The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

An optimal de Quervain's tenosynovitis splint with ergonomic thumb support and evenly distributed pressure

Splinting is a conventional treatment for de Quervain's tenosynovitis (dQt). However, existing splints have problems such as excessive thermal discomfort and poor fit, which have been pointed out in previous studies. This study proposes a new functional splint consisting of both hard and soft materials with the aim of providing wear comfort with a good fit and sufficient stability of the injured hand. Thumb support of the splint is an important component that controls and protects the affected thumb. To develop an ergonomically shaped thumb support, 16 participants with dQt were recruited for three-dimensional (3D) scanning of their hands. The angles of the wrist and the curvature of the thumb were measured using computer software, and the results were used as a reference for the design of the prototype supports. Excessive pressure on particular regions, such as bony areas, may cause discomfort or pain. To ensure the wear comfort of the proposed splint, a finite element model (FEM) was built to simulate the wear process of the splint and hence to predict the pressure distribution exerted from the splint onto the hand of the wearer. The simulated results show that the pressure is evenly distributed over the hand, indicating that patients are likely to wear the proposed splint comfortably during their treatment period.

Acute myocardial infarction and myocarditis following COVID-19 vaccination

Emerging reports raise concerns on the potential association between the COVID-19 vaccines and cardiac manifestations. We sought to evaluate cardiac complications associated with COVID-19 vaccination in a pooled analysis from our institution's cohort study and systematic review. Consecutive patients admitted to a tertiary hospital in Singapore between 1 January 2021 and 31 March 2021, with the onset of cardiac manifestations within 14 days following COVID-19 vaccination, were studied. Furthermore, a systematic review was performed, with PubMed, Embase, Research Square, MedRxiv and LitCovid databases accessed from inception up to 29 June 2021. Relevant manuscripts reporting individual patient data on cardiac complications following COVID-19 vaccination were included. Thirty patients were included in the study cohort, with 29 diagnosed with acute myocardial infarction (AMI) and 1 with myocarditis. Five patients developed heart failure, two had cardiogenic shock, three intubated, and one had cardiovascular-related mortality. In the systematic review, 16 studies were included with 41 myocarditis and 6 AMI cases. In the pooled analysis of the study cohort and the systematic review, 35 patients had AMI and 42 had myocarditis. Majority were men, and myocarditis patients were younger than AMI patients. Myocarditis patients tended to present 72 h postvaccination, while AMI patients were older and typically presented 24 h postvaccination. Majority with AMI or myocarditis developed symptoms after the first and second vaccination dose, respectively. This pooled analysis of patients presenting with cardiac manifestations following COVID-19 vaccination highlights the differences between myocarditis and AMI presentations in temporal association with the vaccination.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Homologous Recombination Deficiency and Tumor Mutational Burden as Clinical Biomarkers for Melanoma

Introduction/Objective

Homologous recombination deficiency (HRD) cancers have high levels of genetic instability, potentially being targets for platinum agents or poly-ADP ribose polymerase inhibitors. Tumor mutational burden (TMB), which is used to guide immunotherapy, is thought to be associated with HRD. This study aimed to evaluate the frequency of HRD and its correlation with other genomic parameters in melanoma.

Methods/Case Report

A total of 14 cases with the diagnosis of melanoma were found in the genomic database between March 1, 2021 to July 30, 2021. One case had an EWSR1-ATF1 translocation and was excluded. Copy number variations and absence of heterozygosity detection were analyzed by the NxClinical software (BioDiscovery, El Segundo, CA). HRD was scored by three DNA-based measures of genomic instability (loss of heterozygosity (LOH), telomeric allelic imbalance (TAI), and large-scale transitions (LST)). HRD-LOH is the number of LOH regions > 15 Mb and do not cross the centromere. HRD-TAI is the number of regions > 10 Mb with allelic imbalance that extend to one of the subtelomeres and do not cross the centromere. HRD-LST is the number of break points between regions > 10 Mb. A high HRD score and LOH percentage were defined as ≥ 42 and ≥ 16%, respectively.

Results (if a Case Study enter NA)

Of the 13 cases, 10 had a high TMB and 3 had a low TMB. A high HRD score was found in 3 cases; high LOH percentage was found in 4 cases. PDL-1 was expressed in 8 of the 11 cases tested. A high HRD score correlated with high LOH percentage by Pearson’s chi-squared test (p < 0.01). No significant association was found between TMB and HRD score or LOH percentage. Common alterations among cases with high TMB included mutations in NRAS (3/13; 23.1%), CDKN2A (2/13; 15.4%), BRAF (2/13; 15.4%), BRCA2 (2/13; 15.4%), RAF1 (2/13; 15.4%), RET (1/13; 7.7%), IDH1 (1/13; 7.7%), PALB2 (1/13; 7.7%), BRCA1 (1/13; 7.7%), ERBB2 (1/13; 7.7%), NF1 (1/13; 7.7%), MLH1 (1/13; 7.7%), ATM (1/13; 7.7%) and MET (1/13; 7.7%). One case had amplifications in CCND1, FGF 3/4/19 and MET. Among cases with low TMB, alterations included MYC amplification (1/3; 33.3%) and BRAF mutations (2/3; 66.6%).

Conclusion

In our study, HRD score is not associated with TMB status. There is a strong correlation between HRD score and LOH percentage, suggesting that LOH is a major component in the genomic scarring seen in HRD. HRD may be an independent biomarker of immunogenicity to guide immunotherapy.

Reconstructed meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting for left main disease

Background

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results.

Objectives

We performed a systematic review from inception to 23 May 2021 and one-stage reconstructed individual-patient data meta-analysis (IPDMA) that included 10-year mortality outcomes.

Methods

The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke and unplanned revascularization at 5 years. We did IPDMA using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups.

Results

Of 583 articles retrieved, 5 RCTs were included. A total of 4595 patients from these 5 RCTs were randomly assigned to PCI (N=2297) or CABG (N=2298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6% respectively (HR 1.093, 95% CI: 0.925–1.292; p=0.296). PCI conferred similar time-to-MI (RMST ratio 1.006, 95% CI: 0.992–1.021, p=0.391) and stroke (RMST ratio 1.005, 95% CI: 0.998–1.013, p=0.133) at 5 years. Unplanned revascularization was more frequent following PCI compared with CABG (HR 1.807, 95% CI: 1.524–2.144, p<0.001) at 5 years.

Conclusion

This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.

Funding Acknowledgement

Type of funding sources: None.

Factors predictive of Ponseti casting for treating clubfoot: analysis of Bayesian Poisson regression model

OBJECTIVE

Clubfoot is a growing public health concern in Bangladesh, with the incidence of approximately 0.64 to 6.8 in every 1000 live births. For over a decade, Ponseti method has been considered a gold standard for treating the clubfoot. Despite few studies have been estimating the number of casts required to correct the clubfoot deformities by Ponseti method, the subject of interest has always remained. Therefore, this current study aimed to investigate the significant predictive factors for the number of casts required to correct congenital clubfoot.

