Comparison of zones 1 to 4 flexor tendon repairs using absorbable and unabsorbable four-strand core sutures

Absorbable sutures behave favourably in vitro and in an animal model. We report the outcome of flexor tendon injuries in a series of 272 consecutive patients treated over 45 months with a mean follow-up of 4 (range 3-12) months. Five hundred and seventy-six tendons were repaired in 416 digits. The patients were not randomised and all repairs were performed using a Strickland four-strand core technique. In 191 (73%) patients an absorbable core suture was used (Group 1) and in 81 (27%) a non-absorbable material was used (Group 2). There were six ruptures (2%) in Group 1 and two (2%) in Group 2. Using the original Strickland criteria, there were 72% excellent/good and 28% fair/poor results in the absorbable core suture group, and 73% and 27%, respectively, in the non-absorbable core suture group. This study suggests that appropriate absorbable core sutures can be used safely for flexor tendon repair.

The multi-FERM-domain-containing protein FrmA is required for turnover of paxillin-adhesion sites during cell migration of Dictyostelium

FERM domain proteins, including talins, ERMs, FAK and certain myosins, regulate connections between the plasma membrane, cytoskeleton and extracellular matrix. Here we show that FrmA, a Dictyostelium discoideum protein containing two talin-like FERM domains, plays a major role in normal cell shape, cell-substrate adhesion and actin cytoskeleton organisation. Using total internal reflection fluorescence (TIRF) microscopy we show that FrmA-null cells are more adherent to substrate than wild-type cells because of an increased number, persistence and mislocalisation of paxillin-rich cell-substrate adhesions, which is associated with decreased motility. We show for the first time that talinA colocalises with paxillin at the distal ends of filopodia to form cell-substrate adhesions and indeed arrives prior to paxillin. After a period of colocalisation, talin leaves the adhesion site followed by paxillin. Whereas talinA-rich spots turnover prior to the arrival of the main body of the cell, paxillin-rich spots turn over as the main body of the cell passes over it. In FrmA-null cells talinA initially localises to cell-substrate adhesion sites at the distal ends of filopodia but paxillin is instead localised to stabilised adhesion sites at the periphery of the main cell body. This suggests a model for cell-substrate adhesion in Dictyostelium whereby the talin-like FERM domains of FrmA regulate the temporal and spatial control of talinA and paxillin at cell-substrate adhesion sites, which in turn controls adhesion and motility.

WITHDRAWN: Glucocorticoids for acute viral bronchiolitis in infants and young children

BACKGROUND

Systemic glucocorticoids have been widely prescribed for use in infants and young children with acute viral bronchiolitis but the actual benefit of this intervention requires clarification.

OBJECTIVES

To systematically review the evidence on the effectiveness of systemic glucocorticoids for the treatment of infants and young children with acute viral bronchiolitis.

SEARCH STRATEGY

Multiple strategies were incorporated to maximize identification of suitable studies. The following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003); MEDLINE (January 1966 to September 2003); Current Contents (1998 to 2000); EMBASE (January 1990 to September 2003); and Sci Search. Handsearches through cited references and contacts with experts were also used.

SELECTION CRITERIA

Only randomised controlled trials (RCT) were eligible for inclusion. Studies were included if participants were diagnosed with acute viral bronchiolitis and treated with systemic (oral, intramuscular or intravenous) corticosteroids. Three reviewers independently selected potentially relevant articles. Four reviewers evaluated these studies, determined eligibility and assessed the methodological quality of each RCT.

DATA COLLECTION AND ANALYSIS

The primary outcome of interest was length of hospital stay (LOS). Secondary outcomes were: respiratory rate, haemoglobin oxygen saturation, and hospital admission and revisit rates. Data were extracted independently by the four reviewers and the results compiled and compared. Two reviewers reassessed studies to clarify points of discrepancy in the data extraction and database entry processes. Missing data were requested from the authors or calculated from other data presented in the study report.

