Time to maximum clinical improvement following minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery

BACKGROUND

There is increasing evidence of positive improvement in clinical and radiological outcomes following minimally invasive hallux valgus deformity correction surgery (MIS). This study investigated the rate of improvement in clinical patient reported outcome measures (PROMs) following MIS as this is not well understood.

METHODS

Between July 2014 and July 2019, data was prospectively collected from consecutive patients pre-operatively and at 6, 12, and 24 months following third-generation minimally invasive chevron and Akin osteotomies (MICA). Radiographic deformity and correction was assessed using weight-bearing radiographs pre-operatively and 6 weeks post-operatively. The primary outcome measure was the change in Manchester Oxford Foot Questionnaire (MOXFQ) score at each time point. Secondary outcomes include radiographic deformity correction, health-related quality of life PROMs and exploration of cases where PROMs did not improve.

RESULTS

There were 202 feet with complete PROM data for every time point. There was a statistically significant improvement in MOXFQ Index score at each time point (p < 0.05) following MICA surgery. The majority of the improvement occurred within the first 6 months. A subgroup of 17 feet (8.4%) were identified which had worse MOXFQ Index scores 6 months following MICA. For 14 feet in this subgroup (82.4%), the MOXFQ Index score subsequently improved over time such that by two years, their score had significantly improved compared to their pre-operative score.

CONCLUSION

The majority of PROM improvement with MICA is gained by 6 months post-operatively but further significant improvement can be seen up to 2 years. Those patients who have not improved at 6 months, are likely to do so with time.

LEVEL OF EVIDENCE

IV.

Definitive treatment choice among Black immigrants with prostate cancer: Analysis of patient surveys distributed at a single safety-net institution

BACKGROUND

Large-scale prostate cancer (PCa) database reviews have found a consistent discrepancy in the mortality rate in Black patients compared to their White counterparts. Furthermore, differences in PCa treatment and outcomes among Black men of different ethnic origins have also been identified. Due to the heterogeneity of PCa-impacted communities and the unclear impact of patient immigration status on treatment outcomes, we sought to determine the demographic factors associated with treatment choice for definitive treatment of PCa in our single institution's patient population of Black immigrants.

METHODS

We distributed surveys to all patients in the Kings County Hospital Center urologic oncology clinic from February 2019 to February 2020 and collected relevant health information via EMR. The survey collected demographic information regarding age, education, health insurance, employment status, socioeconomic status, country of birth, and years living in the United States (US).

RESULTS

Out of the 253 patients surveyed, the majority of patients surveyed were Black and foreign born. There were no significant differences in demographic data between US-born and foreign-born patients except number of years living in the United States. In the intermediate risk group, patients living in the United States for <10 years chose surgery significantly more often than US-born patients (90.9% vs. 50.0%, p = 0.036). On multivariate analysis, patients that chose surgery were more likely to be older when diagnosed (odds ratio [OR] = 1.21) and less likely to be born in the United States than in African or Caribbean countries (OR = 0.054).

CONCLUSIONS

In our study of a majority-Black population, we found that patients born in the United States were less likely than their foreign counterparts to opt for surgery, as previous studies have shown. The choice of definitive treatment modality for Black men with intermediate risk PCa was found to be influenced by age at diagnosis and immigration status.

Minimally invasive surgery for severe hallux valgus in 106 feet

BACKGROUND

There is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1-2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA).

METHODS

This was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale).

RESULTS

Between September 2014 and November 2018, 106 consecutive feet (n = 78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). At two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%.

CONCLUSION

This study has demonstrated third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.

The impact of hallux valgus on function and quality of life in females

BACKGROUND

The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity.

METHODS

Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured in consecutive female patients presenting with HV. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ-5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Pearson R correlation values were calculated for the PROMs and radiographic deformity.

RESULTS

Between July 2015 and March 2020, 425 consecutive female patients presented with HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 of these patients (93.2%). Females less than 65 years with HV had a statistically significantly worse quality of life compared with females of the same age group in the general population. Above the age of 65, there was no statistically significant difference in EQ-5D-5L Index score between the two groups. Younger females reported higher VAS-Pain scores compared to older patients with 91% of patients reporting some degree of pain symptoms. There was a moderate correlation with MOXFQ Index score and EQ-5D-5L Index (R = -0.51, p < 0.001) and VAS-Pain scores (R = 0.54, p < 0.001). There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores although it was noted that there was a trend of increasing HVA/IMA with age.

CONCLUSION

Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with HRQOL measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMsmoderately correlate with HRQOL and may be a better marker of the negative effect of symptomatic hallux valgus deformity on quality of life.

LEVEL OF EVIDENCE

III.

Racial Differences in Incident Genitourinary Cancer Cases Captured in the National Cancer Database

Background and Objectives: The National Cancer Database (NCDB) captures nearly 70% of all new cancer diagnoses in the United States, but there exists significant variation in this capture rate based on primary tumor location and other patient demographic factors. Prostate cancer has the lowest coverage rate of all major cancers, and other genitourinary malignancies likewise fall below the average NCDB case coverage rate. We aimed to explore NCDB coverage rates for patients with genitourinary cancers as a function of race. Materials and Methods: We compared the incidence of cancer cases in the NCDB with contemporary United States Cancer Statistics data. Results: Across all malignancies, American Indian/Alaskan Natives subjects demonstrated the lowest capture rates, and Asian/Pacific Islander subjects exhibited the second-lowest capture rates. Between White and Black subjects, capture rates were significantly higher for White subjects overall and for prostate cancer and kidney cancer in White males, but significantly higher for bladder cancer in Black versus White females. No significant differences were observed in coverage rates for kidney cancer in females, bladder cancer in males, penile cancer, or testicular cancer in White versus Black patients. Conclusions: Differential access to Commission on Cancer-accredited treatment facilities for racial minorities with genitourinary cancer constitutes a unique avenue for health equity research.

