[Effects of bariatric surgery on sex hormones in male patients with obesity]

Objective: To analyze and evaluate the differences in sex hormones after laparoscopic Roux-en-Y Gastric Bypass Surgery (LRYGB) and laparoscopic sleeve gastrectomy (LSG) in male patients with obesity. Methods: This study was a retrospective cohort study. The inclusion criteria were (1) male patients with obesity who met the surgical indications of the "Chinese Guidelines for Surgical Treatment of Obesity and Type 2 Diabetes" (2019 Edition); (2) patients with a body mass index (BMI) of ≥27.5 kg/m2 and obesity-related metabolic diseases, or patients with severe obesity and a BMI of ≥35 kg/m2; and (3) sex hormone levels checked 1 year after surgery. The exclusion criteria included (1) patients with endocrine diseases (thyrotoxicosis, hyperprolactinemia) and hypothalamic-pituitary lesions and (2) those with severe major organ dysfunction who could not tolerate anesthesia or surgery. According to the above criteria, the clinical data of male patients with obesity admitted to the Gastrointestinal Surgery/Bariatric Center of the First Affiliated Hospital of Jinan University from October 2017 to January 2020 were included. A total of 52 male patients with obesity were included in this study. The mean age, body weight, BMI, and total testosterone level were (29.3±10.2) years, (123.6±35.4) kg, (40.1±11.1) kg/m², and 7.6 (5.5, 9.1) nmol/L, respectively. Forty-five patients (86.5%) exhibited testosterone deficiency. Among all the patients, 29 underwent LSG (LSG group) and 23 underwent LRYGB surgery (LRYGB group). The main outcome measure was the change in sex hormone levels before and after bariatric surgery in all the patients. The secondary outcome measures were the comparison of changes in sex hormone levels before and after LSG and LRYGB. Results: Pearson correlation analysis showed that preoperative estradiol was positively correlated with waist circumference (R=0.299, P<0.05), hip circumference (R=0.326, P<0.05), and chest circumference (R=0.388, P<0.05). Testosterone was negatively correlated with BMI (R=-0.563, P<0.01), waist circumference (R=-0.521, P<0.01), hip circumference (R=-0.456, P<0.01), chest circumference (R=-0.600, P<0.01), and neck circumference (R=-0.547, P<0.01). One year following bariatric surgery, the serum testosterone (7.6 [5.5, 9.1] nmol/L vs. 13.6 [10.5, 15.4] nmol/L, Z=-5.910, P<0.001), follicle-stimulating hormone (4.7 [2.7, 5.3] IU/L vs. 6.5 [3.6, 7.8] IU/L, Z=-4.658, P<0.001), and progesterone (1.2 [0.4, 1.5] nmol/L vs. 1.9 [0.8, 1.3] nmol/L, Z=-2.542, P=0.011) levels were significantly higher in all the patients. Both estradiol (172.8 [115.6, 217.5] pmol/L vs. 138.3 [88.4, 168.1] pmol/L, Z=-2.828, P=0.005) and prolactin (11.4 [6.4, 14.6] mIU/L vs. 8.6 [4.8, 7.3] mIU/L, Z=-2.887, P=0.004) levels were decreased. In addition to prolactin levels in the LRYGB group, there were statistically significant differences in the levels of estradiol (P=0.030), follicle-stimulating hormone (P < 0.001), luteinizing hormone (P=0.033), progesterone (P=0.034), and testosterone (P<0.001) compared with their preoperative levels. In the LSG group, there were statistically significant differences in the levels of follicle-stimulating hormone (P=0.011), prolactin (P=0.023), and testosterone (P<0.001) compared with their preoperative levels. Conclusion: The degree of obesity in men was negatively correlated with testosterone levels. Both LRYGB and LSG can significantly improve sex hormone levels in male patients with obesity, and testosterone levels show a significant increase after surgery.

[Establishment and application of a clustered management plan for pulmonary care of massive burn casualties]

Objective: To establish a clustered management plan for pulmonary care of massive burn casualties (hereinafter referred to as the clustered management plan for pulmonary care), and to explore its application effects. Methods: (1) A clustered care intervention group was established, including the medical and nursing staff from the Department of Burns and Plastic Surgery, Department of Respiratory Medicine, and Department of Infection Control at the Fourth Medical Center of PLA General Hospital (hereinafter referred to as our hospital). Four major links, including pulmonary care assessment, chest and lung physical therapy, artificial airway management, and specialized infection control were sorted out according to the key points and difficulties in pulmonary care for massive burn casualties. Evidence-based nursing methods were employed to retrieve articles related to the above-mentioned four links from PubMed, Chinese Journal Full-Text Database, VIP Database and Wanfang Data using terms of " mass burn, respiratory management and airway management" and terms of ",," , and the clustered management plan for pulmonary care was established based on reading and discussion in combination with clinical practice and experience. (2) In this non-randomized controlled study, the clustered management plan for pulmonary care was applied to 73 massive burn patients (48 males and 25 females, aged 32 (25, 38) years) who were admitted to our hospital from January 2016 to December 2019 and met the inclusion criteria, and they were included into the clustered care group; 43 massive burn patients (25 males and 18 females, aged 35 (17, 45) years) who were admitted to our hospital from January 2013 to December 2015, received routine care and met the inclusion criteria were retrospectively included into routine care group. The pulmonary infection rate and mortality of patients in the two groups were recorded during the hospital stay. Data were statistically analyzed with chi-square test, Mann-Whitney U test, and independent sample t test. Results: (1) The clustered management plan for pulmonary care included a total of 12 specific measures covering four aspects of pulmonary care. The contents in pulmonary care assessment clearly stated to include the previous medical history, history of injury, respiratory status, hoarseness, pulmonary auscultation, etc. Chest and lung physical therapy included how to guide patients to effectively cough and do pursed lip breathing and abdominal breathing exercise, etc. Artificial airway management specified the preparation for the establishment of artificial airway at clinical reception, the observation index and frequency after tracheotomy, the method of humidification, the method and frequency of sputum suction, and the management of mechanical ventilation, etc. Specialized infection control required to strengthen hand hygiene and ventilator management. (2) The pulmonary infection rate and mortality of patients in the clustered care group were 2.74% (2/73) and 4.11% (3/73), respectively, significantly lower than 25.58% (11/43) and 18.60% (8/43) in routine care group (χ(2)=11.986, 5.043, P<0.05 or P<0.01). Conclusions: The clustered management plan for pulmonary care developed for massive burn casualties focuses on the major links and key points. The measures are systemic and comprehensive, simple but precise, and highly operable, covering the entire process of massive burn care, hereby reducing the pulmonary infection rate significantly and improving the success rate of treatment.

[Detection and clinical significance of circulating tumor cells in osteosarcoma using immunofluorescence combined with in situ hybridization]

Objective: To investigate the clinical significance of detection of circulating tumor cells (CTCs) in peripheral blood from patients with osteosarcoma (OS) using the iFISH (immunofluorescence and fluorescence in situ hybridization) method. Methods: The live cells recovery rate of immune-magnetic beads was evaluated by live-cell fluorescent tracer technology. The expression of CD45 and CK18 on the cell surface of HOS and HepG2 cells was measured by flow cytometry. And the chromosome aneuploidy was detected by centromeric FISH probe CEP8. Subsequently, 23 OS patients were enrolled and divided into two groups, relapse or metastasis group and primary group. And the prognostic significance of CTCs numbers was analyzed. Results: The live cells recovery rate of immune-magnetic beads was higher than 90%. The flow cytometry results showed that HOS cells were double negative for the surface biomarkers of CD45 and CK18. In addition, the FISH-CEP8 signal abnormality rate were 96.5% in HOS cells. Thus, CTC was identified using the criteria as follows: the cells with CEP8-positive signal >2 accounted for more than 96.5% of the total cells, of which the cells with >3 positive signal were more than 65.0%. Among the enrolled patients, 19 patients had detectable CTCs in the peripheral blood. The CTCs numbers in the relapse or metastasis group and primary group were 2.846±1.281 and 1.400±1.506, respectively. The results showed that the CTCs in patients with recurrence or metastasis were significantly higher than those in primary patients (P=0.021). Conclusions: To our knowledge, this is the first evidence of existence of CTCs in OS patients. The CTCs numbers were positively associated with disease progression and poor prognosis. These results may provide a potential prognostic tool for monitoring metastasis and recurrence in OS patients. Trial registration: Chinese Clinical Trial Registry, ChiCTR-OOC-15005925.