MAIN RESULTS

There was complete agreement on the inclusion of 13 trials and the exclusion of five studies. Two main study recruitment groups were identified: a) infants and young children within the first 48 hours of hospitalisation (10 trials), and b) outpatient infants and young children who were randomised from the emergency department and who may nor may not have required hospital admission (three trials).A total of 1,198 children aged 0 to 30 months were treated with the equivalent of 0.5 to 10 mg/kg of systemic prednisone for two to seven days. Outcomes of interest were not measured in each RCT. In the pooled analysis of seven trials, there was a decrease in LOS in treated children of 0.38 days (95% confidence interval (CI) -0.81 to 0.05), indicating no significant difference between treatment groups. In the pooled analysis of eight trials, the day three clinical score measured: a standard mean difference (SMD) of -0.20 (95% CI -0.73 to 0.32), indicating no difference between treatment groups. Subgroup analyses for base LOS and clinical score outcomes were performed on infants who were a) less than 12 months of age, b) all respiratory syncytial virus (RSV) positive, c) treated with less than 6 mg/kg of prednisone equivalent throughout the illness and d) first-time wheezers. These were limited by the small number of studies in each subgroup. Hospital admission rates were examined in three trials and no difference was seen between treatment groups (odds ratio (OR) 1.05 (95% CI 0.23 to 4.87). Readmission rates were reported in six studies; with no significant differences between treatment groups. Hospital revisit rates were reported in three studies, with a significant difference between treatment groups reported in one study only. The respiratory rate and haemoglobin oxygen saturation were reported descriptively in six RCTs; no differences were found between groups. Co-interventions (oxygen, supportive fluids and bronchodilators) were used similarly between treatment groups in all RCTs.

AUTHORS' CONCLUSIONS

No benefits were found in either LOS or clinical score in infants and young children treated with systemic glucocorticoids as compared to placebo. There were no differences in these outcomes between treatment groups; either in the pooled analysis or in any of the sub analyses. Among the three studies evaluating hospital admission rates following the initial hospital visit there was no difference between treatment groups. There were no differences found in respiratory rate, haemoglobin oxygen saturation, hospital revisit or readmission rates. Subgroup analyses were significantly limited by the low number of studies in each comparison. Marked study heterogeneity and occasionally conflicting direction of benefit between trials suggests that these results should be interpreted with caution. Specific data on the harm of corticosteroid therapy in this patient population are lacking. Available evidence suggests that corticosteroid therapy is not of benefit in this patient group.

Improving sexual health services in the city: can the NHS learn from clients and the service industry

OBJECTIVE

Genitourinary service providers are struggling to meet patient demand and have introduced changes in access structure to cope. In this study, we explored the perspectives of clients and providers upon the different models of access introduced and whether these maintained service quality using the SERQUAL model.

METHODS

Primary data were collected in May 2005 at two genitourinary medicine clinics, two Accident and Emergency Departments and from members of a university 'gay' society all of which were located in London. Forty-four high-risk clients and 11 health service providers underwent semi-structured face-to-face interviews.

RESULTS

Both the walk-in and appointment-based access systems were appreciated by clients. Clients said that the most important issue was that they were not turned away when they presented. Health-care providers had a variety of opinions about the two systems as they had different impacts on morale, training and service provision.

CONCLUSIONS

Service quality can be maintained by using both walk-in and appointment-based systems. This is because our data, in line with Parasuraman's model of service quality, showed that 'access' is but one determinant of quality. Having different modes of access facilitates patient choice, which is paramount in a modern health-care system. However, to provide a good service it is important to maintain a motivated staff, who can be affected by their working environment.

Trends in hospital admissions for adverse drug reactions in England: analysis of national hospital episode statistics 1998-2005

Background

Adverse drug reactions (ADRs) are a frequent cause of mortality and morbidity to patients worldwide, with great associated costs to the healthcare providers including the NHS in England. We examined trends in hospital admissions associated with adverse drug reaction in English hospitals and the accuracy of national reporting.