PATIENTS AND METHODS

In this retrospective cohort study, we used Bayesian Poisson Regression Model to investigate the influencing factors that could predict how many casts are needed to correct the clubfoot. We included 69 patients with 99 affected feet, who completed their corrective phase of treatment in the Ponseti method. For this cohort study, we integrated only pre-tenotomy casting data with no age restrictions. We used Bayesian Poisson regression analysis technique to estimate the predictive factors.

RESULTS

In Bayesian Poisson model, age was the most influencing predictive factor (24.3%) for increasing the number of castings to correct the clubfoot deformity. The clubfoot offspring of the ≤1-year-old was positive, and the incidence rate increased significantly with the casting number. The number of Ponseti casts in male clubfoot children was 28% higher than in female, and this was marginally statistically significant. There was no marked change estimated in the pattern of clubfoot, foot involvement and Pirani score of the severity.

CONCLUSIONS

We concluded that the age factor may influence the number of casts required for the correction of clubfoot and specifically ≤ 1-year-old children are highly impacted. Treating clubfoot at an early age is suggested in this study to increase the success of clubfoot treatment and decrease the risk of relapse.

Echocardiographic global longitudinal strain as a marker of myocardial fibrosis predicts outcomes in aortic stenosis

Background

Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) reflects intrinsic myocardial function, influenced by interstitial abnormalities. Cardiovascular magnetic resonance (CMR) detects myocardial fibrosis non-invasively, but it is limited for widespread use. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on CMR and validate the prognostic value of LV-GLS thresholds associated with fibrosis.

Methods

LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57±10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR for replacement myocardial fibrosis. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71±12 years; 58% males; NYHA functional class I-II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, myocardial infarction and cerebrovascular events.

Results

In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74; 95% confidence interval: 0.66–0.83; P<0.001) and calibration (Hosmer-Lemeshow X2=6.37; P=0.605) for replacement fibrosis. In the outcome cohort, 52 events occurred over 16 [3.1, 42.0] months of follow-up. Patients with LV-GLS >−15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS <−21.0% (corresponding to 95% sensitivity to rule-out myocardial fibrosis) and those between −21.0 and −15.0% (log-rank P<0.001; Figure 1). Furthermore, LV-GLS offered independent prognostic value over clinical variables, AS severity, echocardiographic LVEF and E/e' (hazard ratio 1.18; 95% confidence interval: 1.07 to 1.30; P=0.001).

Conclusions

LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF (Figure 2).

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Figure 1Figure 2

A network meta-analysis on the vasomodulators for portopulmonary hypertension

Background

In patients with portopulmonary hypertension (PoPH) who are eligible and awaiting liver transplant, guidelines recommend lowering pulmonary pressures with vasomodulators as a bridge to transplant. However, efficacy of each vasomodulator class as a bridge to transplant remains unknown.

Purpose

This review compares the use of endothelin receptor antagonists (ERA), phosphodiesterase type-5 inhibitors (PDE5-I), prostacyclin (PC) and combination therapy in its pulmonary pressure-lowering effects and pre-transplant mortality in this strictly selected subset of patients.

Methods

A search conducted on Medline and Embase on articles relating to vasomodulator use in PoPH for pulmonary pressure-lowering effects and mortality. Network analysis was conducted to summarize the evidence. Surface under the cumulative ranking curve (SUCRA) was used to rank treatments.

Results

Ten studies with 180 patients were included. SUCRA analysis demonstrated largest mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) lowering effects in ERA and combination therapy, followed by PDE5-I and PC. mPAP-lowering effects were largest in ERA (MD −19.440, CI: −62.280 to 23.400) and combination therapy (MD −18.223, CI: −29.677 to −6.770) when compared to PDE5-I (table 1). Pre-transplant mortality were comparable between ERA, PDE5-I and combination therapy. Both ERA (RR:0.349. CI: 0.137–0.891) and PDE5-I (RR: 0.279, CI: 0.091–0.854) had significantly lower mortality than PC (table 2).

Conclusion

This meta-analysis provides preliminary evidence that ERA have shown larger pulmonary pressure-lowering effects than PDE5-I in PoPH patients who were eligible for LT. Both ERA and PDE5-I have comparable mortality outcomes, with unfavorable outcomes in PC users.

Funding Acknowledgement

Type of funding sources: None.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

A novel 3D evaluation method for assessing bone to bone relationships in clubfoot

OBJECTIVE

Clubfoot is a complex congenital three-dimensional foot deformity, which affects 150,000-200,000 newborn babies annually around the world. A good understanding of the alignment of the two osseous columns and the lower leg of the ankle and foot complex is essential for evaluating the severity of clubfoot. The purposes of this study were to (1) develop an automated three-dimensional (3D) surface model of severe clubfoot based on two-dimensional (2D) slices of computed tomography (CT) images, (2) evaluate the alignment of foot bones relative to the ankle in severe clubfoot, and (3) examine the structural changes in the shape of the clubfoot.

PATIENTS AND METHODS

Two-dimensional CT image was taken from a four-year-old child with a severe clubfoot. Subsequently, an automated and detailed 3D surface model of the severe clubfoot was developed from the 2D images by using MATLAB software programming. Then, the x, y, and z coordinate angles were automatically calculated for each bone in the foot relative to the ankle (lower end of the tibia) to determine the orientations and relationships among the bones.

RESULTS

The relative position or orientation of each bone of the foot to the ankle of the severe clubfoot was objectively measured which was used to determine the orientation of each bone in the foot. Among the x, y, and z axes of the interested tarsal bones, the z axis represents the smallest moment of inertia, and the results showed that the bones in the x axis shifted medially with higher relative angle.

CONCLUSIONS

This 3D objective measurement method for assessing clubfoot can be used to determine and classify the severity of clubfoot, as well as evaluate and monitor the progress of the clubfoot intervention based on the relative position of the tarsal bones. The method can also be used to quantify the relationship between the tarsal bones of the foot and lower end of the tibia. In addition, angular measurements can be used to assess other pathological conditions of the foot such as pes cavus and pes planus.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Case study on the effects of fit and material of sports gloves on hand performance

Active and sports fashion in the high-end market focuses on fit, superior comfort and functional performance for various end-uses. However, the engineering design of sports gloves in relation to hand anthropometry measurements remains unclear. In this study, two types of ready-to-wear sport gloves, namely, war-gaming glove and hiking glove were purchased from the market. The glove dimensions, fabrication properties and the effect of glove fit on hand and finger dexterity were investigated. Thirty female individuals (20-29 years old) participated a series of hand performance tests and subjective perception rating assessments towards the gloves. Results indicated that the active range of motion of fingers, finger tactile sensitivity, gripping strength and ability to handle pegs and marbles decreased with the use of gloves compared with bare hands. The perceptions of comfort and ease of hand motions decreased with the increased of wear time. The glove fit in terms of finger length dimensions was significantly correlated with hand grip force. The glove fit in hand, wrist and finger circumference dimensions had significant impact on the ability to handle small objects. It is suggested that hand length, hand circumference, finger circumference and the ratio of finger length to palm length should be considered in the design and development of gloves to improve hand performance and comfort.

