or by the combination of all these factors. Disclosures: No relevant conflicts of interest to declare.

The current study evaluated the effect of two beta adrenergic-blocking agents, propranolol (PRP) and atenolol (ATN), versus placebo on cerebral blood flow (CBF) of three homogeneous groups of cirrhotic patients with portal hypertension. CBF was measured by the noninvasive 133-Xenon inhalation method at rest and 1 hour after a single oral dose of PRP (40 mg), or ATN (100 mg), or placebo. Blood pressure and heart rate (HR) were measured at the beginning of each examination, and end-tidal pCO2(PeCO2) was monitored. The HR decreased significantly in both the PRP and ATN groups (P less than .01), whereas no changes were recorded for both PeCO2 and mean arterial blood pressure (MABP). The comparisons of the CBF differences among groups (ANOVA with the significance levels adjusted by the Bonferroni's correction) showed a significant increase in CBF after ATN as compared with both placebo (P less than .02) and PRP (P less than .01), whereas no significant differences were seen after PRP as compared with placebo. Our results confirm that PRP does not significantly affect CBF, whereas ATN induces an increase in CBF, although the underlying mechanism is difficult to explain.

In a man with orthostatic and effort syncopes due to primary dysautonomia, we measured cerebral blood flow (CBF) — by the 133-Xenon inhalation method — in supine and in sitting positions, and after the i.v. administration of Acetazolamide, a potent cereral vasodilator. Heart rate (HR) and blood pressure (BP) were monitored over the 24 hours by a non-invasive device. The CBF was normal in supine position and significantly reduced when the patient was sitting. Despite che sympathetic denervation, good response to acetazolamide infusion was seen. BP changed with the position of the subject according to gravity, and HR was unresponsive to orthostatic and effort stimuli.

(1992). Correlates of contralateral hypoperfusion in chronic stroke patients. Neurological Research: Vol. 14, Supplement, pp. 125-126.

Cerebral blood flow (CBF), measured by the noninvasive xenon-133 inhalation method, EEG, and plasma levels of ammonia (NH3) and free tryptophan were determined in 18 hospitalized cirrhotic patients affected with subclinical hepatic encephalopathy, as diagnosed by the Kurtz test. CBF results were significantly lower (p < 0.001) in the patients' group as compared with a sex- and age-matched normal control population, although seven patients had values in the normal range. NH3 was increased only in six, while free tryptophan was increased in all but two patients. A significant negative correlation (p = 0.02) between CBF and free tryptophan was found, even though it appears to be difficult to interpret. We suggest that CBF impairment in some cirrhotic patients with subclinical hepatic encephalopathy may be related to the systemic metabolic derangement caused by the liver disease; free tryptophan could have some implication in producing CBF reduction.

We retrospectively examined regional cerebral blood flow values in 78 patients in the stabilized phase of stroke to evaluate the consistency of lateralization compared with computed tomographic imaging. Examinations were performed using the xenon-133 inhalation technique, and the data were processed and displayed by a computer-assisted system of our own design that allows statistical analysis in real time and is suitable for clinical use. The consistency of lateralization correlated with computed tomographic findings was tested for absolute values, percent distribution, and asymmetries. The latter yielded the highest degree of sensitivity (in 83.3% of the patients the affected hemisphere was correctly identified). Absolute values showed at least one hypoperfused area in the affected hemisphere in 48.7% of the patients, and percent distribution did so in 57.7%. Furthermore, the combination of the three methods of data analysis yielded a sensitivity of 91%; the remaining 9% of the patients, however, exhibited some abnormalities of regional cerebral blood flow (bilateral or contralateral hypoperfusion). Although good agreement was found for lateralization by computed tomography and by the combined use of the three methods of analysis, a complete overlap between functional and structural examinations should not be expected. Problems concerning the sensitivity of the xenon-133 inhalation technique under conditions of low blood flow and the statistical analysis of regional cerebral blood flow data are discussed.

Regional cerebral blood flow was studied by means of the 133Xe inhalation method in 26 untreated and 10 treated patients with essential hypertension. The untreated subjects were divided into newly and previously diagnosed groups to assess the relation between regional cerebral blood flow and the duration of hypertension. The overall flow reduction was more marked in the frontal and temporal regions in the previously diagnosed group, and this was attributed to pathological changes in the district served by the middle cerebral artery. Regional temporal lobe impairment was also noted in the newly diagnosed and treated subjects. A significant correlation was found between regional cerebral blood flow and mean arterial blood pressure.

Cerebral blood flow (CBF), measured by the non-invasive 133-Xenon inhalation method, plasma levels of ammonia (NH3) and free tryptophan (fTRP) were determined in 30 cirrhotic patients without overt encephalopathy. Psychometric evaluation detected subclinical hepatic encephalopathy (SHE) in 20 of them, and was normal in the other 10. A significant CBF difference (p less than 0.05) was found between the SHE and the non-SHE patients. fTRP levels were significantly (p less than 0.05) higher in patients with SHE than in those without SHE, and a significant negative correlation (p = 0.003) was found between CBF values and fTRP in the whole group of patients. NH3 did not differ in the two subgroups and did not correlate with CBF values. It is concluded that CBF could have some implications in SHE, although its relevance is still unclear. The negative correlation between CBF and fTRP prompts further investigation concerning the relationships between plasma fTRP, brain serotonin, cerebral metabolism and blood flow in the development of brain derangement during cirrhosis.