Methods

Data from the Hospital Episode Statistics database (collected by the Department of Health) was obtained and analysed for all English hospital episodes (1998–2005) using ICD-10 codes with a primary (codes including the words ('drug-induced' or 'due to') or secondary diagnosis of ADR (Y40–59). More detailed analysis was performed for the year 2004–2005

Results

Between 1998 and 2005 there were 447 071 ADRs representing 0.50% of total hospital episodes and over this period the number of ADRs increased by 45%. All ADRs with an external code increased over this period. In 2005 the total number of episodes (all age groups) was 13,706,765 of which 76,692 (0.56%) were drug related. Systemic agents, which include anti-neoplastic drugs, were the most implicated class (15.7%), followed by analgesics (11.7%) and cardiovascular drugs (10.1%). There has been a 6 fold increase in nephropathy secondary to drugs and a 65% decline in drug induced extra-pyramidal side effects. 59% of cases involving adverse drug reactions involved patients above 60 years of age.

Conclusion

ADRs have major public health and economic implications. Our data suggest that national Hospital Episode Statistics in England have recognised limitations and that consequently, admissions associated with adverse drug reactions continue to be under-recorded. External causes of ADR have increased at a greater rate than the increase in total hospital admissions. Improved and more detailed reporting combined with educational interventions to improve the recording of ADRs are needed to accurately monitor the morbidity caused by ADRs and to meaningfully evaluate national initiatives to reduce adverse drug reactions.

Phase 2 study of talabostat/gemcitabine in Stage IV pancreatic cancer

4616

Background: Talabostat is an oral small molecule inhibitor of fibroblast activation protein (FAP), a stromal enzyme with collagenase and dipeptidyl peptidase activity. Talabostat also upregulates cytokine and chemokine production, resulting in immune stimulation. Talabostat is active in pancreatic tumor xenograft models and enhances the activity of gemcitabine in mice. Therefore, a clinical trial in patients with metastatic pancreatic cancer was initiated. Methods: Open-label, single-arm, Phase 2 study in 60 evaluable patients with Stage IV pancreatic cancer. Study treatment is administered in 4 x 4-week cycles; gemcitabine 1g/m2 weekly for 4 weeks in Cycle 1, then once weekly for 3 of 4 weeks. Talabostat 200mcg tablets are given BID for 6 days following each gemcitabine infusion; dose-escalation to 300mcg BID is allowed post-Cycle 1. Either agent alone or in combination can be continued beyond 4 cycles depending on tolerability. Eligible patients have measureable Stage IV pancreatic adenocarcinoma (per RECIST) are chemotherapy-naive, have a KPS ≥50, no CNS metastases, transaminases < 3 X ULN, and total bilirubin < 1.5 X ULN. Primary endpoint is 6-month survival with secondary endpoints of overall survival, PFS, pain, and quality-of-life. Tumor response or PD is assessed per RECIST. Results: As of the cut-off date, 46 patients (30 men, 16 women, median age 66 [range 43–88 years]) have received study treatment. Most patients (76%) were Stage IV at original diagnosis, and 72% have a KPS of 80 or higher. Ten of 21 evaluable patients treated as of June 30, 2006 meet 6-month survival. Median overall survival is currently estimated at 4.8 months (95% CI: 2.9, NE) in all 46 patients, and median PFS at 3.5 months (95% CI: 2.0, 4.9). Tumor responses have been reported in 3 patients: one CR and 2 PRs. Pain and QOL have not yet been analyzed. AEs are consistent with those of gemcitabine, with the exception of edema in 28.3% of patients. Grade 3 anemia, neutropenia, hyponatremia hyperbilirubinemia, and increased alk phos are reported in 2 patients each. No Grade 4 AEs have been reported in more than one patient. Conclusions: Talabostat/gemcitabine shows activity in metastatic pancreatic cancer and can be safety administered. Enrollment completed in early January 2007, and final results will be presented at the annual meeting.

No significant financial relationships to disclose.

