Phenotype-considered kinematically aligned total knee arthroplasty for windswept-deformity-associated osteoarthritis: surgical strategy and clinical outcomes

BACKGROUND

Windswept deformity (WSD) in relation to advanced osteoarthritis (OA) presents a significant surgical challenge in total knee arthroplasty (TKA). The primary goal of this study is to investigate the Prevalance of WSD associated osteoarthritis who have undergone total knee arthroplasty. The secondary goal is to explore the causes of WSD and its association with spinal deformity or leg length discrepancy in these patients. Finally, we evaluate the surgical outcomes of phenotype-considered kinematically aligned TKA (KA-TKA) in treating patients with WSD.

METHODS

A review was conducted on data from 40 knees of 33 WSD patients who underwent phenotype-considered KA-TKA from August 2016 to December 2020. Patient demographics, associated diseases, preoperative and postoperative knee alignment angles, range of motion (ROM), Oxford Knee Score (OKS), and Knee Society Score (KSS) were collected and analyzed. Subgroup analysis for comparing the results between valgus and varus knees were also performed.

RESULTS

Within the studied cohort of WSD patients, a substantial 64% displayed concomitant coronal spinal imbalance and 21% evidenced leg length discrepancy. Postoperative improvements were notable in knee alignments, ROM, OKS, and KSS following the application of the phenotype-considered KA-TKA approach. There were significant differences in the knee alignment angles, including mHKA, LDFA, and MPTA, between the valgus and varus side of knees (P = 0.018). However, no statistically significant difference were observed in the functional scores, comprising ROM, OKS, and KSS, between valgus and varus knees.

CONCLUSIONS

A high percentage of patients with WSD exhibited coronal spinal imbalance and leg length discrepancy. Phenotype-considered KA-TKA effectively provided alignment targets for the treatment of both varus and valgus knees in patients with WSD, achieving excellent short-term outcomes and acceptable knee alignment.

A Retrospective Comparison of Clinical Efficacy between Multimodal Analgesia and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Arthroplasty

Background and Objectives: Adequate pain management during early rehabilitation is mandatory for improving the outcomes of patients undergoing total knee arthroplasty (TKA). Conventional pain management, mainly comprising opioids and epidural analgesia, may result in certain adverse effects such as dizziness, nausea, and motor blockade. We proposed a multimodal analgesic (MA) strategy involving the use of peripheral nerve block (NB), periarticular injection (PAI), and intravenous patient-controlled analgesia (IVPCA). This study compared the clinical efficacy and adverse effects of the proposed MA strategy and patient-controlled epidural analgesia (PCEA). Materials and Methods: We enrolled 118 patients who underwent TKA under spinal anesthesia. The patients followed either the MA protocol or received PCEA after surgery. The analgesic effect was examined using a numerical rating scale (NRS). The adverse effects experienced by the patients were recorded. Results: A lower proportion of patients in the MA group experienced motor blockade (6.45% vs. 22.98%) compared to those in the PCEA group on the first postoperative day. Furthermore, a lower proportion of patients in the MA group experienced numbness (18.52% vs. 43.33%) than those in the PCEA group on the first postoperative day. Conclusions: The MA strategy can be recommended for reducing the occurrence of motor blockade and numbness in patients following TKA. Therefore, the MA strategy ensures early rehabilitation while maintaining adequate pain relief.

Prognostic Importance of Uterine Body Invasion in Para-Aortic Lymph Node Recurrence in Patients with Cervical Carcinoma after Pelvic Radiotherapy

PURPOSE/OBJECTIVE(S)

This study aimed to evaluate the correlation between the extent of uterine body invasion and para-aortic lymph node (PALN) recurrence in patients with cervical carcinoma who received pelvic radiotherapy.

MATERIALS/METHODS

The data of 185 patients diagnosed with cervical carcinoma, initial stage IB to IVA without para-aortic lymph node metastasis, according to the FIGO 2009 Stage System, and treated between January 2011 and December 2016 were retrospectively analyzed. With using pelvic MRI with contrast, the extent of uterine body invasion was assessed and categorized into three types: non-uterine invasion, endocervical invasion, and invasion into the uterine body. Non-uterine invasion, by definition, referred to tumor located at the outer orifice of the cervix or ectocervix, while endocervical invasion referred to tumor invasion up to the endocervical canal, and the uterine body invasion referred to cervical carcinoma invading the uterine cavity from the squamocolumnar junction (SCJ) transformation zone. Definitive or adjuvant pelvic radiotherapy was given to the 185 patients, all of whom did not receive extended-field radiotherapy. The major result of PALN recurrence, defined as a short axial diameter of lymph node greater than 1cm, was diagnosed through computed tomography, pelvic MRI, or PET-CT. The actuarial rates of PALN recurrence were analyzed using Kaplan-Meier curves, and Cox regression models were used for multivariate analyses.

RESULTS

There were 122 (65.9%), 37 (20.0%), and 26 (14.1%) patients with non-uterine invasion, endocervical invasion, and invasion into the uterine body, respectively. The 5-year PALN recurrence rates were 7.8% in the non-uterine invasion group, 13.1% in the endocervical invasion group, and 21.1% in the uterine body invasion group (p = 0.009), after a median follow-up of 65.5 months. The multivariate analysis revealed that uterine body invasion was the only independent factor of PALN recurrence (p = 0.004). Factors such as initial pelvic lymphadenopathy (p = 0.645), initial SCC-Ag level (p = 0.200), non-squamous cell carcinoma (p = 0.882), and FIGO stage III-IVA (p = 0.289) were not significant factors of PALN recurrence.

CONCLUSION

This study demonstrates that cervical cancer patients with uterine body invasion have a higher risk of PALN recurrence following pelvic radiotherapy. Intensive follow-up schedules are recommended for these patients. Extended-field radiotherapy may be considered in cervical cancer patients with uterine body invasion to reduce PALN recurrence.

Enhancement of Osteoblast Function through Extracellular Vesicles Derived from Adipose-Derived Stem Cells

Adipose-derived stem cells (ADSCs) are a type of mesenchymal stem cell that is investigated in bone tissue engineering (BTE). Osteoblasts are the main cells responsible for bone formation in vivo and directing ADSCs to form osteoblasts through osteogenesis is a research topic in BTE. In addition to the osteogenesis of ADSCs into osteoblasts, the crosstalk of ADSCs with osteoblasts through the secretion of extracellular vesicles (EVs) may also contribute to bone formation in ADSC-based BTE. We investigated the effect of ADSC-secreted EVs (ADSC-EVs) on osteoblast function. ADSC-EVs (size ≤ 1000 nm) were isolated from the culture supernatant of ADSCs through ultracentrifugation. The ADSC-EVs were observed to be spherical under a transmission electron microscope. The ADSC-EVs were positive for CD9, CD81, and Alix, but β-actin was not detected. ADSC-EV treatment did not change survival but did increase osteoblast proliferation and activity. The 48 most abundant known microRNAs (miRNAs) identified within the ADSC-EVs were selected and then subjected to gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. The GO analysis revealed that these miRNAs are highly relevant to skeletal system morphogenesis and bone development. The KEGG analysis indicated that these miRNAs may regulate osteoblast function through autophagy or the mitogen-activated protein kinase or Ras-related protein 1 signaling pathway. These results suggest that ADSC-EVs enhance osteoblast function and can contribute to bone regeneration in ADSC-based BTE.

Validation and modification of the Coronal Plane Alignment of the Knee classification in the Asian population

AIMS

The Coronal Plane Alignment of the Knee (CPAK) classification is a simple and comprehensive system for predicting pre-arthritic knee alignment. However, when the CPAK classification is applied in the Asian population, which is characterized by more varus and wider distribution in lower limb alignment, modifications in the boundaries of arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) should be considered. The purposes of this study were as follows: first, to propose a modified CPAK classification based on the actual joint line obliquity (aJLO) and wider range of aHKA in the Asian population; second, to test this classification in a cohort of Asians with healthy knees; third, to propose individualized alignment targets for different CPAK types in kinematically aligned (KA) total knee arthroplasty (TKA).

METHODS

The CPAK classification was modified by changing the neutral boundaries of aHKA to 0° ± 3° and using aJLO as a new variable. Radiological analysis of 214 healthy knees in 214 Asian individuals was used to assess the distribution and mean value of alignment angles of each phenotype among different classifications based on the coronal plane. Individualized alignment targets were set according to the mean lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) of different knee types.

RESULTS

A very high concentration, 191 from 214 individuals (89.3%), were found in knee types with apex distal JLO when the CPAK classification was applied in the Asian population. By using aJLO as a new variable, the high distribution percentage in knee types with apex distal JLO decreased to 125 from 214 individuals (58.4%). The most common types in order were Type II (n = 70; 32.7%), Type V (n = 55; 25.7%), and Type I (n = 46; 21.5%) in the modified CPAK classification.

CONCLUSION

The modified CPAK classification corrected the uneven distribution when applying the CPAK classification in the Asian population. Setting individualized TKA alignment targets according to CPAK type may be a practical method to recreate optimal LDFA and MPTA in KA-TKA. Cite this article: Bone Jt Open 2022;3(3):211-217.