Management Strategies for Nocturia

PURPOSE OF REVIEW

Nocturia is defined as awakening due to the desire to void during a period of intended sleep. The pathophysiology of nocturia is multifactorial and management remains a challenge. Herein, we provide an overview of the management strategies for nocturia and summarize the existing evidence for treatment of nocturia across the condition's broad etiologic categories: nocturnal polyuria, diminished bladder capacity, and global polyuria.

RECENT FINDINGS

Treatment should begin with behavioral modification. A high level of evidence supports the efficacy of desmopressin in the treatment of nocturnal polyuria. Data supporting the efficacy of α-blockers, antimuscarinics, and surgical bladder outlet procedures in the treatment of nocturia remains limited. Treatment options for nocturia are determined by underlying mechanism. Desmopressin is effective in treating nocturnal polyuria. Surgical intervention, α-blockers, and antimuscarinics may improve nocturia when associated with lower urinary tract symptoms or overactive bladder in the setting of diminished bladder capacity.

Modeling the initiation of Ewing sarcoma tumorigenesis in differentiating human embryonic stem cells

Oncogenic transformation in Ewing sarcoma tumors is driven by the fusion oncogene EWS-FLI1. However, despite the well-established role of EWS-FLI1 in tumor initiation, the development of models of Ewing sarcoma in human cells with defined genetic elements has been challenging. Here, we report a novel approach to model the initiation of Ewing sarcoma tumorigenesis that exploits the developmental and pluripotent potential of human embryonic stem cells. The inducible expression of EWS-FLI1 in embryoid bodies, or collections of differentiating stem cells, generates cells with properties of Ewing sarcoma tumors, including characteristics of transformation. These cell lines exhibit anchorage-independent growth, a lack of contact inhibition and a strong Ewing sarcoma gene expression signature. Furthermore, these cells also demonstrate a requirement for the persistent expression of EWS-FLI1 for cell survival and growth, which is a hallmark Ewing sarcoma tumors.

The outcome at 15 years of endoscopic anterior cruciate ligament reconstruction using hamstring tendon autograft for 'isolated' anterior cruciate ligament rupture

The purpose of this study was to report the outcome of 'isolated' anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with 'isolated' ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time. ACL reconstructive surgery in patients with an 'isolated' rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis.

Cross-suturing as an aid to wound closure: a prospective randomised trial using the forearm flap donor site as a model

Direct closure of a full thickness skin defect by suturing is the simplest and best solution in most cases. When suturing is not possible, then a skin graft may be the next choice for reconstruction. It is usual for the graft to be applied to the unaltered defect, accepting the size of the wound as the area to be grafted. This approach ignores the potential contribution of the elastic properties of the wound edges, which are so readily used to advantage in direct closure. A simple technique, which makes skin defects substantially smaller prior to skin grafting, is described. This technique benefits the primary defect by minimising the area of scar produced, as well as minimising the size of skin graft required and thus the graft donor site. The secondary defect of the radial forearm flap was used as a model wound in a prospective randomised trial to assess the use of this technique. Twenty successive patients undergoing free radial forearm flap surgery were entered into the trial. The technique consisted of preliminary cross-suturing of the wound prior to skin grafting. Half of the cases received cross-wound suturing and half of the cases had grafts applied to the unaltered area of the defect. Measurements of the forearm flap donor defects were taken using templates made at the time of surgery and at later intervals. A statistically significant reduction in the flap donor defects was achieved using the cross-suturing technique. Fewer complications such as skin graft failure and tendon adherence to graft were seen with the new technique. This technique is recommended not only for minimising morbidity in the radial forearm flap donor site, but also for reducing the size of any full thickness skin defect prior to skin grafting.

Male breast cancer in World War II aviation: a case report and review

Increased incidence of malignancies within aviators is well documented. Commercial female flyers have been found to have a higher risk of developing breast cancer. However, there has not been any report of male breast cancer related to flying either alone or where malignant melanoma and other primary cancers are also associated. We report two male World War II, British Royal Air Force pilots with primary breast carcinoma associated with two other primary cancer sites.

Design and characterization of a membrane permeable N-methyl amino acid-containing peptide that inhibits Abeta1-40 fibrillogenesis

Alzheimer's disease, Huntington's disease and prion diseases are part of a growing list of diseases associated with formation of beta-sheet containing fibrils. In a previous publication, we demonstrated that the self-association of the Alzheimer's beta-amyloid (Abeta) peptide is inhibited by peptides homologous to the central core domain of Abeta, but containing N-methyl amino acids at alternate positions. When these inhibitor peptides are arrayed in an extended, beta-strand conformation, the alternating position of N-methyl amino acids gives the peptide two distinct faces, one exhibiting a normal pattern of peptide backbone hydrogen bonds, but the other face having limited hydrogen-bonding capabilities due to the replacement of the amide protons by N-methyl groups. Here, we demonstrate, through two-dimensional NMR and circular dichroic spectroscopy, that a pentapeptide with two N-methyl amino acids, Abeta16-20m or Ac-K(Me)LV(Me)FF-NH2, does indeed have the intended structure of an extended beta-strand. This structure is remarkably stable to changes in solvent conditions and resists denaturation by heating, changes in pH (from 2.5 to 10.5), and addition of denaturants such as urea and guanindine-HCl. We also show that this peptide, despite its hydrophobic composition, is highly water soluble, to concentrations > 30 mm, in contrast to the nonmethylated congener, Abeta16-20 (Ac-KLVFF-NH2). The striking water solubility, in combination with the hydrophobic composition of the peptide, suggested that the peptide might be able to pass spontaneously through cell membranes and model phospholipid bilayers such as unilamellar vesicles. Thus, we also demonstrate that this peptide is indeed able to pass spontaneously through both synthetic phospholipid bilayer vesicles and cell membranes. Characterization of the biophysical properties of the Abeta16-20m peptide may facilitate the application of this strategy to other systems as diverse as the HIV protease and chemokines, in which there is dimerization through beta-strand domains.

