[Development of a Ranking Tool for Scientificity, Transparency and Applicability of Clinical Practice Guidelines]

Objective: To address the limitations of existing methods and tools for evaluating clinical practice guidelines, we aimed to develop a comprehensive instrument focusing on the three main dimensions of guideline development: scientificity, transparency, applicability. We will use it to rank the guidelines according to the scores. We abbreviated it as STAR, and its reliability, validity and usability were also tested. Methods: A multidisciplinary expert working group was set up, including methodologists, statisticians, journal editors, medical professionals, and others. Scoping review, Delphi methods and hierarchical analysis were used to determine the final checklist of STAR. Results: The new instrument contained 11 domains and 39 items. Intrinsic reliability of each domain was indicated by Cronbach's α coefficient, with a average value of 0.646. The Cohen's kappa coefficients for methodological evaluators and clinical evaluators were 0.783 and 0.618. The overall content validity index was 0.905. The R2 for the criterion validity analysis was 0.76. The average score for usability of the items was 4.6, and the mean time spent to evaluate each guideline was 20 minutes. Conclusion: The instrument has good reliability, validity and evaluating efficiency, and can be used for evaluating and ranking guidelines more comprehensively.

[Practice guideline for patients with osteoporosis]

In recent years, osteoporosis (OP) has become one of the main diseases affecting the health of middle-aged and elderly people in China, and the prevalence of OP has increased significantly. The clinical diagnosis and treatment guidelines for this disease are also constantly updated. The overall principles speciallyemphasise that doctors and patients need to work together to negotiate the details of the diagnosis and treatment guidelines, in order to improve the OP clinical diagnosis and treatment rate. Therefore, patients' knowledge of the disease, understanding of clinical guidelines, and cooperation with doctors to implement diagnosis and treatment plans are very important. In this study, from the most concerned issues of the patients, we established the OP patient practice guideline working group. 14 recommendations, as the OP patient practice guidelines, are proposed in accordance with the relevant principles of the "World Health Organization guidelines development manual" and the international normative process.

Pancreas Transplantation After Liver Transplantation: A Case Report

Our aim was to describe the clinical indications, surgical technique, and clinical outcomes of a pancreas transplantation, performed 4 years after liver transplantation, as treatment for new-onset, uncontrolled diabetes mellitus in a 53-year-old man. Liver transplantation was performed for end-stage liver disease secondary to hepatitis B virus infection and hepatocellular carcinoma. The patient had no history of diabetes prior to the liver transplantation. The decision to proceed with a pancreas transplantation was made when the patient's blood sugar levels could not be normalized despite insulin doses >100 IU/d. A modified cadaveric transplantation technique was used, with the recipient's inferior vena cava dissected for anastomosis with the portal vein of the graft, using a diamond-shaped patch procedure. Moreover, the right common iliac artery was anastomosed with a Y-graft in the pancreas graft, and the duodenum remnant of the graft was anastomosed to the recipient's duodenum using a side-to-side procedure. The 6-month postoperative follow-up included repeated endoscopic biopsy of the graft duodenum, with no evidence of thrombosis or rejection of the graft, with glucose level within normal limits without requirement for diabetic drugs. To our knowledge, this is the first reported case of pancreas transplantation after liver transplantation.

Inferior Vena Cava-Duodenal Drainage in Pancreas Alone Transplantation for Chronic Pancreatitis: A Case Report

Enteric drainage has been the main trend in solitary pancreas transplantation. Compared with bladder drainage, it does not cause metabolic or urologic complications, but there is no way to perform immunologic monitoring, except by graft pancreas biopsy. Additionally, although portal drainage of the graft vein is considered physiological drainage, it has more of a risk for surgical complications. To overcome these disadvantages, we successfully performed inferior vena cava (IVC)-duodenal drainage in pancreas alone transplantation. A 44-year-old man underwent pancreas alone transplantation. He had insulin-dependent diabetes because of chronic pancreatitis, thus he had taken a pancreatic enzyme. After right-sided medial visceral rotation, the IVC was dissected for anastomosis with a graft portal vein. The right common iliac artery was anastomosed with a Y-graft in the pancreas graft. The graft duodenum was anastomosed with recipient duodenum using the side-to-side manner. Postoperatively, he underwent protocol biopsies of the graft duodenum through endoscopy two times. There was no evidence of graft thrombosis or rejection. He had a normal glucose level without any diabetic drugs, and he required no pancreatic enzyme for digestion. The IVC-duodenum drainage procedure was a feasible method for preventing thrombosis and providing an opportunity for direct graft monitoring through endoscopy.

Complete Regression of Recurrent Advanced Hepatocellular Carcinoma After Liver Transplantation in Response to Sorafenib Treatment: A Case Report

Liver transplantation is a potentially curative treatment for hepatocellular carcinoma. However, patients with recurrent hepatocellular carcinoma after liver transplantation have few treatment options and local treatment may not be feasible. Sorafenib, an orally active multikinase inhibitor approved for the treatment of advanced hepatocellular carcinoma, significantly improves progression-free and overall survival. However, only a few studies have evaluated the efficacy of sorafenib in patients with recurrent hepatocellular carcinoma following liver transplantation. Here, we report a case of a patient with recurrent advanced hepatocellular carcinoma after living donor liver transplantation who achieved complete remission in response to sorafenib treatment. The patient has survived for more than 4 years post-transplantation.