Total knee arthroplasty according to the original knee phenotypes with kinematic alignment surgical technique-early clinical and functional outcomes

Background

The kinematic alignment (KA) technique in total knee arthroplasty (TKA) aims to restore the native alignment of pre-disease knee joint anatomy. Determining the individualized alignment targets is crucial for pre-operative planning, which can be set according to different original knee phenotypes. Five most common knee phenotypes have been categorized for KA-TKA alignment target setting in our previous study. The purpose of this study was to investigate the distribution of the five phenotypes in advanced OA knee patients and evaluate the clinical outcomes of this phenotype-oriented KA-TKA using the generic instrument, with particular emphasis on alignment strategy, surgical technique, survivorship, radiographic and functional outcomes.

Methods

The clinical data of 123 patients (88 women, 35 men) who had undergone 140 TKAs in our hospital were reviewed. All the TKAs were performed with alignment targets set according to the original phenotypes of the knee, with the KA method, using the generic total knee instrument. The patients’ demographics, preoperative and postoperative knee alignment angles, one-year postoperative range of motion (ROM), Oxford knee scores (OKS), Combined knee society score (CKSS) were collected and analyzed.

Results

The 3 years survivorship was 99.3% for all cause of revision, and 100% with revision other than infection as the endpoint. The preoperative phenotypes of the knee were as follows: neutral alignment 20.1% (type 1: 3.6%, type 2: 16.5%), varus alignment 71.2% (type 3: 46.0%, type 4: 25.2%), and valgus alignment (type 5: 8.6%). Using our protocol, patients with different knee phenotypes could get similar great functional improvement though the postoperative alignment parameters were significantly different between the knee phenotypes (P < 0.05).

Conclusion

The early outcomes of this phenotype-oriented KA-TKA using generic total knee instruments are promising. Setting individualized alignment target according to original knee phenotype is rational and practical. The residual varus alignment did not cause any aseptic loosening in the 3 years follow-up. Long-term survivorship and functional outcomes need to be evaluated in future studies.

Carcinogenesis of Male Oral Submucous Fibrosis Alters Salivary Microbiomes

Most oral squamous cell carcinoma (OSCC) tumors arise from oral premalignant lesions. Oral submucous fibrosis (OSF), usually occurring in male chewers of betel quid, is a premalignant stromal disease characterized by a high malignant transformation rate and high prevalence. Although a relationship between the inhabited microbiome and carcinogenesis has been proposed, no detailed information regarding the oral microbiome of patients with OSF exists; the changes of the salivary microbiome during cancer formation remain unclear. This study compared the salivary microbiomes of male patients with OSCC and a predisposing OSF background (OSCC-OSF group) and those with OSF only (OSF group). The results of high-throughput sequencing of the bacterial 16S rRNA gene indicated that OSF-related carcinogenesis and smoking status significantly contributed to phylogenetic composition variations in the salivary microbiome, leading to considerable reductions in species richness and phylogenetic diversity. The microbiome profile of OSF-related malignancy was associated with increased microbial stochastic fluctuation, which dominated the salivary microbiome assembly and caused species co-occurrence network collapse. Artificial intelligence selection algorithms consistently identified 5 key species in the OSCC-OSF group: Porphyromonas catoniae, Prevotella multisaccharivorax, Prevotella sp. HMT-300, Mitsuokella sp. HMT-131, and Treponema sp. HMT-927. Robust accuracy in predicting oral carcinogenesis was obtained with our exploratory and validation data sets. In functional analysis, the microbiome of the OSCC-OSF group had greater potential for S-adenosyl-l-methionine and norspermidine synthesis but lower potential for l-ornithine and pyrimidine deoxyribonucleotide synthesis and formaldehyde metabolism. These findings indicated that the salivary microbiome plays important roles in modulating microbial metabolites during oral carcinogenesis. In conclusion, our results provided new insights into salivary microbiome alterations during the malignant transformation of OSF.

P5644Hypoglycemic episodes increase the risk of ventricular arrhythmias and sudden cardiac arrest in patients with type 2 diabetes - a nationwide cohort study

Background

Hypoglycemic episode (HE) increases the risk of cardiovascular mortality. The impact of HE on the risk of sudden death remains unclear. We hypothesized that HE increases the risks of ventricular arrhythmia (VA) and sudden cardiac arrest (SCA), and that anti-diabetic agents (ADAs) causing hypoglycemia also increase the risks of VA and SCA.

Methods

Patients aged ≥20 years with newly diagnosed diabetes were identified from the Taiwan National Insurance Database. HE was defined as the presentation of hypoglycemic coma or specified/unspecified hypoglycemia. For control group, we included diabetic patients without HE, and they were frequency-matched to the HE group at a 4:1 ratio. The primary outcome was the occurrence of any event of VA (including ventricular tachycardia and fibrillation) and SCA during the defined follow-up periods. Multivariate Cox hazards regression model was used to evaluate the hazard ratio (HR) for VA or SCA.

Results

A total of 54,303 diabetic patients were screened with 1,037 of them in the HE group, and 4,148 in the control group. During a mean follow-up period of 3.3±2.5 years, 29 VA/SCA events had occurred. Compared to the control group, the HE group had a higher incidence of VA/SCA (adjusted HR: 2.42, p=0.04). Diabetic patients medicated with insulin for glycemic control increased the risk of VA/SCA compared to those without insulin (adjusted HR: 3.05, p=0.01).

Kaplan-Meier survival curves

Conclusions

HEs in patients with diabetes increased the risks of VA and SCA compared to those without. Their use of insulin also independently increased the risk of VA/SCA.

Deferred treatment with a fixed-dose combination of sofosbuvir-velpatasvir for chronic hepatitis C virus genotype 1, 2, 4 and 6 infection

Sofosbuvir-velpatasvir is approved for the treatment of chronic hepatitis C virus (HCV) infection. In this single-arm, open-label, phase 3, deferred treatment study, we investigated the efficacy and safety of sofosbuvir-velpatasvir among patients randomized to the placebo group in the ASTRAL-1 study. Patients received sofosbuvir-velpatasvir (400/100 mg) once daily for 12 weeks. The primary efficacy endpoint was the proportion of patients with sustained virologic response 12 weeks after the end of therapy (SVR12). The primary safety endpoint was any adverse events (AEs) leading to the permanent discontinuation of study drug. Overall, 108/111 (97%, 95% confidence interval [CI], 92%-99%) achieved SVR12, and only one patient had virological failure. SVR12 was achieved by 61/63 (97%, 95%CI, 89%-100%) genotype 1 patients, 20/20 (100%; 95%CI, 83%-100%) with genotype 2, 19/19 (100%; 95%CI, 82%-100%) with genotype 4 and 8/9 (89%; 95% CI, 52%-100%) with genotype 6. All (19/19; 95%CI, 82-100) patients with cirrhosis and all (31/31, 95%CI, 89-100) with prior treatment experience achieved SVR12. The safety profile during treatment was similar to that observed in patients receiving placebo treatment. The most common AEs were headache, fatigue and nausea. One patient (1%) discontinued treatment due to an AE of gallbladder carcinoma, which was not considered related to treatment. Of five reported serious AEs, none were considered related to study drug. Sofosbuvir-velpatasvir for 12 weeks was effective and well tolerated among untreated and previously treated patients with HCV genotype 1, 2, 4 or 6 infection, including those with compensated cirrhosis (ClinicalTrials.gov NCT02346721).

Comparison of implant failure rates of different plates for midshaft clavicular fractures based on fracture classifications

Backgrounds

The aim of our study was to investigate failure rates of reconstruction plate and non-reconstruction plate, and find the best strategy for implant selection for different fracture types for midshaft clavicular fractures.

Patients and methods

Two hundred twenty-six consecutive patients with midshaft clavicular fractures who received open reduction and plate fixation during Jan 2012 to July 2017 were reviewed. The correlations between implant failure rates and risk factors including demographic data, fracture classifications, and implant types were analyzed.

Results

AO/OTA fracture classification and plate types are the most important factors affecting implant failure for midshaft clavicular fractures. Reconstruction plate had a significantly higher failure rate (53%) than that of non-reconstruction plates (3%) in comminuted midshaft clavicular (AO/OTA 15-2C) fractures (P value < 0.01). However, the difference was not significant in AO/OTA 15-2A and 2B classifications.

Conclusion

Patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates had very high implant failure rates compared to non-reconstruction plates. We suggested that patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates need more protection and more frequent follow-up in the postoperative period.

Mismatch between femur and tibia coronal alignment in the knee joint: classification of five lower limb types according to femoral and tibial mechanical alignment

Background

Reasons for dissatisfaction with total knee arthroplasty (TKA) include unequal flexion or extension gap, soft tissue imbalance, and patella maltracking, which often occur with mismatch between femoral and tibial coronal bony alignment in the knee joint or extremely varus or valgus alignment. However, lower limb coronal alignment classification is based only on hip–knee–ankle angle (HKAA), leading to oversight regarding a mismatch between femoral and tibial coronal alignment. We aimed to classify alignment of the lower limbs according to the mechanical alignment of the femur and tibia in a healthy population.