Inhibition of beta-amyloid(40) fibrillogenesis and disassembly of beta-amyloid(40) fibrils by short beta-amyloid congeners containing N-methyl amino acids at alternate residues

A potential goal in the prevention or therapy of Alzheimer's disease is to decrease or eliminate neuritic plaques composed of fibrillar beta-amyloid (Abeta). In this paper we describe N-methyl amino acid containing congeners of the hydrophobic "core domain" of Abeta that inhibit the fibrillogenesis of full-length Abeta. These peptides also disassemble preformed fibrils of full-length Abeta. A key feature of the inhibitor peptides is that they contain N-methyl amino acids in alternating positions of the sequence. The most potent of these inhibitors, termed Abeta16-22m, has the sequence NH(2)-K(Me-L)V(Me-F)F(Me-A)E-CONH(2). In contrast, a peptide, NH(2)-KL(Me-V)(Me-F)(Me-F)(Me-A)-E-CONH(2), with N-methyl amino acids in consecutive order, is not a fibrillogenesis inhibitor. Another peptide containing alternating N-methyl amino acids but based on the sequence of a different fibril-forming protein, the human prion protein, is also not an inhibitor of Abeta40 fibrillogenesis. The nonmethylated version of the inhibitor peptide, NH(2)-KLVFFAE-CONH(2) (Abeta16-22), is a weak fibrillogenesis inhibitor. Perhaps contrary to expectations, the Abeta16-22m peptide is highly soluble in aqueous media, and concentrations in excess of 40 mg/mL can be obtained in buffers of physiological pH and ionic strength, compared to only 2 mg/mL for Abeta16-22. Analytical ultracentrifugation demonstrates that Abeta16-22m is monomeric in buffer solution. Whereas Abeta16-22 is susceptible to cleavage by chymotrypsin, the methylated inhibitor peptide Abeta16-22m is completely resistant to this protease. Circular dichroic spectroscopy of Abeta16-22m indicates that this peptide is a beta-strand, albeit with an unusual minimum at 226 nm. In summary, the inhibitor motif is that of alternating N-methyl and nonmethylated amino acids in a sequence critical for Abeta40 fibrillogenesis. These inhibitors appear to act by binding to growth sites of Abeta nuclei and/or fibrils and preventing the propagation of the network of hydrogen bonds that is essential for the formation of an extended beta-sheet fibril.

Familial British dementia: expression and metabolism of BRI

Vidal et al. (1999. Nature 399: 776-778) discovered that the underlying genetic lesion in familial British dementia (FBD) is a T-A transversion at the termination codon of a membrane protein, termed BRI. The mutation creates an arginine codon; translational read-through generates a novel protein, termed BRI-L, that is extended by 11 amino acids at the carboxyl-terminus. BRI-L is the precursor of the ABri peptide, a component of amyloid deposits in FBD brain. We demonstrate that both BRI and its mutant counterpart are constitutively processed by furin, resulting in the secretion of carboxyl-terminal peptide derivatives that correspond to all, or part of, ABri. Notably, elevated levels of peptides are generated from the mutant BRI precursor, suggesting that subtle conformational alterations at the carboxyl-terminus may influence furin-mediated processing. We have examined BRI/BRI-L processing by other members of the prohormone convertase (PC) family (PACE4, LPC, PC 5/6) and found that these enzymes also process BRI, albeit inefficiently. Moreover, BRI-L processing by the other PC members is severely compromised. Finally, our electron microscopic studies reveal that synthetic ABri peptides assemble into insoluble beta-pleated fibrils. Collectively, our results support the view that enhanced furin-mediated processing of mutant BRI generates amyloidogenic peptides that initiate the pathogenesis of FBD.

Basal cell carcinoma in aplasia cutis congenita

A case of multilocal basal cell carcinoma in a 45-year-old man is reported.

A review of 100 consecutive free tissue transfers

Following the introduction of microsurgical techniques the availability of free tissue transfer has radically transformed reconstructive possibilities for both oncological and surgical defects. This study is a review of 100 consecutive free tissue transfers (free flaps), carried out in 96 patients over a period of 25 months in our unit. The indications for surgery in this series mainly resulted from malignancy, trauma, chronic osteomyelitis, burns and congenital abnormalities. The tissues transferred included various combinations of skin, fat, fascia, muscle, bone and several free digits. Fourteen cases required re-exploration, of which 12 were salvaged, and the overall success rate was 96%.

Consequences of premature discontinuation of the developmental test of visual-motor integration: can these tests be salvaged?

The administration of many neuropsychological tests includes discontinuation criteria that are often complex and time-consuming. As a result, it is not uncommon for an examiner to unintentionally discontinue the administration of a test prematurely. This investigation of 56 correctly scored Developmental Test of Visual-Motor Integration protocols was conducted to determine how the premature termination of this particular test significantly affects its overall score, and thus, its interpretation. These data indicate that premature discontinuation of this test results in a minimal loss of points overall, and thus, does not invalidate the interpretation of its score.

Furin mediates enhanced production of fibrillogenic ABri peptides in familial British dementia

The genetic lesion underlying familial British dementia (FBD), an autosomal dominant neurodegenerative disorder, is a T-A transversion at the termination codon of the BRI gene. The mutant gene encodes BRI-L, the precursor of ABri peptides that accumulate in amyloid deposits in FBD brain. We now report that both BRI-L and its wild-type counterpart, BRI, were constitutively processed by the proprotein convertase, furin, resulting in the secretion of carboxyl-terminal peptides that encompass all or part of ABri. Elevated levels of peptides were generated from the mutant BRI precursor. Electron microscopic studies revealed that synthetic ABri peptides assembled into irregular, short fibrils. Collectively, our results support the view that enhanced furin-mediated processing of mutant BRI generates fibrillogenic peptides that initiate the pathogenesis of FBD.

