Femoroacetabular impingement

Femoroacetabular impingement (FAI) is commonly associated with early hip arthritis. We reviewed our series of 1300 hip resurfacing procedures. More than 90% of our male patients, with an average age of 53 years, had cam impingement lesions. In this condition, there are anterior femoral neck osteophytes, and a retroverted femoral head on a normally anteverted neck. It is postulated that FAI results in collision of the anterior neck of the femur against the rim of the acetabulum, causing damage to the acetabular labrum and articular cartilage, resulting in osteoarthritis. Early treatment of FAI involves arthroscopic or open removal of bone from the anterior femoral neck, as well as repair or removal of labral tears. However, once osteoarthritis has developed, hip replacement or hip resurfacing is indicated. Hip resurfacing can re-orient the head and re-shape the neck. This helps to restore normal biomechanics to the hip, eliminate FAI, and improve range of motion. Since many younger men with hip arthritis have FAI, and are also considered the best candidates for hip resurfacing, it is evident that resurfacing has a role in these patients.

The use of botulinum toxin in the management of burns itching: preliminary results

Itching is a common and well recognised problem following burns. As the underlying pathways involved in burns itch have been identified, different pharmacological agents have been introduced to improve the effectiveness of management regimes. We present preliminary data from an on-going study in the use of botulinum toxin as a novel agent in the treatment of this problem.

METHOD

Patients with recalcitrant itching secondary to burns treated with Botox(©) were identified. Data pertaining to burn size, depth and management were recorded. The delay in the onset of the itch, its severity and the speed and duration of any improvement in symptoms were also noted.

RESULTS

10 patients were identified. 1 patient was excluded. Average follow-up was 11.3 months. All patients had deep partial thickness to full thickness burns. Eight patients underwent grafting. The average burn was 24% TBSA. 87.5% of patients rated their burns itch as being severe (>7 on the pain scale). Following the administration of Botox(©) this fell to 0 out of 10 at 4 weeks. The average duration of the symptom free period was nine months (range 3-18 months).

CONCLUSION

Botox(©) can successfully be used to treat burns itch that are resistant to conventional therapies.

Use of tranexamic acid to reduce bleeding in burns surgery

We describe, for the first time, the use of topical tranexamic acid as an adjunct to traditional methods in the control of bleeding in burns surgery. We illustrate our use with a case example and continue to discuss the reasons we believe it is a useful, effective and safe means of achieving haemostasis.

Changing trends in the management of pulmonary atresia with intact ventricular septum: the Melbourne experience

OBJECTIVE

Management of pulmonary atresia with intact ventricular septum (PAIVS) can be directed to either biventricular repair or univentricular palliation. The optimal management strategy has yet to be defined.

METHODS

All patients operated at the Royal Children's Hospital, Melbourne for PAIVS between 1990 and 2006 (n = 81) were reviewed. Patients were retrospectively stratified into a simple three-tiered classification based on right ventricle (RV) size. Multivariate logistic regression analysis was performed to identify risk factors of mortality.

RESULTS

The distribution of RV sizes was normal in 11 (14%), moderate hypoplasia in 45 (56%), and severe hypoplasia in 25 (31%) patients. RV-to-coronary-artery connections were present in 33 (41%) and RV coronary dependence in six patients (7%). Sixteen patients died (20%). The end-status of the remaining patients was biventricular repair in 31/81 (38%), 1½-ventricle repair in 10/81 (12%), Fontan circulation in 14/81 (17%), transplantation in 1/81 (1%), and still awaiting repair in 9/81 (11%). Ten-year survival was 80% (95% confidence interval (CI): 71-87%). Independent predictors of mortality were lower tricuspid valve (TV) annulus size Z-score and the presence of RV-to-coronary-artery connections.

CONCLUSIONS

A simple three-tiered classification based on RV size may allow initial stratification into biventricular or univentricular repair for patients with normal RV size and severe RV hypoplasia. In patients with moderate RV hypoplasia, the presence of RV-to-coronary-artery connections or a TV Z-score<-2 should caution one against attempting biventricular repair.