Preliminary Application of Precision Genomic Medicine Detecting Gene Variation in Patients with Multifocal Osteosarcoma

OBJECTIVES

The purpose of this study was to present our clinical experience of treating multifocal osteosarcoma (MFOS) in our center and gain more insight into the biology of this rare condition; in particular, to address with the help of precision genomic medicine the issue of whether the multiple osteosarcoma (OS) lesions in such patients are multi-centric or originate from one primary lesion and metastasize to other sites. Finally, we aimed to identify particular gene phenotypes and mutations that differentiate MFOS from OS with only one tumor.

METHODS

Clinical data of patients with MFOS treated at our center between June 2007 and October 2014 were collected and analyzed retrospectively. High throughput sequencing of the whole exome of normal tissue and multiple lesions had been performed on samples from two patients (HJF and JZ) diagnosed in 2014. To explore the particular gene phenotype and clinical significance of MFOS, these sequencing results were analyzed and compared with those from patients with osteosarcoma in a single site. Seven patients with MFOS (three male and four female; average age 19.71 ± 3.35 years were enrolled in this study. Two of these patients declined treatment and died after 4 and 6 months, respectively. The remaining patients received standard treatment comprising neoadjuvant chemotherapy, surgery and chemotherapy. The chemotherapy regimen was lobaplatin (45 mg/m(2) ), doxorubicin (60 mg/m(2) ) and ifosfamide (12 g/m(2) ). Patients were followed up every 3 months after completing treatment and evaluated by the Enneking and Response Evaluation Criteria in Solid Tumors scoring systems.

RESULTS

Up to the last follow-up on 1 December 2015, three patients were still alive. The event-free survival ranged from 4 to 144 weeks (median, 50.14 weeks), the mean (±SD) being 55.45 ± 45.47 weeks. Overall survival ranged from 16 to 388 weeks (median, 89 weeks; mean ± SD, 118.7 ± 147.7 weeks). The rates of mutation of the targeted drug-related genes were 133.5% ± 3.0% in the proximal tibia lesion and 113.1% ± 1.9% in the distal femur of patient HJF (P < 0.01) and 136.1% ± 10.8% in the proximal tibial lesion and 122.3% ± 5.5% in the proximal humerus of patient JZ (P = 0.0335). Furthermore, there were several anti-oncogenes in the somatic copy number variation lists analyzed from the two patients, especially TP53. However, no kataegis was found.

CONCLUSIONS

Early and radical surgery accompanied by appropriate chemotherapy is the optimal means of treating MFOS. These patients may benefit from precision genomic medicine.

Imaging and Chemotherapeutic Comparisons of Iron Oxide Nanoparticles Chemically and Physically Coated with Poly(ethylene glycol)-b-Poly(ε-caprolactone)-g-Poly(acrylic acid)

We designed a new copolymer, poly(ethylene glycol)-block-poly(ε-caprolactone)-graft-poly(acrylic acid) (PAA-PEC), which could be chemically and physically coated onto iron oxide (Fe3O4) nanoparticles for theranostic applications. The chemically PAA-PEC-coated Fe3O4 nanoparticles (PAA-PEC-IO) were prepared using the carboxylic groups of PAA-PEC to bind the Fe3O4 nanoparticles during a co-precipitation reaction. Because of the amphiphilic properties of PAA-PEC, the compound self-assembled into a core-shell structure. The hydrophobic oleic acid-coated Fe3O4 nanoparticles could then be physically encapsulated inside the hydrophobic core of PAA-PEC (PAA-PEC-OA-IO) using an emulsion technique. A similar amount of iron content was controlled in both the PAA-PEC-IO and PAA-PEC-OA-IO (-23%). The particle diameters, morphologies, superparamagnetism, drug loading efficiency, and transversal relaxivity (r2) were studied and compared between the two magnetic nanoparticles. All results displayed the chemically-synthesized PAA-PEC-IO nanoparticles had higher potential than did the physically-synthesized PAA-PEC-OA-IO as an MRI contrast agent and a drug delivery carrier. Rodamine123-linked PAA-PEC-IO (PAA-PEC-IO-Rh123) was used as a molecular probe. Flow cytometric diagrams indicated that cellular internalization of PAA-PEC-IO occurred primarily through clathrin-mediated endocytosis.

Effects of Forage:Concentrate Ratio on Growth Performance, Ruminal Fermentation and Blood Metabolites in Housing-feeding Yaks

The objective of this study was to determine the effect of forage: concentrate ratio (F:C) on growth performance, ruminal fermentation and blood metabolites of housing-feeding yaks. Thirty-two Maiwa male yaks (initial body weight = 207.99±3.31 kg) were randomly assigned to four dietary treatments (8 yaks per treatment). Experimental diets were: A, B, C, D which contained 70:30, 60:40, 50:50 and 40:60 F:C ratios, respectively. Dry matter intake and average daily gain in yaks fed the C and D diets were greater (p<0.05) than yaks fed the A and B diets. No differences were found in ruminal NH₃-N, total volatile fatty acids, acetate, butyrate, valerate, and isovalerate concentrations. The propionate concentration was increased (p<0.05) in the C and D groups compared with the A and B diets. In contrast, the acetate to propionate ratio was decreased and was lowest (p<0.05) in the C group relative to the A and B diets, but was similar with the D group. For blood metabolites, no differences were found in serum concentrations of urea-N, albumin, triglyceride, cholesterol, low density lipoprotein, alanine aminotransferase, and aspartate aminotransferase (p>0.05) among treatments. Treatment C had a higher concentration of total protein and high density lipoprotein (p<0.05) than A and B groups. In addition, there was a trend that the globulin concentration of A group was lower than other treatments (p = 0.079). Results from this study suggest that increasing the level of concentrate from 30% to 50% exerted a positive effect on growth performance, rumen fermentation and blood metabolites in yaks.

Angiopep-pluronic F127-conjugated superparamagnetic iron oxide nanoparticles as nanotheranostic agents for BBB targeting

Pluronic® F127-modified water-dispersible poly(acrylic acid)-bound iron oxide (PF127-PAAIO) nanoparticles have been prepared as diagnostic agents. A blood-brain-barrier penetrating peptide, angiopep-2 (ANG), was further conjugated onto the surface of the PF127-PAAIO (ANG-PF127-PAAIO) for brain targeting. The ANG-PF127-PAAIO shows negligible cell cytotoxicity, better cellular uptake, and higher T₂-weighted image enhancement than the PF127-PAAIO in U87 cells. Using an ex vivo blood-brain barrier (BBB) model, we showed that the ANG-PF127-PAAIO shows better permeability to bypass the BBB. This is because the ANG-PF127-PAAIO has a dual-targeting ability, recognition of the low-density lipoprotein receptor-related protein and clathrin-mediated receptor on the U87 surface. Thus, the ANG-PF127-PAAIO is a potential nanotheranostic agent for brain dysfunction.

Synthesis and characterization of S-PCL-PDMAEMA for co-delivery of pDNA and DOX

Similar numbers of repeating units of PCL and pDMAEMA were controlled between L-PCL-PDMAEMA and S-PCL-PDMAEMA. DOX-loaded S-PCL-PDMAEMA micelles showed a better cell-killing effect than DOX-loaded L-PCL-PDMAEMA in four cell lines. The co-delivery of DOX and pDNA was confirmed by CLSM.

Design of magnetic nanoparticles-assisted drug delivery system

Magnetic nanoparticles (MNPs) have been designed for multifaceted applications such as contrast agents in magnetic resonance imaging (MRI) diagnosis, drug/gene carriers for different kinds of therapeutic agents, tissue repair, hyperthermia, immunoassay, and cell separation/sensing. This review highlights synthesis methods, stabilizers used for surface coating on MNPs, and target ligands for ferrying payloads to an interested disease area. Some of the recent biomedical applications of MNPs in the field of drug and DNA targeting delivery are extensively reviewed.

Technological devices in peripheral percutaneous interventions

New innovations and novel approaches to peripheral arterial occlusive disease have brought enormous benefits to the vascular patient. Diseases that were once manageable only by surgical intervention are now easily and successfully treated by minimally invasive procedures. While the early days of percutaneous intervention were filled with inventions of new devices, today the focus centers on using modern technology and manufacturing to further improve upon these devices. Advances in guidewires and catheters have allowed us to visualize and treat lesions in nearly any vessel, and technology is guiding us towards specialized applications for specific lesions in specific vessels. However, one of the big hurdles remaining in treating arterial occlusive diseases is the rate of restenosis and the need for reinterventions. The location and architecture of these vessels make them uniquely difficult to treat, and call for new technology to address these challenges. Current developments of drug-eluting and bioabsorbable stents are at the forefront of new advancements specifically directed at improving current patency and restenosis rates; perhaps the next step in percutaneous intervention will rely on nanotechnology and the molecular surface engineering that may achieve a new era of devices that are able to target specific cell ligands or proteins to prevent the inflammatory and proliferative response from vessels. The present review will focus on the current literature regarding technological devices in peripheral percutaneous interventions and clinical applications. Future advancements in materials engineering and biotechnology will continue to improve the current standard of percutaneous intervention for peripheral arterial occlusive diseases.