Methods

All 214 normal triple films were reviewed retrospectively. HKAA, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), angle between the femoral anatomical axis and the mechanical axis (AA-MA), and knee alignment angle (KAA) were measured. Subjects were categorized into one of five types based on the mechanical alignment of femur and tibia.

Results

Mean HKAA, mLDFA, and mMPTA of all subjects were 1.2°, 87.3°, and 85.8°, respectively. All subjects were classified into one of five types with significant differences (p < 0.001). About 61% of subjects showed neutral alignment, of which nearly 40% were type 2 (valgus of the femur and varus of the tibia with oblique joint line: mLDFA 85.0° ± 1.4°, mMPTA 85.1° ± 1.2°, TJLA 2.7° ± 2.4°) and 60% exhibited neutral alignment with a neutral femur and tibia (type 1). In varus and valgus types, mismatch between the mechanical angle of the femur and tibia was common. Varus alignment, including types 3 (varus of the tibia: mLDFA 88.0° ± 1.4°, mMPTA 83.5° ± 1.6°) and 4 (varus of both the tibia and femur: mLDFA 91.4° ± 1.4°, mMTPA 85.2° ± 2.0°), was found in 30% of subjects. Valgus alignment (type 5 valgus of femur: mLDFA 84.6° ± 1.6°, mMPTA 88.8° ± 2.0°) accounted for 8.9% of all subjects.

Conclusions

Mismatch between mechanical alignment of the femur and tibia was common in varus and valgus alignment types. Joint line obliquity was also observed in 40% of the neutral alignment population. This classification provides a quick, simple interpretation of femoral and tibial coronal alignment, and more detailed guidance for preoperative planning for TKA than the traditional varus–neutral–valgus classification.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2335-9) contains supplementary material, which is available to authorized users.

Ledipasvir-Sofosbuvir Plus Ribavirin in Treatment-Naive Patients With Hepatitis C Virus Genotype 3 Infection: An Open-Label Study

Background

Patients chronically infected with genotype 3 hepatitis C virus (HCV) have faster disease progression and are less responsive to current direct-acting antiviral regimens than patients infected with other genotypes. We conducted an open-label trial to evaluate the safety, tolerability, and efficacy of ledipasvir and sofosbuvir plus ribavirin in patients with genotype 3 HCV infection.

Methods

We enrolled treatment-naive patients with and without compensated cirrhosis at 15 sites in Canada. All patients were treated with ledipasvir-sofosbuvir (90 mg and 400 mg) plus weight-based ribavirin for 12 weeks. The primary endpoint was sustained virologic response 12 weeks after treatment (SVR12). Secondary endpoints included evaluation of baseline and treatment-emergent drug resistance.

Results

Of the 111 patients enrolled, 105 (95%) had subtype 3a HCV and 39 (35%) had compensated cirrhosis. SVR12 was achieved by 99 of 111 patients (89%; 95% confidence interval, 82%-94%). Of the 39 patients with cirrhosis, 31 (79%) achieved SVR12, compared with 68 of 72 (94%) patients without cirrhosis. No treatment-emergent resistance mutations occurred in those who failed treatment. One patient discontinued treatment due to liver cancer and died 22 days after treatment discontinuation. The most common adverse events were fatigue (51%), headache (36%), and nausea (23%).

Conclusions

In this multicenter trial involving treatment-naive patients with genotype 3 HCV, 12 weeks of ledipasvir-sofosbuvir provided a high level of SVR in those without cirrhosis.

Clinical Trials Registration

NCT02413593.

Baseline Factors Associated With Improvements in Decompensated Cirrhosis After Direct-Acting Antiviral Therapy for Hepatitis C Virus Infection

BACKGROUND & AIMS

Treatment with direct-acting antiviral (DAA) agents can reduce Model for End-Stage Liver Disease and Child-Pugh-Turcotte (CPT) scores in patients with decompensated cirrhosis caused by hepatitis C virus. However, many of these patients still die or require liver transplantation. We collected data on baseline features of patients and aimed to develop a scoring system to predict response to DAA therapy.

METHODS

We performed a retrospective analysis of data from 4 trials on the effects of sofosbuvir-based therapy in patients with hepatitis C virus-associated decompensated cirrhosis (502 of CPT class B and 120 of CPT class C). In these trials, patients were given 12 or 24 weeks of treatment with ledipasvir, sofosbuvir, and ribavirin or velpatasvir, sofosbuvir, and/or ribavirin, or 48 weeks of treatment with sofosbuvir and ribavirin. We collected demographic, clinical, treatment response, and laboratory data from patients and tested their associations with patient outcomes at 36 weeks. The primary outcome was factors associated with reduction of CPT score to class A.

RESULTS

The presence of ascites or encephalopathy, serum level of albumin <3.5 g/dL or alanine aminotransferase <60 U/L, and body mass index >25 kg/m² were associated with an increased risk of not achieving a reduction in CPT to class A, independent of sustained viral response to therapy. Serum level of albumin <2.8 g/dL and abnormal level of bilirubin were associated with an increased risk of liver transplantation or death. We developed a scoring system based on 5 baseline factors (body mass index, encephalopathy, ascites, and serum levels of alanine aminotransferase and albumin) associated significantly with patient outcomes, which we called the "BE3A score." For patients with scores of 4-5, the hazard ratio for reduction of CPT score to class A was 52.3 (95% confidence interval, 15.2-179.7).

CONCLUSIONS

We identified 5 baseline factors (body mass index, encephalopathy, ascites, and serum levels of alanine aminotransferase and albumin) associated with a reduction of CPT score to class A in patients with hepatitis C virus-associated decompensated cirrhosis receiving DAA therapy. We developed a predictive score using these factors, called the BE3A score, which can be used as a shared decision-making tool, quantifying the potential benefits of DAA therapy for patients with decompensated cirrhosis.

Sofosbuvir-velpatasvir with ribavirin for 24 weeks in hepatitis C virus patients previously treated with a direct-acting antiviral regimen

The optimal retreatment strategy for patients chronically infected with hepatitis C virus who experience virologic failure after treatment with direct-acting antiviral-based therapies remains unclear. In this multicenter, open-label, phase 2 study, we evaluated the efficacy and safety of a fixed-dose combination of sofosbuvir-velpatasvir (400 mg/100 mg) plus weight-adjusted ribavirin administered for 24 weeks in patients who did not achieve sustained virologic response after prior treatment with direct-acting antiviral regimens that included the nucleotide analogue nonstructural protein 5B inhibitor sofosbuvir plus the nonstructural protein 5A inhibitor velpatasvir with or without the nonstructural protein 3/4A protease inhibitor voxilaprevir. The primary efficacy endpoint was the proportion of patients achieving sustained virologic response at 12 weeks after the cessation of treatment. In total, 63 of 69 (91%; 95% confidence interval, 82%-97%) patients achieved sustained virologic response at 12 weeks, including 36 of 37 (97%; 95% confidence interval, 86%-100%) patients with hepatitis C virus genotype 1 infection, 13 of 14 (93%; 95% confidence interval, 66%-100%) patients with genotype 2 infection, and 14 of 18 (78%; 95% confidence interval, 52%-94%) patients with genotype 3 infection. Most adverse events were of mild or moderate severity. The most frequently reported adverse events were fatigue, nausea, headache, insomnia, and rash. One patient (1%) with genotype 1a infection discontinued all study drugs due to an adverse event (irritability).

CONCLUSION

Retreatment of patients who previously failed direct-acting antiviral-based therapies with sofosbuvir-velpatasvir plus ribavirin for 24 weeks was well tolerated and effective, particularly those with hepatitis C virus genotype 1 or 2 infection. (Hepatology 2017;66:1083-1089).

Severe hypoglycemia and hip fracture in patients with type 2 diabetes: a nationwide population-based cohort study

Hypoglycemia is a major concern in glycemic control. Using the Taiwan National Health Insurance Research Database, we found that the risk of hip fracture was associated with emergency or hospitalization visits of severe hypoglycemia in patients with type 2 diabetes; greater visits were associated with higher incidence of hip fracture.

INTRODUCTION

The objective of the study was to assess the risk of hip fracture among patients with type 2 diabetes mellitus (T2DM) and severe hypoglycemia.

METHODS

Using the National Health Insurance Research database in Taiwan, we identified 2588 patients with T2DM who had developed severe hypoglycemia from 2001 to 2009. A comparison cohort who had never developed severe hypoglycemia was frequency matched at a ratio of approximately 1:2. Multivariate Cox proportional hazard regression analysis was used to evaluate the risk of hip fracture.