Faecal sterols analysis for the identification of human faecal pollution in a non-sewered catchment

In this study, faecal sterols were used to identify human faecal pollution in a non-sewered catchment in Southeast Queensland, Australia. In all, 36 water samples were collected from six sites on six occasions and the concentration of sterols were determined using gas chromatography and mass spectrometry. The stanols concentration in water samples generally increased with increased catchment runoff. After moderate rainfall, high coprostanols levels found in water samples indicated human faecal pollution via defective septic systems. In contrast, it appears that during dry weather human faecal pollution is not occurring in the study catchment. Sterol profiles also pointed to a cattle farm polluting during modest catchment runoff. The method used in this study was able to identify the sources of faecal pollution to the catchment due to rainfall.

Conservative treatments for tennis elbow do subgroups of patients respond differently?

OBJECTIVES

To determine if subgroups of patients with tennis elbow respond differently in treatment.

METHODS

This study used individual patient data (n = 383) from two randomized controlled trials that investigated a wait-and-see policy, corticosteroid injections and physiotherapy. Common outcome measures were: pain severity, global improvement, severity assessed by a blinded assessor, elbow disability and pain free grip strength. Subgroup analyses for previous history of elbow pain, baseline pain severity, duration of the current episode and employment status were performed at 6 and 52 weeks.

RESULTS

Patients' age, previous elbow symptoms and baseline pain severity were similar between trials, but other characteristics differed between trial populations. Based on individual patient data from both trials, we found that corticosteroid injections were statistically and clinically superior at 6 weeks, but significantly worse at 52 weeks compared with both wait-and-see and physiotherapy. Subgroup effects were scarce and small. Patients with higher baseline pain score showed less benefit on pain outcomes between physiotherapy and a wait-and-see policy at 6 weeks. It also appeared that non-manual workers who had an injection were the only work subgroup to follow the general trend that injections were significantly worse than a wait-and-see policy on global improvement at 52 weeks.

CONCLUSION

The treatment outcomes were largely similar between trials and not different between most subgroups studied. In tennis elbow, it would appear that patient characteristics play only a small role in predicting treatment outcomes, which supports the generalizability of individual trial results.

Balancing paediatric anaesthesia: preclinical insights into analgesia, hypnosis, neuroprotection, and neurotoxicity

Logistical and ethical reasons make conducting clinical research in paediatric practice difficult, and therefore safe and efficacious advances are dependent on good preclinical research. For example, notable advances have been made in preclinical studies of pain processing that correlate well with patient data. Other areas of paediatric anaesthetic research remain in their infancy including mechanisms of anaesthesia and anaesthetic neuroprotection and neurotoxicity. Animal data have identified the potential 'double-edged' sword of administering anaesthetic agents in the young; although these agents can be neuroprotective in certain circumstances, they can be neurotoxic in others. The potential for this toxicity must be balanced against the importance of providing adequate anaesthesia for which there can be no compromise. We review the current state of preclinical research in paediatric anaesthesia and identify areas which require further exploration in order to provide the foundations for well-conducted clinical trials.

Application of biochemical fingerprinting and fatty acid methyl ester profiling to assess the effect of the pesticide Atradex on aquatic microbial communities

We investigated changes in biomass, biochemical fingerprints, fatty acid methyl ester (FAME) profile and functional status of the natural aquatic microbial communities upon impact of an Atradex pulse. The Atradex was applied to microcosm tanks at concentrations ranging from 24.5microgL(-1) to 245mgL(-1). The biomass of all microbial communities declined to a minimum level on day 4 with the effect being more pronounced in treated groups. Similarity between microbial communities also decreased on day 4 with the greatest change occurring at a concentration of 245mgL(-1) Atradex. After 8 days exposure to Atradex, microbial communities in all treated groups (except tanks spiked with 245mgL(-1) Atradex) recovered and showed similar metabolic fingerprints and FAME profiles to those of controls. Our results indicate that exposure to an Atradex pulse at concentration above 245mgL(-1), may irreversibly change the structure and functional status of aquatic microbial communities.