Firework related injury and legislation: the epidemiology of firework injuries and the effect of legislation in Northern Ireland

The efficacy of legislation in reducing firework associated injuries is uncertain as is the nature of the problem within the United Kingdom (UK). In September 1996 the legislation governing firework sale in Northern Ireland was relaxed thus equalling that of the rest of the UK. For the 2 years following the change in legislation we prospectively assessed those patients who were admitted with a firework injury over the Halloween period. We then compared these results with retrospective data for the 3 years prior to the change in firework law. In the pre-legislation series the mean number of patients admitted annually was 0.38 per 100,000 while in the post-legislation series the mean was 0.43 per 100,000. Blast injury to the hand was the commonest injury accounting for 53% of cases in both series. Burn injuries were the second commonest form of injury comprising 30% of all admissions. Of those admitted with a hand injury 47% had at least one finger terminalised and nearly half of those patients admitted with burns (44%) required skin grafting. We conclude that early evidence suggests that liberalisation of the law on firework sale has not resulted in a significant increase in firework related injuries requiring hospital admission.

Time trends in the use of cholesterol-lowering agents in older adults: the Cardiovascular Health Study

OBJECTIVES

To describe recent temporal patterns of cholesterol-lowering medication use and the characteristics that may have influenced the initiation of cholesterol-lowering therapy among those aged 65 years or older.

SUBJECTS AND METHODS

A cohort of 5201 adults 65 years or older were examined annually between June 1989 and May 1996. We added 687 African American adults to the cohort in 1992-1993. We measured blood lipid levels at baseline and for the original cohort in the third year of follow-up. We assessed the use of cholesterol-lowering drugs at each visit.

RESULTS

The prevalence of cholesterol-lowering drug use in 1989-1990 was 4.5% among the men and 5.9% among the women; these figures increased over the next 6 years to 8.1% and 10.0%, respectively, in 1995-1996. There was a 4-fold increase in the use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors during the 6 years of follow-up, from 1.9% of all participants in 1989-1990 to 7.5% in 1995-1996. The use of bile acid sequestrants, nicotinic acid, and probucol declined from initial levels of less than 1% each. Among the participants who were untreated in 1989-1990, but eligible for cholesterol-lowering therapy after a trial of dietary therapy according to the 1993 guidelines of the National Cholesterol Education Panel, less than 20% initiated drug therapy in the 6 years of follow-up, even among subjects with a history of coronary heart disease. Among participants untreated at baseline but eligible for either cholesterol-lowering therapy or dietary therapy, initiation of cholesterol-lowering drug therapy was directly associated with total cholesterol levels, hypertension, and a history of coronary heart disease, and was inversely related to age, high-density lipoprotein cholesterol levels, and difficulties with activities of daily living. Other characteristics that form the basis of the 1993 National Cholesterol Education Panel guidelines-diabetes, smoking, family history of premature coronary heart disease, and total number of risk factors-were not associated with the initiation of cholesterol-lowering drug therapy.

CONCLUSIONS

Given the clinical trial evidence for benefit, those aged 65 to 75 years and with prior coronary heart disease appeared undertreated with cholesterol-lowering drug therapy.

Factors affecting high-density lipoproteins

Although it is well established that a low-circulating level of high-density lipoprotein (HDL) cholesterol is strongly associated with the likelihood of developing atherosclerotic coronary heart disease (CHD), the causal nature of this association has not been shown. Low levels of HDL cholesterol frequently are associated with other CHD risk factors, whose correction, often by hygienic means, may reduce CHD risk with minimal risk of adverse side-effects. However, other recommended hygienic interventions may lower HDL cholesterol levels. Specific safe and effective drugs for correcting a low HDL cholesterol level are not available and the potential value of specific pharmacologic treatment of this condition in the treatment or prevention of CHD remains unproven. Thus, while HDL measurement should be incorporated routinely in risk-assessment, intervention efforts should focus primarily on lowering low-density lipoprotein cholesterol.

Neuropeptide modulation of Th1 and Th2 cytokines in peripheral blood mononuclear leucocytes in atopic dermatitis and non-atopic controls

The neuropeptides substance P (SP) and vasoactive intestinal peptide (VIP) are present in the nerve endings in the skin and SP is thought to be present at abnormal concentrations in atopic dermatitis (AD) patients. Th1 and Th2 imbalance in AD has been the focus of recent immunological investigations and a preferential Th2 response by atopic cells on stimulation has been proposed. We wished to establish whether neuropeptides acted on T cells to affect their cytokine profile directly, using an accessory cell-independent stimulus (anti-CD3 monoclonal antibody and neuropeptides at several concentrations. We found that interferon (IFN)-gamma and interleukin (IL)-4 release were lower in AD. SP had an enhancing effect on both IFN-gamma and IL-4 at physiological concentrations (10(-10)-10(-6) mol/L) in AD, which was significantly different from controls (P < 0.05). VIP had inhibitory effects over this range in AD and in controls. We conclude that these neuropeptides have a modest effect on T-cell cytokine release and that their action is not cytokine-specific.

