Homeopathy for seasonal allergic rhinitis: rationale, design and methods of the three-armed randomized controlled HOMEOSAR trial

BACKGROUND

Patients with seasonal allergic rhinitis (SAR) frequently use homeopathic therapy. Although there is some evidence that homeopathy may be effective in treating symptoms of SAR, there is a lack of high-quality clinical trials. Therefore, the aim of the homeopathy for SAR (HOMEOSAR) trial is to determine the efficacy of individualized or standardized homeopathic drug treatment compared to placebo regarding rhinitis-related quality of life in patients with SAR.

METHODS

This randomized, placebo-controlled, double-blind, three-armed intervention study will be conducted at two university hospital outpatient clinics for complementary and integrative medicine in Berlin and in 12 office-based practices specializing in homeopathic treatment in Germany. A total of 270 patients with clinical symptoms of SAR and positive allergy test to birch and grass pollen will receive homeopathic anamnesis and subsequently be randomized into (a) standardized homeopathic drug treatment with Galphimia Glauca (potency D6), (b) individualized homeopathic drug treatment (D6), or (c) placebo. All three groups can receive on-demand rescue medication as needed. Treatment will consist of two consultations and daily intake of the study medication for 4 weeks during the pollen season. The primary outcome is the mean overall score of the Rhinitis Quality of Life Questionnaire (RQLQ) in weeks 3 and 4, analyzed using analysis of covariance (adjusted for baseline RQLQ overall score and study center). A closed testing procedure will be used to control the overall type I error comparing the 3 treatment groups. Secondary outcomes include the overall RQLQ and its seven domain scores, responder status (decrease in RQLQ overall score of at least 0.5 points compared to the baseline value), use of rescue medication, intensity of total and individual SAR symptoms based on visual analog scale, generic health-related quality of life, safety, utilization of health care resources and associated costs. In addition, a qualitative data analysis is planned.

CONCLUSION

The results of our study will contribute to clarifying the possible therapeutic effects of homeopathic drug treatment for patients with SAR.

TRIAL REGISTRATION

This study has been registered in the German Clinical Trial Registry with trial ID DRKS00018081 on June 09, 2020.

Quantification of left atrial contractile function using two-dimensional speckle tracking echocardiography in horses after conversion of atrial fibrillation to sinus rhythm

INTRODUCTION/OBJECTIVES

In horses, persistent atrial dysfunction is a prognostic indicator of recurrence of atrial fibrillation (AF). The objective of this study was to quantify left atrial (LA) contractile function in Warmblood horses after successful cardioversion of AF to sinus rhythm, using standard two-dimensional echocardiography (2DE) and two-dimensional speckle tracking (2DST) analyses, and to provide proof-of-concept for use of 2DST to detect LA contractile dysfunction in horses.

ANIMALS, MATERIALS, AND METHODS

Nineteen Warmblood horses with AF and successful transvenous electrical cardioversion (TVEC) or medical cardioversion using quinidine sulfate (QS) were included. Echocardiography was performed at 24 hr, 72 hr, and 1-6 months after cardioversion. Conventional 2DE-derived indices of LA size and function and global longitudinal strain (S_L) and longitudinal strain rate (SR_L) during LA contractile function were measured to detect differences in LA size and function over time and between treatment modalities. The association between 2DE-derived indices and global S_L and SR_L, respectively, and the agreement of the variables to detect LA dysfunction were assessed.

RESULTS

Global S_L and SR_L, as well as active LA fractional area change (FAC) identified cases with LA dysfunction after TVEC and QS cardioversion and proved useful to demonstrate LA functional recovery over time. Agreement between active LA FAC and S_L and SR_L, respectively, to diagnose atrial dysfunction was substantial to fair at 24 hr after cardioversion and decreased with time.

CONCLUSION

This study shows that 2DST is useful to quantify LA contractile dysfunction in horses after cardioversion of AF.

Evaluation of the role of heterogeneities on transverse mixing in bench-scale tank experiments by numerical modeling

In this work, numerical modeling is used to evaluate and interpret a series of detailed and well-controlled two-dimensional bench-scale conservative tracer tank experiments performed to investigate transverse mixing in porous media. The porous medium used consists of a fine matrix and a more permeable lens vertically aligned with the tracer source and the flow direction. A sensitivity analysis shows that the tracer distribution after passing the lens is only slightly sensitive to variations in transverse dispersivity, but strongly sensitive to the contrast of hydraulic conductivities. A unique parameter set could be calibrated to closely fit the experimental observations. On the basis of calibrated and validated model, synthetic experiments with different contrasts in hydraulic conductivity and more complex setups were performed and the efficiency of mixing evaluated. Flux-related dilution indices derived from these simulations show that the contrasts in hydraulic conductivity between matrix and high-permeable lenses as well as the spatial configuration of tracer plumes and lenses dominate mixing, rather than the actual pore scale dispersivities. These results indicate that local material distributions, the magnitude of permeability contrasts, and their spatial and scale relation to solute plumes are more important for macro-scale transverse dispersion than the micro-scale dispersivities of individual materials. Local material characterization by thorough site investigation hence is of utmost importance for the evaluation of mixing-influenced or -governed problems in groundwater, such as tracer test evaluation or an assessment of contaminant natural attenuation.