Effect and safety of paroxetine for vasomotor symptoms: systematic review and meta-analysis

BACKGROUND

Paroxetine is the first non-hormone therapy for vasomotor symptoms (VMS) approved based on the results of two phase 3, randomised, placebo-controlled trials by the Food and Drug Administration (FDA) in 2013.

OBJECTIVE

To confirm the effect and safety of paroxetine for vasomotor symptoms (VMS).

SEARCH STRATEGY

MEDLINE, EMBASE, PsycINFO, CENTRAL, WHO International Clinical Trials Registry Platform (ICTRP) and four Chinese databases was searched from the date of their inception to 7 June 2014.

SELECTION CRITERIA

We included RCTs on the effect of paroxetine compared with placebo or no treatment for perimenopausal and postmenopausal women who experienced moderate-to-severe vasomotor symptoms.

DATA COLLECTION AND ANALYSIS

Two reviewers screened records and extracted the information independently. The included studies were appraised by two independent reviewers using the Cochrane risk of bias tool. We synthesised the data in random-effects models and rated the quality of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.

MAIN RESULTS

Five articles with six RCTs (1571 participants) were included. Paroxetine significantly reduced the frequency of hot flushes by 8.86 per week (95% confidence interval (CI) 5.69-12.04, P < 0.00001, I(2)  = 83%) at week 4 and 7.36 per week (95% CI, 4.25-10.46, P < 0.00001, I(2)  = 62%) at week 12. The quality of the evidence on the effect of paroxetine for VMS was moderate.

CONCLUSIONS

There was moderate quality of evidence supporting the effectiveness of paroxetine for vasomotor symptoms; however, it causes nausea and dizziness.

TWEETABLE ABSTRACT

Review finds paroxetine effective for menopausal symptoms with some side effects: evidence strength moderate.

Vaginal deployment and tenofovir delivery by microbicide gels

Gels are one of the soft material platforms being evaluated to deliver topically acting anti-HIV drugs (microbicides) to the vaginal environment. For each drug, its loaded concentration, gel properties and applied volume, and frequency of dosing can be designed to optimize PK and, thence, PD. These factors also impact user sensory perceptions and acceptability. Deterministic compartmental modeling of vaginal deployment and drug delivery achieved by test gels can help delineate how multiple parameters characterizing drug, vehicle, vaginal environment, and dosing govern details of PK and PD and also gel leakage from the canal. Such microbicide delivery is a transport process combining convection, e.g., from gel spreading along the vaginal canal, with drug diffusion in multiple compartments, including gel, mucosal epithelium, and stroma. The present work builds upon prior models of gel coating flows and drug diffusion (without convection) in the vaginal environment. It combines and extends these initial approaches in several key ways, including: (1) linking convective drug transport due to gel spreading with drug diffusion and (2) accounting for natural variations in dimensions of the canal and the site of gel placement therein. Results are obtained for a leading microbicide drug, tenofovir, delivered by three prototype microbicide gels, with a range of rheological properties. The model includes phosphorylation of tenofovir to tenofovir diphosphate (which manifests reverse transcriptase activity in host cells), the stromal concentration distributions of which are related to reference prophylactic values against HIV. This yields a computed summary measure related to gel protection ("percent protected"). Analyses illustrate tradeoffs amongst gel properties, drug loading, volume and site of placement, and vaginal dimensions, in the time and space history of gel distribution and tenofovir transport to sites of its anti-HIV action and concentrations and potential prophylactic actions of tenofovir diphosphate therein.

A systematic review on the use of daily subcutaneous administration of teriparatide for treatment of patients with osteoporosis at high risk for fracture in Asia

This systematic review aimed to examine the evidence for teriparatide in Asia for osteoporosis with a high fracture risk and for exploratory (unapproved) bone-related indications. MEDLINE (1946+), EMBASE (1966+), and ClinicalTrials.gov (2008+) were searched (16 August 2013); all studies of daily subcutaneous teriparatide 20 μg for bone-related conditions from China, Hong Kong, Japan, Republic of Korea, Philippines, Singapore, and Taiwan were included. Evidence on efficacy/safety was retrieved primarily from randomized controlled trials (10 publications) of postmenopausal women from Japan and China. In these studies, teriparatide was well tolerated; subjects had significantly greater increases in lumbar spine bone mineral density (BMD) from baseline compared with placebo, antiresorptive agents, or elcatonin/calcitonin; bone turnover markers increased from baseline and were sustained at elevated levels during teriparatide treatment. Few studies reported fracture risk, pain, or quality of life; one study showed a lower incidence of new-onset vertebral fracture with teriparatide versus antiresorptive agents. Nonrandomized studies (nine publications, one unpublished trial) conducted mainly in Taiwan, Japan, and the Republic of Korea provided supporting data for efficacy. The exploratory (unapproved) use of teriparatide (17 publications) for fracture healing and osteonecrosis of the jaw was described primarily in case reports. The clinical effectiveness of teriparatide for treatment of postmenopausal women with osteoporosis who are at high risk of fracture in Asia is focused primarily on improvements in BMD and tolerability. Recommended additional studies may include assessment of fracture risk and the effect of teriparatide on pain, quality of life, and mortality in Asia.