Randomized trial comparing self gripping semi re-absorbable mesh (PROGRIP) with polypropylene mesh in open inguinal hernioplasty: the 6 years result

OBJECTIVES

The use of absorbable polylactic acid hook self-gripping polypropylene mesh in open inguinal hernia may potentially reduce operative time and enhance patient recovery. The objective of this randomized trial is to compare the outcomes following self-gripping mesh repair to polypropylene mesh secured with sutures in open inguinal hernioplasty.

METHOD

Eligible patients aged 18-80 years old, who had primary unilateral uncomplicated inguinal hernia, were randomized into either Polypropylene (PL) group or PROGRIP (PG) group just before the placement of mesh intra-operatively by computer generated code. The primary outcome was the time from mesh placement to end of operation, whereas secondary outcomes included the total operative time, amount of analgesic used, length of post-operative stay, seroma formation, chronic discomfort, chronic pain score and recurrence. The study has been registered in http://www.clinicaltrial.gov carrying an ID of NCT00960011. Patients were followed-up in outpatient clinic for up to 6 years after operation.

RESULTS

From March 2009 to April 2016, 45 patients were included. The mean age of PG group (n = 22) was 62.0 ± 15.7 years old while that of the PL group was 62.6 ± 4.9 years old (n = 23). There was no significant difference regarding the smoking habit, drinking habit, comorbidities, previous hernia operation and Nyhus type of hernia between the two groups. The size of defects, the time of groin dissection and the size of incision were similar. In the PG group, there was significant reduction in the time for mesh placement (11.8 ± 3.1 vs. 21.0 ± 6.2 min, p < 0.001) and total operative time (39.2 ± 9.8 vs. 47.7 ± 8.0 min, p = 0.003). There was one recurrence in PL group and nil in PG group. Although there was a significant difference in paresthesia between 2 groups after operation, the difference disappears with time and comparable from post-operative 1 year onwards. There was no difference in chronic pain, chronic discomfort, affect daily activities, palpable mesh demonstrated throughout the whole study period till 6 years after operation.

CONCLUSIONS

The use of polylactic acid self-gripping mesh in open inguinal hernia repair effectively reduces the operating time with comparable long-term surgical outcome with traditional polypropylene mesh.

Effects of indoor slippers on plantar pressure and lower limb EMG activity in older women

Open-toe mule slippers are popular footwear worn at home especially by older women. However, their biomechanical effects are still poorly understood. The objective of this study is to therefore evaluate the physical properties of two typical types of open-toe mule slippers and the changes in plantar pressure and lower limb muscle activity of older women when wearing these slippers. Five walking trials have been carried out by ten healthy women. The results indicate that compared to barefoot, wearing slippers results in significant increases in the contact area of the mid-foot regions which lead to plantar pressure redistribution from metatarsal heads 2-3 and the lateral heel to the midfoot regions. However, there is no significant difference in the selected muscle activity across all conditions. The findings enhance our understanding of slipper features associated with changes in biomechanical measures thereby providing the basis of slipper designs for better foot protection and comfort.

Effects of custom-made textile insoles on plantar pressure distribution and lower limb EMG activity during turning

Background

Turning during locomotion involves considerable changes of the body’s center of mass and reduced stability, as well as lower limb kinematics and kinetics. However, many previous studies have been carried out to evaluate the effectiveness and applications of orthotic insoles as well as different types of orthotic materials in various clinical symptoms, which are focused primarily on straight line walking. Hence, the influence of custom-made insoles with the use of advanced three-dimensional spacer fabrics on biomechanics parameters in terms of plantar pressure distribution and lower limb electromyography during turning movement was studied.

Methods

Twelve subjects performed 180-degree turning at a speed 3.07-3.74 km/h for five successful trials under 3 insoles conditions: wearing traditional ethylene vinyl acetate insoles and two different spacer-fabricated insoles, with the plantar pressure and lower limb muscle activity collected simultaneously. Turning movement was broken down into 3 phases for analysis: Turning initiation, turn around and turn termination.

Results

There was a statistically significance difference in plantar pressure between the traditional insoles and the insoles made of a spacer fabric as the top layer (p < 0.05). Compared to the traditional insoles, insoles made of a spacer fabric reduced the peak pressure (>12 %) and pressure–time integral (>13 %) in toes, metatarsal head 1 and metatarsal heads 2–3 at turning initiation; (>15 %) and (>17 %) in medial midfoot and medial heel at turn around. Insoles with spacer fabrics on the top and middle layer reduced both pressure parameters (>18 %) in toes and MTH 1 at turn termination. In terms of muscle activities, insoles with two-layer spacer fabrics could lower maximum muscle activities of vastus lateralis (>16 %; p < 0.05) at turn around.

Conclusions

Insoles with different fabrications could offer various pressure offloading patterns across the plantar and muscle activity changes while turning. Insoles with a spacer fabric on the top tend to reduce plantar pressure loading at different regions during turn initiation and turn around phases, while two-layer spacer-fabricated insoles may contribute to reduced vastus lateralis muscle activation during turn around. More importantly, this study provides a new dimension in the potential use of the textile-fabricated insoles which may widen the range of insole materials selection in the design and development of insoles so as to enhance the effectiveness of orthotic treatment.

Measures of socioeconomic status and self-reported glaucoma in the U.K. Biobank cohort

PURPOSE

To determine ocular, demographic, and socioeconomic associations with self-reported glaucoma in the U.K. Biobank.

METHODS

Biobank is a study of U.K. residents aged 40-69 years registered with the National Health Service. Data were collected on visual acuity, intraocular pressure (IOP), corneal biomechanics, and questionnaire from 112,690 participants. Relationships between ocular, demographic, and socioeconomic variables with reported diagnosis of glaucoma were examined.

RESULTS

In all, 1916 (1.7%) people in U.K. Biobank reported glaucoma diagnosis. Participants reporting glaucoma were more likely to be older (mean 61.4 vs. 56.7 years, P<0.001) and male (2.1% vs. 1.4%, P=0.001). The rate of reported glaucoma was significantly higher in Black (3.28%, P<0.001) and Asian (2.14%, P=0.009) participants compared with White participants (1.62%, reference). Cases of reported glaucoma had a higher mean IOP (18 mm Hg both eyes, P<0.001), lower corneal hysteresis (9.96 right eye, 9.89 left eye, P<0.001), and lower visual acuity (0.09 logMAR right eye, 0.08 logMAR left eye, P<0.001) compared with those without (16 mm Hg both eyes, hysteresis 10.67 right eye, 10.63 left eye, 0.03 logMAR right eye, 0.02 logMAR left eye). The mean Townsend deprivation index was -0.72 for those reporting glaucoma and -0.95 for those without (P<0.001), indicating greater relative deprivation in those reporting glaucoma. Multivariable logistic regression showed that people in the lowest income group (<£18,000/year) were significantly more likely to report a diagnosis of glaucoma compared with any other income level (P<0.01). We observed increasing glaucoma risk across the full range of income categories, with highest risk among those of lowest income, and no evidence of a threshold effect.