Evaluation of transverse dispersion effects in tank experiments by numerical modeling: parameter estimation, sensitivity analysis and revision of experimental design

Transverse dispersion represents an important mixing process for transport of contaminants in groundwater and constitutes an essential prerequisite for geochemical and biodegradation reactions. Within this context, this work describes the detailed numerical simulation of highly controlled laboratory experiments using uranine, bromide and oxygen depleted water as conservative tracers for the quantification of transverse mixing in porous media. Synthetic numerical experiments reproducing an existing laboratory experimental set-up of quasi two-dimensional flow through tank were performed to assess the applicability of an analytical solution of the 2D advection-dispersion equation for the estimation of transverse dispersivity as fitting parameter. The fitted dispersivities were compared to the "true" values introduced in the numerical simulations and the associated error could be precisely estimated. A sensitivity analysis was performed on the experimental set-up in order to evaluate the sensitivities of the measurements taken at the tank experiment on the individual hydraulic and transport parameters. From the results, an improved experimental set-up as well as a numerical evaluation procedure could be developed, which allow for a precise and reliable determination of dispersivities. The improved tank set-up was used for new laboratory experiments, performed at advective velocities of 4.9 m d(-1) and 10.5 m d(-1). Numerical evaluation of these experiments yielded a unique and reliable parameter set, which closely fits the measured tracer concentration data. For the porous medium with a grain size of 0.25-0.30 mm, the fitted longitudinal and transverse dispersivities were 3.49×10(-4) m and 1.48×10(-5) m, respectively. The procedures developed in this paper for the synthetic and rigorous design and evaluation of the experiments can be generalized and transferred to comparable applications.

Functional results after giant cell tumor operation near knee joint and the cement radiolucent zone as indicator of recurrence

BACKGROUND

Giant cell tumor of bone near the knee joints is a dilemma for the operating surgeon. Curettage and bone grafting have a high recurrence, whereas wide resection has a reduced recurrence rate with the compromise of limb function.

MATERIALS AND METHODS

Thirty-eight patients with histologically proven giant cell tumor near the knee joint were treated. All patients were reviewed with regard to the operative method, recurrence rate, postoperative arthritis and functional results of the joint. In cases of cement filling, the radiolucent zone and the sclerotic rim were assessed as possible markers for recurrence.

RESULTS

14 male and 24 female patients were included in this study (mean age 28 years, range 13-56 years). All patients underwent surgery, 21 patients were treated with a bone cement filling and additional osteosynthesis after curettage. Seventeen patients were filled with cancellous bone or curettage alone. In the group with bone cement filling after curettage, the recurrence rate was 23.8%, whereas a recurrence rate of 52.9% was detected in the group with cancellous bone filling or curettage alone. The average time to recurrence was two years (5 months to 6 years). An increase of the radiolucent zone was seen in 80% of all patients with a recurrence.

CONCLUSION

Cement filling after extensive curettage does not increase the recurrence rate and does not induce osteoarthritis, as long as the continuity of articular cartilage is maintained. Patients with giant cell tumor of bone near the knee joint can be treated satisfactorily with intralesional resection and bone cement packing. The extension of the radiolucent zone after bone cement filling is a reliable indicator for a possible local recurrence.

Orthopaedic limb salvage with a mega prosthesis in a patient with haemophilia A and inhibitors ? a case report

Inhibitors against FVIII or FIX in patients with haemophilia are a common and serious complication. Until recently, elective surgery was associated with major bleeding despite the availability of a sufficient substitution therapy. We report about the major orthopaedic reconstruction of the right limb in a patient with severe haemophilia A and inhibitors. This reconstruction was the after effect of a traumatic periprosthetic fracture of the right femur after total knee replacement 6 months ago. This fracture could be stabilized by internal fixation. Two months later, a non-traumatic femur fracture occurred. Therefore, we removed the distal part of the femur and the joint replacement, and implanted a custom made tumour prosthesis (Type MUTARS (c), Münster). These three successive operations, which included emergency and elective surgery, were performed within 8 months. This is, to the best of our knowledge, the first patient with inhibitors undergoing such a complicated reconstruction of a limb. We conclude that successful elective orthopaedic surgery could be accomplished safely in this patient with high responding inhibitors using recombinant FVIIa. After a follow-up of 9 months, no major complications were seen.

Total hip replacement in patients with severe bleeding disorders. A 30 years single center experience

Arthropathy of the hip is moderate in frequency in haemophiliac patients, but is less common than ankle, knee or elbow arthropathy. We report about our experience with total hip replacement in patients with severe bleeding disorders over a period of 30 years. Between July 1972 and 2002, 15 hips in 13 patients were replaced. The main bleeding disorders were Haemophilia A in ten patients and severe v. Willebrand disease in three patients. The mean follow-up was 132 months (range 12-363). We can demonstrate good long-term results, with only one aseptic loosening after 14 years and one septic loosening after 14 months in an HIV-positive patient. The Harris Hip Score increased from 48 points (32-66) preoperatively to 89 (76-100) postoperatively. In conclusion, total hip replacement performed in a specialised haemophiliac centre is a safe procedure, and results in pain relief and improvement of the quality of life in patients with severe bleeding disorders.