Efficacy and safety of LCI699 for hypertension: a meta-analysis of randomized controlled trials and systematic review

OBJECTIVE

This study reviews the available data from randomized controlled trials on efficacy and safety of LCI699, a novel inhibitor of aldosterone synthase, as treatment of hypertension.

MATERIALS AND METHODS

We performed a meta-analysis of phase II randomized, controlled trials comparing the efficacy/safety of LCI699 with placebo in hypertension patients. For this purpose, PubMed, Embase, Cochrane Library database, ISI-Science Citation Index, and the Chinese Biomedicine Literature Database were searched until August 2013. The available data on mean sitting systolic blood pressure (MSSBP), mean sitting diastolic blood pressure (MSDBP), adverse effects, renin-angiotensin-aldosterone system biomarkers (RAASB) and adrenocorticotropic hormone-stimulated cortisol concentration (AHSC) were collected. All data were analyzed using Review Manager, version 5.2.

RESULTS

The present study finally included three randomized controlled trials, comprising of 623 patients in total. The daily use of ≥ 1 mg LCI699 was associated with a significant reduction of MSSBP (Weighted mean difference/WMD = -8.80, 95% CI: -11.31 to -5.68, p < 0.00001, I2 = 0%) and MSDBP (WMD = -4.94, 95% CI: -7.49 to -2.40, p = 0.00001, I2 = 9%). Adverse reactions occurred in 73 of the 139 patients (52.51%) treated with LCI699 and in 34 of the 63 patients (53.96%) treated with placebo. Pooled meta-analysis showed that the use of LCI699 was associated with no increased risk of side effects compared with placebo (RR = 0.90; 95% CI: 0.68 to 1.18, p = 0.43, I2 = 0%). Suppression of plasma aldosterone was measured at all doses of LCI699 treatment groups. LCI699 suppressed the ACTH-stimulated cortisol response in a dose- and time-dependent manner.

CONCLUSIONS

Current evidence indicates that the novel aldosterone inhibitor LCI699 is an effective and well-tolerated antihypertensive agent that lowers plasma aldosterone concentration and produces a mild ACTH-stimulated cortisol response suppressive effect.

The Hybrid III upper and lower neck response in compressive loading scenarios with known human injury outcomes

OBJECTIVE

Physical biomechanical surrogates are critical for testing the efficacy of injury-mitigating safety strategies. The interpretation of measured Hybrid III neck loads in test scenarios resulting in compressive loading modes would be aided by a further understanding of the correlation between the mechanical responses in the Hybrid III neck and the probability of injury in the human cervical spine. The anthropomorphic test device (ATD) peak upper and lower neck responses were measured during dynamic compressive loading conditions comparable to those of postmortem human subject (PMHS) experiments. The peak ATD response could then be compared to the PMHS injury outcomes.

METHODS

A Hybrid III 50th percentile ATD head and neck assembly was tested under conditions matching those of male PMHS tests conducted on an inverted drop track. This includes variation in impact plate orientation (4 sagittal plane and 2 frontal plane orientations), impact plate surface friction, and ATD initial head/neck orientation. This unique matched data with known injury outcomes were used to evaluate existing ATD neck injury criteria.

RESULTS

The Hybrid III ATD head and neck assembly was found to be robust and repeatable under severe loading conditions. The initial axial force response of the ATD head and neck is very comparable to PMHS experiments up to the point of PMHS cervical column buckle or material failure. An ATD lower neck peak compressive force as low as 6,290 N was associated with an unstable orthopedic cervical injury in a PMHS under equivalent impact conditions. ATD upper neck peak compressive force associated with a 5% probability of unstable cervical orthopedic injury ranged from as low as 3,708 to 3,877 N depending on the initial ATD neck angle.

CONCLUSIONS

The correlation between peak ATD compressive neck response and PMHS test outcome in the current study resulted in a relationship between axial load and injury probability consistent with the current Hybrid III injury assessment reference values. The results add to the current understanding of cervical injury probability based on ATD neck compressive loading in that it is the only known study, in addition to Mertz et al. (1978), formulated directly from ATD compressive loading scenarios with known human injury outcomes.

Toward a more robust lower neck compressive injury tolerance-an approach combining multiple test methodologies

OBJECTIVE

The compressive tolerance of the cervical spine has traditionally been reported in terms of axial force at failure. Previous studies suggest that axial compressive force at failure is particularly sensitive to the alignment of the cervical vertebra and the end conditions of the test methodology used. The present study was designed to develop a methodology to combine the data of previous experiments into a diverse data set utilizing multiple test methods to allow for the evaluation of the robustness of current and proposed eccentricity based injury criteria.