RESULTS

During a median follow-up period of 3.9 years, there were 219 hip fracture events in 5173 comparison cohorts and 148 hip fracture events in 2588 hypoglycemia cohorts. The incidence of hip fracture was higher in patients with severe hypoglycemia than without severe hypoglycemia (17.19 vs. 8.83 per 1000 person-years; adjusted HR 1.71, 95% CI = 1.35-2.16). Approximately half of the individuals developed hip fracture within 2 years from the first occurrence of severe hypoglycemia. There was a significant associated trend towards increased hip fracture risk with increasing average visit of severe hypoglycemia per year (p for trend <0.001). Medication analysis showed that patients taking sulfonylurea alone, insulin alone, and insulin secretagogues combined with insulin had a higher associated risk to develop hip fracture.

CONCLUSIONS

Severe hypoglycemia was associated with a higher risk to develop hip fracture. The more the visits of severe hypoglycemia per year indicated the higher associated risk in patients with T2DM. Fall is likely an important reason for severe hypoglycemia in relation to increased risk of hip fracture.

Sofosbuvir and Velpatasvir for the Treatment of Hepatitis C Virus in Patients Coinfected With Human Immunodeficiency Virus Type 1: An Open-Label, Phase 3 Study

BACKGROUND

A safe, simple, effective, and pan-genotypic regimen to treat hepatitis C virus (HCV) infection in patients coinfected with human immunodeficiency virus type 1 (HIV-1) remains a medical need. We assessed the efficacy and safety of the NS5B polymerase inhibitor sofosbuvir and the NS5A inhibitor velpatasvir for HCV in patients coinfected with HIV-1.

METHODS

This phase 3, open-label, single-arm study at 17 sites in the United States enrolled patients with HCV of any genotype and HIV-1 coinfection, including those with compensated cirrhosis. All patients received sofosbuvir-velpatasvir once daily for 12 weeks. The primary endpoint was sustained virologic response 12 weeks after treatment (SVR12). Efficacy and safety were assessed in all patients receiving at least 1 dose of treatment.

RESULTS

Of 106 patients, 91 (86%) were men, 48 (45%) were black, and 19 (18%) had cirrhosis. SVR12 was achieved by 101 of 106 (95% [95% confidence interval {CI}, 89%-99%]) patients: 74 of 78 (95% [95% CI, 87%-99%]) with genotype 1; all 11 (100% [95% CI, 72%-100%]) with genotype 2; 11 of 12 (92% [95% CI, 62%-100%]) with genotype 3; and all 5 (100% [95% CI, 48%-100%]) with genotype 4. All 19 patients with cirrhosis had SVR12. Two patients relapsed, 2 were lost to follow-up, and 1 withdrew consent. Two discontinued treatment due to adverse events and 2 had serious adverse events. The most common adverse events were fatigue (25%), headache (13%), upper respiratory tract infection (8%), and arthralgia (8%).

CONCLUSIONS

Sofosbuvir-velpatasvir for 12 weeks was safe and provided high rates of SVR12 in patients coinfected with HCV and HIV-1.

CLINICAL TRIALS REGISTRATION

NCT02480712.

Sofosbuvir, Velpatasvir, and Voxilaprevir for Previously Treated HCV Infection

BACKGROUND

Patients who are chronically infected with hepatitis C virus (HCV) and who do not have a sustained virologic response after treatment with regimens containing direct-acting antiviral agents (DAAs) have limited retreatment options.

METHODS

We conducted two phase 3 trials involving patients who had been previously treated with a DAA-containing regimen. In POLARIS-1, patients with HCV genotype 1 infection who had previously received a regimen containing an NS5A inhibitor were randomly assigned in a 1:1 ratio to receive either the nucleotide polymerase inhibitor sofosbuvir, the NS5A inhibitor velpatasvir, and the protease inhibitor voxilaprevir (150 patients) or matching placebo (150 patients) once daily for 12 weeks. Patients who were infected with HCV of other genotypes (114 patients) were enrolled in the sofosbuvir-velpatasvir-voxilaprevir group. In POLARIS-4, patients with HCV genotype 1, 2, or 3 infection who had previously received a DAA regimen but not an NS5A inhibitor were randomly assigned in a 1:1 ratio to receive sofosbuvir-velpatasvir-voxilaprevir (163 patients) or sofosbuvir-velpatasvir (151 patients) for 12 weeks. An additional 19 patients with HCV genotype 4 infection were enrolled in the sofosbuvir-velpatasvir-voxilaprevir group.

RESULTS

In the three active-treatment groups, 46% of the patients had compensated cirrhosis. In POLARIS-1, the rate of sustained virologic response was 96% with sofosbuvir-velpatasvir-voxilaprevir, as compared with 0% with placebo. In POLARIS-4, the rate of response was 98% with sofosbuvir-velpatasvir-voxilaprevir and 90% with sofosbuvir-velpatasvir. The most common adverse events were headache, fatigue, diarrhea, and nausea. In the active-treatment groups in both trials, the percentage of patients who discontinued treatment owing to adverse events was 1% or lower.

CONCLUSIONS

Sofosbuvir-velpatasvir-voxilaprevir taken for 12 weeks provided high rates of sustained virologic response among patients across HCV genotypes in whom treatment with a DAA regimen had previously failed. (Funded by Gilead Sciences; POLARIS-1 and POLARIS-4 ClinicalTrials.gov numbers, NCT02607735 and NCT02639247 .).

Integrated risk scoring model for predicting dynamic hip screw treatment outcome of intertrochanteric fracture

BACKGROUND

Dynamic hip screw (DHS) is a common device for treating intertrochanteric fracture (ITF). Various risk factors have been reported to be associated with the operative treatment outcome. However, an integrated risk scoring prediction model is lacking. In this study, we aimed to develop a prediction model for treatment outcome of intertrochanteric fracture.

METHODS

We analyzed 442 AO/OTA 31-A1 and A2 fractures which were treated with DHS during the period January 2000 to June 2014 in a level I trauma center. Risk factors including age, gender, injured side, lag screw position, AO/OTA classification, tip-apex distance, postoperative lateral wall fracture, reduction patterns were analyzed to determine their influence on treatment outcome. Integrated risk scores of significant predictors were used to construct a prediction model.

RESULTS

AO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. The failure risk for low- and high-risk groups were significantly different (P<0.001) CONCLUSION: AO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. We developed a model that integrates these factors to predict the treatment outcome, which had excellent prediction accuracy and discriminatory ability. The models may provide useful information for orthopedic doctors to identify patients who need early intervention as well as ITF patients who require more frequent follow-up in the postoperative period.

Biomechanical Analysis of Implanted Clavicle Hook Plates With Different Implant Depths and Materials in the Acromioclavicular Joint: A Finite Element Analysis Study

Clinical implantation of clavicle hook plates is often used as a treatment for acromioclavicular joint dislocation. However, it is not uncommon to find patients that have developed acromion osteolysis or had peri-implant fracture after hook plate fixation. With the aim of preventing complications or fixation failure caused by implantation of inappropriate clavicle hook plates, the present study investigated the biomechanics of clavicle hook plates made of different materials and with different hook depths in treating acromioclavicular joint dislocation, using finite element analysis (FEA). This study established four parts using computer models: the clavicle, acromion, clavicle hook plate, and screws, and these established models were used for FEA. Moreover, implantations of clavicle hook plates made of different materials (stainless steel and titanium alloy) and with different depths (12, 15, and 18 mm) in patients with acromioclavicular joint dislocation were simulated in the biomechanical analysis. The results indicate that deeper implantation of the clavicle hook plate reduces stress on the clavicle, and also reduces the force applied to the acromion by the clavicle hook plate. Even though a clavicle hook plate made of titanium alloy (a material with a lower Young's modulus) reduces the force applied to the acromion by the clavicle hook plate, slightly higher stress on the clavicle may occur. The results obtained in this study provide a better reference for orthopedic surgeons in choosing different clavicle hook plates for surgery.

Biomechanical analysis of acromioclavicular joint dislocation treated with clavicle hook plates in different lengths

PURPOSE

Clavicle hook plates are frequently used in clinical orthopaedics to treat acromioclavicular joint dislocation. However, patients often exhibit acromion osteolysis and per-implant fracture after undergoing hook plate fixation. With the intent of avoiding future complications or fixation failure after clavicle hook plate fixation, we used finite element analysis (FEA) to investigate the biomechanics of clavicle hook plates of different materials and sizes when used in treating acromioclavicular joint dislocation.

METHODS

Using finite element analysis, this study constructed a model comprising four parts: clavicle, acromion, clavicle hook plate and screws, and used the model to simulate implanting different types of clavicle hook plates in patients with acromioclavicular joint dislocation. Then, the biomechanics of stainless steel and titanium alloy clavicle hook plates containing either six or eight screw holes were investigated.

RESULTS

The results indicated that using a longer clavicle hook plate decreased the stress value in the clavicle, and mitigated the force that clavicle hook plates exert on the acromion. Using a clavicle hook plate material characterized by a smaller Young's modulus caused a slight increase in the stress on the clavicle. However, the external force the material imposed on the acromion was less than the force exerted on the clavicle.

CONCLUSIONS

The findings of this study can serve as a reference to help orthopaedic surgeons select clavicle hook plates.