[The use of bisphosphonates in arthroplasty]

The use of bisphosphonates in joint arthroplasty is the latest field of application for these agents. The mechanism of action of bisphosphonates suggests that they may optimize long-term survival of the implant. Most important is their potency in suppressing periprosthetic osteolysis due to the inflammatory foreign body reaction of wear debris, to decrease periprosthetic osteopenia caused by stress-shielding and to improve the osseointegration of cementless metal implants. The present review provides the latest information on definite and presumed mechanisms of action of bisphosphonates and their clinical importance.

[Effects of bisphosphonates in arthroplasty]

AIM

This study presents an overview of the general effects of bisphosphonates and in particular of their effects on different problems in joint arthroplasty.

METHOD

First the chemical properties are described, then the biological effects. It is already known that bisphosphonates have effects on orthopaedic diseases and an increasing number of studies are investigating what effects can be achieved in joint arthroplasty with these substances.

RESULTS

The bisphosphonates group was derived from industrial pyrophosphate which is used to prevent calcification. Bisphosphonates inhibit bone mineralisation and resorption. Several direct and indirect mechanisms are responsible for these effects. The inhibition of bone resorption is used to benefit patients suffering from various diseases causing increased bone resorption. Treatment with bisphosphonates results in greater bone density and improved mechanical bone quality. Indications for this treatment include osteoporosis, tumour-associated osseo-destruction, fibrous dysplasia and Paget's disease. Recent studies have shown that osseo-integration of metal implants is accelerated and periprosthetic bone loss, which is caused by various different mechanisms during the lifetime of an implant, can be reduced.

CONCLUSION

Bisphosphonates have been an established element in the treatment of bone metabolic disorders for many years. Their use in joint arthroplasty could become increasingly important.

[Improved osseointegration and periprosthetic bone volume around cementless metal implants under bisphosphonate treatment]

AIM

The effects of a systemic treatment with the bisphosphonate ibandronate on osseointegration of uncoated and hydroxyapatite-coated titanium implants and on periprosthetic bone volume have been evaluated and the dosage of medication had to be defined.

METHOD

We used an animal model of the rat, the animals were assigned to three treatment groups receiving 1 microg, 5 microg and 25 microg/kg body weight and one control group receiving NaCl 0.9%. An uncoated and a hydroxyapatite-coated titanium rod were inserted into the medullary canal of the femur. After 28 days the specimens were harvested and histomorphometric evaluation revealed extend of osseointegrated implant surface and changes of periprosthetic bone volume.

RESULTS

Treatment groups receiving 5 microg and 25 microg ibandronate showed significant improvement of osseointegrated implant surface compared to the control group. Enhancement of periprosthetic bone volume was revealed in all treatment groups but only application of 25 microg ibandronate was significantly improved compared to the control group.

CONCLUSION

A minor dose of 1 microg ibandronate is not effective to improve osseointegration. A high dosed bisphosphonate treatment with 5 microg or 25 microg ibandronate is potent to improve osseointegrated implant surface significantly compared to an untreated control in both uncoated and hydroxyapatite-coated titanium implants and to enhance periprosthetic bone volume. By that, improved secondary stability and prolonged survival time of cementless metal implants can be expected.

The bisphosphonate ibandronate improves implant integration in osteopenic ovariectomized rats

Osteoporosis is known to impair the process of implant osseointegration. Bisphosphonates are drugs that inhibit osteoclast-mediated bone resorption and normalize the high rate of bone turnover that characterizes this disease. Consequently, there is a rationale for using bisphosphonates to enhance the early stabilization of implants in subjects with low bone mass. In this study, 84 rats received titanium-only or hydroxyapatite (HA)-coated titanium femoral implants, 3 months after being ovariectomized (OVX) or sham operated. They were then treated for 4 weeks. The OVX rats were randomly assigned to daily subcutaneous injections of either saline or the bisphosphonate ibandronate (at a dose of 1 microg/kg or 25 microg/kg), while the sham-operated animals received saline throughout. The 1 microg/kg or 25 microg/kg ibandronate doses are considered translatable to doses used to treat osteoporosis and metastatic bone disease (MBD), respectively, in rats, and roughly reflect those used in humans. At the end of the treatment period, bone mineral density (BMD) at the lumbar spine increased in both of the ibandronate-treated groups when compared with the OVX control animals and to a level similar to that of the sham-operated control group. Osseointegration, determined by histomorphometric analysis and expressed as percentage of osseointegration implant surface (OIS), did not differ between groups for the titanium-only implants. For the HA-coated implants, however, OIS was 113.5% and 185% higher in the groups receiving 1 microg/kg or 25 microg/kg ibandronate, respectively, relative to the OVX controls. In turn, the OIS of the HA-coated implants was 56.5% lower in the OVX control group than in the sham control group. These findings clearly demonstrate that OVX-induced osteopenia impairs the osseointegration of HA-coated titanium implants and that ibandronate, administered at doses analogous to those used to clinically treat osteoporosis and MBD, counters this harmful effect. Ibandronate may, therefore, have a role in improving the osseointegration of implants in patients with osteoporosis and MBD.