METHODS

Data were combined from 2 studies composed of dynamic experiments including whole cervical spine and head kinematics that utilized different test methodologies with known end conditions, spinal posture, injury outcomes, and measured kinetics at the base of the neck. Loads were transformed to the center of the C7-T1 intervertebral disc and the eccentricity of the sagittal plane resultant force relative to the center of the disc was calculated. The correlation between sagittal plane resultant force and eccentricity at failure was evaluated and compared to the correlation between axial force and sagittal plane moment and axial force alone.

RESULTS

Accounting for the eccentricity of the failure loads decreased the scatter in the failure data when compared to the linear combination of axial force and sagittal plane moment and axial force alone. A correlation between axial load and sagittal plane flexion moment at failure (R² = 0.44) was identified. The sagittal plane extension moment at failure did not have an identified correlation with the compressive failure load for the tests evaluated in this data set (R² = 0.001). The coefficients of determination for the linear combinations of sagittal plane resultant force with anterior and posterior eccentricity are 0.56 and 0.29, respectively. These correlations are an improvement compared to the combination of axial force and sagittal plane moment.

CONCLUSIONS

Results using the outlined approach indicate that the combination of lower neck sagittal plane resultant force and the anterior-posterior eccentricity at which the load is applied generally correlate with the type of cervical damage identified. These results show promise at better defining the tolerance for compressive cervical fractures in male postmortem human subjects (PMHS) than axial force alone. The current analysis requires expansion to include more tolerance data so the robustness of the approach across various applied loading vectors and cervical postures can be evaluated.

Morphological changes of the lateral meniscus in end-stage lateral compartment osteoarthritis of the knee

OBJECTIVE

The aim of this study was to evaluate the morphological changes of the lateral meniscus in end-stage lateral compartment osteoarthritis (OA) of the knee.

METHODS

One hundred fifty-eight knee joints from 133 patients that subsequently underwent total knee joint arthroplasty from January 2008 to December 2009 were enrolled. There were 26 men and 107 women. Their ages ranged from 56 to 81 (mean 67.4 ± 6.5 years). All study participants had complete obliteration of the lateral joint space identified by weight-bearing radiography. Meniscal position was assessed by measuring meniscal subluxation and meniscal height. The meniscal morphology was assessed using a modification of the whole-organ magnetic resonance imaging score (WORMS). The frequency of different meniscal morphology and their respective positions was calculated.

RESULTS

The predominant type (42.4%, 53.8% and 52.5% in the anterior horn, mid-body and posterior horn, respectively) of abnormal meniscal morphology was a complete maceration/destruction or complete resection. The anterior horn of non-macerated lateral meniscus was more subluxed than that of the non-macerated medial meniscus in patients with lateral OA.

CONCLUSION

This study suggests that the lateral meniscus in persons with end-stage lateral OA are mostly macerated or destroyed. Also, unlike isolated end-staged medial compartment OA, the anterior horn of the lateral meniscus in isolated end-stage lateral OA is commonly affected.

The effects of laparoscopic vs. open gastric bypass for morbid obesity: a systematic review and meta-analysis of randomized controlled trials

The aim of this meta-analysis was to assess the effects of laparoscopic vs. open gastric bypass for morbid obesity. A systematic review of the literature was undertaken to assess randomized controlled trials on laparoscopic and open gastric bypass for morbid obesity. Six randomized controlled trials involving a total of 422 patients were included. There were 214 patients in the laparoscopic group and 208 patients in the open group separately. Compared with open surgery, laparoscopic surgery for morbid obesity could significantly shorten hospital stays (WMD=-1.11 d, 95% confidence interval [CI][-1.65, -0.56]). However, laparoscopic surgery for morbid obesity showed higher re-operation (RR=4.82, 95% CI [1.29, 17.98]) and longer surgical time (WMD=28.00 min, 95% CI [7.84, 48.16]). There were no statistical differences in complication (RR=0.84, 95% CI [0.64, 1.10]) and weight loss (WMD=1.00 kg m(-2), 95% CI [-0.79, 2.79]). The effects of laparoscopic and open gastric bypass for morbid obesity were basically the same except that laparoscopic had a shorter hospital stay and open surgery had a rate of fewer re-operations and shorter surgical time. Further high-quality, long follow-up period randomized controlled trials should be carried out to provide more reliable evidence.

Formation of distinct inclusion bodies by inhibition of ubiquitin-proteasome and autophagy-lysosome pathways

Accumulation of misfolded proteins is caused by the impairment of protein quality control systems, such as ubiquitin-proteasome pathway (UPP) and autophagy-lysosome pathway (ALP). In this study, the formation of inclusion bodies was examined after the blockade of UPP and/or ALP in A549 cells. UPP inhibition induced a single and large inclusion body localized in microtubule-organizing center. Interestingly, however, ALP inhibition generated dispersed small inclusion bodies in the cytoplasm. Tuberous sclerosis complex 2 was selectively accumulated in the inclusion bodies of UPP-inhibited cells, but not those of ALP-inhibited cells. Blockade of transcription and translation entirely inhibited the formation of inclusion body induced by UPP inhibition, but partially by ALP inhibition. Moreover, the simultaneous inhibition of two protein catabolic pathways independently developed two distinct inclusion bodies within a single cell. These findings clearly demonstrated that dysfunction of each catabolic pathway induced formation and accumulation of unique inclusion bodies on the basis of morphology, localization and formation process in A549 cells.