Irregular osteotomy in limb salvage for juxta-articular osteosarcoma under computer-assisted navigation

BACKGROUND

Joint-preserving limb salvage surgery has been expected to have good functional outcomes. However, it is still a unsolved problem to perform a joint preserving resection for patients with juxta-articular osteosarcoma invading epiphyseal line. We determined whether irregular osteotomy under image-guided navigation make joint-saving resection possible for juxta-articular osteosarcoma while adhering oncological principles.

METHODS

We performed joint-preserving limb salvage surgeries on six patients with juxta-articular osteosarcoma of the long bone. Three lesions located in humerus, two in tibia and one in femur. Two tumors extend to and four beyond the epiphyseal line. CT and MRI data fusion images were applied for intraoperative navigation. Planned irregular osteotomy under image-guided navigation was employed for obtaining clear surgical margin while maximizing host tissue preservation. All tumors were en bloc removed and intercalary defect were reconstructed by allograft in one and combination of allograft with vascularized fibula graft in five patients. All specimens were examined for resection margin. Patients were followed up for average of 17.5 months for evaluating of functional and oncology outcomes.

RESULT

Entire joint were preserved in three patients and part of joint were saved in another three patients. Clear surgical margin was obtained in all specimens with a minimum of 6-mm distance between tumor and osteotomy line. No patient experienced a local recurrence. One patient developed lung metastasis and had no evidence of disease at the most recent follow-up. All allografts but one healed during the study period. The MSTS average score was 88.8% at final follow-up.

CONCLUSIONS

With careful patient selection, the irregular osteotomy under navigation guidance was proved to be an effective and safe technique for precise tumor resection in joint preserving limb salvage procedures for treating patients with juxta-articular osteosarcomas.

Comparative effectiveness of cisplatin-based and carboplatin-based chemotherapy for treatment of advanced urothelial carcinoma

BACKGROUND

Cisplatin-based chemotherapy is a standard treatment of metastatic urothelial carcinoma (UC), though carboplatin-based chemotherapy is frequently substituted due to improved tolerability. Because comparative effectiveness in clinical outcomes of cisplatin- versus carboplatin-based chemotherapy is lacking, a meta-analysis was carried out.

METHODS

PubMed was searched for articles published from 1966 to 2010. Eligible studies included prospective randomized trials evaluating cisplatin- versus carboplatin-based regimens in patients with metastatic UC. Individual patient data were not available and survival data were inconsistently reported. Therefore, the analysis focused on overall response (OR) and complete response (CR) rates. The Mantel-Haenszel method was used for combining trials and calculating pooled risk ratios (RRs).

RESULTS

A total of 286 patients with metastatic UC from four randomized trials were included. Cisplatin-based chemotherapy was associated with a significantly higher likelihood of achieving a CR [RR = 3.54; 95% confidence interval (CI) 1.48-8.49; P = 0.005] and OR (RR = 1.34; 95% CI 1.04-1.71; P = 0.02). Survival end points could not be adequately assessed due to inconsistent reporting among trials.

CONCLUSIONS

Cisplatin-based, as compared with carboplatin-based, chemotherapy significantly increases the likelihood of both OR and CR in patients with metastatic UC. The impact of improved response proportions on survival end points could not be assessed.

The use of allograft shell with intramedullary vascularized fibula graft for intercalary reconstruction after diaphyseal resection for lower extremity bony malignancy

BACKGROUND

Reconstruction after excision of the femur and tibia malignancy is a challenging issue for the reconstructive surgeon. The combined use of a vascularized fibular flap and allograft can provide a reliable reconstructive option. This article describes the authors' experience with this technique for the treatment of large-segmental bone defects after intercalary resection of lower extremity malignancy.

METHODS

From 2003 to 2008, 11 patients that had intercalary resection of lower extremity malignancy underwent reconstruction with an allograft and vascularized fibular construct. Time to union was recorded through evaluation of plain radiographs. Patients were examined clinically and radiographically and were assessed functionally with MSTS score.

RESULT

The average age at time of operation was 18.5 years. The mean follow-up time was 34.1 months. The oncology result was continuous disease free in 7 patients, no evidence of disease in 2, alive with disease in 1, and died of disease in 1. Free vascularized fibula flap was used in 7 patients and ispilateral pedicle vascularized fibula in 4. The average length of the resected segment was 12.1 cm and that of the fibula flap was 16.2 cm. The primary unions were achieved in all patients except one with tibia reconstruction. The average time for bone union was 5.4 months at fibula-host junction and 11.8 months at allograft-host junction. There were no allograft fractures and no infections. Five patients had 7 local complications. The MSTS average score was 91.8% at final follow-up. The mean time of weight-bearing was 12.4 months.

CONCLUSIONS

Intramedullary fibular flap in combination with massive allografts provide an excellent option for reconstruction of large-bony defects after lower extremity malignancy extirpation. The viability of the fibula is a cornerstone in success of reconstruction that prevents allograft nonunion and result in decreased time to bone healing, leading to earlier patient recovery and return of function.

α-Galactosylceramide protects mice from lethal Coxsackievirus B3 infection and subsequent myocarditis

Myocarditis is an inflammation of the myocardium which often follows virus infections. Coxsackievirus B3 (CVB3), as a marker of the enterovirus group, is one of the most important infectious agents of virus-induced myocarditis. Using a CVB3-induced myocarditis model, we show that injection α-galactosylceramide (α-GalCer), a ligand for invariant natural killer (NK) T (iNK T) cells, can protect the mice from viral myocarditis. After the systemic administration of α-GalCer in CVB3 infected mice, viral transcription and titres in mouse heart, sera and spleen were reduced, and the damage to the heart was ameliorated. This is accompanied by a better disease course with an improved weight loss profile. Compared with untreated mice, α-GalCer-treated mice showed high levels of interferon (IFN)-γ and interleukin (IL)-4, and reduced proinflammatory cytokines and chemokines in their cardiac tissue. Anti-viral immune response was up-regulated by α-GalCer. Three days after CVB3 infection, α-GalCer-administered mice had larger spleens. Besides NK T cells, more macrophages and CD8(+) T cells were found in these spleens. Upon stimulation with phorbol myristate acetate plus ionomycin, splenocytes from α-GalCer-treated mice produced significantly more cytokines [including IFN-γ, tumour necrosis factor-α, IL-4 and IL-10] than those from untreated mice. These data suggest that administration of α-GalCer during acute CVB3 infection is able to protect the mice from lethal myocarditis by local changes in inflammatory cytokine patterns and enhancement of anti-viral immune response at the early stage. α-GalCer is a potential candidate for viral myocarditis treatment. Our work supports the use of anti-viral treatment early to reduce the incidence of virus-mediated heart damage.

Limb salvage surgery for calcaneal malignancy

BACKGROUND

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy increasingly possible. However, reconstructions of the calcaneal remain a major surgical challenge because of the rarity and specific anatomy of this condition.

METHODS

we retrospectively reviewed five patients who had primary calcaneal malignancy and underwent total calcanectomy and reconstructions with the distally pedicled osteocutaneous folded fibular flap between 2001 and 2007. The diagnoses included chondrosarcoma in 2, Ewing's sarcoma in 2 and osteosarcoma in 1. Three tumors were classified as stage-II B lesions, one as I A and one as II A. Wide resection margins were achieved in all patients. The patients were followed up for a mean of 50.4 months (range, 32-76 months). Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score.

RESULTS

Four patients had no evidence of disease, and lung metastasis was found in one patient who was alive with disease. No local recurrence occurred in this series. At latest evaluation four patients had no evident limp or limitation of daily activities and one patient had mild limp. The average MSTS 93 score and AOFAS score were 83.2% and 86.4% at the last follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. Fibula hypertrophies were seen in three patients. The overall mean time for bone union was 6.2 months. The mean time to full weight-bearing was 8.6 months. The average two-point discrimination was 2.3 cm at the time of final follow-up. Two patients had surgery-related complications including hematoma in 1 and skin margin necrosis in 1.

CONCLUSIONS

Following the wide resection of calcaneal malignancy, biological reconstruction using distally pedicled osteocutaneous fibular has proven to be a successful limb salvage procedure, offering satisfactory local tumor control and functional restoration of the lower extremity function.