Early detection of skin cancer (EDISCIM) through the use of non-invasive confocal imaging

In the past 15 years the number of malignant melanomas and non-melanoma skin cancer, (i.e. squamous cell carcinoma, basal cell carcinoma), have increased dramatically throughout the whole world, in particular among people with white skin. For example, in Germany the number of new cases of melanoma is about 10 to 12 per 100,000 people, (for basal cell carcinoma as a non-melanoma skin cancer 140 per 100,000), the absolute number of annual new cases of melanoma is an estimated 9,000 to 10,000, and the increasing rate is 5 to 10%. However, there are more than 40 differential diagnoses for skin cancer which makes it difficult even for expert dermatologists to give correct diagnosis, (estimated 75% correct diagnoses). This figure is even worse for doctors from other specialities. There is only a chance of high cure rates when skin tumours are detected at an early stage. The prognosis of skin cancer is dependent very much on the thickness, (as a sign of invasiveness), of the tumour and the number of mitotic figures in the tumour, (as a sign of proliferation activity). However, the final diagnosis of skin cancer is usually done by biopsy, the sample being investigated by a specialist. This is an invasive method, which is painful for the patient and might require several cuts and samples taken before being absolutely certain. Due to the potential risk of dissemination of tumour cells, taking an incisional biopsy is obsolete in malignant melanoma. Therefore the correct diagnosis of malignant melanoma can be made only after a total removal of the lesion and consecutive histopathological examination. The EDISCIM project intends to develop a system for the early diagnosis of skin cancer which uses confocal imaging for the non-invasive diagnosis of the upper layers of the skin that aids the physician in the analysis of the images and therefore with the diagnosis, allows for potential remote diagnosis by specialist dermatologists via tele-diagnosis if need be. The objectives of the system are Captures microscopic images of the skin by confocal imaging, Processes and records these images in real time, Compares these images against a knowledge base of known skin symptoms, Displays the results in a suitable interface to the physician performing the diagnosis, And supports the online telematic support by specialists.

[Rachitic knock knees in children]

Knee malpositions, for example valgus or varus deformations or flexion contractures, were often cited in the historical literature. In earlier times, clinical pictures such as rickets were often the reason for this kind of deformity. A causal therapy did not exist until the twentieth century. In most cases of rickets, genu valgum was reported as the typical knee deformation. The differential diagnosis for genu valgum caused by rickets was genu valgum traumaticum, paralyticum, and inflammatorium. The most important reports on the pathogenesis of valgus deformation can be found in publications by Hueter and von Mikulicz. The causal therapy of rickets was introduced at the beginning of the twentieth century.Vitamin therapy and UV phototherapy were developed during this period. Using these therapies, rickets decreased dramatically. Kurt Huldschinsky, a pediatrician from Berlin,was one of the main inventors of UV phototherapy in Germany. At the end of the nineteenth century, the operative correction of knee deformities increased while conservative treatment continued to be applied. Plaster casts,orthoses, and osteoclast therapy were the main noninvasive therapeutic possibilities. Positive aspects of the conservative techniques were mostly the good results and easy, timesaving technique compared with the operative treatment. The operative therapy increased with the knowledge of antisepsis and asepsis as well as advances in anesthetic procedures. Operative treatment modalities, for example tibial and femoral osteotomies, were more precise, but connected with multiple complications and greater time expenditure. Sufficient vitamin prophylaxis rendered knee deformations caused by rickets a rarity.

[Ten year follow-up after single incision anterior cruciate ligament reconstruction using patellar tendon autograft]

AIM

We evaluated 74 patients 10 years after arthroscopically assisted ACL reconstruction using the central third of the patellar tendon as autograft.

METHOD

IKDC, Tegner and Lysholm scores were used for clinical evaluation. Ligament stability was tested using the Rolimeter instrument. For statistics we used the Chi square test.

RESULTS

At follow-up the Tegner activity level was 5.2, the Lysholm score was 93.6 points. Subjective assessment for function was rated normal or nearly normal in 83.7 %, for stability in 71.6 %. The side-to-side difference measured with the Rolimeter was normal in 87.8% and nearly normal in 12.2 %. Pivot shift was proven to be negative in 94.6 %. 29.7 % of patients showed degenerative changes in X-rays at follow-up. There was a significant correlation between time interval from injury to surgery and the grade of degenerative changes. Arthrosis significantly correlates with the rate of meniscus injury. Acute operative treatment increases the rate of arthrofibrosis significantly.

CONCLUSION

To avoid osteoarthrosis we recommend an early (subacute) ACL reconstruction and meniscus refixation in the case of meniscus injury.

[History of surgery of the anterior cruciate ligament]

Early comments on the anterior cruciate ligament were found in ancient literature, and the first scientific reports were published in the nineteenth century. The first surgical treatment of a ruptured anterior cruciate ligament was carried out in 1895 by Robson performing a primary suture of the torn ligament. In 1903 F. Lange suggested a complete replacement of the injured ligament using silk ligaments and in 1914 Grekow was probably the first who recommended autogenous transplants by using a fascia lata strip. In 1917 Hey-Groves presented his surgical technique that was the fundament for reconstruction surgery in the following years. Today, the autogenous transplant is accepted to be the golden standard for replacement of the injured anterior cruciate ligament. The bone-tendon-bone transplant of the patellar ligament and the semitendinosus or gracilis tendon are recommended by most surgeons. In the history of anterior cruciate ligament surgery, the surgical technique of the operative procedures has also changed. The evolution started with open arthrotomy followed by mini-arthrotomy and led to arthroscopically assisted replacement of the anterior cruciate ligament.