Paper-based ELISA to rapidly detect Escherichia coli

Escherichia coli is a generic indicator of fecal contamination, and certain serotypes cause food- and water-borne illness such as O157:H7. In the clinic, detection of bacteriuria, which is often due to E. coli, is critical before certain surgical procedures or in cases of nosocomial infection to prevent further adverse events such as postoperative infection or sepsis. In low- and middle-income countries, where insufficient equipment and facilities preclude modern methods of detection, a simple, low-cost diagnostic device to detect E. coli in water and in the clinic will have significant impact. We have developed a simple paper-based colorimetric platform to detect E. coli contamination in 5h. On this platform, the mean color intensity for samples with 10(5)cells/mL is 0.118±0.002 (n=4), and 0.0145±0.003 (P<0.01⁎⁎) for uncontaminated samples. This technique is less time-consuming, easier to perform, and less expensive than conventional methods. Thus, paper-based ELISA is an innovative point-of-care diagnostic tool to rapidly detect E. coli, and possibly other pathogens when customized as appropriate, especially in areas that lack advanced clinical equipment.

Single-blinded, randomised preliminary study evaluating the effects of 2 Hz electroacupuncture for postoperative pain in patients with total knee arthroplasty

OBJECTIVE

To explore the point-specific clinical effect of 2 Hz electroacupuncture (EA) in treating postoperative pain in patients undergoing total knee arthroplasty (TKA), METHODS: In a randomised, partially single-blinded preliminary study, 47patients with TKA were randomly divided into three groups: control group (CG, n=17) using only patient-controlled analgesia (PCA); EA group (EAG, n=16) with 2 Hz EA applied at ST36 (Zusanli) and GB34 (Yanglingquan) contralateral to the operated leg for 30 min on the first two postoperative days, also receiving PCA; and non-point group (NPG, n=14), with EA identical to the EAG except given 1 cm lateral to both ST36 and GB34. The Mann-Whitney test was used to show the difference between two groups and the Kruskal-Wallis test to show the difference between the three groups.

RESULTS

The time until patients first required PCA in the CG was 34.1±22.0 min, which was significantly shorter than the 92.0±82.7 min in the EAG (p<0.001) and 90.7±94.8 min in the NPG (p<0.001); there was no difference between the EAG and NPG groups (p>0.05). The total dosage of PCA solution given was 4.6±0.9 mL/kg body weight in the CG, 4.2±1.0 mL/kg in the EAG and 4.5±1.0 mL/kg in the NPG; there were no significant differences (p>0.05) among the three groups.

CONCLUSIONS

In this small preliminary study, EA retarded the first demand for PCA in comparison with no EA. No effect was seen on the total dosage of PCA required and no point-specific effect was seen.

Trochanter stabilising plate improves treatment outcomes in AO/OTA 31-A2 intertrochanteric fractures with critical thin femoral lateral walls

BACKGROUND

For AO/OTA 31-A2 fractures (A2 fractures) treated with dynamic hip screw (DHS), postoperative lateral wall fracture (PLWF) is thought to be a major cause of femoral medialisation and reoperation. Though trochanter stabilising plate (TSP) had been reported to have a good effect in preventing femoral medialization, its effects and indication in A2 fractures remain controversial. We hypothesized that TSP may improve treatment outcomes in patients with high risk of postoperative lateral femoral wall fractures. The purpose of this study was to investigate (1) the main risk factors predictive of PLWF in A2 fractures and, (2) whether TSP can improve treatment outcomes in patients with high risk of PLWF.

METHODS

Two hundred and fifty-two A2 fractures treated with DHS or DHS and TSP (DHS-TSP) during January 2000 and June 2013 were enrolled in this study. Standard univariate and multivariate analyses were performed to determine statistically significant risk factors for PLWF in 205 patients who were treated with DHS alone. The risk factor found to be associated with PLWF was utilized to include 171 patients who were at high risk of PLWF. Standard univariate and multivariate analyses were performed to evaluate the effect of TSP on treatment outcomes.

RESULTS

Lateral wall thickness was found to be the main risk factor for PLWF in A2 fractures. A lateral wall thickness of 2.24 cm was found to be the best cutoff point to determine which patients were at high risk for PLWF. In 171 patients with a lateral wall thickness less than 2.24 cm, patients treated with DHS-TSP had significantly decreased lag screw sliding distances, PLWF rate, and reoperation rate (P=0.028, <0.001 and P=0.003, respectively) compared to the corresponding values of those treated with DHS alone. In the multivariate analysis, TSP decreased the reoperation rate by 13 times compared to that of patients who were treated with DHS alone.

CONCLUSION

Lateral wall thickness is the main risk factor for PLWF in A2 fractures treated with DHS. Use of TSP in A2 fractures with critical thin lateral wall thickness <2.24 cm can significantly decrease the lag screw sliding distances, PLWF rate and reoperation rate.

The impact of joint range of motion limitations on health-related quality of life in patients with haemophilia A: a prospective study

In patients with haemophilia A, repeated occurrences of haemarthrosis and synovitis lead to limitations in range of motion (ROM) of major joints. However, the effect of limitations in joint ROM on health-related quality of life (HRQOL) in these patients has not been studied previously. The aim of this study was to assess the impact of ROM limitations of 10 major joints (bilateral shoulders, elbows, hips, knees and ankles), combined with other possibly influential factors, on HRQOL in patients with haemophilia A. The ROM limitations in 13 movements and pain intensity of the 10 major joints were measured. The socio-demographic and clinical data were recorded. Short-Form 36 was used as the HRQOL measurement. Eighteen patients (mean age: 36.9 years) were included. Hip ROM limitations, knee ROM limitations and hip pain intensity predicted physical functioning scale (P < 0.001; adjusted R2 = 0.553). Shoulder ROM limitations and age predicted role limitation were due to emotional problems scale (P < 0.001; adjusted R2 = 0.373). Elbow ROM limitations and haemophilia severity predicted mental health scale (P = 0.001; adjusted R2 = 0.320). Hip ROM limitations predicted social functioning scale (P = 0.041; adjusted R2 = 0.091). Educational level and elbow ROM limitations predicted vitality scale (P < 0.001; adjusted R2 = 0.416). The ROM limitations of hip, knee, shoulder and elbow could be predictors for HRQOL in patients with haemophilia A. Improving ROM of major joints could be an appropriate treatment strategy to enhance HRQOL in these patients.

A potential role of myeloid DAP12-associating lectin (MDL)-1 in the regulation of inflammation in rheumatoid arthritis patients

The pathogenic roles of myeloid DAP12-associating lectin-1(MDL-1) and DAP12 in human rheumatoid arthritis (RA) remain unknown. Frequencies of MDL-1-expressing monocytes in 22 active RA patients, 16 inactive RA patients, 12 osteoarthritis (OA) patients and 10 healthy controls (HC) were determined by flow-cytometry analysis. The mRNA expression levels of MDL-1 and DAP12 on PBMCs were evaluated by quantitative PCR, and their protein expression levels in the synovium were examined by immunohistochemistry. Significantly higher median percentages of circulating MDL-1-expressing monocytes were observed in active RA patients (53.6%) compared to inactive RA patients (34.1%), OA patients (27.9%), and HC (21.2%). Levels of MDL-1 and DAP12 gene expression in PBMCs and their protein expression in the synovium were significantly higher in active RA patients than in inactive RA or OA patients. MDL-1 levels were positively correlated with parameters of disease activity, articular damage, and levels of proinflammatory cytokines. MDL-1 activator (Dengue virus type 2 antigen) stimulation on PBMCs resulted in significantly enhanced levels of proinflammatory cytokines in RA patients compared to those in OA patients or HC, indicating that MDL-1 activation is functional. Frequencies of MDL-1-expressing monocytes and levels of MDL-1 and DAP12 gene expression significantly decreased after effective therapy. Concordant overexpression of MDL-1 and DAP12 were correlated with increased production of proinflammatory cytokines in RA patients, suggesting their roles in regulating articular inflammation.

Evaluation of methods and timing in nail dynamisation for treating delayed healing femoral shaft fractures

INTRODUCTION

Dynamisation is a simple method for treating femoral shaft fractures (FSFs) in patients with delayed healing after intramedullary nailing. However, only around half of patients with a slow-healing FSF have been successfully treated with this strategy. Although it is thought that dynamisation with a screw preserved in the dynamic locking hole improves treatment outcome in these patients, to date, no studies have demonstrated empirical evidence supporting this technique. In this study, we investigated the effects of dynamisation with and without rotation and length control as well as timing of dynamisation on treatment outcomes in FSF patients with delayed healing.

PATIENTS AND METHODS

Thirty-nine consecutive acute FSF patients with static locking intramedullary nails who subsequently underwent dynamisation were recruited between January 2000 and June 2011. The indication for dynamisation was the presence of gap caused by bone absorption or over-traction at the fracture site when the locking screws were placed. Age, gender, dynamisation method, fracture classification, duration from nail insertion to dynamisation (i.e., timing of dynamisation) and dynamisation outcome were included in the statistical analysis.