Capecitabine/oxaliplatin as first-line treatment for metastatic colorectal cancer: a meta-analysis

OBJECTIVE

A meta-analysis of randomized controlled trials (RCT) was carried out to determine the efficacy and safety of capecitabine plus oxaliplatin (CAPOX) or fluorouracil plus oxaliplatin (FUOX) as first-line treatment for metastatic colorectal cancer (MCRC).

METHOD

A literature search was conducted of the Cochrane Controlled Trials Register Databases, Medline, Embase, ISI databases and Chinese Biomedical Literature Database without exclusion of material published in any language. RCTs conducted between 1998 and 2008 of CAPOX compared with FUOX regimens were considered for inclusion. Statistical analyses were carried out using RevMan software.

RESULTS

Ten RCTs were included, involving 3208 patients. The meta-analysis showed that there were no statistically significant differences in tumour response rate (RR, 0.93; 95% CI, 0.87-1.01; P = 0.09), progression-free survival (PFS) (RR, 0.98; 95% CI, 0.94-1.01; P = 0.19), and overall survival (OS) (RR, 1.02; 95% CI, 0.97-1.07; P = 0.47) between CAPOX and FUOX regimen. However, symptoms of thrombocytopenia and hand-foot syndrome (HFS) were increased in the CAPOX regimen (RR, 1.89; 95% CI, 1.33-2.69; P = 0.0004 and RR, 3.40; 95% CI, 2.25-5.15; P < 0.00001 respectively), while neutropenia and leucopenia occurred more frequently in the FUOX regimen (RR, 0.29; 95% CI, 0.15-0.55; P = 0.0002 and RR, 0.41; 95% CI, 0.18-0.95; P = 0.04 respectively).

CONCLUSION

CAPOX was equivalent to FUOX in terms of tumour response rate, progression-free survival (PFS), and OS in first-line treatment for patients with MCRC, which may be considered as standard first-line treatment in patients with MCRC.

Bioengineered skin in diabetic foot ulcers

OBJECTIVE

Bioengineered skin (BS) has been shown to play an important role in the treatment of diabetic foot ulcers (DFUs). Whether BS in the therapy of DFU can improve the outcomes still remains uncertain. We performed a quantitative meta-analysis of available randomized controlled trials to determine the effectiveness and safety of BS in the treatment of patients with DFUs.

DESIGN AND METHODS

Comprehensive search strategies of various electronic databases were used for this study to evaluate the effectiveness and safety between BS and conventional treatment (CT) in patients with DFU, and only randomized controlled trials were adopted in our review. Search terms included 'bioengineered skin', 'tissue-engineering skin', 'human-tissue graft', 'human-skin device', 'living-skin equivalent' and 'diabetic foot', 'diabetic ulcer', 'diabetic wound'. Analysis outcomes included complete wound closure, complications, ulcer recurrence and adverse severe events (ASEs).

RESULTS

Seven randomized controlled trials on BS vs. CT were included, and 880 participants met inclusion criteria. Pooled analysis showed a significant effectiveness and safety advantages for BS treatment compared to CT for patients with DFUs. In analysis of complications, only statistically significant difference of infection was noted. And no included trials reported ASEs related to these treatments.

CONCLUSIONS

Based on the meta-analysis, patients with DFUs may benefit from the BS because of its high effectiveness and safety and reduced risk for infections in comparison to CT.

Induction with and without antithymocyte globulin combined with cyclosporine/tacrolimus-based immunosuppression in renal transplantation: a meta-analysis of randomized controlled trials

OBJECTIVE

The objective of this study was to conduct a meta-analysis of randomized controlled trials (RCT) to compare the effectiveness and safety of induction with and without antithymocyte globulin (ATG) combined with cyclosporine/tacrolimus-based immunosuppression in renal transplantation.

METHODS

Trials were identified through a computerized literature search of PubMed, EMBASE, Cochrane controlled trials register, Cochrane Renal Group Specialized Register of RCTs, and Chinese Biomedical database. Two independent reviewers assessed trials for eligibility and quality, and then extracted data. Data were extracted for patient and graft survival, acute rejection, the incidence of Banff, cytomegalovirus (CMV) infection, leukopenia, and thrombocytopenia. Dichotomous outcomes were reported as relative risk (RR) with 95% confidence intervals (CI).

RESULTS

Four RCTs (892 patients) were identified. The data showed that induction with ATG was more beneficial than no induction with ATG to reduce the incidence of chronic rejection (RR 0.70; 95% CI, 0.57-0.84) and acute rejection within 6 months (RR 0.68; 95% CI, 0.49-0.96) and at 12 months (RR 0.67; 95% CI, 0.50-0.89) as well as Banff II episodes (RR 0.53; 95% CI, 0.30-0.91), but increased the incidences of CMV infection (RR 1.61; 95% CI, 1.27-2.04) and leukopenia (RR 3.88; 95% CI, 2.80-5.38) and thrombocytopenia (RR 2.92; 95% CI, 1.77-4.04). There was no statistical difference between patient or graft survival rates at 6 and 12 months, as well as the incidences of Banff III or Banff I after transplantation.