CONCLUSIONS

In a large U.K. cohort, individuals reporting glaucoma had more adverse socioeconomic characteristics. Study of the mechanisms explaining these effects may aid our understanding of health inequality and will help inform public health interventions.

Patient reported outcome measures in male incontinence surgery

INTRODUCTION

Patient reported outcome measures (PROMs) were used to evaluate outcomes of the artificial urinary sphincter (AUS) and the AdVance™ (American Medical Systems, Minnetonka, MN, US) male sling system (AVMS) for the symptomatic management of male stress urinary incontinence.

METHODS

All male patients with stress urinary incontinence referred to our specialist clinic over a two-year period completed the ICIQ-UI SF (International Consultation on Incontinence Questionnaire on Urinary Incontinence Short Form) and the ICIQ-MLUTS LF (International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms Long Form) at consultation as well as at subsequent follow-up appointments. The Wilcoxon signed-rank test for non-parametric paired data was used for pre and postoperative comparisons. The chi-squared test was used for categorical variables.

RESULTS

Thirty-seven patients (forty surgical cases) completed a preoperative and at least one follow-up questionnaire. There was a statistically significant improvement in PROMs postoperatively, regardless of mode of surgery (p<0.01). Analysis of the ICIQ-MLUTS LF showed that patients with higher preoperative scores (>25) had greater improvement with an AUS than with the AVMS (p<0.01).

CONCLUSIONS

This prospective study shows that completion and collection of PROMs as part of routine clinical practice is achievable and useful in the assessment of male stress incontinence surgery. PROMs are important instruments to assess effectiveness of healthcare intervention and they are useful adjuncts in surgical studies.

Coarctation of the aorta: nonsurgical treatment using stent implantation

INTRODUCTION

Coarctation of the aorta (CoA) accounts for 5%-8% of all congenital heart defects. If left untreated, most patients with significant CoA will have varying degrees of morbidity (e.g. hypertension, stroke, collateral formation and ventricular hypertrophy), possibly even mortality. Traditionally, treatment for this condition is surgical. Herein, we report stenting during catheterisation as an alternative nonsurgical treatment option for patients with CoA, and present the treatment outcomes of patients who underwent this treatment option.

METHODS

We retrospectively reviewed four patients (2 men and 2 women; age range 20-41 years) who underwent CoA stenting under general anaesthesia for the treatment of native CoA or restenosis of CoA at our institution. Three patients had a 40-mm Palmaz stent inserted, while one had a 39-mm Cheatham-Platinum covered stent inserted. Angiography and measurement of pressure gradients were performed before and after stent implantation to ensure good treatment outcomes.

RESULTS

The patients' treatment outcomes were good, with a significant reduction in pressure gradients across the narrowed segments. Angiography showed relief of CoA. The patients were followed up for 1-3 years, during which no complications were noted.

CONCLUSION

This is the first reported series in Singapore on the nonsurgical treatment of CoAs in adult patients using stents during interventional cardiac catheterisation. This less invasive procedure may lead to a new paradigm shift with regard to the treatment of CoA.

2D and 3D anatomical analyses of hand dimensions for custom-made gloves

Measuring hand anthropometric data for the development of good-fitting gloves is crucial. In pursuing higher accuracy in hand anthropometric measurements, scanning of hand surfaces with the aids of image analysis system to acquire measurements is an alternative to the manual methods. This study proposes a new hand measuring approach by using 2D and 3D scanning which are evaluated through comparisons of manual measurements. Thirty-three dimensions are measured by using (1) tape and calliper measurement; (2) 2D image analysis; (3) 3D image analysis based on ten captures; and (4) 3D image analysis based on three captures, respectively. Repeated-measures ANOVA, correlation analysis and RMSE are used to examine the results. The hand dimensions obtained from the four methods are highly linearly correlated. Hand data taken from 3D image analysis has no significant difference compared with manual measurements on hand and wrist circumferences, length and breadth dimension, regardless of the number of captures.

Therapeutic effect of alpha-fetoprotein promoter-mediated tBid and chemotherapeutic agents on orthotopic liver tumor in mice

Previous studies have shown that the application of Ad/AFPtBid significantly and specifically killed hepatocellular carcinoma (HCC) cells in culture and subcutaneously implanted in mice. This study was to test the therapeutic efficacy of Ad/AFPtBid in an orthotopic hepatic tumor model. Four weeks after implantation of tumor cells into the liver, nude mice were treated with Ad/AFPtBid alone or in combination with 5-fluorouracil (5-FU). Serum alpha-fetoprotein (AFP) was measured as a marker for tumor progression. The results showed that Ad/AFPtBid significantly inhibited Hep3B tumor growth. Ad/AFPtBid and 5-FU in combination was more effective than either agent alone. Tumor tissues of Ad/AFPtBid alone or combination treatment groups showed a decrease in cells positive for proliferation cell nuclear antigen, but an increase in apoptosis. Ad/AFPtBid did not suppress the hepatic tumor formed by non-AFP-producing hepatoma SK-HEP-1 cells or colorectal adenocarcinoma DLD-1 cells. The survival rate was higher in mice treated with Ad/AFPtBid plus 5-FU than those treated with either agent alone. No acute toxic effect was observed in mice receiving Ad/AFPtBid. Collectively, Ad/AFPtBid can specifically target and effectively suppress the AFP-producing orthotopic liver tumor in mice without obvious toxicity, indicating that it is a promising tool in combination with chemotherapeutic agents for treatment of AFP-producing HCC.

A platelet tetraspanin superfamily member, CD151, is required for regulation of thrombus growth and stability in vivo

BACKGROUND

This study was designed to determine the role of CD151 in platelet thrombus formation in vivo and define the contribution of platelet vs. endothelial CD151 in regulating platelet thrombus formation in vivo.

METHODS AND RESULTS

Using intravital microscopy and ferric chloride (FeCl(3)) injury of mesenteric arterioles, we found that thrombi formed in CD151(+/-) and CD151(-/-) mice were smaller and less stable, than those formed in CD151(+/+) mice, with a tendency for embolization. Similarly, in Folt's FeCl(3)-induced carotid injury model, both CD151(+/-) and CD151(-/-) mice showed more prolonged times to 95% vessel occlusion than CD151(+/+) mice. In addition, laser-induced injury of cremaster muscle arterioles showed that thrombi formed in CD151(+/-) and CD151(-/-) mice were smaller and less stable than those formed in CD151(+/+) mice. Following platelet depletion/reconstitution with ex vivo-labeled donor platelets, platelet-depleted CD151(+/+) mice that received reconstitution with CD151(-/-) platelets had smaller thrombi that were unstable and embolized. In contrast, platelet-depleted CD151(-/-) mice that received reconstitution with CD151(+/+) platelets had normal thrombi that were stable.

CONCLUSIONS

These data provide evidence that platelet CD151 is required for regulating thrombus formation in vivo.

Protein-losing enteropathy post-valvular surgery with severe tricuspid regurgitation in Subutex-related endocarditis

We report a 25-year-old Malay man with Subutex-related endocarditis, complicated by protein-losing enteropathy from severe tricuspid regurgitation and congestive heart failure. The intestinal protein loss was reversed with surgical valvular intervention. This case highlights the importance of recognising the rare association between protein-losing enteropathy and congestive heart failure in the setting of endocarditis.

