Systematic review: the chemoprevention of oesophageal adenocarcinoma

The incidence of oesophageal adenocarcinoma is increasing in the UK faster than any other malignancy. Despite its relatively poor prognosis and the limited success of existing treatments, there is enthusiasm that chemopreventive agents might be able to stem the transition from normal squamous epithelium to adenocarcinoma. We discuss gastro-oesophageal reflux as the main risk factor for the development of Barrett's metaplasia, the only known precursor of oesophageal adenocarcinoma. Treatment options for reflux disease are considered with regard to their effects on cancer risk. Recent advances in the molecular and cell biology of Barrett's are outlined, and potential targets for chemoprevention examined. Available treatments for reflux disease have not convincingly altered the likelihood of cancer development. Epidemiological and animal studies support the use of non-steroidal anti-inflammatory drugs as potential chemopreventive agents. Dietary agents, however, have a more favourable side-effect profile and may prove to be an attractive alternative, although more work is needed to fully explore this prospect.

Changes in functional gastrointestinal symptoms as a result of antireflux surgery

BACKGROUND

This study identifies how functional symptoms are altered after antireflux surgery and whether there are any predictors of such change.

METHODS

A total of 206 patients underwent successful laparoscopic Nissen fundoplication. A questionnaire was sent at a median of 4.3 years (range = 0.3-8.4) after fundoplication. Patients were asked to provide scores for reflux and functional symptoms that were experienced prior to surgery and at the time of the questionnaire.

RESULTS

Eighty-one percent of patients responded. Scores for heartburn, regurgitation, and difficulty swallowing were felt to have significantly improved (p < 0.01). Flatulence was the only functional symptom to have significantly worsened (p < 0.01). A regression analysis incorporating prospectively collected data identified variables that were predictive of changes in functional symptoms following surgery.

CONCLUSIONS

Flatulence was the only functional symptom to have worsened overall after surgery. Predictors of changes in functional symptoms may help clinicians when informing patients about gastrointestinal side effects following antireflux surgery.

Seroprevalence of Chalmydia trachomatis infection amongst patients with pelvic inflammatory diseases and infertility

Chlamydia trachomatis (C. trachomatis) is a common cause of pelvic inflammatory disease in female population. This infection can be diagnosed both by culture and serology. The present study evaluated the seroprevalence of chlamydial infection in patients with pelvic inflammatory disease (ND) and infertility and in control population of healthy normal females. The seroprevalence was found to be 82.7% in patients and 32% in controls by Enzyme Linked Immuno Sorbent Assay (ELISA) for any one or more class of antichlamydial antibodies (IgG/IgM/ IgA). The study demonstrates the importance of serology to monitor trends of chlamydial infections in women with PID and infertility.

Modern surgical treatment of primary aneurysmal bone cyst of the spine in children and adolescents

Aneurysmal bone cyst (ABC) is a benign but locally aggressive tumor-like condition. Treating children with spinal involvement poses special hazards due to the proximity of the lesion to the spinal cord and the need to preserve spinal stability and balance after surgery. Twelve children with ABC treated between 1990 and 2002 at a tertiary pediatric musculoskeletal tumor center using modern surgical techniques and technology were retrospectively reviewed. A surgical technique using a four-step approach of intralesional curettage, high-speed bur, electrocautery, and bone grafting was found to have a significantly reduced rate of recurrence (0/8 cases) compared with traditional intralesional curettage and bone grafting (4/4 cases) (P < 0.002). Short-segment spinal fusion with instrumentation was also done in five cases immediately after excision of the ABC under the same anesthesia and was a nonsignificant marker for reduced rate of recurrence (P < 0.08), likely secondary to wide exposure. Overall, at last follow-up, all 12 patients were alive and well with no evidence of disease and no significant spinal deformity. The four-step approach to treatment of ABC of the spine with appropriate spinal instrumentation and fusion is recommended for successful treatment of this aggressive lesion.