A preliminary study on investigating the attachment of soft tissue onto micro-arc oxidized titanium alloy implants

Intraosseous transcutaneous amputation prostheses (ITAP) rely on the integrity of the soft tissue-implant interface as a barrier to exogenous agents, and in the prevention of avulsion and marsupilization. This experimental work aimed at the in vivo evaluation of soft tissue attachment to Ti alloy (Ti6Al4V) transcutaneous custom-made screws treated by a micro-arc oxidation (MAO) method. Prior to implantation, the surface of the MAO treated implants was analyzed by scanning electron microscopy (SEM), energy dispersive spectroscopy (EDS) and x-ray diffraction (XRD). The experimental model comprised implantation of 16 transcutaneous screws (two groups: MAO and machined (control); total eight implants/group) in the medial aspect of the left tibia of eight female goats. The animals were euthanized at eight weeks and the samples harvested and processed for histological and histomorphometrical analysis of soft tissue attachment to the implant surface. Significant higher soft tissue attachment was observed in the MAO-modified group compared to the control. The in vivo data indicated that MAO-modified Ti alloy could be a useful biomaterial for tissue engineering and benefit applications where bone-anchored transcutaneous implants are used.

Preparation and characterizations of ZnO nanotubes by acidic etching nanowires

Single crystalline ZnO nanowires were synthesized by hydrothermal process and then formed nano-tubes by acidic etching these nanowires in acetic solution at 85 degrees C. The nanotube diameter can be easily controlled by dividing the nanowires growth and etching process. The ZnO nanotubes remain single crystalline hexagonal structure after the etching process. The defects existed in the nanowires and the dangling bonds of the nanowires' surface play the important roles for the etching process. An etching model for forming ZnO nanotubes is proposed, which can be proved by our experimental results.

An immortalized rat ventral mesencephalic cell line, RTC4, is protective in a rodent model of stroke

One therapeutic approach to stroke is the transplantation of cells capable of trophic support, reinnervation, and/or regeneration. Previously, we have described the use of novel truncated isoforms of SV40 large T antigen to generate unique cell lines from several primary rodent tissue types. Here we describe the generation of two cell lines, RTC3 and RTC4, derived from primary mesencephalic tissue using a fragment of mutant T antigen, T155c (cDNA) expressed from the RSV promoter. Both lines expressed the glial markers vimentin and S100beta, but not the neuronal markers NeuN, MAP2, or beta-III-tubulin. A screen for secreted trophic factors revealed substantially elevated levels of platelet-derived growth factor (PDGF) in RTC4, but not RTC3 cells. When transplanted into rat cortex, RTC4 cells survived for at least 22 days and expressed PDGF. Because PDGF has been reported to reduce ischemic injury, we examined the protective functions of RTC4 cells in an animal model of stroke. RTC4 or RTC3 cells, or vehicle, were injected into rat cortex 15-20 min prior to a 60-min middle cerebral artery ligation. Forty-eight hours later, animals were sacrificed and the stroke volume was assessed by triphenyl-tetrazolium chloride (TTC) staining. Compared to vehicle or RTC3 cells, transplanted RTC4 cells significantly reduced stroke volume. Overall, we generated a cell line with glial properties that produces PDGF and reduces ischemic injury in a rat model of stroke.

The effect of extracts from ginger rhizome on inflammatory mediator production

Compounds from rhizomes of Zingiber officinale, commonly called ginger, have been purported to have anti-inflammatory actions. We have used an in vitro test system to test the anti-inflammatory activity of compounds isolated from ginger rhizome. U937 cells were differentiated and exposed to lipopolysaccharide (LPS) from Escherichia coli (1 microg/ml) in the presence or absence of organic extracts or standard compounds found in ginger (6-, 8-, 10-gingerol or 6-shogaol) for 24 h. Supernatants were collected and analyzed for the production of prostaglandin E(2) (PGE(2)) and tumor necrosis factor alpha (TNF-alpha) by standard ELISA assays. Predominant compounds in the organic extracts were identified as 6-, 8- 10-gingerols and 6-, 8-, 10-shogaols. Organic extracts or standards containing gingerols were not cytotoxic, while extracts or standards containing predominantly shogaols were cytotoxic at concentrations above 20 microg/ml. Crude organic extracts of ginger were capable of inhibiting LPS induced PGE(2) (IC(50)<0.1 microg/ml) production. However, extracts were not nearly as effective at inhibiting TNF-alpha (IC(50)>30 microg/ml). Thirty three fractions and subfractions, prepared by column chromatography, were analyzed for bioactivity. Extracts containing either predominantly gingerols or shogaols (identified by HPLC) were both highly active at inhibiting LPS-induced PGE(2) production (IC(50)<0.1 microg/ml), while extracts that contained unknown compounds were less effective (IC(50)<3.2 microg/ml). Extracts or standards containing predominantly gingerols were capable of inhibiting LPS-induced COX-2 expression while shogaol containing extracts had no effect on COX-2 expression. These data demonstrate that compounds found in ginger are capable of inhibiting PGE(2) production and that the compounds may act at several sites.

Histogranin reduced brain injury after transient focal ischemia in rats

Excitatory amino acids (EAAs) play an important role during ischemic brain injury. In this study we examined the protective effect of histogranin (HN), an endogenous peptide that antagonizes excitatory amino acids-mediated activity noncompetitively, in an animal model of cerebral ischemia. Adult rats were anesthetized with chloral hydrate. Histogranin was given intracerebroventricularly before a 60-min middle cerebral artery occlusion (MCAo). Animals were examined for their locomotor activity 2 days after MCAo. Histogranin significantly increased locomotor activity in the stroke rats. Histogranin pretreatment reduced the volume of cerebral infarction and the caspase-3 immunoreactivity in the stroke animals. Taken together, our data suggest that histogranin is protective against ischemic brain injury. The protective effect may involve anti-apoptotic mechanisms.

The effect of turmeric extracts on inflammatory mediator production

Major compounds of several commonly used botanicals, including turmeric, have been purported to have anti-inflammatory actions. In order to test the anti-inflammatory activity of compounds isolated from rhizomes of Curcuma longa L. (Zingiberaceae), we have established an in vitro test system. HL-60 cells were differentiated and exposed to lipopolysaccharide (LPS) from Escherichia coli (1 microg/ml) in the presence or absence of botanical compounds for 24 h. Supernatants were collected and analyzed for the production of tumor necrosis factor alpha (TNF-alpha) and prostaglandin E2 (PGE2) using standard ELISA assays. Water-soluble extracts were not cytotoxic and did not exhibit biological activity. Organic extracts of turmeric were cytotoxic only at concentrations above 50 microg/ml. Crude organic extracts of turmeric were capable of inhibiting LPS-induced TNF-alpha (IC50 value = 15.2 microg/ml) and PGE2 (IC50 value = 0.92 microg/ml) production. Purified curcumin was more active than either demethoxy- or bisdemethoxycurcumin. Fractions and subfractions of turmeric extracts collected via preparative HPLC had differing biological activity, ranging from no activity to IC50 values of < 1 microg/ml. For some fractions, subfractionation resulted in a loss of activity, indicating interaction of the compounds within the fraction to produce an anti-inflammatory effect. A combination of several of the fractions that contain the turmeric oils was more effective than the curcuminoids at inhibiting PGE2. While curcumin inhibited COX-2 expression, turmeric oils had no effect on levels of COX-2 mRNA.

Neurotrophic effects of bone morphogenetic protein-7 in a rat model of Parkinson's disease

Previous studies have demonstrated that pretreatment with bone morphogenetic protein-7 (BMP7) reduces ischemic neuronal injury in vivo. Moreover, exogenous application of BMP7 increases both the number of tyrosine hydroxylase (+) cells and dopamine (DA) uptake in rat mesencephalic cell cultures. The purpose of this study was to investigate the in vivo effects of BMP7 on 6-hydroxydopamine (6-OHDA) induced lesioning of midbrain DA neurons. Adult Fischer 344 rats were anesthetized and injected with BMP7 or vehicle into the left substantia nigra, followed by local administration of 9 microg of 6-OHDA into the left medial forebrain bundle. The lesioned animals that received BMP7 pretreatment, as compared to vehicle/6-OHDA controls, had a significant reduction in methamphetamine-induced rotation 1 month after the surgery. BMP7-pretreatment partially preserved KCl-induced dopamine release in the lesioned striatum and significantly increased TH immunoreactivity in the lesioned nigra and striatum. In summary, our data suggest that BMP7 has neuroprotective and/or neuroreparative effects against 6-OHDA lesioning of the nigrostriatal DA pathway in an animal model of Parkinson's disease (PD).