Haem oxygenase-1 plays a central role in NNK-mediated lung carcinogenesis

The tobacco-specific nitrosamine, 4-(N-methyl-N-nitrosoamino)-1-(3-pyridyl)-1-butanone (NNK), is a potent lung cancer inducer. However, how NNK induces lung cancer is still largely unknown. Haem oxygenase (HO)-1 was evaluated in 30 pairs of lung cancer tumour samples and matched nontumour tissues from patients with a history of cigarette smoking. Expression of HO-1, p21(Cip1/Waf1/Cid1) (p21), B-cell lymphoma (Bcl)-2 family members, mitogen-activated protein kinase and nuclear factor (NF)-kappaB was also studied in lung cancer cells treated with NNK. The levels of HO-1 and p21 were significantly increased in lung tumour tissues. There was a positive relationship between these two proteins in the tumour. NNK stimulated lung cell proliferation and elevated the levels of HO-1, p21, inhibitor of apoptosis protein (c-IAP)2 and Bcl-2, but downregulated Bad. These effects of NNK were blocked by zinc protoporphyrin-XII, an HO-1 inhibitor. The NNK-mediated expression of HO-1 was governed by NF-kappaB and extracellular signal-regulated kinase 1/2, since blocking either of these prevented the stimulatory effect of NNK on HO-1, as well as molecules downstream of HO-1, such as p21, c-IAP2, Bcl-2 and Bad. In conclusion, haem oxygenase-1 plays a central role in NNK-mediated cell proliferation by promoting the expression of p21(Cip1/Waf1/Cid1), inhibitor of apoptosis protein 2 and B-cell lymphoma-2 but inhibiting the activity of Bad. Nuclear factor-kappaB and extracellular signal-regulated kinase 1/2 function upstream of haem oxygenase-1. Therefore, haem oxygenase-1 is likely to be a potential target in the treatment of smoking-related lung cancer.

The action of TNFα and TGFβ include specific alterations of the glycosylation of bovine and human chondrocytes

Joint destruction in arthritis is often associated with high levels of inflammatory cytokines. Previous work has shown that inflammatory conditions can alter the activities of glycosyltransferases that synthesize the glycan chains of glycoproteins, and that these changes in turn can influence the functions of glycoproteins. We therefore examined glycosyltransferases involved in glycoprotein biosynthesis in primary cultures of bovine articular chondrocytes and human chondrocytes isolated from knee cartilage of osteoarthritis patients. Bovine chondrocytes exhibited enzyme activities involved in the synthesis of bi-antennary complex Asn-linked N-glycans, as well as the enzymes involved in the synthesis of GalNAc-Ser/Thr-linked O-glycans with the core 1 structure. Human chondrocytes, in addition, were able to synthesize more complex O-glycans with core 2 structures. TNFalpha was found to induce apoptosis in chondrocytes, and this process was associated with significant changes in lectin binding to chondrocyte cell surface glycans. TGFbeta increased cell proliferation, and had significant effects on cell surface glycosylation in bovine but not in human cells. These cytokine-specific effects were partially correlated with changes in glycosyltransferase activities. Thus, chondrocytes have many of the enzymes necessary for the synthesis of N- and O-glycan chains of glycoproteins. The O-glycosylation pathways and the effects of TNFalpha and TGFbeta on glycosylation differed between bovine and human chondrocytes. These alterations are of potential importance for the regulation of the functions of cell surface receptors on chondrocytes, and for an understanding of the pathophysiology of arthritis.

Transcatheter device closure of atrial septal defects in the elderly: Technical considerations and short-term outcomes

BACKGROUND

Device closure of an atrial septal defect (ASD) results in symptom-reduction, right heart remodelling and lower pulmonary artery pressures. However it is unclear if there is a chronological limit to these benefits and whether device closure is safe in elderly subjects. The aim of this study was, therefore, to assess the safety and efficacy of device closure in patients >60 years.

METHODS

Retrospective study of Amplatzer Septal Occluder device closures from a single institution (May 1999-August 2002).

RESULTS

Fifty subjects aged >60 years (range 60-85 years) had ASD device closure (27% of the total cohort). Defect size and shunt size were similar for both younger and older groups (2.2:1 in both groups, p=0.9) as were procedural duration, fluoroscopy time and device size deployed. Baseline right ventricular (RV) systolic pressure ((younger vs. older) 39 vs. 49 mmHg, p<0.001) and right ventricular size (45 vs. 51 mm, p<0.001) were greater in the older group. Following closure RV systolic pressure (49 vs. 45 mmHg, p<0.01) and RV size (51 vs. 44 mm, p=0.01) decreased in the older group.

CONCLUSION

Device closure of an ASD can be performed safely in older patients. The right heart shows signs of remodelling even in elderly subjects.

Outcomes and alternative techniques for device closure of the large secundum atrial septal defect

Outcomes of device closure of large and small secundum atrial septal defects (ASDs) as related to rim anatomy with the Amplatzer atrial septal occluder were compared. Rim adequacy (> or = 5mm) of the anterior, inferior, posterior, and superior rims was determined using transesophageal echocardiography. Balloon-stretched defect size defined patients into two groups: group 1, < or = 25 mm (n = 138); group 2, > 25 mm (n = 34). Rim deficiency (n = 62) was more frequent in group 2 compared to group 1 (50% vs. 33%; P = 0.07), especially inferior rim deficiency (35% vs. 2%; P = 0.005). Device deployment was successful in group 1 and group 2 (100% vs. 91%; P = 0.007). Unsuccessful deployment was associated with an ASD of > 25 mm (P = 0.007) and inferior rim deficiency (P = 0.001). At first follow-up (54 +/- 16 days), right ventricular systolic pressure had improved in both groups (P < 0.001). Closure of a large ASD associated with a lack of support in the inferior rim may warrant alternative strategies to position the device successfully.

Prevalence and risk indicators for destructive periodontal diseases in 3 urban American minority populations

BACKGROUND, AIMS

Destructive periodontal diseases have been reported disproportionately more prevalent and severe in African-Americans relative to other American populations. Differences in subgingival microbiota and host immune response have also been reported for African-Americans, implying that risk factors for disease progression may also differ for these populations. Since it is not clear whether these differences are truly genetic or due to confounding variables such as social economic status, we examined a series of clinical, environmental, demographic, and microbiologic features associated with periodontal disease status in a group of 185 urban minority subjects resident within the greater New York metropolitan area.

METHODS

The study population consisted of 56 Asian-American, 71 African-American and 58 Hispanic subjects. Clinical data recorded included pocket depth, attachment level, gingival erythema, bleeding upon probing, suppuration, and the presence of supragingival plaque. Environmental and demographic data recorded included smoking history, years resident in the United States, whether the subject reported a private dentist and occupational status. Subgingival plaque was sampled from the mesial aspect of all teeth exclusive of third molars and the levels of 40 subgingival species enumerated using checkerboard DNA-DNA hybridization.