IFN-gamma enhances paclitaxel-induced apoptosis that is modulated by activation of caspases 8 and 3 with a concomitant down regulation of the AKT survival pathway in cultured human keratinocytes

The aim of this study was to investigate the molecular effects of paclitaxel and IFN-gamma on cultured human keratinocyte cells (HaCaT) assessing the induction of both the apoptotic pathway and cell survival signals. Cellular cytotoxicity assays were performed by MTT dye assay. Caspases 8, 3 and AKT (Ser473 and Thr308 residues) were assessed by Western blot analysis. Morphological characteristics were examined by Wright stain analysis. Paclitaxel reduced keratinocyte growth in a 3-day bioassay with an effective ED(50) of 6-600 ng/ml. A large variation in ED(50) can be attributed to the asynchronous population of cells. Paclitaxel treatment induced activation of the AKT survival pathway in a time-dependent manner. The down-regulation of AKT signal was preceded by the subsequent activation of caspases 8 and 3 leading to apoptosis. These results indicate that paclitaxel activates both the PI3-K/AKT cell survival pathway followed by induction of apoptotic signals in cultured human keratinocytes. The induction of apoptosis in paclitaxel-treated cells is enhanced by coadministration of IFN-gamma. The synergistic effect of these two agents on HaCaT cells relies on a pathway involving caspases 8 and 3, with activity increasing by 48 h. Collectively, our data indicate that i) paclitaxel-induced apoptosis is enhanced by IFN-gamma; ii) the down-regulation of PI3-K/AKT survival pathway may help potentiate the apoptotic effects of paclitaxel and iii) the apoptotic signaling pathways are initiated with the activation of caspases 8 and 3 activities.

Nucleus Implant Parameters Significantly Change the Compressive Stiffness of the Human Lumbar Intervertebral Disc

Nucleus replacement by a synthetic material is a recent trend for treatment of lower back pain. Hydrogel nucleus implants were prepared with variations in implant modulus, height, and diameter. Human lumbar intervertebral discs (IVDs) were tested in compression for intact, denucleated, and implanted condition. Implantation of nucleus implants with different material and geometric parameters into a denucleated IVD significantly altered the IVD compressive stiffness. Variations in the nucleus implant parameters significantly change the compressive stiffness of the human lumbar IVD. Implant geometrical variations were more effective than those of implant modulus variations in the range examined.

Effect of bracing on paralytic scoliosis secondary to spinal cord injury

BACKGROUND

The incidence of paralytic scoliosis subsequent to acquired spinal cord injury (SCI) has been reported to range from 46% to 97% in patients injured before the adolescent growth spurt.

OBJECTIVE

The purpose of this report is to review early bracing of children with SCI as a means of preventing or delaying surgical fusion.

METHODS

Patient records from January 1996 to December 2001 from the Shriners Hospitals for Children-Philadelphia were retrospectively reviewed; 123 patients met the inclusion criteria of cervical or thoracic SCI prior to skeletal maturity. Patients were divided into 5 groups based on their radiographic curve severity at presentation, and then they were subdivided into a group that was managed with prophylactic bracing and a group that was not braced. End-points included completion of bracing regimen, surgery, or cessation of growth.

RESULTS

Forty-two patients presented with a curve < 10 degrees, 29 of whom were braced, and 13 who were not. Of the braced group, 13 (45%) went on to surgery, whereas 10 (77%) of the nonbraced group had surgical correction (P = 0.03). Of the patients who were initially braced, the average time to surgery was 8.5 years, whereas that for the nonbraced group was 4.2 years (P = 0.002). A similar trend was seen in the patients who presented with an initial curve between 11 degrees and 20 degrees (P < 0.001). There was no significant difference between time to surgery for the braced and nonbraced patient groups at higher (> 20 degrees) initial curve presentations.

CONCLUSION

Bracing of children with SCI before significant curve formation (< 20 degrees) delays the time to surgical correction of the deformity as it progresses. At smaller curves (< 10 degrees), bracing may even prevent the need for surgery. As curve size increases (> or = 20 degrees), bracing seems to play a limited role, because it does not seem to prevent surgery or delay time to surgical correction.