Neuronal thread protein regulation and interaction with microtubule-associated proteins in SH-Sy5y neuronal cells

In Alzheimer's disease (AD), neuronal thread protein (NTP) accumulates in cortical neurons and colocalizes with phospho- tau-immunoreactive cytoskeletal lesions that correlate with dementia. To generate additional information about the potential role of NTP in AD, we characterized its expression and regulation in human SH-Sy5y neuronal cells. Quantitative real-time reverse transcription-polymerase chain reactin and Western blot analysis demonstrated prominent insulin, moderate insulin-like growth factor, type 1 (IGF-1) and minimal nerve growth factor stimulation of NTP expression. In addition, NTP protein was more stable and it progressively accumulated in cells that were stimulated with insulin for 24 or 48 h. Metabolic labeling and phospho-amino acid analysis demonstrated phosphorylation of NTP on Serine residues, 30-60 min after insulin or IGF-1 stimulation, when glycogen synthase kinase 3beta (GSK-3beta) activity would no longer have been suppressed. Kinase inhibitor and in vitro phosphorylation studies demonstrated a role for GSK-3beta in the positive regulation of NTP expression and phosphorylation. Coimmunoprecipitation studies demonstrated physical interactions between NTP and tau or microtubule-associated protein 1b (MAP-1b), and ubiquitin immunoreactivity in NTP immunoprecipitates. In summary, these studies showed that (i) NTP expression is regulated at the level of transcription by insulin and IGF-1 stimulation; (ii) NTP is phosphorylated by GSK-3beta; (iii) NTP can physically interact with tau and MAP-1b and (iv) NTP-MAP complexes are ubiquitinated. The results suggest a functional role for NTP in relation to the turnover or processing of neuronal cytoskeletal proteins, attributes that may be modulated by insulin/IGF-1-mediated signaling.

Validation of virtual colonoscopy in the detection of colorectal polyps and masses: rationale for proper study design

BACKGROUND

Colorectal cancer, the second-leading cause of cancer-related mortality, is a preventable malignancy in many cases. Despite the availability of several screening modalities, compliance with screening recommendations remains unacceptably low. Virtual colonoscopy is a novel, minimally-invasive technique with the potential to increase colorectal cancer screening rates, but its effectiveness must first be validated. Published studies comparing virtual colonoscopy to conventional colonoscopy have reported varying results. These discrepancies may be attributed to differences in bowel preparation and scanning techniques, as well as errors in endoscopic lesion measurement, endoscopic colonic segmental localization, and the ability of conventional colonoscopy to actually detect lesions. These methodological issues can affect scientific results and ultimately affect the public's perception of this emerging technique.

AIM

The goal of this report is to expose existing methodological shortcomings and propose solutions incorporated in this study design. This article describes the rationale, study design, and outcome definitions of a single-center, blinded, direct comparative trial aiming at assessing the ability of virtual colonoscopy to detect colorectal polyps and masses relative to the criterion standard, conventional colonoscopy. DESIGN FEATURES: Bowel preparation was standardized using oral sodium phosphate lavage, orally administered iodinated contrast, and controlled colonic insufflation. Segmental unblinding allowed a second-look when results were discrepant and polyp matching was performed using an algorithm based on segmental localization and lesion size determination.

CONCLUSIONS

This methodology could be applied to other studies assessing the accuracy of virtual colonoscopy in order to have uniformity of results.

First human ventral mesencephalon and striatum cografting in a Parkinson patient

Fetal ventral mesencephalon (VM) transplantation has been reported to improve parkinsonian symptoms. Animal studies show that cografting of striatal tissue increases the survival of dopamine neurons. Whether or not VM and striatum cografting could ameliorate motor dysfunction in a Parkinson's disease (PD) patient was explored in this study. The patient was a 53-year-old male who had presented with symptoms of tremor, rigidity and bradykinesia for 11 years. He had been treated with L-dopa and had progressive deterioration of symptoms even with the daily dosage of L-dopa increased to 900 mg per day. Before transplantation, his PD symptoms were scored with Unified Parkinson's Disease Rating Scale (UPDRS) and video recordings. The influx constant (ki) of the [18F] 6-fluoro-L-dopa uptake in the striatum was measured by positron emission tomography (PET) imaging. The fetal VM and the lateral part of the lateral ganglionic eminence (LGE) were cografted into the right putamen and, one week later, fetal VM alone was transplanted into the left putamen. After the transplantation, the patient's UPDRS score improved from 128 to 62 at 6 months and to 24 at 22 months during the "off" phase. The score of daily living disability improved from 35 to 18 at 6 months and to 10 at 22 months post transplantation. Twenty-two months after grafting, "off" phases were almost absent, and the freezing had totally disappeared. The [18F] 6-fluoro-L-dopa PET studies were performed 1 month before and 21 months after transplantation. The ki for [18F] 6-fluoro-L-dopa was decreased by 15% in the right caudate and 5% in the left caudate, both of which did not have any ventral mesencephalic grafts. However, the ki was increased by 35%, in the left non-cografted putamen, and by 58% in the right cografted putamen. In conclusion, cografting the fetal VM and the LGE in the putamen may improve the motor function of PD patients.

Waiting times to see a dermatologist are perceived as too long by dermatologists: implications for the dermatology workforce

BACKGROUND

The issue of workforce requirements in dermatology has come to attention in recent years because it affects the delivery of dermatologic care in the United States.

OBJECTIVE

To determine the waiting times for appointments with dermatologists in order to assess the adequacy of the current level of dermatology workforce.

METHODS

Waiting times were determined for new and return patient appointments by telephone survey of a random sample of American Academy of Dermatology members. Physicians' perception of the adequacy of the number of dermatologists in their area was used as a criterion standard to validate waiting times as a measure of workforce adequacy. Benchmark waiting times of 3 weeks for a new patient appointment and 2 weeks for a return appointment were established.

RESULTS

Physicians' estimates of the waiting time for a new patient appointment and their perceptions of the adequacy of the number of practicing dermatologists in their area were closely correlated (r = -0.65; P<.001), validating the use of waiting times as a measure of workforce adequacy. More than 60% of the dermatologists surveyed exceeded the criterion cutoff waiting times, and more than 42% of the US population lives in areas underserved by dermatologists. Dermatologists practicing in areas of higher population density were more likely to have shorter waiting times for new patient appointments and were more likely to include cosmetic dermatology in their practices.

CONCLUSION

The long waiting times for appointments suggests that the current supply of dermatologists is not adequate to meet the demand for dermatologists' services.

Expressions of cancer-testis antigens in human hepatocellular carcinomas

Though regular sonographic examination can early detect small hepatocellular carcinoma, the therapeutic results remains unsatisfactory. Antigen-specific immunotherapy is an alternative approach for controlling tumors. The prerequisite for antigen-specific cancer immunotherapy is the identification of appropriate tumor antigens. Recently, a new category of tumor-specific shared antigens, called cancer-testis antigens, has been identified. The cancer-testis antigens have been found in a variety of cancers. However, the expression of cancer-testis antigens in human hepatocellular carcinomas is unknown. The aim of this current study is to investigate the expression of cancer-testis antigens in human hepatocellular carcinomas. Reverse-transcription polymerase chain reaction (RT-PCR) was used to investigate the expression of the SSX-1,-2,-4,-5, SCP-1, NY-ESO-1 genes in tumorous and corresponding non-tumorous liver tissues. In the 30 hepatocellular carcinomas studied, SSX-1,-2,-4,-5, SCP-1, and NY-ESO-1 mRNA expressions were detected in 24 (80%), 14 (46.7%), 22 (73.3%), 10 (33.3%), 2 (6.7%), and 11 (36.7%), respectively. Expressions of these genes were detected in few non-tumor liver tissues. The cancer-testis antigens are expressed in a high percentage of hepatocellular carcinomas. These cancer-testis antigen gene products are potential targets for antigen-specific immunotherapy of hepatocellular carcinoma.

[Cloning of the recombinant human hepatocyte growth factor gene]

The full length of HGF cDNA gene(2,184 bp) was amplified successfully from human placental tissue using RT-PCR technique, and then cloned into pGEM-T vector, which was identified and confirmed by restriction endonuclease mapping using Nde I, Bg1 II, Hind III, BamH I and Xho I, as well as DNA sequencing. The above clone of HGF cDNA gene was successfully subcloned into the retrovirus vector(pLNL-XHC), which may be used for further studies of gene expression and gene therapy.

Cost-effectiveness of aerobic and resistance exercise in seniors with knee osteoarthritis

PURPOSE

The purpose of this study was to determine, in a randomized clinical trial of 439 individuals with knee osteoarthritis, the incremental cost-effectiveness of aerobic versus weight resistance training, compared with an education control intervention.