CONCLUSION

Based on available data induction with ATG was more efficient to reduce the rate of acute rejection episodes and chronic rejection responses after renal transplantation, but was associated with increased side effects, particularly CMV infections. It is important to provide the most benefit for an individual patient.

Microbial ecology and performance of ammonia oxidizing bacteria (AOB) in biological processes treating petrochemical wastewater with high strength of ammonia: effect of Na(2)CO(3) addition

This study evaluated nitrification performance and microbial ecology of AOB in a full-scale biological process, powder activated carbon treatment (PACT), and a pilot-scale biological process, moving bed biofilm reactor (MBBR), treating wastewater collected from a petrochemical industry park. The petrochemical influent wastewater characteristics showed a relative low carbon to nitrogen ratio around 1 with average COD and ammonia concentrations of 310 mg/L and 325 mg-N/L, respectively. The average nitrification efficiency of the full-scale PACT process was around 11% during this study. For the pilot-scale MBBR, the average nitrification efficiency was 24% during the Run I operation mode, which provided a slightly better performance in nitrification than that of the PACT process. During the Run II operation, the pH control mode was switched from addition of NaOH to Na(2)CO(3), leading to a significant improvement in nitrification efficiency of 51%. In addition to a dramatic change in nitrification performance, the microbial ecology of AOB, monitored with the terminal restriction fragment length polymorphism (T-RFLP) molecular methodology, was found to be different between Runs I and II. The amoA-based TRFLP results indicated that Nitrosomonas europaea lineage was the dominant AOB population during Run I operation, while Nitrosospira-like AOB was dominant during Run II operation. To confirm the effects of Na(2)CO(3) addition on the nitrification performance and AOB microbial ecology observed in the MBBR process, batch experiments were conducted. The results suggest that addition of Na(2)CO(3) as a pH control strategy can improve nitrification performance and also influence AOB microbial ecology as well. Although the exact mechanisms are not clear at this time, the results showing the effects of adding different buffering chemicals such as NaOH or Na(2)CO(3) on AOB populations have never been demonstrated until this study.

The main functions and structural modifications of tripeptide N-formyl-methionyl-leucyl-phenylalanine (fMLP) as a chemotactic factor

Gram negative bacteria-derived and synthetic N-formyl peptides play a key role in host defense as chemotactic factors for phagocytic leukocytes. The first compound to be identified was N-formylmethionyl-leucyl-phenylalanine (fMLP) which contains highly potent leukocyte chemoattractant. Natural fMLP was subsequently purified and identified in supernatants of gram negative bacteria. Recently, much more attention has been focused on the human formyl peptide receptor (FPR) and its variant formyl peptide receptor-like 1 (FPRL1) and formyl peptide receptor-like 2 (FPRL2). Chemotactic factors such as fMLP interact with their specific cell surface receptors, which results in multiple biological responses through a G protein-coupled signal pathway. In this review, the functions and structural modifications of fMLP are discussed in view of future drug development.

Inhibition of atopic dermatitis-like skin lesions by topical application of a novel ceramide derivative, K6PC-9p, in NC/Nga mice

Atopic dermatitis (AD) is a chronic inflammatory skin disease that commonly begins in childhood. K6PC-9p (N-(Ethyl dihydrogenphosphate)-2-hexyl-3-oxo-decanamide) is a synthetic ceramide derivative of PC-9S (N-Ethanol-2-mirystyl-3-oxo-staramide), which was known to be effective in atopic patients. In this study, we examined the effect of topical application of K6PC-9p on skin inflammation and AD-like skin lesions in mouse models. K6PC-9p dose-dependently inhibited phorbol ester-induced increase in ear thickness in BALB/c mice. Moreover, topical application of K6PC-9p suppressed dust mite extract-induced AD-like skin lesions in NC/Nga mice. Histopathological analysis revealed that both ear swelling and leucocyte infiltration were suppressed by K6PC-9p treatment. K6PC-9p also suppressed IL-4 and TNF-alpha expression in the ears and mast cell infiltration into the ears in NC/Nga mice. Further study demonstrated that K6PC-9p inhibited ConA-induced IL-4 secretion and LPS-induced macrophage activation. Taken together, our results showed that topical application of K6PC-9p exerts beneficial effects in animal model of skin inflammation and AD, suggesting that K6PC-9p might be a promising topical agent for the treatment of inflammatory skin diseases.