Utilization of oncotype DX in node-negative, ER-positive breast cancer patients

11067

Background: The 21 gene RT-PCR assay Oncotype DX (Genomic Health, CA) stratifies patients into low, intermediate and high risk for systemic recurrence. The objective of this study was to examine the patterns of use of Oncotype DX in a single institution. Methods: All patients who had ODX testing requested by the University of Pennsylvania were identified and recurrence scores (RS) obtained. Patient and tumor characteristics, as well as treatment administered, were obtained by chart review for analysis. Results: 100 ODX tests were ordered between 1/1/05–11/30/06. RS results classified 51% of breast cancers as low risk, 38% intermediate risk, and 11% high risk. Characteristics of the tumors of the overall population and by RS group are shown in Table . 99% of patients received hormonal therapy. Of the low risk patients, only one patient was treated with chemotherapy (2%) while 34% of the intermediate risk group and 80% of the high risk group received chemotherapy. Notably, only 4/100 patients with ODX were under age 35 and 17/100 had tumors over 2cm. Conclusions: In this series, ODX use is accelerating. The results of the ODX tests appear to be used clinically as demonstrated by the very low use of chemotherapy in the low risk group. Comparison to the overall population of ER positive, node negative patients seen at this institution is underway.

[Table: see text]

No significant financial relationships to disclose.

National trends in the use and costs of anti-obesity medications in England 1998–2005

BACKGROUND

To report the trends in the use and costs of anti-obesity medications in England from 1998 to 2005.

METHODS

We analysed data on all community anti-obesity drug prescriptions in England collated by the prescription cost analysis system.

RESULTS

Between 1998 and 2005, Orlistat prescriptions rose 36-fold from 17,880 to 646,700 and total cost increased by over 35-fold. Sibutramine prescriptions rose from 2001 to 2005 from 53,393 to 227,000, a 4-fold increase. Although prescriptions of Orlistat and Sibutramine have increased substantially since they were first introduced, the rate of growth decreased substantially in recent years until 2005, when a significant increase in the number and cost of prescriptions for orlistat occurred yet again.

CONCLUSIONS

We found a large increase in the use and costs of anti-obesity prescriptions, consistent with the increased awareness of obesity amongst health care professionals and the public. Despite this large increase, there are still no head-to-head studies at a national level that directly compare all anti-obesity medication in use in the UK.

Bone anchored hearing aids: a second fixture reduces auditory deprivation in Cambridge

Bone anchored hearing aids are well established for canal atresia, otosclerosis and chronic suppurative otitis media. Refinements in technique to maximise gain while keeping the complications to a minimum are desirable. This study was taken up in order to explore the potential advantage of a second or spare fixture placed at the time of primary surgery. A group of patients who underwent BAHA insertion at The Emmeline Centre for Cochlear Implants and Bone Anchored Hearing Aids, Addenbrookes hospital, Cambridge, UK with the placement of a spare fixture between 1999 and 2002 were compared to those patients with one fixture BAHA undertaken from 1991. Main outcome measures were complications encountered and duration of disability, (i.e. loss of hearing while waiting for new fixture placement). Both groups had similar incidence of complications, but the group with two fixtures suffered a shorter period of disability when a fixture failed. In our experience the use of second or spare fixture reduces the duration of disability. It engenders no additional complications with minimal extra cost.

Is it possible to distribute a scarce resource equitably? Access to invasive procedures for patients with acute myocardial infarction

AIMS

To compare waiting times for inpatient cardiac catheterisation between a hospital with on-site cardiac catheterisation facility (Auckland City Hospital, ACH) and one of its referring hospitals (North Shore Hospital, NSH).

METHODS

Patients were included if they were admitted ACH or NSH with a myocardial infarction, and subsequently underwent inpatient coronary angiography.

RESULTS

853 patients were identified from NSH and 600 from ACH. Patients from NSH waited significantly longer for coronary angiography (median delay 6 versus 3 days, p<0.0009) and fewer underwent this procedure within 48 hours of admission (11% versus 36%, p<0.0009). Delays in percutaneous coronary intervention were significantly longer for NSH patients (6 versus 3 days, p<0.0009), and fewer NSH patients underwent this procedure within 48 hours (12% versus 41%, p<0.0009).