RESULTS

Patients whose nail was dynamised with a screw preserved in the dynamic locking hole had a significantly higher successful bone union rate (14/15 vs. 14/24, p=0.028) compared with those with all screws removed from one end of the nail. The patients treated in 10-24 weeks had a significantly increased chance of bone union than those treated after 24 weeks (p=0.027). A significantly higher bone union rate (p=0.036) was observed in 10-24 weeks (83.3%) than after 24 weeks (33.3%) in the group of dynamisation with all screws removed from one end of the nail. No statistical difference in bone union success rate was found between patients at 10-24 weeks and after 24 weeks in the group of dynamisation with a screw preserved in the dynamic locking hole. There were no significant differences in outcome based on other variables.

CONCLUSION

(1) Dynamisation with a screw preserved in the dynamic locking hole was associated with a higher success rate in bone union than all screws removed from one end of the nail for patients with delayed healing FSFs. (2) Early dynamisation (10-24 weeks) had a better outcome than late dynamisation (>24 weeks). Late dynamisation with all screws removed from one end of the nails resulted in a poor success rate. Alternative treatment should be considered if the latter approach is to be adopted.

Outcomes of arthroscopic double-bundle PCL reconstruction using the LARS artificial ligament

The purpose of this study was to assess the outcomes of posterior cruciate ligament (PCL) reconstruction using the Ligament Augmentation and Reconstruction System (LARS) (JK Orthomedic Ltd, Dollard-des-Ormeaux, Quebec, Canada) artificial ligament. Compared with older artificial ligaments, the LARS, which has been used in Europe for 15 years, is more resistant to wear and tear, has satisfactory torsional fatigue resistance, and has good biocompatibility. The current is study included 38 double-bundle PCL reconstructions using the LARS artificial ligament in 38 patients. Mean patient age was 32.6 years, and mean time from injury to surgery was 6 months. Mean follow-up was 37 months (range, 30-68 months). The study endpoint was 2-year follow-up. Mean Tegner score improved from 3.4 ± 0.6 preoperatively to 6.0 ± 1.4 postoperatively (P<.001), and mean Lysholm score improved from 70.0 ± 11.0 pre-operatively to 91.7 ± 5.5 postoperatively (P<.001). Knee laxity decreased significantly postoperatively (P<.001), and no differences existed at 1- and 2-year follow-up. After surgery using the Y-type LARS artificial ligament, knee function and stability improved. Using the LARS artificial ligament for double-bundle reconstruction of the PCL avoids donor-site morbidity and disease transmission. The complication rate is low, and the results appear to be stable with time and comparable with those obtained with other grafts. Double-bundle PCL reconstruction with the LARS artificial ligament may be an alternative treatment option.

Adiponectin increases MMP-3 expression in human chondrocytes through AdipoR1 signaling pathway

Articular adipose tissue is a ubiquitous component of human joints, and adiponectin is a protein hormone secreted predominantly by differentiated adipocytes and involved in energy homeostasis. The adiponectin is significantly higher in synovial fluid of patients with osteoarthritis and rheumatoid arthritis. Matrix metalloproteinases (MMP)-3 may contribute to the breakdown of articular cartilage during arthritis. We investigated the signaling pathway involved in MMP-3 caused by adiponectin in human chondrocytes. Adiponectin increased the secretion of MMP-3 in cultured human chondrocytes, as shown by qPCR, Western blot, and ELISA analysis. Adiponectin-mediated MMP-3 expression was attenuated by AdipoR1 but not AdipoR2 siRNA. Pretreatment with 5'-AMP-activated protein kinase (AMPK) inhibitor (araA and compound C), p38 inhibitor (SB203580), and NF-κB inhibitor (PDTC and TPCK) also inhibited the potentiating action of adiponectin. Activations of p38, AMPK, and NF-κB pathways after adiponectin treatment were demonstrated. Taken together, our results provide evidence that adiponectin acts through AdipoR1 to activate p38 and AMPK, resulting in the activations of NF-κB on the MMP-3 promoter and contribute cartilage destruction during arthritis.

Elevated serum dehydroepiandrosterone sulphate level correlates with increased risk for metabolic syndrome in the elderly men

BACKGROUND

The previous studies regarding the association between endogenous dehydroepiandrosterone (DHEA) sulphate level and metabolic syndrome are inconsistent. This study aimed to investigate such relationship in elderly Taiwanese men.

MATERIALS AND METHODS

Five hundred and eighty-five elderly Taiwanese men (mean age 68.7 +/- 8.3 years) were enrolled as the baseline cohort population in 2000. In addition to a questionnaire, body mass index (BMI), blood pressure, fasting blood glucose, lipids, albumin and serum DHEA-S levels were measured for each participant. Metabolic syndrome was based on the definition by the America Heart Association/National Heart Lung Blood Institute.

RESULTS

The prevalence of metabolic syndrome was 33.3%. Using multivariate logistic regression analyses with adjustments for age, smoking, alcohol, physical activities, albumin and BMI, there was a positive relationship between serum DHEA-S level and metabolic syndrome. The highest DHEA-S quartile group had increased risk for metabolic syndrome (odds ratio = 2.68, 95% confidence interval: 1.44-5.01, P < 0.01) compared with the lowest quartile group. The mean serum DHEA-S level increased with increasing number of metabolic syndrome components.

CONCLUSIONS

The prevalence of metabolic syndrome increases with elevated DHEA-S levels among elderly Taiwanese men. Thus, elevated serum DHEA-S level should be treated as an important risk factor for metabolic syndrome in elderly men.

Peptidoglycan enhances IL-6 production in human synovial fibroblasts via TLR2 receptor, focal adhesion kinase, Akt, and AP-1- dependent pathway

Peptidoglycan (PGN), the major component of the cell wall of Gram-positive bacteria, activates the innate immune system of the host and induces the release of cytokines and chemokines. We investigated the signaling pathway involved in IL-6 production stimulated by PGN in rheumatoid arthritis synovial fibroblasts. PGN caused concentration- and time-dependent increases in IL-6 production. PGN-mediated IL-6 production was attenuated by TLR2 small interfering RNA and nucleotide-binding oligomerization domain 2 small interfering RNA. Pretreatment with PI3K inhibitor (Ly294002 and wortmannin), Akt inhibitor, and AP-1 inhibitor (tanshinone IIA) also inhibited the potentiating action of PGN. PGN increased the focal adhesion kinase (FAK), PI3K, and Akt phosphorylation. Stimulation of rheumatoid arthritis synovial fibroblast cells with PGN increased the accumulation of phosphorylated c-Jun in the nucleus, AP-1-luciferase activity, and c-Jun binding to the AP-1 element on the IL-6 promoter. PGN mediated an increase in the accumulation of phosphorylated c-Jun in the nucleus, AP-1-luciferase activity, and c-Jun binding to AP-1 element was inhibited by Ly294002, Akt inhibitor, and FAK mutant. Our results suggest that PGN increased IL-6 production in human synovial fibroblasts via the TLR2 receptor/FAK/PI3K/Akt and AP-1 signaling pathway.

Involvement of AdipoR receptor in adiponectin-induced motility and alpha2beta1 integrin upregulation in human chondrosarcoma cells

Chondrosarcoma is a type of highly malignant tumor with a capacity to invade locally and cause distant metastasis. Chondrosarcoma shows a predilection for metastasis to the lungs. Adiponectin is a protein hormone secreted predominantly by differentiated adipocytes and is involved in energy homeostasis. However, the effect of adiponectin on migration activity in human chondrosarcoma cells is mostly unknown. We found that adiponectin increased the migration and expression of alpha2beta1 integrin in human chondrosarcoma cells. The protein and messenger RNA expression of adiponectin receptor (AdipoR1 and AdipoR2) in chondrosarcoma patients and chondrosarcoma cell lines were significantly higher than the normal cartilage. Moreover, primary chondrosarcoma and chondrosarcoma cell lines (SW1353 and JJ012) were more invasive than normal chondrocytes. Adiponectin-mediated migration and integrin expression was attenuated by 5'-adenosine monophosphate-activated protein kinase (AMPK) small interfering RNA and an AMPK inhibitor (Ara A and compound C). Activation of p38 and nuclear factor-kappa B (NF-kappaB) pathways after adiponectin treatment was demonstrated, and adiponectin-induced expression of integrins and migration activity was inhibited by the specific inhibitor and mutant of p38 and NF-kappaB cascades. This study showed for the first time that adiponectin mediates the migration of human chondrosarcoma cells. One mechanism underlying adiponectin-directed migration was transcriptional upregulation of alpha2beta1 integrin and activation of AdipoR receptor, AMPK, p38 and NF-kappaB pathways.

The metabolic syndrome increases cardiovascular mortality in Taiwanese elderly

BACKGROUND

The prevalence of the metabolic syndrome (MetS) is high among the elderly. However, evidence that mortality increases with MetS is rare. In this study, we investigated the relationship between MetS, cardiovascular disease (CVD) and all cause mortality in the elderly.