Actin-sequestering protein, thymosin-beta-4 (TB4), inhibits caspase-3 activation in paclitaxel-induced tumor cell death

Thymosin-beta-4 (TB4) as an actin-sequestering peptide has been detected outside of cells in blood plasma or in wound fluid. TB4 induces tumor metastasis and paclitaxel resistance, which is the most significant obstacle to successful therapy in tumors. Here we investigated the inhibitory effect of TB4 peptides on tumor cell death by paclitaxel. The effect of TB4 peptides was assayed by the measurement of caspase-3 activity, G2/M arrest, and Bcl-2 phosphorylation. Cell survival rate was increased and caspase-3 activity was decreased by the treatment with TB4 peptides. In contrast, small interfering RNA (siRNA) of TB4 inhibited cell viability and augmented caspase-3 activity. Significant changes in Bcl-2 phosphorylation were detected by TB4 peptide treatment or by the overexpression of TB4 gene in Hela cells. The reduced population in G2/M phase by TB4 peptide treatment was correlated with the decreased expression of cyclin B1. The data were confirmed in gastric tumor cell lines, SNU 638 (low TB4 level) and SNU 668 (high TB4 level), which were established from clinically isolated gastric tumors. In conclusion, soluble TB4 peptides produced in cancer cells could be an obstacle to treat tumors with paclitaxel. Therefore, TB4 could be a novel target to control paclitaxel resistance.

Differential role of peroxiredoxin II (PrxII) on the expression of toll-like receptor 4 (TLR4) and B-cell activating factor (BAFF) in ovalbumin (OVA)-induced mouse asthma

Peroxiredoxin II (PrxII) is one of reactive oxygen species (ROS)-degrading enzyme. Here, we investigated the role of PrxII on toll-like receptor 4 (TLR4) and B-cell activating factor (BAFF) expression in ovalbumin (OVA)-induced mouse asthma. We used ROS-producing PrxII-/- mice of which cells up-regulate BAFF expression. As significant changes were detected in TLR4 mRNA with real-time quantitative RT-PCR analysis, TLR4 protein was decreased in PrxII-/- mouse splenocytes and peritoneal macrophages, compared to wild type cells. Airway hyper-responsiveness (AHR) was more severe in PrxII-/- mice than wild type mice, which was measured by the level of various parameters, number of eosinophils, IgE level, airway thickness, and mucous secretion. BAFF was detected in cells surrounding airways of OVA-induced mouse and it was highly augmented in PrxII-/- mice. BAFF promoter activity was also higher in PrxII-/- mouse embryonic fibroblast (MEF) than in wild type MEF. Collectively, results show that PrxII may have benefits in asthma through reducing ROS. It suggests that BAFF and TLR4 expressions are differentially regulated by PrxII and TLR4 protein level may not be crucial in OVA-induced asthma.

Topical application of a novel ceramide derivative, K6PC-9, inhibits dust mite extract-induced atopic dermatitis-like skin lesions in NC/Nga mice

Atopic dermatitis (AD) is a chronic inflammatory skin disease. K6PC-9 (N-Ethanol-2-hexyl-3-oxo-decanamide) is a novel synthetic ceramide derivative of PC-9S (N-Ethanol-2-mirystyl-3-oxo-stearamide), which was known to be effective in atopic and psoriatic patients. To investigate the immunomodulatory activity of K6PC-9, we examined the effect of K6PC-9 on T lymphocyte and macrophage function and the effect of topical application of K6PC-9 on skin inflammation and AD-like skin lesions in mouse models. K6PC-9 had no effect on concanavalin A-induced proliferation, interleukin (IL)-2 secretion and IL-4 secretion in mouse splenocytes. In contrast, lipopolysaccharide-induced nitrite generation was potently suppressed by K6PC-9 in mouse peritoneal macrophages. In mouse model of skin inflammation, K6PC-9 inhibited phorbol ester-induced increase in ear thickness and expression of tumor necrosis factor-alpha in the ear of BALB/c mice. Topical application of K6PC-9 also suppressed mite extract-induced AD-like skin lesions in NC/Nga mice. Increase in ear thickness was significantly inhibited by K6PC-9 in this model. K6PC-9 also blocked the infiltration of mast cells and neutrophils into the ear. Further study demonstrated that the mRNA expression of tumor necrosis factor-alpha and adhesion molecules, such as vascular cell adhesion molecule-1, intercellular adhesion molecule-1, E-selectin, was also suppressed by K6PC-9 in the ear of mite extract-treated NC/Nga mice. Taken together, the results presented in this report show that K6PC-9 has an anti-inflammatory potential and exerts beneficial effects in an animal model of AD, indicating that K6PC-9 might be used as a topical agent for the treatment of AD.

Sensitivity of the tibio-femoral response to finite element modeling parameters

A generic finite element (FE) model of the lower limb was used to study the knee response in-vivo during a one-legged hop. The approach uses an explicit FE code and a combination of estimated muscle forces and measured three-dimensional tibio-femoral kinematics and ground reaction force as input to the FE model. The sensitivity of the simulated tibio-femoral response to variations of key geometric and material parameters was investigated by performing a total of 38 different simulations. The amplitudes of both kinematic and kinetic responses were affected by the change of these parameters. For the current approach, the results suggest that while cartilage mechanical and geometric properties are very important for the estimation of tibio-femoral cartilage pressure, they have limited effects on the overall kinematic response. The study may help to better define the relative importance of modeling parameters for the development of subject-specific models.

Steroid Withdrawal Increases Risk of Acute Rejection but Reduces Infection: A Meta-Analysis of 1681 Cases in Renal Transplantation

OBJECTIVE

To evaluate the safety of steroid withdrawal in renal transplantation recipients.