RESULTS

The African-American group had more missing teeth, deeper periodontal pocket depth and more attachment loss than the Asian-American or Hispanic groups. However, the African-American group were less likely to report having a private dentist, had a greater proportion of smokers and a greater proportion of unskilled individuals. The profile of subgingival species differed among the three ethnic/racial groups with A. actinomycetemcomitans, N. mucosa, S. noxia and T. socranskii significantly elevated in the Asian-American group and P. micros significantly elevated in the African-American group. When subset by occupational status, numbers of missing teeth, pocket depth, attachment level and prior disease activity were all found increased in the unskilled relative to the professional group. Local factors including the mean % of sites with plaque, marginal gingival erythema, bleeding upon probing and suppuration were also elevated in the unskilled group. The microbial profile differed among the 3 occupational groups with the unskilled group having elevated numbers of species associated with destructive periodontal diseases.

CONCLUSIONS

Although greater destructive periodontal disease prevalence and severity were found in the African-American group, these results suggest that environmental and demographic variables, such as occupational status, may have a greater influence on risk indicators associated with disease prevalence and progression in these populations.

Localization of NK1 and NK3 receptors in guinea-pig brain

In this study the localizations of tachykinin neurokinin-1 (NK1) and neurokinin-3 (NK3) receptors in the guinea-pig brain are described. In agreement with studies in rat and human brain, the neurons that exhibited the most marked NK1 receptor immunoreactivity were found in the dorsomedial caudate putamen. NK1 receptors were also widely distributed in diencephalic structures and in the mid and hind brain. NK3 receptors were distributed in both superficial and deep layers of the cortex and many appeared to be located on cells with astrocyte-like morphology in the glia limitans. In several regions including the thalamus, hypothalamus, amygdala, periaqueductal gray, substantia nigra and area postrema, both NK1 and NK3 immunoreactivity were found. The present study revealed that tachykinin receptors are widely distributed in the guinea-pig central nervous system.

Localization of tachykinin receptors and Fos-like immunoreactivity induced by substance P in guinea-pig brain

1. In the present study, a comparison was made between the distribution of tachykinin NK1 and NK3 receptor immunoreactivity and the distribution of Fos-like immunoreactivity induced by the tachykinin agonist substance P (SP) in the guinea-pig brain. 2. In agreement with results from previous studies in rat brain, NK1 receptor-immunoreactive neurons were found to be widely distributed throughout the brain in the striatum and in diencephalic and mesencephalic structures, while NK3 receptor-immunoreactive neurons were mainly in telencephalic structures. Considerable overlap was observed between NK1 and NK3 receptor distributions. 3. Substance P induced Fos-like immunoreactivity (Fos-LI) in extensive areas of the guinea-pig brain. The induction of Fos-LI was markedly inhibited in many areas by pretreatment with the NK1 receptor antagonist SR 140333. The NK3 receptor antagonist SR 142801 reduced Fos-LI staining in fewer areas, although a reduction was observed in the cortex, striatum and hypothalamus. 4. In general, tachykinin receptors were located at sites corresponding to areas of functional activation by SP, as shown by Fos-LI. These results extend previous studies by adding a functional dimension to tachykinin receptor localization studies.

Distribution of Fos-like immunoreactivity in guinea-pig brain following administration of the neurokinin-1 receptor agonist, [SAR9,MET(O2)11]substance P

The tachykinins are a family of peptides with putative neurotransmitter roles in the nervous system. They mediate their effects via neurokinin-1, neurokinin-2 and neurokinin-3 receptors. There has been increasing interest in the therapeutic application of the tachykinin neurokinin-1 receptor antagonists in the treatment of pain and emesis, and more recently in depression. However, the central role of neurokinin-1 receptors is not well understood. The aims of the present study were to determine the behavioural responses of guinea-pigs, and the distribution of Fos-like immunoreactivity in the guinea-pig brain, following intracerebroventricular administration of the neurokinin-1 receptor-selective agonist, [Sar9,Met(O2)11]substance P. The effects of pretreatment with the neurokinin-1 receptor antagonist, SR 140333, were also investigated. Administration of [Sar9,Met(O2)11]substance P induced increased locomotor activity, as well as face washing, grooming and wet-dog shake behaviours, all of which were inhibited by the neurokinin-1 receptor antagonist, SR 140333, indicating the involvement of neurokinin-1 receptors. In order to localize the brain regions activated by [Sar9,Met(O2)11]substance P, the distribution of neurons expressing Fos-like immunoreactivity was examined. [Sar9,Met(O2)11]substance P induced increased Fos-like immunoreactivity in widespread areas, including the frontal cortex, hippocampus, amygdala, thalamus, hypothalamus, periaqueductal gray, area postrema and nucleus of the solitary tract. SR 140333 reduced Fos-like immunoreactivity induced by [Sar9,Met(O2)11]substance P in most areas. Thus, brain regions associated with emotion, sensation, learning and memory, autonomic regulation and emesis were activated by stimulation of neurokinin-1 receptors. The present data have added a functional domain to previous neurokinin-1 receptor localization studies by describing the extensive regions of the CNS that may be activated by stimulation of these receptors, and the potential of neurokinin-1 receptor antagonists to inhibit activation of these regions.

Resistance to insulin-mediated glucose disposal as a predictor of cardiovascular disease

Resistance to insulin-mediated glucose disposal has been postulated to predispose individuals to a cluster of associated abnormalities (Syndrome X) known to increase risk of cardiovascular disease (CVD). Although several abnormalities subsumed under the rubric of Syndrome X have been shown to predict CVD, there has been no prospective study evaluating the power of insulin resistance, the putative fundamental defect in the syndrome, in this context. Therefore, this study was initiated to evaluate the hypothesis that resistance to insulin-mediated glucose disposal would predict the development of CVD in healthy volunteers. To accomplish this goal, 147 normal, healthy, nonobese, volunteers were evaluated [4.7 +/- 0.1 yr (mean +/- SEM)] after baseline measurements of steady state plasma glucose concentration (an estimate of insulin-mediated glucose disposal), as well as other CVD risk factors. Clinical end points developed in 13 subjects during the follow-up period; hypertension in 5, coronary artery disease in 4, cerebrovascular accident in 3, and peripheral vascular disease in 1. There was a significant univariate relationship between SSPG and CVD (P < 0.002), with the majority of the events taking place in the tertile of subjects with the highest SSPG concentration, i.e. the greatest degree of insulin resistance. In contrast, no CVD events were observed in the tertile with the lowest SSPG concentrations; the most insulin sensitive. SSPG was also related significantly to diastolic blood pressure, triglyceride, and low-density lipoprotein and high-density lipoprotein cholesterol concentrations, and the glucose and insulin responses to oral glucose. All of these relationships were independent of age, gender, body mass index, estimates of physical activity, and smoking history. When SSPG was paired with each of the other variables in a series of multiple regression models, only SSPG, or insulin response, were independent predictors of CVD events. In conclusion, approximately one of every five healthy, nonobese subjects in the most insulin-resistant tertile, followed for approximately 5 yr, had a serious clinical event. These data highlight the importance of insulin resistance as a predictor of CVD.