METHODS

Cost estimates of the intervention were based upon the cost of purchasing from the community similar services to provide exercise or health education. Effect at 18 months was measured using several variables, including: self-reported disability score, 6-min walking distance, stair climb, lifting and carrying task, car task, and measures of pain frequency and pain intensity on ambulation and transfer.

RESULTS

The total cost of the educational intervention was $343.98 per participant. The aerobic exercise intervention cost $323.55 per participant, and the resistance training intervention cost $325.20 per participant. On all but two of the outcome variables, the incremental savings per incremental effect for the resistance exercise group was greater than for the aerobic exercise group.

CONCLUSION

The data obtained from this study suggest that, compared with an education control, resistance training for seniors with knee osteoarthritis is more economically efficient than aerobic exercise in improving physical function. However, the magnitude of the difference in efficiency between the two approaches is small.

Cost-effectiveness of lifestyle and structured exercise interventions in sedentary adults: results of project ACTIVE

BACKGROUND

Project ACTIVE was a randomized clinical trial comparing two physical activity interventions, lifestyle and traditional structured exercise. The two interventions were evaluated and compared in terms of cost effectiveness and ability to enhance physical activity among sedentary adults.

DESIGN

This was a randomized clinical trial.

SETTING/ PARTICIPANTS

The study included 235 sedentary but healthy community-dwelling adults.

INTERVENTION

A center-based lifestyle intervention that consisted of behavioral skills training was compared to a structured exercise intervention that included supervised, center-based exercise.

MAIN OUTCOME MEASURES

The main outcome measures of interest included cost, cardiorespiratory fitness, and physical activity.

RESULTS

Both interventions were effective in increasing physical activity and fitness. At 6 months, the costs of the lifestyle and structured interventions were, respectively, $46.53 and $190.24 per participant per month. At 24 months these costs were $17.15 and $49.31 per participant per month. At both 6 months and 24 months, the lifestyle intervention was more cost-effective than the structured intervention for most outcomes measures.

CONCLUSIONS

A behaviorally-based lifestyle intervention approach in which participants are taught behavioral skills to increase their physical activity by integrating moderate-intensity physical activity into their daily lives is more cost-effective than a structured exercise program in improving physical activity and cardiorespiratory health. This study represents one of the first attempts to compare the efficiency of intervention alternatives for improving physical activity among healthy, sedentary adults.

Behavioral and immune changes in v-Ha-ras transgenic mice

Transgenic mice (Oncomice) with an activated v-Ha-ras oncogene under the control of the mouse mammary tumor virus promoter develop mammary tumors. We wondered if the expression of the v-Ha-ras oncogene product would induce changes in mice behavioral activity, that could be associated with alterations in their immune system. Behavior was evaluated in an open field study considering line crossings and rears. Oncomice consistently showed less activity than FVB mice. Lieber-DeCarli diet decreased both types of activity in both strains. Cocaine treatment increased line crossings in both strains. Oncomice spleen and thymus cell supernatants contained higher levels of IL-2. Oncomice serum had higher levels of IL-1alpha. Our results suggest a direct association between higher levels of IL-1alpha and lower open field activity. Therefore, we can infer that the increased level of IL-1alpha found in Oncomice, could have a key role in oncogene induced immune and behavioral changes, and could be a requirement to facilitate its transforming activity.

Cost-benefit of a nursing telephone intervention to reduce preterm and low-birthweight births in an African American clinic population

BACKGROUND

A cost-benefit analysis was performed to estimate the cost-savings obtained from a nursing telephone intervention delivered to pregnant women identified as being at risk for preterm or low-birthweight births.

METHODS

After being screened for eligibility, a total of 1,554 women receiving prenatal care in a clinic located in Winston-Salem, North Carolina were randomized to intervention and control groups. Women in the intervention group received telephone calls from a registered nurse one or two times each week from the 24th through the 37th week of gestation.

RESULTS

No clinical benefits were realized by Caucasian participants. The intervention reduced preterm and low-birthweight births, and resulted in cost savings, for African-American mothers ages 19 and over. No significant differences were seen in the rates of low-birthweight or preterm births and no cost savings were realized from intervention with women ages 18 and younger.

CONCLUSIONS

A prenatal nursing support intervention in a clinic population of pregnant African American women was cost-beneficial for these adults (< or =19 years of age).

Economic aspect of health care systems. Advantage and disadvantage incentives in different systems

European health care delivery systems illustrate the effect of economic incentives on health care delivery. Each country faces the issue of trying to balance the desire for economic efficiency with comprehensive, quality medical care. Without careful use of economic incentives achievable with central control, one gets to pick only two of the three desired goods--high quality, low cost, and comprehensive coverage. In the United States, payment approaches for health care have been undergoing tremendous changes since the early 1980s. These changes have escalated during the 1990s. The basic approach for reimbursing hospital care has been completely restructured by many payers for care, and payment approaches for physicians and long-term care providers also are being restructured. Financing approaches vary from provider to provider and payer to payer, and financing approaches will continue to evolve over time. In the traditional fee-for-service reimbursement system, the incentive to physicians is to do more because more services lead to more revenue. The use of incentives to influence health care practitioners' behavior is common. Incentives are generally financial in nature and expose health care providers to some risk or reward for certain patterns of behavior. Some common incentives used in managed care include capitation payment, in which a physician is paid a fixed fee, regardless of the number of services administered; bonus distribution; and withhold accounts, through which a practitioner stands to gain or lose some amount of money for overuse or underuse of medical resources against budget. In many countries, a strengthening of the position of primary care providers can be observed: Finland, Germany, Greece, Italy, the Netherlands, Norway, Sweden, the United Kingdom, and now the United States. General practitioners are assumed to function as a gatekeeper to second-line care, such as specialist care, prescription drugs, and hospital care. A further step is to give the primary care providers financial responsibility for the costs of the follow-up care provided by others to their patients. By examining the health care systems of other countries, the potential negative impact of such an approach on the use of specialists can be seen. The negative impact of these approaches on patient care is clear when dermatologists and general practitioners are compared in the delivery of dermatologic health care.

Restriction site-free insertion of PCR products directionally into vectors

A restriction site-free cloning method has been developed for inserting a PCR product into a vector flexibly and precisely at any desired location with high efficiency. The method uses a pair of DNA integration primers with two portions. The 3' portion isolates the inserts by PCR, and the 5' portion integrates the PCR products into the homologous region of the vector. For mutagenesis, a third portion of mutation-generating sequences can be placed in between the 3' and 5' portions. This method has been used to clone the E. coli gene that codes for peptidyl-tRNA hydrolase, expressing it as a native protein and as a glutathione S-transferase fusion protein. It was also applied to convert a construct of the E. coli fatty acid biosynthesis protein with an N-terminal hexa-histidine tag into a construct with a C-terminal hexa-histidine tag.

Effect of short-term cocaine administration on the immune system of young and old C57BL/6 female mice

It has been shown that either cocaine or aging alone can alter the immune system. Our objective was to study if the immune system of aging mice was more susceptible to the effect of cocaine than the immune system of young mice. We used a short term (20 days) cocaine daily administration protocol. Cocaine only decreased the absolute number of Thy 1+, CD4+, CD8+, IL-2R+, Mac 1+ and B cells, in the spleen of old mice. Old untreated mice had a lower number of Thy 1+ cells in the thymus, and a higher number of cells expressing IL-2R. Cocaine decreased the number of Thy 1+ cells in the thymus of both age groups. Old mice showed a lower number of IgA+ plasma cells in the intestinal lamina propria (ILP) than young mice. Short term cocaine administration provoked a decrease in the number of CD4+ cells in young mice ILP and of CD8+ cells in old mice ILP. Our data suggest that cocaine can potentiate the effect of aging on the thymus and on the mucosal immune system. Taken together, our findings indicate that aging and cocaine can potentiate each other to impairing the host immune system.

Functional alterations of alveolar macrophages subjected to smoke exposure and antioxidant lazaroids

Acute inhalation of diesel fuel-polycarbonate plastic (DFPP) smoke causes severe lung injury, leading to acute respiratory distress syndrome (ARDS) and death. It has been reported that the initiation of acute lung injury is associated with the activation of pulmonary alveolar macrophages (PAM). To further explore the pathogenesis, alveolar macrophages (AM) of New Zealand rabbits ventilated and exposed to a 60 tidal volume of DFPP smoke in vivo were recovered at 1 h post-smoke. Smoke exposure induced significant increases in both mRNA and protein levels for PAM tumor necrosis factor-alpha (TNF-alpha), when compared to smoke control. Smoke also induced a biphasic response (inhibited at 2 h, enhanced at 24 h after cell isolation) in the production of superoxide (O2-) by PAM. However, aerosolized lazaroid, U75412E (1.6 mg/kg body weight), significantly attenuated smoke-induced expression in AM TNF-alpha at the protein level but not at the mRNA level, and smoke-induced changes in AM production of O2-. This study suggests that highly expressing AM TNF-alpha following smoke may be a key contributor to the cascade that establishes an acute injury process and exacerbates oxidant-derived cell injury. Whereas, the lazaroid may ameliorate smoke-induced lung injury by attenuating AM TNF-alpha release, in addition to its primary antioxidative mechanism.