Synthesis of aryl semicarbazones as potential anticonvulsant agents

A series of 4-ethoxyphenyl semicarbazones (1-10) have been synthesized using an appropriate synthetic route and characterized by elemental analyses and spectral data. The anticonvulsant activity of all the synthesized compounds was evaluated against maximal electroshock induced seizures (MES) and subcutaneous pentylenetetrazole (scPTZ) induced seizure models in mice. The neurotoxicity was assessed using the rotorod method. All the test compounds were administered at doses of 30, 100, and 300 mg/kg body weight and the anticonvulsant activity was noted at 0.5 and 4 h time intervals after the drug administration. Among the compounds tested, compounds except 3, 4 and 10 showed protection from seizures in both the animal models. Compounds 6 and 8 were found to increase gamma-aminobutyric acid (GABA) levels in the medulla oblongata region of the rat brain.

Anticonvulsant and neurotoxicity evaluation of some 6-substituted benzothiazolyl-2-thiosemicarbazones

Various 6-substituted benzothiazolyl-2-thiosemicarbazones were synthesized and screened for anticonvulsant activity in maximal electroshock induced seizure (MES) and subcutaneous pentylenetetrazole (scPTZ) induced seizure models in mice. The neurotoxicity was assessed using the rotorod method. The 6-methyl benzothiazolyl-2-thiosemicarbazones showed anticonvulsant activity in both mice i.p. and rat oral MES screen. The 6-nitro benzothiazolyl thiosemicarbazone derivative 1a emerged as the most promising one with anti-MES activity in mice i.p., rat i.p. and rat p.o. evaluations. All the compounds exhibited lesser or no neurotoxicity compared to phenytoin. The isatinimino derivatives had shown better activity when compared to the benzylidene or acetophenone derivatives.

The relationship between required medical school instruction in musculoskeletal medicine and application rates to orthopaedic surgery residency programs

BACKGROUND

Orthopaedic residency programs lack gender and race diversity. This study examines the hypothesis that exposure to a required course in musculoskeletal medicine in medical school is associated with a higher rate of application to orthopaedic surgery residency programs by underrepresented groups.

METHODS

All 122 medical schools in the United States were surveyed in 2001 to determine whether they required dedicated course work in musculoskeletal medicine, defined as a preclinical module or clinical clerkship in orthopaedic surgery, rheumatology, or physiatry. Data from the Electronic Residency Application Service were obtained for the class of 2002. From these two sources, the rate of applications from students to orthopaedic surgery residency programs was calculated as a function of exposure to a required course in musculoskeletal medicine. Subgroup analysis was further carried out for women and for African Americans, Latinos, and Native Americans.

RESULTS

In 2002, there were 16,294 graduates of American medical schools, of whom approximately 55% had mandatory instruction in musculoskeletal medicine. The rate of application to orthopaedic surgery residency programs was 5.7% among the students with required instruction compared with a rate of 5.1% for students without such required instruction. The rate of application for female students was 2.0% for those who had required courses and 1.1% for the female students who had not had the required courses. The rate of application for minority students in schools with required courses was 8.2% compared with a rate of 6.1% for those students without such exposure.

CONCLUSIONS

Required instruction in musculoskeletal medicine was associated with a 12% higher rate of application to orthopaedic surgery residency programs among all students (5.7% of those who received required instruction compared with 5.1% of those who did not). The relative difference was more pronounced among women (a 75% difference in the rate of application) and minorities (a 35% difference in the rate of application). This study suggests that required instruction in musculoskeletal medicine can help to promote diversity in orthopaedic surgery residency programs.

The tension required at repair to reappose the supraspinatus tendon to bone rapidly increases after injury

Rotator cuff tears occur frequently and can cause significant pain and reduced shoulder function. A high percentage of patients are satisfied after surgical repair of rotator cuff tears, but a smaller percentage of patients with chronic tears continue to have pain and poor shoulder function. This may be partly attributable to an increase in the repair tension, the force required at repair to reappose the tendon to its original insertion site on the humerus. Increases in repair tension have been shown to occur for long-standing ruptures of the supraspinatus tendon, but the precise tension at various times after injury are unknown. Therefore, the objective of the current study was to determine the repair tension at various times after a rotator cuff tear. This was achieved by creating a full-thickness supraspinatus tendon tear in a rat model and measuring the mechanical characteristics of the musculotendinous unit at 0, 2, 4, 9, and 16 weeks after injury. The repair tension rapidly increased initially after injury followed by a progressive, but less dramatic, increase with additional time. These findings suggest that rotator cuff tears should be repaired early in the clinical setting. Future studies will investigate the effect of repair tension on tendon to bone healing after repair.