Localization of Fos-like immunoreactivity induced by the NK3 tachykinin receptor agonist, senktide, in the guinea-pig brain

1. The effects of intracerebroventricular (i.c.v.) administration of the NK3 tachykinin receptor agonist, senktide (10 nmol each side), in guinea-pigs pretreated with the selective NK3 tachykinin receptor antagonist, SR142801 (3 mg kg(-1) subcutaneous, s.c., 30 min before senktide), or its less active enantiomer, SR142806 (3 mg kg(-1) s.c. 30 min before senktide), on behaviour and on the distribution of Fos-like immunoreactivity (Fos-LI) in central neurones were investigated. Guinea-pigs were chosen for the study since they possess NK3 tachykinin receptors with pharmacological characteristics similar to those in man. 2. Wet-dog shakes, but not locomotor activity, elicited by senktide i.c.v. were significantly reduced by SR142801 but not by SR142806, confirming the involvement of NK3 tachykinin receptors in wet-dog shake behaviour. 3. Senktide induced increased numbers of Fos-LI neurones in the following brain areas: frontal, parietal and piriform cortex, the lateral septum, the CA1, CA2, subiculum and dentate gyrus of the hippocampus, most areas in the amygdala, thalamus and hypothalamus, medial geniculate nucleus and the ventral cochlear nucleus. Pretreatment with SR142801, but not with SR142806, before administration of senktide inhibited Fos-LI expression in the cingulate cortex, dentate gyrus of the hippocampus, some regions of the thalamus, hypothalamus and amygdala and the ventral cochlear nucleus. 4. The present results are the first demonstration that senktide induces Fos-LI in widespread areas of the guinea-pig brain. It is proposed that NK3 tachykinin receptors may play a more extensive role in the control of diverse brain functions, including cortical processing, learning and memory, neuroendocrine and behavioural regulation, than is currently recognized.

Enhanced collagen synthesis in cultured skin fibroblasts from insulin-dependent diabetic patients with nephropathy

Excessive production and deposition of extracellular matrix proteins are characteristic features of diabetic nephropathy. This study tests the hypothesis that cells from diabetic patients who develop nephropathy have a disturbance in collagen metabolism compared with cells from diabetic patients without complications. Kinetics of overall collagen metabolism and total protein synthesis were examined in serially passaged, subconfluent, quiescent skin fibroblasts cultured in either normal (5 mM) or high (25 mM) glucose concentrations from 14 insulin-dependent diabetic (IDDM) patients with nephropathy; 14 IDDM patients without nephropathy matched for age, diabetes duration, and body mass index; and 14 healthy subjects. Fibroblasts were incubated in the presence of 2 microCi/ml [3H]proline, and after labeling the incorporation of [3H]proline into total protein, collagen (collagenase-sensitive material), and noncollagen proteins (collagenase-resistant material) was determined at different time points. Collagen degradation was determined in pulse-chase experiments by following the residual collagen-bound radioactivity after incubation for 8 h with 10 microCi/ml [3H]proline. In high glucose concentrations (25 mM), overall collagen synthesis (measured as [3H]proline incorporation into extracellular and intracellular collagenase-sensitive material) was significantly greater in the patients with nephropathy (mean +/- SEM after a 24-h labeling period: 7189 +/- 671 dpm/10(6) cells) than in the patients without (4341 +/- 267 dpm/10(6) cells; P < 0.01) or healthy control subjects (3836 +/- 234 dpm/10(6) cells; P < 0.01). No significant differences were observed in noncollagen protein production or in collagen degradation rates among the three groups of subjects. In the presence of normal glucose concentrations (5 mM), collagen synthesis was lower in all groups studied, but the differences between IDDM patients with nephropathy and those without remained unaltered. These results suggest that long-term cultured fibroblasts derived from diabetic patients with nephropathy exhibit an abnormality in collagen metabolism. Cells from long-standing diabetic patients without nephropathy have normal collagen metabolism. The increased collagen synthesis is likely to be intrinsic to those diabetic patients susceptible to nephropathy and may play an important role in the sclerotic processes that occur in the kidneys, arteries, and heart.

Distribution and substrate properties of agrin, a heparan sulfate proteoglycan of developing axonal pathways

The distribution and substrate properties of agrin, an extracellular matrix heparan sulfate proteoglycan (HSPG), was investigated in the developing chick nervous system by immunocytochemistry, Western blotting, and in neurite outgrowth assays. By comparing the distribution of agrin with that of laminin-1, merosin (laminin-2), neurofilament, and neural cell adhesion molecule (NCAM), it was found that throughout development, agrin is a constituent of all basal laminae. From embryonic day (E) 4 onwards, agrin is also abundant in axonal pathways of the central nervous system, such as the optic nerve, the tectobulbar pathway, the white matter of the spinal cord, and the marginal and the molecular layers of the forebrain and the cerebellum. The abundance of agrin in brain decreases from E13 onwards. In the peripheral nervous system, agrin is present throughout development as a constituent of the Schwann cell basal laminae. Western blots confirmed the immunocytochemical data, showing maximum expression of agrin occurs during the early to medium stages of brain development. Western blots also showed that in mouse and human brain, agrin exists as an HSPG. Purified agrin did not support neurite outgrowth, rather it inhibited retinal neurite extension on mixed agrin/merosin substrates. Despite the fact that agrin, when used as a substrate inhibited neurite outgrowth, its temporal and spatial overlap with growing axons suggests that agrin has a supportive role in the development of axonal pathways, possibly as a binding component for growth factors and cell adhesion proteins.

The dorsal neural tube organizes the dermamyotome and induces axial myocytes in the avian embryo

Somites, like all axial structures, display dorsoventral polarity. The dorsal portion of the somite forms the dermamyotome, which gives rise to the dermis and axial musculature, whereas the ventromedial somite disperses to generate the sclerotome, which later comprises the vertebrae and intervertebral discs. Although the neural tube and notochord are known to regulate some aspects of this dorsoventral pattern, the precise tissues that initially specify the dermamyotome, and later the myotome from it, have been controversial. Indeed, dorsal and ventral neural tube, notochord, ectoderm and neural crest cells have all been proposed to influence dermamyotome formation or to regulate myocyte differentiation. In this report we describe a series of experimental manipulations in the chick embryo to show that dermamyotome formation is regulated by interactions with the dorsal neural tube. First, we demonstrate that when a neural tube is rotated 180 degrees around its dorsoventral axis, a secondary dermamyotome is induced from what would normally have developed as sclerotome. Second, if we ablate the dorsal neural tube, dermamyotomes are absent in the majority of embryos. Third, if we graft pieces of dorsal neural tube into a ventral position between the notochord and ventral somite, a dermamyotome develops from the sclerotome that is proximate to the graft, and myocytes differentiate. In addition, we also show that myogenesis can be regulated by the dorsal neural tube because when pieces of dorsal neural tube and unsegmented paraxial mesoderm are combined in tissue culture, myocytes differentiate, whereas mesoderm cultures alone do not produce myocytes autonomously. In all of the experimental perturbations in vivo, the dorsal neural tube induced dorsal structures from the mesoderm in the presence of notochord and floorplate, which have been reported previously to induce sclerotome. Thus, we have demonstrated that in the context of the embryonic environment, a dorsalizing signal from the dorsal neural tube can compete with the diffusible ventralizing signal from the notochord. In contrast to dorsal neural tube, pieces of ventral neural tube, dorsal ectoderm or neural crest cells, all of which have been postulated to control dermamyotome formation or to induce myogenesis, either fail to do so or provoke only minimal inductive responses in any of our assays. However, complicating the issue, we find consistent with previous studies that following ablation of the entire neural tube, dermamyotome formation still proceeds adjacent to the dorsal ectoderm. Together these results suggest that, although dorsal ectoderm may be less potent than the dorsal neural tube in inducing dermamyotome, it does nonetheless possess some dermamyotomal-inducing activity. Based on our data and that of others, we propose a model for somite dorsoventral patterning in which competing diffusible signals from the dorsal neural tube and from the notochord/floorplate specify dermamyotome and sclerotome, respectively. In our model, the positioning of the dermamyotome dorsally is due to the absence or reduced levels of the notochord-derived ventralizing signals, as well as to the presence of dominant dorsalizing signals. These dorsal signals are possibly localized and amplified by binding to the basal lamina of the ectoderm, where they can signal the underlying somite, and may also be produced by the ectoderm as well.