Is prior authorization of topical tretinoin for acne cost effective?

OBJECTIVE

To determine whether prior authorization of topical tretinoin for acne is in the best interest of health insurers and, if so, to determine the optimal prior authorization age for topical tretinoin.

STUDY DESIGN

A retrospective, cross-sectional study of data from the National Ambulatory Medical Care Survey was performed.

PATIENTS AND METHODS

We performed a sensitivity analysis using published data on the age distribution for topical tretinoin prescriptions for acne and nonacne indications to estimate the cost of topical tretinoin and the cost of performing prior authorizations as a function of the prior authorization age.

RESULTS

A prior authorization age of 25 for topical tretinoin is not cost effective for health insurers. If prior authorization is required, an age threshold of 35 or older is most cost effective. The total cost of topical tretinoin (the sum of the drug costs plus the prior authorization costs) changes little with changes in the prior authorization age; if the prior authorization age is set too low, total costs increase (because the number of prior authorizations increase).

CONCLUSIONS

Prior authorization for topical tretinoin is of no great benefit to insurers. As the prior authorization age decreases, the cost of requiring prior authorization increases. Eliminating prior authorization altogether would result in at most a small increase in costs and would be balanced by the benefits to both patients and physicians.

A confirmatory factor analysis of the Caregiving Appraisal Scale for caregivers of home-based ventilator-assisted individuals

OBJECTIVE

To confirm the underlying dimensions of the Caregiving Appraisal Scale (CAS) with use of data collected from caregivers of home-based ventilator-assisted individuals (VAIs).

DESIGN

Cross-sectional survey.

SETTING

Residences of home-based VAIs.

SAMPLE

Two hundred seventy-seven primary family caregivers of VAIs.

MEASURES

Twenty-eight-item CAS developed by Lawton et al. (1989), and an investigator-developed instrument to assess physical health and sociodemographic characteristics of both VAIs and their caregivers.

INTERVENTION

None.

ANALYSIS

Confirmatory factor analysis with principal components extraction. An oblique (oblimin) solution was used for rotation of the factor matrices. The number of common factors needed to obtain the best fit of the factor model was determined with use of maximum-likelihood estimation. Confirmatory factor analysis with linear structural equation modeling was also performed.

RESULTS

Confirmatory factor analysis did not fully replicate the factor structure proposed by Lawton et al.

CONCLUSIONS

The model proposed by Lawton et al. provides a useful foundation for examining the appraisal of family caregivers of home-based VAIs. Additional development work is needed for the CAS.

Cost-utility of lung transplantation: a pilot study

BACKGROUND

The purpose of this study was to conduct a pilot investigation of the cost-utility of lung transplantation. With this study we provide a threshold analysis to estimate the survival gains that must be achieved for lung transplantation to be considered a beneficial use of society's resources.

METHODS

A cross-sectional cohort design was used. All patients having undergone lung transplantation at the University of Pittsburgh Medical Center between March 1 and August 31, 1994, were identified via roster of transplant recipients (n = 20). Surviving patients were interviewed, by telephone, at their 1-year anniversary date. Utility was assessed by use of the quality of well-being scale. Direct cost of care was estimated from adjusted charges for the surgical admission, plus physician fees per the Medicare Physician Fee Schedule.

RESULTS

The mean quality of well-being score for this group was 0.54 +/- 0.198 SD (median = 0.599, range 0 to 0.728). Summing the physician cost and the adjusted charges for the inpatient operative admission, the average cost of lung transplantation was $153,921 +/- $133,981 SD (median $94,324, range $63,405 to $598,482). At a cost of $94,324 and a utility of 0.599, the survival gain from surgery must be 2.7 years for the cost of the procedure to be justified from a societal perspective.

CONCLUSIONS

Because of the many limitations in this pilot study, no firm policy implication may be drawn from these data. Directions for future research are discussed.

A free radical scavenger (Lazaroid U75412E) attenuates tumor necrosis factor-alpha generation in a rabbit model of smoke-induced lung injury

The lazaroid (21-aminosteroid) analogue U75412E was evaluated in rabbits exposed to diesel fuel-polycarbonate plastic smoke. Inhalation of total of 4.6 mg U75412E aerosolized at a rate of 1.53 mg/min for 3 min before or after smoke significantly prevented or limited the extent of alveolar hypoventilation, interstitial edema, and tumor necrosis factor-alpha (TNF-alpha) by pulmonary alveolar macrophages (PAM) ex vivo observed at 2 h. The smoke-induced changes in wet lung/body weight ratios and the production of superoxide (O2-) by PAM ex vivo were also attenuated by the drug treatment after smoke exposure (p < 0.05). This study suggests that lazaroids may ameliorate the oxygen-radical-initiated cytokine processes and inflammation cascade as a result of the smoke insult.

The prophylactic effects of U75412E pretreatment in a smoke-induced lung injury rabbit model

The effects of the lazaroid analogue U75412E (21-[4-(3-ethylamino-2-pyridinyl)-1-piperazinyl]-16 alpha-methylpregna-1,4,9]-(11)-triene-3,20-dione) were examined in an acute lung injury rabbit model. Standard doses of 0, 8 and 16 mM U75412E were aerosolized and ventilated into the lungs for 3 min. via an endotracheal tube. A 60 tidal volume dose of diesel fuel-polycarbonate plastic smoke was then instilled, followed by mechanical ventilation for one hour. Pretreatment with 16 mM U75412E significantly increased blood PaO2 and pH values, and decreased blood PaCO2 as compared to smoke only exposures. It also significantly decreased the total cell counts and granulocytes in bronchoalveolar lavage fluid, and the ability of pulmonary alveolar macrophages to produce tumour necrosis factor-alpha in vitro after cell isolation and culture. Histopathology indicated that 16 mM U75412E pretreatment attenuated increases in wet lung/body weight ratios, inflammatory focus, and interstitial oedema associated with smoke insult. In summary, U75412E pretreatment may possess the potential to improve acute smoke-induced lung injury, in part, through modulation of tumour necrosis factor-alpha production from pulmonary alveolar macrophages.

Alteration of cerebral microcirculation by hemodilution with hemosome in awake rats

Our study showed that hemodilution with modified fluid gelatin resulted in an increase in local cerebral blood flow (LCBF), but no change at all in local cerebral oxygen delivery (LCOD) in rats. Hemosome, a lecithin encapsulated hemoglobin having the oxygen-carrying capacity, was developed to improve LCOD by hemodilution. Therefore, we have hypothesized that LCBF & LCOD would be increased by hemodilution with hemosome. To test this hypothesis, adult male Sprague-Dawley rats weighing approximately 350g were used and divided into the hemodilution and the control groups. Hemosome was made from pig red blood cells and lecithin. It's mean diameter was approximately 0.3 um and hemoglobin concentration was approximately 4g/dl. Isovolemic hemodilution, which lowered the systemic hematocrit from approximately 50% to approximately 30%, was achieved by rapidly replacing blood with the same volume of hemosome. Ten min later, LCBF in 14 brain structures were measured using the 14C-iodoantipyrine technique. Our results showed that LCBF of the control group ranged from 115 +/- 11 ml/100g/min in the medulla to 260 +/- 31 ml/100g/min in the occipital cortex. LCBFs were generally higher (p < 0.05, MANOVA) by 16% in the hemodilution group than in the control group. However LCODs were generally decreased (p < 0.05, MANOVA) by 18% in the hemodilution group than in the control. In conclusion, hemodilution with hemosome indeed improves LCBF but lowers LCOD in awake rats.