CONCLUSIONS

Inpatients with myocardial infarction waited longer for coronary angiography and percutaneous coronary intervention at a hospital without invasive facility than similar patients at the regional referral hospital with on-site invasive facility.

Role of circulating tumour cells in predicting recurrence after excision of primary colorectal carcinoma

BACKGROUND

This study assessed the potential for reverse transcriptase-polymerase chain reaction (RT-PCR)-based circulating tumour cell identification to predict colorectal cancer recurrence.

METHODS

mRNA for carcinoembryonic antigen and cytokeratin 20 was identified by RT-PCR in blood from patients with colorectal cancer, before and after primary tumour resection. Cancer recurrence was assessed at follow-up, and the accuracy of RT-PCR and primary tumour lymph node positivity in predicting recurrence was estimated.

RESULTS

One hundred and ninety-six patients with colorectal cancer were studied over a median follow-up of 1393 days from surgery. Regression analysis selected 24-h post-resection RT-PCR positivity (hazard ratio for a positive test in predicting recurrence 8.66 (95 per cent confidence interval (c.i.) 3.08 to 24.33)) before lymph node involvement (hazard ratio 7.92 (95 per cent c.i. 3.26 to 19.20)). When 24-h post-resection RT-PCR was combined with lymph node positivity, the hazard ratio increased to 18.54 (95 per cent c.i. 4.01 to 85.11), attributing a 3 per cent recurrence risk to 52 per cent, and a 50 per cent recurrence risk to 48 per cent, of patients with colorectal cancer resected with curative intent.

CONCLUSION

RT-PCR positivity within 24 h of primary colorectal cancer resection is a strong predictor of colorectal cancer recurrence, and may be useful clinically.

Reliability of Echocardiographic Indices of Dyssynchrony

BACKGROUND

Echocardiographic indices of dyssynchrony are increasingly used to select candidates for cardiac resynchronization therapy. For widespread screening of heart failure patients, such variables need to be comparable when evaluated by different operators using different equipment.

OBJECTIVE AND METHODS

To evaluate the reproducibility and obtainability of echocardiographic indices of mechanical dyssynchrony, we studied 40 subjects stratified according to QRS morphology and systolic function. Two echocardiograms were performed on each patient by different sonographers on different machines and each study was analyzed by two observers.

RESULTS

All blood-pool and tissue Doppler indices of dyssynchrony were obtainable in over 97% of cases. Blood-pool Doppler measures were the most reproducible indices of intraventricular dyssynchrony (aortic ejection delay) and interventricular dyssynchrony (aortopulmonary difference in ejection delay). For annular tissue Doppler delays, the time to peak velocity was consistently more reproducible than the time to velocity onset.

CONCLUSION

Differences in the reliability of echocardiographic indices may affect their suitability as screening tests for dyssynchrony.

Defining 'full-length' recombinant factor VIII: a comparative structural analysis

Coagulation factor VIII (FVIII) is an important glycoprotein co-factor involved in haemostasis, functioning to accelerate activation of factor X by activated factor IX. Insertion of expression vectors containing the full-length cDNA sequence of human FVIII into mammalian cell lines results in the production of recombinant factor VIII (rFVIII), typically referred to as 'full-length' rFVIII (FLrFVIII). Both FLrFVIII and plasma-derived FVIII exist primarily as heterodimeric proteins, consisting of a heterogenous light and heavy chain. The objectives of this study were to compare the structural heterogeneity of high-purity FVIII preparations and further define the term 'full length' as it refers to rFVIII protein structure. Five commercially available FVIII concentrates were characterized based on SDS-PAGE, N-terminal sequencing, and peptide and domain mapping coupled to mass spectrometry. The major heavy chain species identified in FLrFVIII included various B-domain-truncated forms of FVIII, with the predominant species terminating at Arg(1313). This study demonstrates that the use of full-sequence FVIII cDNA for the production of rFVIII does not result in a homogeneous FLrFVIII protein product. Rather, commercially available FLrFVIII represents a heterogenous mixture of various B-domain-truncated forms of the molecule, with no evidence of a contiguous, intact B-domain.