ApoE genotype does not predict lipid response to changes in dietary saturated fatty acids in a heterogeneous normolipidemic population. The DELTA Research Group. Dietary Effects on Lipoproteins and Thrombogenic Activity

Recent studies have suggested that variations in apoE genotypes may influence the magnitude of plasma lipid changes in response to dietary interventions. We examined the ability of apoE genotype to predict plasma lipid response to reductions in percent of calories from total fat (TF) and saturated fat (SF) in a normolipidemic study population (n = 103) heterogeneous with respect to age, gender, race, and menopausal status. Three diets, an average American diet (34.3% TF, 15.0% SF), an AHA Step 1 diet (28.6% TF, 9.0% SF), and a low saturated fat (Low-Sat) diet (25.3% TF, 6.1% SF) were each fed for a period of 8 weeks in a three-way crossover design. Cholesterol was kept constant at 275 mg/d; monounsaturated and polyunsaturated fat were kept constant at approximately 13% and 6.5% of calories, respectively. Fasting lipid levels were measured during each of the final 4 weeks of each diet period. Participants were grouped by apoE genotype: E2 (E2/2, E2/3, E2/4); E3 (E3/3); E4 (E3/4, E4/4). Relative to the average American diet, both the Step 1 and Low-Sat diets significantly reduced total cholesterol, LDL cholesterol, and HDL cholesterol in all three apoE genotype groups. No evidence of a significant diet by genotype interaction, however, could be identified for any of the measured lipid and lipoprotein end points. Additional analysis of the data within individual population subgroup (men and women, blacks and whites) likewise provided no evidence of a significant diet by genotype interaction. Thus, in a heterogeneous, normolipidemic study population, apoE genotype does not predict the magnitude of lipid response to reductions in dietary saturated fat.

Substance P binding to peripheral blood mononuclear leukocytes in atopic dermatitis

Substance P has various immunomodulatory effects, including in vitro modification of lymphocyte proliferation and cytokine release. Elevated levels of substance P and increased staining of substance P-positive nerve fibres have been reported in atopic dermatitis patients. We examined fluoresceinated substance P binding to a range of lymphocyte subsets and compared the results in atopic dermatitis, non-atopic psoriasis patients and normal controls. Fluoresceinated substance P and phycoerythrin-labelled monoclonal antibodies to CD3, CD4, CD8, CD57, CD19 and CD14 were incubated in duplicate with Ficoll-Hypaque separated peripheral blood mononuclear leukocytes. With flow cytometry the fluoresceinated substance P-positive cells were identifiable as a peak of positively fluorescent cells, and the percentages of positive cells were measured. We have demonstrated binding of fluoresceinated substance P to all subsets examined, with significantly less binding to atopic dermatitis CD3-, CD8- and CD57-positive cells. This may affect cytokine release and hence be important in the pathogenesis of atopic dermatitis.

Effect of pharmacologic lipid lowering on health-related quality of life in older persons: results from the Cholesterol Reduction in Seniors Program (CRISP) Pilot Study

OBJECTIVE

To determine the effect of lovastatin therapy on health-related quality of life in older persons.

DESIGN

A prospective, randomized, double blind clinical trial.

SETTING

Four university medical center research clinics.

PARTICIPANTS

There were 431 men and women, primarily 65 years of age or older, with low density lipoprotein levels greater than 159 mg/dL and less than 221 mg/dL. Exclusion criteria included a Mini-Mental state score less than 24 or presence of recent cardiovascular events or other serious chronic disease likely to shorten survival.

INTERVENTION

All participants were administered the National Cholesterol Education Program step one diet and were then randomized to placebo, 20 mg lovastatin, or 40 mg lovastatin.

MEASUREMENTS

Areas of health-related quality of life assessed in the Cholesterol Reduction in Seniors Program (CRISP) included: (1) physical functioning, (2) sleep behavior, (3) social support, (4) depression, (5) cognitive function, and (6) health perception. Three global change questions asked the patients to judge change in general health since starting the study diet or the study medication and change in ability to function or care for self. Although some patients were followed for a total of 12 months, all participants were followed for 6 months, and 6-month data have been used for the primary analysis in this paper.

RESULTS

Patients treated with 20 mg of lovastatin had a 17% and 24% reduction in total cholesterol and LDL-cholesterol, respectively. Patients treated with the 40-mg lovastatin dose achieved reductions of 20% for total cholesterol and 28% for LDL-cholesterol. Complaints of possible adverse events were remarkably similar in the two active treatment groups and the placebo group. At 6 months of follow-up there were no statistically significant differences found in mean change scores from baseline between treatment groups on the health-related quality of life measures (physical functioning, sleep, social support, depression, cognitive function scales, health perception) or global questions.

CONCLUSIONS

This study demonstrates that lovastatin was extremely well tolerated in an older cohort, both with regard to symptoms and to health-related quality of life.

Recurrence of thin melanoma: how effective is follow-up?

In order to assess the benefit to patients with thin malignant melanoma (< 0.76 mm) of a 5-year clinical follow-up programme, we have studied 602 patients with a minimum time from primary surgery of 5 years. Tumour recurrence occurred in 24 patients (4% of all patients) but only five surgically treatable recurrences (< 1% of all patients) occurred within the 5-year period following primary surgery. After 5 years there were four surgically treatable recurrences, but their prognosis was generally poor. The remaining cases of tumour recurrence were not surgically treatable. In the face of an increasing incidence of melanoma, and the accompanying increase in demand for surgical treatment and outpatient review, we question the need for prolonged hospital follow-up of thin melanoma.

Rationale and design for the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT Research Group

Are newer types of antihypertensive agents, which are currently more costly to purchase on average, as good or better than diuretics in reducing coronary heart disease incidence and progression? Will lowering LDL cholesterol in moderately hypercholesterolemic older individuals reduce the incidence of cardiovascular disease and total mortality? These important medical practice and public health questions are to be addressed by the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind trial in 40,000 high-risk hypertensive patients. ALLHAT is designed to determine whether the combined incidence of fatal coronary heart disease (CHD) and nonfatal myocardial infarction differs between persons randomized to diuretic (chlorthalidone) treatment and each of three alternative treatments--a calcium antagonist (amlodipine), an angiotensin converting enzyme inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin). ALLHAT also contains a randomized, open-label, lipid-lowering trial designed to determine whether lowering LDL cholesterol in 20,000 moderately hypercholesterolemic patients (a subset of the 40,000) with a 3-hydroxymethylglutaryl coenzyme A (HMG CoA) reductase inhibitor, pravastatin, will reduce all-cause mortality compared to a control group receiving "usual care." ALLHAT's main eligibility criteria are: 1) age 55 or older; 2) systolic or diastolic hypertension; and 3) one or more additional risk factors for heart attack (eg, evidence of atherosclerotic disease or type II diabetes). For the lipid-lowering trial, participants must have an LDL cholesterol of 120 to 189 mg/dL (100 to 129 mg/dL for those with known CHD) and a triglyceride level below 350 mg/dL. The mean duration of treatment and follow-up is planned to be 6 years. Further features of the rationale, design, objectives, treatment program, and study organization of ALLHAT are described in this article.