MATERIALS AND METHODS

A total 10 547 participants, aged 65 years and older, of baseline cohort were recruited from four nationwide Health Screening Centres in Taiwan from 1998 to 1999. The metabolic syndrome was defined according to the America Heart Association/National Heart Lung Blood Institute definition. Cox proportional hazards regression analyses were used to estimate the relative risks (RRs) of CVD and all cause mortality for those with MetS for up to 8 years of follow-up.

RESULTS

The baseline prevalence of MetS was 50.1% (45.6% in men and 54.4% in women, respectively). A total of 1312 participants died; of these, 300 participants died from CVD. Adjusted for age, gender, smoking, total cholesterol and estimated glomerular filtration rate, the RRs for CVD and all cause mortality among participants with MetS were 1.48 (95% confidence interval = 1.16-1.90) and 1.16 (1.03-1.30), respectively, for participants compared to those without MetS. The mean RRs for CVD, however, ranged from 1.21 to 5.31 among different combinations of MetS components.

CONCLUSION

The elderly with MetS, compared to those without MetS, had a higher CVD and all cause mortality in Taiwan. Furthermore, different combinations of MetS components posed different risks to the mortality, which deserves further research in the future.

Clinicopathological and molecular biological features of colorectal cancer in patients less than 40 years of age

BACKGROUND

The aim of the present study was to identify the clinicopathological and molecular biological characteristics of early-onset colorectal cancers.

METHODS

The clinicopathological and molecular biological parameters of 138 consecutive patients with colorectal cancer aged less than 40 years were compared with those of 339 patients aged 60 years or more.

RESULTS

The younger patients with colorectal cancer had more mucin-producing (14.5 versus 4.7 per cent; P < 0.001) and poorly differentiated (7.2 versus 3.3 per cent; P = 0.015) tumours, a higher incidence of synchronous (5.8 versus 1.2 per cent; P = 0.007) and metachronous (4.0 versus 0.6 per cent; P = 0.023) colorectal cancers, and more advanced tumour stage (P < 0.001) than older patients. The operative mortality rate was lower (0.7 versus 5.0 per cent; P = 0.026), and cancer-specific survival was similar (in stage I, II and III disease; P > 0.05) or better (in stage IV disease; 95 per cent confidence interval 22.50 to 28.41 versus 12.61 to 17.05 months; P < 0.001). There was a higher percentage of normal p53 expression (61.1 versus 46.8 per cent; P = 0.023) and high-frequency microsatellite instability (MSI-H) (29.4 versus 6.3 per cent; P < 0.001), and a similar family history of cancer (17.5 versus 14.2 per cent; P > 0.05), compared with older patients.

CONCLUSION

Young patients with colorectal cancer have several distinct clinicopathological and molecular biological features. The mechanisms underlying the inconsistency between the presence of MSI-H and a family history of cancer in these early-onset colorectal cancers deserve further investigation.

Clinical features and outcome of crush syndrome caused by the Chi-Chi earthquake

BACKGROUND AND PURPOSE

Few reports exist concerning the peak serum concentration of creatine kinase (CK) and the severity of crush syndrome, and the efficacy of fasciotomy in crush syndrome patients remains controversial. This study aimed to analyze and assess the clinical features, treatment, and outcome of patients with crush syndrome sustained in the Chi-Chi earthquake in September 21, 1999.

METHODS

Pertinent data were collected from major hospitals in central Taiwan via questionnaire. Patients with a peak serum CK concentration of more than 1,000 U/L within 2 weeks following the earthquake were included in the study. Eight hospitals responded and a total of 95 patients were included for the analysis.

RESULTS

Forty-four patients (46.3%) with acute renal failure were found to have a serum creatinine level of more than 159 mumol/L (1.8 mg/dL) or daily urine output of less than 400 mL. Thirty patients (31.6%) required hemodialysis, which completely restored renal function. The incidence of acute oliguria, acute renal failure, and the need for hemodialysis were significantly increased if the peak CK concentration was more than 50,000 U/L (p < 0.01). Thirty-five patients underwent fasciotomy to treat compartment syndrome caused by crush syndrome. Among these, 31 patients (88.6%) had a peak CK concentration higher than 10,000 U/L. The incidence of acute renal failure (p < 0.01) and the need for hemodialysis (p < 0.01) were significantly higher in the fasciotomy group than in the non-fasciotomy group. Eight patients developed superficial infection and 16 developed deep infections after fasciotomy. Six patients underwent amputations and one patient died of sepsis due to uncontrolled infection of the fasciotomy wound.

CONCLUSION

CK concentration is a good indicator of the occurrence of acute renal failure and the need for dialysis. The high infection rate and amputation rate after fasciotomy may be due to inadequate debridement. Fasciotomy in crush syndrome patients with high serum CK concentrations should be deliberated.

Topoisomerase II poisoning by ICRF-193

Antineoplastic bis(dioxopiperazine)s, such as meso-2,3-bis(2,6-dioxopiperazin-4-yl)butane (ICRF-193), are widely believed to be only catalytic inhibitors of topoisomerase II. However, topoisomerase inhibitors have little or no antineoplastic activity unless they are topoisomerase poisons, a special subclass of topoisomerase-targeting drugs that stabilize topoisomerase-DNA strand passing intermediates and thus cause the topoisomerase to become a cytotoxic DNA-damaging agent. Here we report that ICRF-193 is a very significant topoisomerase II poison. Detection of topoisomerase II poisoning by ICRF-193 required the use of a chaotropic protein denaturant in the topoisomerase poisoning assays. ICRF-193 caused dose-dependent cross-linking of human topoisomerase IIbeta to DNA and stimulated topoisomerase IIbeta-mediated DNA cleavage at specific sites on (32)P-end-labeled DNA. Human topoisomerase IIalpha-mediated DNA cleavage was stimulated to a lesser extent by ICRF-193. In vivo experiments with MCF-7 cells also showed the requirement of a chaotropic protein denaturant in the assays and selectivity for the beta-isozyme of human topoisomerase II. Studies with two topoisomerase IIbeta-negative cell model systems confirmed significant topoisomerase II poisoning by ICRF-193 in the wild type cells and were consistent with beta-isozyme selectivity. Common use of only the detergent, SDS, in assays may have led to failure to detect topoisomerase II poisoning by ICRF-193 in earlier studies.

Pinworm control and risk factors of pinworm infection among primary-school children in Taiwan

Longitudinal pinworm (Enterobius vermicularis) infection rates were estimated at a mass screening for first-grade children during 1991-1996; children were provided medication at the screening. This campaign was able to decrease the infection rates for the 1991 cohort from 16.3% to 0.6%. A case-control study was further conducted for the investigation of risk factors among fourth-graders. Cases comprised 429 children with at least one infection between September 1996 to June 1999, and controls were 280 randomly selected uninfected classmates. Parents were asked to complete a questionnaire survey to report students' personnel hygiene habits. The case-control study revealed that significant factors associated with the infection included playing on the floor (odds ratio [OR], 2.5), nail biting (OR, 2.1), failure to wash hands before meals (OR, 1.7) and living in nonapartment dwellings (OR, 1.6). Girls were at a higher, but not significant, risk (OR, 1.4), than boys. In conclusion, inadequate personal hygiene increases the risk for pinworm infection. The mass screening-medication campaign can be adapted to countries with a similar parasitic problem.

Oxidation of chlorinated ethenes by potassium permanganate: a kinetics study

The kinetics of oxidation of perchloroethylene (PCE), trichloroethylene (TCE), three isomers of dichloroethylene (DCE) and vinyl chloride (VC) by potassium permanganate (KMnO(4)) were studied in phosphate-buffered solutions of pH 7 and ionic strength approximately 0.05 M and under isothermal, completely mixed and zero headspace conditions. Experimental results have shown that the reaction appears to be second order overall and first order individually with respect to both KMnO(4) and all chlorinated ethenes (CEs), except VC. The degradation of VC by KMnO(4) is a two-consecutive-step process. The second step, being the rate-limiting step, is of first order in VC and has an activation energy (E(a)) of 7.9+/-1 kcal mol(-1). The second order rate constants at 20 degrees C are 0.035+/-0.004 M(-1) s(-1) (PCE), 0.80+/-0.12 M(-1) s(-1) (TCE), 1.52+/-0.05 M(-1) s(-1) (cis-DCE), 2.1+/-0.2 M(-1) s(-1) (1,1-DCE) and 48.6+/-0.9 M(-1) s(-1) (trans-DCE). The E(a) and entropy (DeltaS(*)) of the reaction between KMnO(4) and CEs (except VC) are in the range of 5.8-9.3 kcal mol(-1) and -33 to -36 kcal mol(-1) K(-1), respectively. Moreover, KMnO(4) is able to completely dechlorinate CEs, and the increase in acidity of the solution due to CE oxidation by KMnO(4) is directly proportional to the number of chlorine atoms in CEs.