Revision ACL reconstruction using autogenous patellar tendon graft

This retrospective study examined revision anterior cruciate ligament reconstruction using a bone-tendon-bone autograft of the patellar ligament. We followed up 44 patients (mean age 27.9 years) for an average of 41.2 months. Clinical examination with the Lachmann and pivot shift tests showed clearly improved stability; KT-1000 arthrometer measurements had a mean difference of 3.5 mm in side-to-side comparison. The evaluated knee scores were significantly improved (P<0.01); the median Lysholm score was 85 and the median Tegner activity score 5.0 at follow-up. In the IKDC ranking system 75.0% of knees were rated normal or nearly normal (grades A and B). According to a modified Fairbank scale, progression of radiographic signs of osteoarthritis was noted in 36.4%. There was a significant difference (P<0.05) in progression of radiographic signs of osteoarthritis between patients with major (grades III, IV) versus minor (grades I, II) lesions of the articular cartilage surface and between knees with versus without extensive synovitis due to previous synthetic graft reconstruction (P<0.05). Revision anterior cruciate ligament reconstruction using an autogenous patellar tendon graft shows good results with improved knee function compared to the prerevision status and is in line with various operative techniques described in the literature. Progression of osteoarthritis must be expected in patients with major lesions of the articular cartilage surface and knees with long-term extensive synovitis due to previous anterior cruciate ligament reconstruction using synthetic grafts.

Effects of revisional ACL surgery in semi-professional athletes in "high-risk pivoting sports" with chronic anterior instability of the knee

This is a retrospective study of semi-professional athletes in "high-risk pivoting sports" after repetitive injuries of the anterior cruciate ligament (ACL) with chronic anterior instability of the knee. Effects of revisional ACL surgery on the progression of osteoarthritis, sport capacity, and knee pain were observed. Twenty-four patients, with an average age of 25.5 years, were examined on average 36.9 months postoperatively. Compared with the preoperative findings we noted a significant increase in the Lysholm and the Tegner activity score (P < 0.001). Sixteen patients (67%) were able to continue their sporting career; 17 patients (71%) were completely satisfied with the operative result. Nevertheless, 15 patients (63%) complained of persistent pain caused by sport activity. According to the Fairbank scale, 15 patients (63%) showed an increase in osteoarthritic signs between the preoperative and follow-up roentgenograms. Furthermore, there was a highly significant correlation (P < 0.001) between progression of osteoarthritis and continuous sport activity. We conclude that, after stabilization with a "bone-tendon-bone" autograft, athletes have a good chance to return to their sport. In most patients, the knee pain persisted and progression of osteoarthritis was detected. In individuals who play sport continuously, we recommend an annual follow-up with clinical examination and roentgenographic or magnetic resonance imaging examinations.

cDNA cloning, expression and chromosomal localization of two human lysophosphatidic acid acyltransferases

In this report we describe a pair of human LPAAT isozymes. These isozymes are encoded by distinct genes located on different chromosomes, but share sequence homology, substrate specificity, and intracellular location. The biological value of maintaining the two closely related LPAAT genes in the human genome is not clear. We find that both isozymes are widely expressed, although expression levels do diverge significantly in tissues such as the liver, placenta, testes, and pancreas. We also find that, at least in the artificial system of over-expression in COS7 cells, both isozymes localize to the ER membrane. Thus, distinct tissue-specific or subcellular compartment-specific roles for the two isozymes are not supported by the current experimental evidence. It does remain possible that induction of expression or subcellular translocation of one or the other isozyme may distinguish their functions. A survey of a limited number of acyl CoA substrates indicates that the two isozymes display similar substrate specificities, although slight differences are suggested by the data. However, extensive analysis of both isozymes with multiple substrates in the same assay system will be required to detect physiologically relevant differences in substrate specificity. LPA and PA are central intermediates in phospholipid biogenesis. Furthermore, they have the capacity to mediate signaling both between and within cells. The importance of these mediators is reflected in the growing body of literature dedicated to unraveling the mechanistic basis for their actions. Until recently, the field has been hampered by a dearth of reagents appropriate for the molecular dissection of the LPA and PA metabolic and signaling pathways in eukaryotes. However, the recent cloning of possible LPA receptors will promote further understanding of LPA signaling. Similarly, the recent appearance of LPAAT homologs in the EST database has prompted a flurry of reports describing their characterization. These clones will afford opportunity for defining the function of LPAAT in eukaryotic phospholipid metabolism.