Infantile haemangiopericytoma of the hand

Infantile haemangiopericytomas (IHP) are rare subcutaneous tumours arising from pericytes. Clinically they are difficult to diagnose and pathologically they appear to be locally invasive, but they have a better prognosis than adult haemangiopericytomas. We report a case of IHP affecting the hand of a 7-week-old child that required urgent treatment.

An empirical evaluation of the placebo run-in

A prerandomization placebo run-in period is often used in an attempt to exclude potential clinical trial participants who are likely to be poor adheres. It is assumed that potential participants who are poor adherers during the run-in will be less likely to take medication during the trial. This assumption was tested in the Cholesterol Reduction in Seniors Program (CRISP), by prescribing placebo for a 3-week period, but not using the results of the run-in as an entry criterion. The CRISP study was a pilot study designed to compare the effects on lipids and the safety of two doses of lovastatin and placebo in persons 65 years of age and older. After general entry criteria were satisfied, each participant was prescribed placebo for a 3-week period. At the end of the 3-week period, all participants were randomized to one of the three treatment groups, regardless of their adherence to the placebo. Of the 431 participants in the study, 66 (15%) who took less than 80% of the prescribed placebo or who failed to return their unused placebo pills were classified as poor run-in adherers. Poor run-in adherence was associated with lower educational attainment. At 3 and 6 months of follow-up mean adherence was 89.3% and 83.4% among all participants. Exclusion of poor run-in adherers would have increased these means to 90.9% and 85.5%, respectively. Treatment effect as measured by fall in LDL cholesterol would have increased by 2.9 mg/dl in the 40 mg/day dose group at 3 months of follow-up with the addition of a placebo run-in. We conclude that a placebo run-in would have had little effect on the outcome of the CRISP study and would have substantially increased recruitment difficulties. Lower educated persons were more likely to be excluded by a placebo run-in, but the effect of the run-in on follow-up adherence was stronger in less educated participants. More research about the role of a placebo run-in is needed in order to determine the appropriate role of this method in clinical trials.

The sliding fasciocutaneous flap

A sliding fasciocutaneous flap on the medial side of the lower third of the leg is described. Its application in the management of skin defects in this area is illustrated.

Cholesterol lowering in the elderly. Results of the Cholesterol Reduction in Seniors Program (CRISP) pilot study

BACKGROUND

Total and lipoprotein cholesterol levels continue to be predictors of coronary heart disease risk in men and women over 65 years old. Cholesterol-lowering trials, however, while sometimes including such subjects, have not concentrated on this age group. The Cholesterol Reduction in Seniors Program was a five-center pilot study to assess feasibility of recruitment and efficacy of cholesterol lowering in this age group.

METHODS

The study was a randomized, double-masked clinical trial with placebo, 20-mg lovastatin, and 40-mg lovastatin arms. Major efforts were made to recruit women and minorities. Participants were followed up for 1 year on a cholesterol-lowering diet plus placebo or study drug. End points were changes in blood lipid levels. Data on other blood chemistry values, as well as quality-of-life measures and coronary heart disease morbidity and mortality, were also collected.

RESULTS

Four hundred thirty-one subjects with low-density lipoprotein cholesterol levels greater than 4.1 and less than 5.7 mmol/L (159 and 221 mg/dL) were randomized, of whom 71% were women and 21% were African Americans; the mean age was 71 years. In the 20- and 40-mg lovastatin groups, total cholesterol levels fell 17% and 20%; low-density lipoprotein cholesterol levels fell 24% and 28%; triglyceride levels fell 4.4% and 9.9%, respectively. High-density lipoprotein cholesterol levels rose 7.0% and 9.0%, respectively. No changes were observed in the placebo group. Gender, race, and age did not significantly affect responses. Coronary heart disease morbidity and mortality data were collected but not analyzed for this study.

CONCLUSION

Older subjects of both genders and a variety of racial and ethnic groups can be successfully recruited into a cholesterol-lowering trial. Lovastatin has effects similar to those reported in younger subjects in previous controlled trials. There is little advantage to the higher lovastatin daily dose. Side effects were remarkably low in all groups.

Prevalence of high blood cholesterol among US adults. An update based on guidelines from the second report of the National Cholesterol Education Program Adult Treatment Panel

OBJECTIVE

To estimate the current levels and trends in the proportion of US adults with high blood cholesterol based on guidelines from the second report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP II).

DESIGN

Nationally representative cross-sectional surveys.

SETTING/PARTICIPANTS

Data for 7775 participants 20 years of age and older from phase 1 of the third National Health and Nutrition Examination Survey (NHANES III) (data collected from 1988 through 1991) and for 9797 participants 20 through 74 years of age from NHANES II (data collected from 1976 through 1980) were used.