Sourcing faecal pollution: a combination of library-dependent and library-independent methods to identify human faecal pollution in non-sewered catchments

Library-dependent (LD) (biochemical fingerprinting of Escherichia coli and enterococci) and library-independent (LI) (PCR detection of human-specific biomarkers) methods were used to detect human faecal pollution in three non-sewered catchments. In all, 550 E. coli isolates and 700 enterococci isolates were biochemically fingerprinted from 18 water samples and compared with metabolic fingerprint libraries of 4508 E. coli and 4833 enterococci isolates. E. coli fingerprints identified human unique biochemical phenotypes (BPTs) in nine out of 18 water samples; similarly, enterococci fingerprints identified human faecal pollution in 10 water samples. Seven samples were tested by PCR for the detection of biomarkers. Human-specific HF134 Bacteroides and enterococci surface protein (esp) biomarkers were detected in five samples. Four samples were also positive for HF183 Bacteroides biomarker. The combination of biomarkers detected human faecal pollution in six out of seven water samples. Of the seven samples analysed for both the indicators/markers, at least one indicator/marker was detected in every sample. Four of the seven PCR-positive samples were also positive for one of the human-specific E. coli or enterococci BPTs. The results indicated human faecal pollution in the studied sub-catchments after storm events. LD and LI methods used in this study complimented each other and provided additional information regarding the polluting sources when one method failed to detect human faecal pollution. Therefore, it is recommended that a combination of methods should be used to identify the source(s) of faecal pollution where possible.

BAY 43–9006 (sorafenib-BAY) alters proliferation pathways and mutant specific-PCR (MS-PCR) improves detection of BRAF mutations in metastatic melanoma (MM)

8542

Background: Approximately 60% of melanomas carry BRAF mutations (mut). BAY is a multi-kinase inhibitor that inhibits the BRAF pathway. A phase II trial of BAY in MM is being conducted to: 1) determine if treatment (tx) with BAY can alter proliferation as measured by cyclin D1, Ki-67 and ERK, 2) assess for differential anti-tumor responses and 3) to assess a newly developed fluorescent-based PCR assay to detect mutant BRAF. Methods: Eligibility criteria: Biopsy (bx)-accessible, untreated MM. Measurable disease (RECIST). Stratification of tumor BRAF status determined by routine PCR sequencing for codon 600 mut prior to tx and fluorescent MS-PCR sequencing for confirmation. MS-PCR specifically amplified the M-BRAF allele without amplifying the wild-type (WT)allele. Tx: BAY 400 mg po BID D1–28 q4w. Repeat bx on Day 28. Bx assessed for Ki-67, cyclin-D1 and ERK. Serum collagen cryptic epitopes were measured serially. Re-imaging was done every 2 cycles and pts treated until POD. Results: 29 pts (9-M1a, 8-M1b, 12-M1c) enrolled. 26 wild type (WT) and 3 mutant (M) BRAF by routine PCR. Due to the low yield of mut on routine PCR, MS-PCR was done. 6 mutants were detected in the first 16 pts with MS-PCR compared to 2 with routine sequencing. Median age: 68 (range 22–91). 8 pts with LDH ≥ 1.5 × nl. Tox: Gr I-diarrhea(7), alopecia(4), rash(6), mucositis(4), nausea(4), pain(4), hand-foot(2); Gr II- HTN(4), fatigue(2),mucositis(1), rash(3), pain(3), hand-foot(2); Gr III-hand-foot(1), rash(1), fatigue(1) and intestinal perforation(1). Responses: 12 NE (2 WD, 8 early POD, 1 tox, 1 too early); M BRAF- 1 PR (lymph nodes and large SQ arm masses) and 2 PD; WT BRAF- 1 PR, 7 POD after 2 cycles, 6 SD. Matched paired biopsies demonstrated down regulation of tumor ki-67, erk and cyclin-D1. Collagen cryptic epitopes correlated with tumor responses. Conclusions: MM patients with tumors that were molecularly characterized for BRAF mutational status were entered on this single agent BAY trial and responses were seen in both M and WT arms. Down-regulation of Ki-67, cyclin D1 and ERK was demonstrated and MS-PCR improved the sensitivity to detect BRAF mut. Supported by NCI N01-CM17103 and TRI.