Sublingual misoprostol versus methylergometrine for active management of the third stage of labor

OBJECTIVE

To compare the efficacy and side effects of sublingual misoprostol and intravenous methylergometrine for active management of third stage of labor.

METHOD

One hundred twenty low risk pregnant women at term with spontaneous onset of labor were included in the study. The women were randomized to receive either two tablets of misoprostol (200 microg/tablet) sublingually or 1 ml of methylergometrine (200 microg) intravenous injection, after the delivery of the anterior shoulder of the baby. The main outcome measures were: need for additional oxytocic drugs, blood loss >or=500 ml, change in hemoglobin levels and side effects.

RESULTS

Postpartum hemorrhage as defined by hemorrhage >or=500 ml occurred in 3.1% of the women in the sublingual misoprostol group but none of the women in the methylergometrine group (P > 0.05). There was a need for additional oxytocic drugs in 5.0% and 8.3% after methylergometrine and misoprostol, respectively (P > 0.05). The change in hemoglobin levels at 24 h postpartum were 0.8 and 0.7 gm% in methylergometrine and misoprostol group, respectively(P > 0.05). In the misoprostol group, 6.6% women developed fever >or=38 degrees C and 21.6% had shivering while in methylergometrine group none experienced these side effects. However, the incidence of other side effects like nausea, vomiting, headache and giddiness were similar in both groups.

CONCLUSION

Sublingual misoprostol appears to be as effective as intravenous methylergometrine in the prevention of postpartum hemorrhage. However, larger randomized studies are needed to advocate its routine use.

Langerhans cell histiocytosis of the spine in children. Long-term follow-up

BACKGROUND

Langerhans cell histiocytosis causes destructive lesions in a child's spine. Few large, long-term studies have evaluated the clinical and radiographic presentation, natural history, outcomes of modern treatment approaches, and maintenance of normal spinal growth and stability after the diagnosis of this disease in children.

METHODS

Twenty-six children with biopsy-proven Langerhans cell histiocytosis involving the spine were treated at our institution between 1970 and 2003. They had a total of forty-four involved vertebrae (twenty cervical, fourteen thoracic, and ten lumbar). Vertebral body collapse was measured on radiographs and classified as grade I (0% to 50% collapse) or grade II (51% to 100% collapse) and subclassified as A (symmetric collapse) or B (asymmetric collapse). Lesions of the posterior elements of the spine were classified as grade III. Twenty-three children were followed for two years or more (mean, 9.4 years), and the analyses of treatment and long-term outcomes were performed in that group of patients.

RESULTS

There was a predominance of lesions in the cervical spine (p </= 0.02). Sixteen (62%) of the twenty-six children were found to have multifocal skeletal disease. Cervical and lumbar lesions were more commonly associated with multilevel spinal disease. The extent of the initial collapse seen radiographically was grade IA for twenty vertebrae, IB for three, IIA for ten, IIB for nine, and III for two. Grade-I lesions were more likely to be associated with symmetric collapse than were grade-II lesions. Spinal deformity developed in four children, and two later required spinal fusion. No relationship was observed between the grade of the initial collapse and the subsequent development of spinal deformity. Despite heterogeneous treatment, all patients were alive and well with resolution of all presenting signs and symptoms and no evidence of active disease at the time of the most recent follow-up.

CONCLUSIONS

We found a particularly high prevalence of lesions in the cervical spine and a high prevalence of multiple skeletal lesions. In contrast to the classic finding of vertebra plana, we found that more severe lesions often led to asymmetric collapse; yet, asymmetric collapse was not found to be associated with the development of subsequent spinal deformity. The natural history of these lesions in the spine in the absence of systemic disease or spinal deformity is such that aggressive surgical management is usually not indicated; only follow-up is necessary to monitor recovery and spinal balance.