Serum leptin and leptin receptor isoforms in omental adipose tissue of nondiabetic women undergoing gynecologic surgery for benign disease

BACKGROUND AND PURPOSE

Leptin is important in the regulation of fat mass and body weight. Adipose tissue not only secretes leptin but also serves as a site of action for leptin. This study was designed to examine the relationships among tissue expression of leptin receptors, serum leptin, and body mass index.

METHODS

Omental adipose tissue and fasting blood samples were obtained from 57 nondiabetic women who underwent surgery for either myoma of the uterus or ovarian cyst. Tissue RNA was extracted using Trizol reagent and serum leptin concentrations were determined with commercial kits. The leptin receptor isoforms in tissues were quantified using real-time Taqman technology.

RESULTS

Three leptin receptor isoforms, Ob-Rb, HuB219.1, and HuB219.3, were found in human omental adipose tissue. The amounts of HuB219.1 and HuB219.3 mRNA relative to that of Ob-Rb were 1314.2 and 16.7, respectively. Higher body mass index was significantly correlated with an increase in serum leptin concentration and a decrease in leptin receptor HuB219.1 isoform in omental fat, even after adjustment for age and menopausal status. There was no direct association between serum leptin concentration and tissue HuB219.1 mRNA level.

CONCLUSIONS

HuB219.1 is the major isoform of leptin receptor expressed in human omental adipose tissue. Our findings suggest that the shorter leptin receptor isoforms in human omental adipose tissue might play an important role in body weight control. Further studies on the inter-relationship between leptin concentrations and multiple leptin receptor isoforms are needed to elucidate the exact mechanism of obesity.

Interword spacing in Chinese text layout

Three experiments using Chinese text were conducted to investigate word spacing and its effect on reading performance. In Exp. 1, a sonogram detector was used to analyze interword and intercharacter (within a word) time intervals from text read aloud by professional TV broadcasters versus college graduates. The results showed interword intervals were significantly longer than intercharacter intervals, indicating that interword spacing has psychological reality in speech. Exp. 2 examined the effect on reading performance due to separating the characters that compose a word. Separating the characters of a word did not decrease reading accuracy but did result in significantly longer reading times. Exp. 3 explored the effect of word spacing in Chinese sentences on reading performance. Analysis showed that word spacing did not affect reading accuracy, but half character and whole-character spacing significantly reduced reading time. The results of the present study suggest that word spacing in Chinese text layout enhances reading performance. Word spacing may help the reader to segment more quickly a string of characters into words and reduce the likelihood of misinterpretation. Also, ambiguity of sentence structure severely degraded reading accuracy. The implications of the results for word spacing design in Chinese text are discussed.

A probability prediction rule for malignant cervical lymphadenopathy using sonography

BACKGROUND

Our purpose was to weigh various sonographic parameters as predicting malignant cervical lymphadenopathy and build a reliable prediction rule.

METHODS

One hundred and eighty-nine cervical lymph node lesions from 125 consecutive patients were used for building the prediction model. Sonographic variables, including 15 morphologic features of B-mode, 5 vascular parameters of color Doppler mode, along with age and sex, were analyzed with multivariate logistic regression to evaluate the joint effect of a set of independent variables. A prediction rule for malignant lymphadenopathy was established, and prospective validation was assessed on a new group consisting of 100 lymph nodes from another 60 consecutive patients.

RESULTS

The association of heterogeneous content, long transverse diameter, pathologic vascular pattern, high vascular density, and older age provided the most robust prediction value. Scoring scale was designed as 1x (age) + 2x (vascularity index) + 3x (short axis) + 4x (vascular pattern) + 4x (internal echo) according to the parameter estimates of multivariate logistic regression analysis. Cut-off value of score >==10 as malignancy resulted in 89.2% sensitivity and 85.2% specificity. Prospective validation also showed satisfactory results (sensitivity, 82.9%; specificity, 86.2%).

CONCLUSIONS

By measuring only 4 sonographic parameters and age, this prediction rule could provide the physician a nonconfusing and reliable probability reference for managing cervical lymphadenopathy.

Effects of word spacing on reading Chinese text from a video display terminal

This study investigated the effects of designing space between words in Chinese text, i.e., whether using a "word" instead of a "character" as a presentation unit, will facilitate the performance of reading from a video display terminal. Experimental results indicated that the main effect of word spacing significantly affected the reading time and the number of questions answered correctly. Subjects spent less time on the text with half-character word spacing or with whole-character word spacing than with conventional type (without word spacing). We also discovered that the number of questions answered correctly for stimuli with half-character spacing is significantly greater than that for stimuli with whole-character spacing, while both are smaller than for stimuli with conventional type. The additional variables, such as text difficulty and display control have significant effects as well. Our results suggested that the optimal word spacing in Chinese text should be greater than that in the traditional layout and less than a whole-character spacing. Apparently, in Chinese text, using a "word" as a presentation unit is more favorable than the traditional layouts that do not have any explicit word boundaries. The word spacing design may benefit in reading difficult or unfamiliar materials and further apply in emergency situations or in reading ambiguous sentences.

[The reasonable design of the combined spinal epidural needles (CSEN) in aneasthesia]

This paper discusses the reasonable factors of parameters in CSEN design and has also raised some useful reasonable parameters concerned.

XK469, a selective topoisomerase IIbeta poison

XK469 (NSC 697887) is a synthetic quinoxaline phenoxypropionic acid derivative that possesses unusual solid tumor selectivity and activity against multidrug-resistant cancer cells. We report here that XK469 and its S(-) and R(+)-isomers induce reversible protein-DNA crosslinks in mammalian cells. Under protein denaturing conditions, the protein-DNA crosslinks are rendered irreversible and stable to DNA banding by CsCl gradient ultracentrifugation. Several lines of evidence indicate that the primary target of XK469 is topoisomerase IIbeta. Preferential targeting of topoisomerase IIbeta may explain the solid tumor selectivity of XK469 and its analogs because solid tumors, unlike leukemias, often have large populations of cells in the G(1)/G(0) phases of the cell cycle in which topoisomerase IIbeta is high whereas topoisomerase IIalpha, the primary target of many leukemia selective drugs, is low.

Maintenance of episomal SV40 genomes in GM637 human fibroblasts

Episomal SV40 (SV40: simian virus 40, Polyomavirus maccacae) has been reported in SV40-transformed human fibroblast cell lines the integrated SV40 sequences of which are unlikely to give rise to episomal copies by recombinational mechanisms. The levels of episomal viral DNA in these lines are high, being easily visualized by ethidium staining of agarose gels after electrophoresis. We find that the episomal mutant gmSV40 in GM637 cells represents a persistent lytic infection that can be cured by treatment with neutralizing antibody, leaving only the chromosomally integrated viral genomes. The finding that maintenance of the gmSV40 in GM637 cells is due to persistent infection raises a note of caution for SV40-transformed lines with episomal SV40 genomes because these lines often are used in studies of DNA replication and repair. An infective center assay that does not depend on plaque formation shows that gmSV40 is a host range mutant, with poor infectivity for CV-1 monkey kidney cells and greatly increased infectivity for human cells. Passage of gmSV40 through monkey kidney cells selects for variants with greatly increased infectivity for monkey cells and, independently, for cytopathic variants that produce plaques. Thus plaque assays can give very unreliable infective center values in studies of host range mutants.

Anterior tarsal tunnel syndrome: case report

Anterior tarsal tunnel syndrome is a rare entrapment neuropathy involving the deep peroneal nerve beneath the inferior extensor retinaculum of the ankle and foot. This syndrome may be a clinically under-recognized entity, thus making a missed diagnosis and delayed treatment likely. We present the case of a 53-year-old woman who for many years had experienced the clinical symptoms of anterior tarsal tunnel syndrome, including pain in the dorsum of the right foot with numbness radiating to the first web space. Roentgenograms of the foot revealed osteophytes on the dorsum of the talus as it articulated with the navicular bone. During surgery, the osteophytes were found to be irritating the deep peroneal nerve. After surgical decompression of the anterior tarsal tunnel, the patient had a significant reduction of symptoms. One year later, she was noted to be asymptomatic with normal physical findings. We believe that this case points to the necessity of more thoughtful attention to this syndrome and its diagnosis. That is to say, a thorough knowledge of the pathogenesis and a comprehensive physical examination are the prerequisites for correct diagnosis and appropriate treatment.

Characterization of a new ribotoxin gene (c-sar) from Aspergillus clavatus

A new ribotoxin, c-sarcin, was isolated from a culture of Aspergillus clavatus. A full-length genomic DNA (c-sar) coding for c-sarcin was cloned and sequenced. The deduced amino acid sequence showed a high homology to restrictocin and alpha-sarcin. The native toxin as well as the recombinant protein hydrolysed ribosomes and naked RNA. The genomic structure of the c-sar gene had an intron located between the coding sequences for secretory signal peptide and the mature protein. The intron contained a stretch of 38 adenines. The intron sequence of c-sar was different from that of restrictocin but resembled that of alpha-sarcin. There was 34% identity between the intron of c-sarcin and alpha-sarcin, and this similarity was further increased to 83% if the stretch of polyadenine was omitted.