No significant financial relationships to disclose.

Shedding of distinct cryptic epitope (HU177) in sera of melanoma patients

8550

Background: Our preclinical data suggest that a newly identified cryptic epitope HU177 within collagen regulates endothelial and tumor cell adhesion in-vitro and angiogenesis and tumor growth in-vivo. We investigated whether 1) HU177 shedding can be measured in melanoma patients’ sera, and 2) if HU177 concentration correlates with clinicopathological features, recurrence and survival. Methods: Sera from 291 melanoma patients (primary Stage I, n=140; II n=41; III n=29; recurrent/metastatic n=81) and 30 normal volunteers prospectively enrolled at the NYU School of Medicine were analyzed for HU177 epitope concentration (ng/ml) by ELISA. Microtiter plates were incubated overnight with monoclonal antibody (anti-HU177 epitope). Patients’ sera and standards (denatured type-IV collagen) were added in duplicate followed by dilutions of biotinylated anti-collagen type IV polyclonal and HRP-labeled anti-biotin antibodies with multiple washes after each incubation. Absorbance was monitored at 400 nm. Results: The mean concentration of anti-HU177 epitope was 5.8 ng/ml (range 0.1 to 139.8). Normal volunteers were 1.6±0.3 (mean ± SEM). A significant correlation was observed between HU177 concentration and tumor thickness in patients who presented with primary melanoma (=1.00 mm, n=113, 3.8±0.4; 1.01–3.99 mm, n=72, 8.9 ±2.1; =4.00 mm, n=22, 10.3±2.2; P=0.003 by ANOVA test) and nodular melanoma histological subtype (nodular, n=47, 10.5±3.1; superficial spreading, n=95, 4.4±0.5; others, n=68, 6.0±2.1; P=0.02, ANOVA). Multivariate analysis confirmed the independent correlation between higher HU177 concentration and nodular subtype after controlling for tumor thickness (P=0.04). Primary patients with ulcerated melanomas and those who developed recurrences both showed higher HU177 epitope levels, however, the difference was not significant (P>0.05). Conclusions: This is the first study on HU177 epitope shedding in melanoma patients. Data demonstrate the clinical feasibility of HU177 testing in melanoma patients’ sera and suggest that HU177 epitope shedding correlates with thicker primary melanomas. Longer follow-up is required to better define the prognostic value of HU177 epitope shedding in melanoma patients.

[Table: see text]

Differential expression of insulin like growth factor binding protein-4 (IGFBP4) in melanoma progression

8557

Background: Members of the IGFBP family are thought to regulate tumor progression through both IGF-dependent and independent mechanisms. Moreover, IGFBPs may exhibit distinct functions depending on whether they are present locally in tissue or systemically. Our preclinical data suggest that IGFBP4 serves as an endogenous inhibitor of angiogenesis and melanoma tumor growth. To examine the clinical validity of our observations, we compared IGFBP4 expression in tissue and sera in primary melanoma patients with a low risk of metastases versus patients with established metastatic disease. Methods: Eighty-nine melanoma patients (primary stage IA, n=57; metastatic, n=32; 44 M, 45 F; Median Age=56) prospectively enrolled in the Interdisciplinary Melanoma Cooperative Group at the NYU School of Medicine were studied. IGFBP4 protein expression in tumors was assessed in 83 patients using goat anti-human IGFBP4 antibody (R&D Systems) in an immunohistochemical assay. For each case, the percentage of tumor cells that stained positively was estimated. IGFBP4 concentration in the serum was measured in 64 patients by an ELISA assay (Diagnostic Systems Laboratories, Inc.). Fifty-eight patients had both sera and tumor specimens available for correlation. Results: The median IGFBP4 expression in tumor specimens from primary patients was 70% compared to 5% in metastatic patients (P=0.002, Wilcoxon rank-sum test). The median concentration of IGFBP4 in sera was 43.8 ng/ul in primary patients versus 41.0 ng/ul in metastatic patients (P=0.83). A weak association between IGFBP4 expression in tissue and IGFBP4 shedding in sera was observed (Spearman correlation coefficient=0.16, P=0.24) in the 58 cases with both sera and tissue available. Conclusions: Our data demonstrate that IGFBP4 expression in melanoma clinical specimens decreases in the progression from primary to metastatic melanoma, consistent with its potential role as an inhibitor of angiogenesis. Data also suggest that IGFBP4 tissue expression may be more clinically relevant than its sera shedding. Future studies using a larger sample size and extended follow up are needed to further define the role of IGFBP4 in melanoma progression.