Reconstruction plate fixation with bone graft for mid-shaft clavicular non-union in semi-professional athletes

From 1993 to 1997, 22 semi-professional athletes (14 men and 8 women), aged 18-33 years (mountain bike racers, soccer players, handball players, swimmers, and short distance runners) with a non-union of the middle third of the clavicle were treated operatively by reconstruction plating and bone grafting. Fourteen clavicular non-unions were caused by falls. Eight non-unions were the result of a car, motorcycle, or bicycle accident. There were 19 atrophic and 3 hypertrophic non-unions. In all patients, initially a figure-of-eight strap or a sling was used for immobilization and no radiographic union was documented within 5 months. None of the athletes had gone back to their sports and all had pain and limitation of shoulder function. For open reduction and internal fixation, an AO 3.5-mm seven-hole reconstruction plate was used. The sclerotic bone ends were freshened and a cortical bone transplant or cancellous bone from the iliac crest (depending on the shortening of the clavicle) was packed around the fracture or between the reduced fracture ends. In all athletes, radiographic consolidation was achieved after an average of 14 weeks (range, 11-16 weeks) and the average increase in the Constant and Murley Score was from 79 points preoperatively to 97 points after surgery. No operative or postoperative complications occurred and all athletes returned to their sports.

Mitral E wave propagation as an index of left ventricular diastolic function. I: Its hydrodynamic basis

BACKGROUND AND AIMS OF THE STUDY

Left ventricular (LV) diastolic dysfunction is an early sign of myocardial disease and an important determinant of symptoms and prognosis in patients with various cardiovascular disorders. Evidence suggests the presence and clinical importance of abnormal LV diastolic function in patients with valvular heart diseases, but it is difficult to measure non-invasively. Mitral E wave propagation inside the left ventricle studied by analysis of digitized color M-mode and pulsed wave Doppler technique is a promising technique for the evaluation of LV relaxation. However, the precise mechanism of its transmission is not clearly defined. Understanding the precise hydrodynamic basis of E wave propagation would be helpful for its meaningful application to the evaluation of LV diastolic performance. This study investigates the hydrodynamic determinants of mitral E wave propagation in an in vitro setting.

METHODS AND RESULTS

Thirty-one sets of experiments were conducted in a linear, pulsatile left ventricle model with varying operative diastolic characteristics. The rate of transmission of the onset of the E wave was strongly related to operative LV diastolic stiffness (r = 0.93, p < 0.0001), and weakly to mean left atrial (LA) pressure (r = 0.46, p < 0.01), heart rate (r = 0.57, p < 0.01) and stroke volume (r = -0.58, p < 0.01) through an effect on operative LV diastolic stiffness. The peak of the E wave transmission was influenced not only by operative LV diastolic stiffness (r = 0.87, p < 0.0001), but also by the mean LA pressure, heart rate and stroke volume, in an independent fashion.

CONCLUSIONS

The rate of transmission of the onset of the mitral E wave is determined solely by operative LV diastolic stiffness, whereas that of the peak is also affected by the mean LA pressure, heart rate and stroke volume. Analysis of mitral E wave propagation in patients with valvular heart disease may give clinically useful insights into LV diastolic function.

Human lysophosphatidic acid acyltransferase. cDNA cloning, expression, and localization to chromosome 9q34.3

Lysophosphatidic acid (1-acyl-sn-glycero-3-phosphate (LPA)) is a phospholipid with diverse biological activities. The mediator serves as an intermediate in membrane phospholipid metabolism but is also produced in acute settings by activated platelets. LPA is converted to phosphatidic acid, itself a lipid mediator, by an LPA acyltransferase (LPAAT). A human expressed sequence tag was identified by homology with a coconut LPAAT and used to isolate a full-length human cDNA from a heart muscle library. The predicted amino acid sequence bears 33% identity with a Caenorhabditis elegans LPAAT homologue and 23-28% identity with plant and prokaryotic LPAATs. Recombinant protein produced in COS 7 cells exhibited LPAAT activity with a preference for LPA as the acceptor phosphoglycerol and arachidonyl coenzyme A as the acyl donor. Northern blotting demonstrated that the mRNA is expressed in most human tissues including a panel of brain subregions; expression is highest in liver and pancreas and lowest in placenta. The human LPAAT gene is contained on six exons that map to chromosome 9, region q34.3.

Platelet-activating factor acetylhydrolase deficiency. A missense mutation near the active site of an anti-inflammatory phospholipase

Deficiency of plasma platelet-activating factor (PAF) acetylhydrolase is an autosomal recessive syndrome that has been associated with severe asthma in Japanese children. Acquired deficiency has been described in several human diseases usually associated with severe inflammation. PAF acetylhydrolase catalyzes the degradation of PAF and related phospholipids, which have proinflammatory, allergic, and prothrombotic properties. Thus, a deficiency in the degradation of these lipids should increase the susceptibility to inflammatory and allergic disorders. Miwa et al. reported that PAF acetylhydrolase activity is absent in 4% of the Japanese population, which suggests that it could be a common factor in such disorders, but the molecular basis of the defect is unknown. We show that inherited deficiency of PAF acetylhydrolase is the result of a point mutation in exon 9 and that this mutation completely abolishes enzymatic activity. This mutation is the cause of the lack of enzymatic activity as expression in E. coli of a construct harboring the mutation results in an inactive protein. This mutation as a heterozygous trait is present in 27% in the Japanese population. This finding will allow rapid identification of subjects predisposed to severe asthma and other PAF-mediated disorders.