RESULTS

From the data collection period in NHANES II (1976 through 1980) to the period in NHANES III (1988 through 1991), the proportion of adults with high blood cholesterol levels (> or = 240 mg/dL [6.21 mmol bd) fell from 26% to 20%, while the proportion with desirable levels (< 200 mg/dL [5.17 mmol/L]) rose from 44% to 49%. Currently, using the ATP II guidelines and NHANES III data, 40% of all adults 20 years of age and older would require fasting lipoprotein analysis; and 29% of all adults would be candidates for dietary therapy (as compared with 36%, using NHANES II data). Based on 1990 population data, it is estimated that approximately 52 million Americans 20 years of age and older would be candidates for dietary therapy. Assuming that dietary intervention would reduce low-density lipoprotein (LDL) cholesterol levels by 10%, as many as 7% of all adult Americans (approximately 12.7 million) might be candidates for cholesterol-lowering drugs. This estimate reflects approximately 4 million adults with established coronary heart disease, of whom half are aged 65 years and older, and up to 8.7 million adults without established coronary heart disease, of whom up to 3.1 million are aged 65 years and older.

CONCLUSIONS

Substantial progress has been made in reducing the prevalence of high blood cholesterol; yet a large proportion of all adults, approximately 29%, require dietary intervention for high blood cholesterol.

Declining serum total cholesterol levels among US adults. The National Health and Nutrition Examination Surveys

OBJECTIVE

To examine the secular trend in serum total cholesterol levels of the US adult population.

DESIGN

Nationally representative cross-sectional surveys with both an in person interview and a medical examination that included the measurement of blood lipid levels.

SETTING/PARTICIPANTS

Between 6000 and 13,000 adults aged 20 through 74 years examined in each of four separate national surveys during 1960 through 1962, 1971 through 1974, 1976 through 1980, and 1988 through 1991.

RESULTS

Mean serum total cholesterol levels in US adults aged 20 through 74 years have consistently declined over the time period 1960 through 1991. More than half of the decline occurred during the time period 1976 through 1991. This decline occurred across the entire distribution of serum cholesterol levels and in all age-sex groups. High-density lipoprotein cholesterol and very low-density lipoprotein cholesterol levels have not changed, suggesting that the decline in total cholesterol levels is due to a decline in low-density lipoprotein cholesterol levels.

CONCLUSIONS

These results document a continuing and substantial decline in serum cholesterol levels among US adults. They suggest that public health programs, designed to reduce cholesterol levels, are proving successful. The observed downward trend in serum cholesterol levels has coincided with a continuing decline in coronary heart disease mortality. These observations suggest that the Healthy People 2000 goal of reducing the mean serum cholesterol level of US adults to no more than 200 mg/dL (5.17 mmol/L) is attainable.

Investigation of possible adverse allergic reactions to mycoprotein ('Quorn')

Mycoprotein ('Quorn') is a food produced for human consumption from Fusarium graminearum. Crossreactivity studies showed that mycoprotein shared multiple common allergenic determinants with Aspergillus fumigatus and Cladosporium herbarum and some with Alternaria alternata. There is, therefore, a potential for mould allergic patients to react adversely to inhaled or ingested mycoprotein. Mycoprotein RAST screening of mycoprotein production workers was made during a 2 year period. Two of the production workers had specific RAST binding > or = 2% but none reported symptoms. Two of 10 patients referred to hospital following vomiting and diarrhoea after ingestion of mycoprotein had a mycoprotein skin-prick test weal > or = 2 mm but none had a significantly raised RAST. These largely negative results are important and reassuring because consumption of the product in the U.K. is now widespread and increasing.

Rationale and design of the Department of Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial (HIT) for secondary prevention of coronary artery disease in men with low high-density lipoprotein cholesterol and desirable low-density lipoprotein cholesterol

Although a large body of epidemiologic evidence suggests that low levels of high-density lipoprotein (HDL) cholesterol are strongly associated with an increased risk of coronary artery disease (CAD), no large-scale clinical trials focusing on this association have been reported. This report describes the rationale and design of the Department of Veterans Affairs HDL Intervention Trial (HIT), a multicenter, randomized, controlled clinical trial designed to determine whether lipid therapy reduces the combined incidence of CAD death and nonfatal myocardial infarction in men with established CAD who have low levels of HDL cholesterol with "desirable" levels of low-density lipoprotein (LDL) cholesterol. Twenty-five hundred men with CAD and HDL cholesterol < or = 40 mg/dl, LDL cholesterol < or = 140 mg/dl, and triglycerides < or = 300 mg/dl are being recruited at 20 Department of Veterans Affairs medical centers, randomized to either gemfibrozil or placebo, and followed in a double-blind manner for an average of 6 years. In this population, gemfibrozil is expected to increase HDL cholesterol by 10 to 15%, have a negligible effect on LDL cholesterol, and lower triglycerides by 30 to 40%. Because an estimated 20 to 30% of patients with CAD have a low HDL cholesterol as their primary lipid abnormality, the results of this trial are expected to have far-reaching clinical implications.

A correlation between DNA-nuclear matrix binding and relative radiosensitivity in two human squamous cell carcinoma cell lines

Three aspects of DNA topology were examined in two human squamous cell carcinoma lines of differing radiosensitivity (SQ-9G, D0 = 1.46 Gy; and SQ-20B, D0 = 2.36 Gy). High-salt-extracted nuclei (nucleoids) were taken from gamma-irradiated cells, stained with ethidium bromide and examined by flow cytometry. After 5 Gy, nucleoids from SQ-9G cells became 30% less efficient at adopting positive DNA supercoils than were unirradiated controls. In contrast, only a 4% difference was found with the radioresistant SQ-20B line. Both lines produced positive supercoils more efficiently after irradiation if first exposed to the topoisomerase II inhibitor VP16. Ethidium bromide titration of nucleoids was consistent with each containing similar numbers and sizes of DNA loops. In each line approximately 30-35% of DNA was accessible to trioxsalen, as shown by inter-strand crosslinking after UV photo-activation. Exhaustive digestion of nuclear DNA by DNase I removed more DNA from the radiosensitive than from the radioresistant cell line (12% vs 28% remaining). This difference was thought to be due to the increased accessibility of SQ-9G DNA in vitro. We suggest that a looser association of SQ-9G DNA with the nuclear matrix both promotes DNase I digestion and affects the ability of SQ-9G nucleoids to maintain positive DNA supercoils after irradiation. These data implicate the DNA matrix attachment region in the expression of radiation sensitivity in the cell lines studied.