No significant financial relationships to disclose.

Prevalence of dementia in Chamorros on Guam: Relationship to age, gender, education, and APOE

OBJECTIVES

To estimate the prevalence of dementia and its clinical subtypes among Chamorros on Guam aged 65 years or older and to examine associations with age, gender, education, and APOE genotype.

BACKGROUND

Chamorros, the indigenous people of Guam, had a high incidence of ALS and parkinsonism-dementia complex (PDC), in the 1950s. Over the next 50 years, ALS incidence declined markedly, but PDC only slightly. The prevalence of late life dementia in Chamorros and its relationship to ALS/PDC are unknown.

METHODS

Island-wide population-based survey of Chamorros aged 65 years or older as of January 1, 2003. Two-stage assessment: cognitive and motor screening, followed by neurologic and psychometric evaluation. Data were reviewed at consensus conference to make clinical diagnoses.

RESULTS

Of 2,789 Chamorros aged 65 years or older, 73% were enrolled; 27% declined participation, died before contact or screening, or moved off Guam. The point prevalence of all-cause dementia on February 1, 2004, was 12.2%. Prevalence data for subtypes were as follows: Guam dementia (clinically equivalent to AD), 8.8%; PDC, 1.5%; pure vascular dementia, 1.3%; other, 0.6%. The prevalence of dementia rose exponentially with age. Low education was significantly associated with dementia, but gender was not. There was a trend toward higher PDC prevalence among men. The APOE epsilon4 allele was not associated with dementia.

CONCLUSIONS

The prevalence of dementia among elderly Chamorros is relatively high. Guam dementia is the most common diagnosis and exceeds parkinsonism-dementia complex. Age and low education are strongly associated with dementia, but gender and APOE epsilon4 are not. Incidence studies will allow risk factors for dementia to be clarified.

An integrated analysis of five double-blind, randomized controlled trials evaluating the safety and efficacy of a hyaluronan product for intra-articular injection in osteoarthritis of the knee

OBJECTIVE

Five double-blind, randomized, saline-controlled trials (RCTs) were included in the United States marketing application for an intra-articular hyaluronan (IA-HA) product for the treatment of osteoarthritis (OA) of the knee. We report an integrated analysis of the primary Case Report Form (CRF) data from these trials.

METHOD

Trials were similar in design, patient population and outcome measures - all included the Lequèsne Algofunctional Index (LI), a validated composite index of pain and function, evaluating treatment over 3 months. Individual patient data were pooled; a repeated measures analysis of covariance was performed in the intent-to-treat (ITT) population. Analyses utilized both fixed and random effects models. Safety data from the five RCTs were summarized.

RESULTS

A total of 1155 patients with radiologically confirmed knee OA were enrolled: 619 received three or five IA-HA injections; 536 received "placebo" saline injections. In the active and control groups, mean ages were 61.8 and 61.4 years; 62.4% and 58.8% were women; baseline total Lequèsne scores 11.03 and 11.30, respectively. Integrated analysis of the pooled data set found a statistically significant reduction (P < 0.001) in total Lequèsne score with hyaluronan (HA) (-2.68) vs placebo (-2.00); estimated difference -0.68 (95% CI: -0.56 to -0.79), effect size 0.20. Additional modeling approaches confirmed robustness of the analyses.

CONCLUSIONS

This integrated analysis demonstrates that multiple design factors influence the results of RCTs assessing efficacy of intra-articular (IA) therapies, and that integrated analyses based on primary data differ from meta-analyses using transformed data.