Abnormal blood vessel development and lethality in embryos lacking a single VEGF allele

The endothelial cell-specific vascular endothelial growth factor (VEGF) and its cellular receptors Flt-1 and Flk-1 have been implicated in the formation of the embryonic vasculature. This is suggested by their colocalized expression during embryogenesis and the impaired vessel formation in Flk-1 and Flt-1 deficient embryos. However, because Flt-1 also binds placental growth factor, a VEGF homologue, the precise role of VEGF was unknown. Here we report that formation of blood vessels was abnormal, but not abolished, in heterozygous VEGF-deficient (VEGF+/-) embryos, generated by aggregation of embryonic stem (ES) cells with tetraploid embryos (T-ES) and even more impaired in homozygous VEGF-deficient (VEGF-/-) T-ES embryos, resulting in death at mid-gestation. Similar phenotypes were observed in F1-VEGF+/- embryos, generated by germline transmission. We believe that this heterozygous lethal phenotype, which differs from the homozygous lethality in VEGF-receptor-deficient embryos, is unprecedented for a targeted autosomal gene inactivation, and is indicative of a tight dose-dependent regulation of embryonic vessel development by VEGF.

Plasma platelet-activating factor acetylhydrolase is a secreted phospholipase A2 with a catalytic triad

Platelet-activating factor (PAF) is a potent pro-inflammatory autacoid with diverse physiological and pathological actions. These actions are modulated by PAF acetylhydrolase, which hydrolyzes the sn-2 ester bond to yield the biologically inactive lyso-PAF. In contrast to most secreted phospholipase A2s, plasma PAF acetylhydrolase is calcium-dependent and contains a GXSXG motif that is characteristic of the neutral lipases and serine esterases. In this study we tested whether the serine in this motif is part of the active site of plasma PAF acetylhydrolase and, if so, what the other components of the active site are. Using site-directed mutagenesis, we demonstrated that Ser-273 (of the GXSXG motif), Asp-296, and His-351 are essential for catalysis. These residues were conserved in PAF acetylhydrolase sequences isolated from bovine, dog, mouse, and chicken. The linear orientation and spacing of these catalytic residues are consistent with the alpha/beta hydrolase conformation of other lipases and esterases. In support of this model, analysis of systematic truncations of PAF acetylhydrolase revealed that deletions beyond 54 amino acids from the NH2 terminus and 21 from the COOH terminus resulted in a loss of enzyme activity. These observations demonstrate that although plasma PAF acetylhydrolase is a phospholipase A2 it has structural properties characteristic of the neutral lipases and esterases.

Anti-inflammatory properties of a platelet-activating factor acetylhydrolase

Platelet-activating factor (PAF) is a potent pro-inflammatory phospholipid that activates cells involved in inflammation. The biological activity of PAF depends on its structural features, namely an ether linkage at the sn-1 position and an acetate group at the sn-2 position. The actions of PAF are abolished by hydrolysis of the acetyl residue, a reaction catalysed by PAF acetylhydrolase. There are at least two forms of this enzyme--one intracellular and another that circulates in plasma and is likely to regulate inflammation. Here we report the molecular cloning and characterization of the human plasma PAF acetylhydrolase. The unique sequence contains a Gly-Xaa-Ser-Xaa-Gly motif commonly found in lipases. Recombinant PAF acetylhydrolase has the substrate specificity and lipoprotein association of the native enzyme, and blocks inflammation in vivo: it markedly decreases vascular leakage in pleurisy and paw oedema, suggesting that PAF acetylhydrolase might be a useful therapy for severe acute inflammation.

Oncostatin M is a mitogen for rabbit vascular smooth muscle cells

The growth regulatory protein oncostatin M was initially discovered in macrophage-conditioned medium. We investigated the effects of oncostatin M on cultured rabbit aorta smooth muscle cells (SMCs) and found that the peptide stimulated an increase in the incorporation of [3H]thymidine into DNA. The magnitude of the stimulation was dependent on oncostatin M concentration and SMC confluency. In subconfluent cultures, 1-2 nM stimulated 4- to 5-fold increases in DNA synthesis after 20 hr. Other structurally related cytokines (granulocyte colony-stimulating factor, leukemia inhibitory factor, interleukin 6, ciliary neurotrophic factor) did not affect SMC DNA synthesis. After 5 or 8 days, oncostatin M caused a doubling in SMC number and also induced a transformed phenotype. The combination of oncostatin M and platelet-derived growth factor for 8 days resulted in a 4-fold increase in cell number, approximately the same increase in cell number as induced by the addition of 10% fetal calf serum. Further investigation suggested that the mitogenic effect of oncostatin M was in part due to tyrosine kinase activation. Within 1-2 min, the factor increased phosphotyrosine levels of several SMC proteins. In addition, detectable increases in diacylglycerol levels occurred within 2-5 min, reached 50% above control by 30 min, and remained elevated through 45 min of incubation with oncostatin M. SMC inositol phosphate levels were also elevated within 2 min and then returned to near control values by 20 min. Within 30 min, oncostatin M induced expression of the immediate-early gene EGR-1. These data indicate that oncostatin M may be an important, naturally occurring mitogen for vascular SMCs.