Hydrogen peroxide lethality is associated with a decreased ability to maintain positive DNA supercoiling

Hydrogen peroxide is more toxic to mammalian cells at 37 degrees C than 0 degree C at all concentrations studied. Histone-free nuclei (nucleoids) extracted from treated cells have a reduced ability to maintain positive DNA supercoiling, with the maximum effect at the higher temperature. Prior exposure of cells to sodium ascorbate at 0 degree C increased both toxicity and the inhibition of nuclear supercoil rewinding. After exposure at 0 degrees C, normal levels of supercoiling returned with both a fast and a slow component, kinetics characteristic of DNA single-strand break repair; the fast component was eliminated when cells were exposed at 37 degrees C due to in situ rejoining. At least a portion of the lethal lesions induced by hydrogen peroxide are DNA double-strand breaks (dsb) because the dsb repair-deficient mutant, xrs-5, is approximately two to three times more sensitive than wild-type cells over the initial portion of the survival curve. However, the increased toxicity found after exposure at 37 degrees C is observed equally in both cell lines, indicating that temperature-dependent cell killing is not directly linked to DNA dsb. It is suggested that cell killing at 37 degrees C is mediated through two linked processes. First, hydrogen peroxide may disrupt cation-stabilized nuclear supercoiling by direct ion oxidation. Second, as a part of the oxidation process, hydrogen peroxide will produce potentially cytotoxic free radicals close to the DNA-linked metal site, limited in extent only by the presence of chemicals capable of reducing metal ions prior to reoxidation.

Cost and health implications of cholesterol lowering

BACKGROUND

A broad, scientific consensus supports the role of cholesterol as a risk factor for coronary heart disease and agrees that lowering cholesterol levels will reduce coronary heart disease incidence. Cost-effectiveness analysis is a potentially powerful method for measuring the benefits to be achieved by expenditures of health care dollars.

METHODS AND RESULTS

The literature related to the effectiveness and cost-effectiveness of cholesterol lowering was reviewed. Application of cost-effectiveness methodology to the question of cholesterol reduction generally supports the use of population-wide educational programs and the aggressive use of cholesterol-lowering therapy for the secondary prevention of subsequent coronary events in persons with preexisting coronary heart disease. For primary prevention, however, therapy with medication has a favorable cost-effectiveness ratio only in identifiable high-risk persons, and the different costs of the various available medications should be taken into account. Therapy with medications, especially for primary prevention, would be more appealing if the price of the available medications were lower.

CONCLUSIONS

High priority should be given to research that could validate these cost-effectiveness projections as well as to further studies of the elderly and women, in whom direct data on the precise costs, risks, and benefits of interventions to lower cholesterol remain sparse.

The addition of muscle to the lateral arm and radial forearm flaps for wound coverage

There is good evidence of the benefit of transferring vascularized muscle into wounds that are contaminated or have been infected previously. This benefit particularly applies in cavities around bones and joints. We present two patients in whom the inclusion of a portion of muscle in the lateral arm and radial forearm flaps allowed the effective combination of good-quality skin cover with the properties of vascularized muscle.

Comparison of allergic responses to dust mites in U.K. bakery workers and Swedish farmers

The IgE RAST response to Dermatophagoides pteronyssinus and four storage mites (Lepidoglyphus destructor, Tyrophagus putrescentiae, Glycyphaghus domesticus, and Acarus siro) was examined in 251 U.K. bakery workers and compared with that previously found in 440 Swedish farmers. Storage mites are found commonly in stored hay and grain so both these groups potentially encounter them in their work. In neither group of workers was a positive RAST (greater than or equal to 0.35 PRU) to D. pteronyssinus correlated with a positive RAST to a single storage mite. As in the Swedish farmers, significant though not strong correlations were found in the U.K. bakers between positive RAST responses to G. domesticus and L. destructor and to T. putrescentiae and L. destructor (P less than 0.05). Homologous and heterologous RAST inhibition studies showed there was low cross-reactivity between storage mites and D. pteronyssinus. L. destructor showed the least inhibition by the other antigens, suggesting it possessed the fewest common allergens. The most important difference in the IgE responses between the two groups was the much higher response to D. pteronyssinus in the U.K. bakers, which was not found in the Swedish farmers whose highest IgE response was to L. destructor.

Neutron and cobalt-60 gamma irradiation produce similar changes in DNA supercoiling

The effects of 60Co gamma-ray and d(20 MeV)Be neutron irradiation on DNA supercoiling have been studied using a nucleoid rewinding technique. Irradiation of viable CHO AA8 cells on ice with from 4 to 25 Gy of either radiation produced a similar resistance to rewinding of nuclear supercoils after treatment with ethidium bromide. The restitution from the effects of 12 Gy of either radiation was also similar, leaving no detectable residual damage. The discrepancy between these data and the reduced ability of neutrons to produce DNA breaks, as defined by the alkaline elution assay, is explained by the discontinuous deposition of dose associated with neutron irradiation. It is suggested from a microdosimetric analysis that the neutron radiation interacts with DNA at sites on average 5-10 times further apart than the interactions with gamma rays. The long DNA sequences which results after neutron irradiation are consequently eluted inefficiently during alkaline elution, giving a reported RBE of approximately 0.3. Restrictions in the rewinding of individual supercoils are not dependent on the interionization distance and thus give rise to an RBE of approximately 1. Furthermore, the complete removal of DNA damage, as measured by this technique, supports the hypothesis that neutron toxicity is associated with incorrect, not incomplete, rejoining of the DNA molecule.