Effect of arsenic exposure on alveolar macrophage function. II. Effect of slightly soluble forms of As(III) and As(V)

The pulmonary toxicity of a substance depends on a number of chemical and physical characteristics, including the solubility of the compounds. In the lung, insoluble forms of metals may be more tumorigenic than soluble forms despite the fact that this effect has not been quantitated and the mechanism of action has not been elucidated. The toxic effects of slightly soluble forms of As(III) and As(V) were evaluated by determining alteration in function of pulmonary alveolar macrophages (PAM) following in vivo and in vitro exposure. Male Sprague-Dawley rats were used throughout. Twenty-four hours following intratracheal instillation of 1 mg/kg (as arsenic) of either arsenic trisulfide (As(III)) or calcium arsenate (As(V)), PAM were lavaged and analyzed for alterations in superoxide (O2-), and tumor necrosis factor (TNF-alpha) production. There were no differences in bronchoalveolar lavage fluid TNF-alpha. PAM lavaged from As(V)-exposed animals showed significant increases in O2- production and in basal release of TNF-alpha. PAM lavaged from animals receiving As(III) did not show significant alterations. To test the direct effects of arsenic, PAM were lavaged from control animals and exposed to concentrations of 0.1 to 300 micrograms/ml arsenic in vitro for up to 24 hr. Doses used were not cytotoxic to PAM, since LDH release was not significantly increased. Significant dose-dependent inhibition of O2- production was only evident after 24 hr exposure to arsenicals. Both As(III) and As(V) produced inhibition at concentrations of 10 micrograms/ml. Suppression of LPS-induced release of TNF-alpha also occurred at similar concentrations for both arsenicals (4-5 micrograms/ml). Neither arsenical inhibited prostaglandin E2 production. Measurement of soluble arsenic concentrations indicated dissolution of the compounds could not account for all of the effects seen. Arsenic-induced alteration in PAM function may compromise host defense.

Similarity of nucleotide interactions of BiP and GTP-binding proteins

BiP is a member of the Hsp70 heat shock protein family found in the lumen of the endoplasmic reticulum, that binds to a variety of proteins destined to be secreted. Substance P (SP) has been used as a model peptide to study the interaction of BiP with protein substrates. SP stimulates BiP ATPase activity and forms a stable complex with BiP that is dissociated in the presence of levels of ATP > 50 microM. At lower concentrations of ATP, the SP remains bound to BiP, and the results are consistent with the view that a BiP-ATP complex is initially formed that reacts with SP to form a ternary complex, SP-BiP-ATP. Hydrolysis of ATP in this complex yields a SP-BiP-ADP complex. An exchange of ATP with ADP bound to BiP has also been demonstrated, and the results suggest that the interactions of BiP with ATP resemble those seen with GTP-binding proteins and GTP.

Effect of arsenic exposure on alveolar macrophage function. I. Effect of soluble as(III) and as(V)

Despite potential differences in the mechanism and potency of toxicity between the two common oxidation states of arsenic (As(III) and As(V)), assessments of the risk from inhaled arsenic generally ignore the oxidation state of inorganic arsenicals. Differences between potency and toxicity of As(III) and As(V) were evaluated by determining alteration in function of pulmonary alveolar macrophages (PAM) following in vivo and in vitro exposure to soluble arsenic. Male Sprague-Dawley rats were used throughout. One day following intratracheal instillation of 1 mg/ml (as arsenic) of either sodium arsenite (As(III)) or sodium arsenate (As(V)), PAM were lavaged and analyzed for alterations in superoxide (O2-), prostaglandin E2 (PGE2), and tumor necrosis factor (TNF-alpha) production. There were no differences in bronchoalveolar lavage fluid PGE2 or TNF-alpha. PAM lavaged from As(V)-exposed animals showed significant increases in O2- production. In vivo exposure to either oxidative form of arsenic decreased basal and lipopolysaccharide (LPS)-induced release of TNF-alpha production by PAM, but did not suppress LPS-induced production of PGE2. To test the direct effects of arsenic on PAM function, PAM were lavaged from control animals and exposed, in vitro, to either arsenical for up to 24 hr to concentrations of 0.1 to 300 micrograms/ml arsenic. Doses used were not cytotoxic to PAM, since LDH release was not significantly increased, even at the highest dose. Significant dose-dependent inhibition of O2- production was only evident after 24 hr exposure to arsenicals. As(III) was more potent than As(V), inhibiting O2- at concentrations as low as 0.1 micrograms/ml compared to 1.0 micrograms/ml of As(V). Suppression of LPS-induced release of TNF-alpha also occurred at lower concentrations of As(III), 50% inhibition at 0.15 micrograms/ml, compared to As(V), 50% inhibition at 1.8 micrograms/ml. While As(III) exposure had no affect on PGE2 production, As(V) caused inhibition of LPS-induced PGE2 production at concentrations above 1.0 micrograms/ml. Differences between As(III) and As(V) indicate that different mechanisms and/or potencies exist between the two arsenic species. Arsenic-induced alteration in PAM function may compromise host defense against infections and alter immune surveillance.

[Assay of DNA content and estrogen receptor status in human breast cancer]

Cellular DNA content of 72 samples was analyzed by flow cytometry. The results showed that 20 benign tumors and 10 normal breast tissue specimens were found to be DNA diploidy. 26 (62%) of 42 cases of breast cancer were DNA aneuploidy and the remainders were DNA diploidy. The median s-phase cell percentage was significantly higher in aneuploid tumors (28%) than diploid tumors (13%) and benign tumors (4%). Estrogen receptors were also investigated in 42 breast cancer specimens. There were 31 ER positive (74%) cases and 11 negative (26%) cases. The aneuploid DNA content was usually associated with lack of estrogen receptors. DNA content correlated significantly with age and ER status. The results suggest that flow cytometric analysis of cellular DNA content of breast cancer and status of estrogen receptors can provide an objective quantitative and reproducible new parameter for predicting prognosis of breast cancer.

Spleen and thymus cell subsets modified by long-term morphine administration in protein-undernourished mice--I

Severe infections in intravenous drug abusers could be the consequence of morphine-induced damage on the immune system. To evaluate the long-term effect of in vivo morphine administration on the immune system we developed an experimental model where we studied the combined effects of morphine treatment and protein malnutrition. We treated protein-undernourished mice daily for 11 weeks with increasing doses of morphine. Morphine treatment produced a decrease in body weight and spleen cell number. The changes observed were partially independent of the nutritional status of the host. Saline-injected mice showed a decrease in the percentage of Thy 1+ cells in the spleen. Morphine treatment induced a decrease in the total number of cells and therefore in the absolute number of T-(Thy 1, CD4, CD8), B- and Mac 1+ (macrophages) cells in protein-undernourished mice. Saline-injected mice showed a decrease in the percentage of Thy 1+ cells and an increase in the percentage of B- and Ia(+)-cells in the spleen. We conclude that morphine altered the immune system by down-regulating splenocyte proliferation. We also studied the effects of i.p. administered morphine on expression of thymocyte phenotype in well-nourished and protein-undernourished mice. In well-nourished mice, morphine treatment reduced the number of Thy 1+, CD4+ and CD8+ cells per thymus to 30% of that found in untreated mice and to 40% of the cells in those saline-treated controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Spleen and thymus cell subsets modified by long-term morphine administration and murine AIDS--II

Intravenous heroin abusers suffer a great variety of infections, including AIDS (acquired immune deficiency syndrome). We developed an experimental mouse model to evaluate the long-term effect of in vivo morphine administration during retrovirus-induced immune dysfunction. Mice were treated daily for 11 weeks with increasing doses of morphine. Morphine treatment produced a decrease in body weight and spleen cell number. Murine retrovirus infection provoked an increase in body weight due to enlargement of lymphoid organs, and an increase in the percentage and absolute number of CD4+ and Mac 1+ cells. Interestingly, retrovirus-infected mice that were also morphine-treated did not show the increase in the relative proportion of Mac 1+ cells. Moreover, under the experimental conditions of protein-malnutrition and morphine treatment potentiation of immune dysfunction by murine retrovirus infection was investigated. Retrovirus infection-induced splenocyte proliferation was partially regulated by morphine treatment. Splenocytes from retrovirus-infected mice presented a higher percentage of IL-2R+ cells and, lower levels of sIL-2R in splenocyte supernatants. Mitogen-stimulated splenocytes had a lower production of interferon-gamma as well as an increase in the secretion of tumor necrosis factor-alpha. Thus morphine altered the immune system by down-regulating splenocyte proliferation, because retrovirus infection-induced splenocyte proliferation was partially regulated by morphine treatment. We also evaluated the effects of joint murine retrovirus infection and protein undernutrition on the thymus cell subsets. Retrovirus infection was associated with a decrease in the absolute number of Thy 1+, CD4+ and CD8+ cells per thymus with the CD8+ cell subset being the most affected. Moreover, retrovirus-infected mice presented a dramatic decrease in the percentage of double-positive (CD4+ CD8+) cells in the thymus as well as changes in its immunoarchitecture. While protein undernutrition alone did not produce further differences between infected versus non-infected, protein-undernourished, morphine treatment induced a greater decrease in thymocyte number than that seen in retrovirus- or morphine-treated animals alone.