[Comparison of IgG determination in foals using commercially available rapid tests]

The three tests (EQUI Z-Test, AGLUTINADE FOAL IMMUNITY, CITE Foal IgG-Test) were evaluated for their accuracy and usefulness in the field. Single radial immunodiffusion was used as reference method. All tests were easily and rapid to perform and results were obtained within a few minutes. It was easy to get the results of the CITE Foal IgG-Test, but use of the EQUI Z-Test and the FOAL AGLUTINADE IMMUNITY-Test needed some practice to get correct results. Results obtained by the CITE Foal IgG-Test correlated to single radial immunodiffusion in 94%, those obtained by FOAL AGLUTINADE IMMUNITY-Test in 74.1% and those obtained by EQUI Z-Test in 57.1%. Best results with a correspondence of 97.1% (CITE Foal IgG-Test) and 100% (EQUI Z-Test) were seen in the group having > 800 mg IgG/100 ml and in the group having < 200 mg IgG/100 ml with 93.3% (CITE Foal IgG-Test) and 82.1% (EQUI Z-Test). The AGLUTINADE FOAL IMMUNITY-Test had the same accuracy in all groups (70.9%-77.8%).

Direct interaction with primed CD4+ CD45R0+ memory T lymphocytes induces expression of endothelial leukocyte adhesion molecule-1 and vascular cell adhesion molecule-1 on the surface of vascular endothelial cells

The process of recruitment of leukocytes at sites of inflammation involves direct cell-to-cell interactions between leukocytes and vascular endothelial cells (EC) mediated by various adhesion receptors on leukocytes and their inducible endothelial ligands. In this study we have examined the induction on EC of endothelial leukocyte adhesion molecule-1 (ELAM-1), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) upon their interaction with subpopulations of human T cells. When co-cultured with EC both resting CD4+ T and CD8+ T cells caused a modest increase in the expression of endothelial ICAM-1. Moreover, resting CD4+ but not CD8+ T cells induced expression of ELAM-1 and VCAM-1 on a small fraction of unstimulated EC. Prior activation with phorbol 12-myristate 13-acetate (PMA) significantly increased the ability of T cells to up-regulate endothelial ICAM-1 and also induced the expression of both ELAM-1 and VCAM-1. PMA-primed CD4+ T cells induced both VCAM-1 and ELAM-1 on EC more efficiently than CD8+ T cells. Furthermore, the ability to induce the expression of ELAM-1 and VCAM-1 was confined to the CD4+ CD45R0+ memory/primed subpopulation of T cells. This induction of various endothelial adhesion ligands could also be mediated by antigen-primed CD4+ T cell lines. The CD4+ T cell-mediated induction of adhesion ligands required direct intercellular contact with EC because neither cultures of EC and PMA-primed CD4+ T cells separated by a microporous membrane insert nor the conditioned medium of PMA-primed T cells induced expression of ELAM-1 and VCAM-1 on EC. Cyclosporin A significantly inhibited the activation of T cells with PMA but had no effect on the ability of PMA-primed T cells to up-regulate endothelial CAM. Thus, CD4+CD45R0+ T cells via as yet unknown mechanism can significantly enhance the expression of each of the three endothelial adhesion ligands and, thereby, may facilitate the process of recruitment of additional leukocytes to exacerbate inflammation.

Plasma heparin values and hemostasis in equids after subcutaneous administration of low-dose calcium heparin

Different doses of heparin were given to equids SC to establish 0.05 to 0.20 U of heparin/ml of plasma. Plasma heparin values and antithrombin III activities were assayed, using chromogenic substrate methods. Activated partial thromboplastin and thrombin times were determined, using conventional coagulation assays. Tests were run every hour (or every 2 hours for antithrombin III) for 12 hours from 5 groups of 5 equids each after single injection of 40, 60, 80, 100, or 125 U of calcium heparin/kg of body weight and from 11 equids after injection of 150 U of calcium heparin/kg. The smaller dose (40 U/kg) did not or only insufficiently increase plasma heparin values. After 150 U of heparin/kg, plasma heparin concentrations were increased for 11 hours and were significantly (P = 0.05) increased between postadministration hours 2 and 7. The desired range beyond 0.05 U of heparin/ml was achieved between postadministration hours 2 and 6. Antithrombin III, activated partial thromboplastin time, and thrombin time were not significantly affected by any heparin dose. In cumulative studies, 2 equids were given 150 U of heparin/kg 7 times at 12-hour intervals. After the 3rd injection, a mean plasma concentration of 0.20 U of heparin/ml was achieved; after the 7th injection, the mean concentration was 0.22 U of heparin/ml. Four equids were given 150 U of heparin/kg initially, followed by 125 U of heparin/kg 6 times at 12-hour intervals. After the 3rd injection, a maximal plasma heparin concentration of 0.12 U of heparin/ml was achieved; after the 7th injection, the mean concentration was 0.18 U of heparin/ml. Repeated SC heparin injections caused moderate swelling at the injection sites.(ABSTRACT TRUNCATED AT 250 WORDS)