Effect of aqueous solutions of sucralose on plaque pH

PURPOSE

To compare the effect on in vivo plaque pH of rinsing with an aqueous solution of sucralose (alone or in combination with maltodextrin or maltodextrin and dextrose) to the effect of rinsing with an aqueous solution of sucrose.

MATERIALS AND METHODS

Each solution (four in total) had a sweetness equivalent to two teaspoons of sucrose in 6 oz. of water. The four test solutions were administered randomly over four test visits (one solution per visit) to 10 subjects presenting 2-day resting plaque. Before, and at specified time intervals over 60 minutes following the rinse, in vivo plaque pH was monitored at six designated sites using a Beckman 3500 digital pH meter. Data were analyzed by ANOVA.

RESULTS

The mean pH minimum for the sucralose rinse (6.56) was significantly higher than the sucralose/maltodextrin (SM), sucralose/maltodextrin/dextrose (SMD), and sucrose rinses (6.15, 5.84, and 5.29, respectively). The mean delta pH (difference between resting and minimum pH) for the sucralose rinse (0.45) was significantly lower when compared to the SM (0.79), SMD (1.14), and sucrose (1.69) rinses. The differences seen in mean pH minimum and mean delta pH for the SM and SMD groups vs. the sucrose group were also statistically significant. Mean areas under the pH vs. time curve for the sucralose, SM and SMD rinses were all significantly less compared to the sucrose rinse. Rinsing with aqueous solutions of sucralose, or of sucralose in combination with maltodextrin and/or dextrose (commercially available formulations, of sucralose) was less acidogenic than rinsing with a sucrose solution of equivalent sweetness.

A comparison of intralesional triamcinolone and cryosurgery in the treatment of acne keloids

Keloid scarring presents a difficult therapeutic problem. It is a recognized sequel to acne vulgaris, and may be extensive and disfiguring. The data from this double-blind study, in which intralesional triamcinolone or cryosurgery were used as treatment for keloids, demonstrate that by treating early, and in particular vascular, keloids with the latter, 85% will show a moderate to good response in terms of flattening. Treatment with intralesional triamcinolone was also beneficial, but the response to cryosurgery was significantly better in early, vascular lesions.

Serum sialic acid, a risk factor for cardiovascular disease, is increased in IDDM patients with microalbuminuria and clinical proteinuria

OBJECTIVE

An elevated serum sialic acid concentration has recently been shown to be a potent cardiovascular risk factor in the general population. Because clinical proteinuria is associated with a high frequency of cardiovascular disease, and because microalbuminuria predicts the development of renal and cardiovascular disease in diabetes, we investigated whether serum sialic acid levels are increased in insulin-dependent diabetes mellitus (IDDM) patients with microalbuminuria or clinical proteinuria.

RESEARCH DESIGN AND METHODS

We studied 23 patients with IDDM who had a normal urinary albumin excretion rate, 23 patients who had microalbuminuria, and 23 patients with clinical proteinuria. The patients were matched for age, sex, duration of diabetes, GHb levels, and body mass index (BMI). Fasting blood samples were taken for measurement of sialic acid, cholesterol, triglyceride, creatinine, and GHb.

RESULTS

Serum sialic acid was significantly higher in the microalbuminuric patients compared with the normoalbuminuric group (mean +/- SD: 1.93 +/- 0.26 vs. 1.76 +/- 0.27 mM, P < 0.01). Moreover, serum sialic acid was also significantly higher in the group with clinical proteinuria compared with the microalbuminuric patients (2.34 +/- 0.24 vs. 1.93 +/- 0.26 mM, P < 0.001). Serum sialic acid was not related independently to age, BMI, diabetes duration, GHb, blood pressure, serum cholesterol, triglyceride, or creatinine concentration in any of the diabetic groups.

CONCLUSIONS

These observations suggest that the serum sialic acid concentration is raised in IDDM patients with both microalbuminuria and clinical proteinuria and may play a role as a cardiovascular risk factor or disease marker in these conditions.

Insulin resistance in insulin-dependent diabetic patients with microalbuminuria

In insulin-dependent diabetes, microalbuminuria increases the risk of cardiovascular and renal disease. By means of a euglycaemic hyperinsulinaemic clamp method, we measured total-body glucose utilisation rate and studied the interaction of this measure of insulin sensitivity with known risk factors for cardiovascular disease in 14 diabetic patients with microalbuminuria and 14 with normal albumin excretion (median albumin excretion rate [AER] 56.2 [range 39.2-80.6] vs 8.8 [7.4-10.7] micrograms per min). The two groups were of similar age, duration of diabetes, and body-mass index. Total-body glucose disposal rate was significantly lower in the patients with microalbuminuria than in those without (mean 7.86 [SD 1.40] vs 9.04 [0.90] mg/kg per min; p < 0.05). There were also significant differences between the groups in the daily insulin dose needed for equivalent glucose control (0.76 [0.20] vs 0.65 [0.10] U/kg, p < 0.05), mean systolic blood pressure over 24 h ambulatory monitoring (134 [7] vs 127 [7] mm Hg; p < 0.05), and various plasma lipid concentrations, contributing to a more atherogenic profile in the microalbuminuric group. Total-body glucose disposal rate was inversely correlated with body-mass index and log10 AER. The insulin sensitivity of the microalbuminuric group remained impaired after adjustment for blood pressure and body-mass index. Impaired insulin sensitivity is a feature of insulin-dependent diabetic patients with microalbuminuria, which adds, with other factors, to the increased risks of renal and cardiovascular disease in these patients.

Reducing bacteria in dental aerosols: pre-procedural use of an antiseptic mouthrinse

This study, using a simulated office visit model, showed that the pre-procedural use of an antimicrobial mouthrinse produces a significant reduction in number of viable bacteria in a dental aerosol.