METHODS

These following databases were searched: Medline (1966 to September 2005), OVID (1966 to 2004), Embase (1984 to 2004), Cochrane library (issue 4, 2005), Highwire (1849 to September 2005), American Transplant Congress (2005), Chinese Biomedicine database (CBM 1994 to 2005). The safety was measured by the following factors: patient and graft survival, acute rejection, chronic rejection, infection, serum creatinine. We performed meta-analysis by using Revman 4.2.7.

RESULTS

Nine randomized clinical trials were identified to have a steroid withdrawal and a steroid continuing group. They included 1681 patients: 845 with steroid withdrawal and 836 with continuing steroid. The risk of acute rejection after steroid withdrawal was two times higher than steroid-continuing group (RR 2.05; 95% confidence interval [CI]: 1.54, 2.72; P < .00001), while the incidence of opportunistic infection and urinary tract infection of steroid withdrawal group were lower than the control group (RR 0.80; 95%CI 0.64, 1.00; P = .05 vs RR 0.74; 95%CI, 0.60, 0.92; P = .004, respectively). The graft and patient survivals, chronic rejection, and serum creatinine were similar to the steroid continuing group.

CONCLUSION

Steroid withdrawal can significantly increase the risk of acute rejection episodes, but reduces the incidence of infection to a certain extent. To prophylaxis against serious infection, steroid withdrawal is worth considering using a sufficient immunosuppressive regimen. The key point is to balance the benefit and harm for the individual recipient.

A mechanism of injury to the forefoot in car crashes

OBJECTIVE

The purpose of this study was to determine a mechanism of injury of the forefoot due to impact loads and accelerations as noted in some frontal offset car crashes.

METHODS

The impact tests conducted simulated knee-leg-foot entrapment, floor pan intrusions, whole-body deceleration, muscle tension, and foot/pedal interaction. Specimens were impacted at speeds of up to 16 m/s. To verify this injury mechanism research was conducted in an effort to produce Lisfranc type injuries and metatarsal fractures. A total of 54 lower legs of post-mortem human subjects were tested. Two possible mechanisms of injury were investigated. For the first mechanism the driver was assumed to be braking hard with the foot on the brake pedal and at 0 deg plantar flexion (Plantar Nominal Configuration) and the brake pedal was in contact with the foot behind the ball of the foot. The second mechanism was studied by having the ball of the foot either on the brake pedal or on the floorboard with the foot plantar-flexed 35 to 50 deg (Plantar Flexed Configuration).

RESULTS

The Plantar Nominal injury mechanism yielded few injuries of the type the study set out to produce. Out of 13 specimens tested at speeds of 16 m/s, three had injuries of the metatarsal (MT) and tarsometatarsal joints. The Plantar Flexed Configuration injury mechanism yielded 65% injuries at high (12.5-16 m/s) and moderate (6-12 m/s) speeds.

CONCLUSION

It is concluded that Lisfranc type foot injuries are the result of impacting the forefoot in the Plantar Flexed Configuration. The injuries were consistent with those reported by physicians treating accident victims and were verified by an orthopedic surgeon during post impact x-ray and autopsy. They included Lisfranc fractures, ligamentous disruptions, and metatarsal fractures.

Head injuries in airbag-equipped motor vehicles with special emphasis on AIS 1 and 2 facial and loss of consciousness injuries

OBJECTIVES

Safety of the airbag supplemental restraint system (airbag) is a well-known concern. Although many lives are saved each year through airbag use, injuries continue to occur, especially to the head. Airbag safety research has focused primarily on severe injuries, while minor and moderate injuries have been largely ignored.

METHODS

In this study, 205,977 injury cases from the 1995 to 2001 National Automotive Sampling System (NASS)/ Crashworthiness Data System (CDS) were surveyed to determine the prevalence of AIS 1 and 2 facial and brain loss of consciousness (LOC) injuries and determine if these injuries are a concern. The query was focused on frontal impacts in vehicles equipped with airbags. Only occupants wearing appropriate seatbelts were included in this study so that the airbag would provide occupant protection under optimal conditions. Of the 205,977 injury cases studied, 2.4% met this criterion.

RESULTS

From the data gathered, the trends seem to indicate an increase in these specific injuries, both in terms of the total number and the proportion to all injury cases. In 1995, AIS 1 and 2 head injuries accounted for 96.5% of all head injuries caused by airbags. By 2001, the percentage had risen 3.0% to 99.5%. Injuries occurring in vehicles equipped with first-generation versus second generation airbags were compared, and data seem to suggest that there is a higher rate of minor and moderate head injuries when occupants are in second-generation airbag-equipped vehicles, even when appropriate lap and shoulder belts are used.

CONCLUSIONS

The short timeframe surveyed prevents drawing meaningful conclusions about statistical significance, but the graphical representations of the data in this study underscore an urgent need for further investigation based on current trends in order to understand the issue of minor and moderate head injury prevention in regard to airbags.

Strain-rate dependent material properties of the porcine and human kidney capsule

This study was performed to characterize the mechanical properties of the kidney capsular membrane at strain-rates associated with blunt abdominal trauma. Uniaxial quasi-static and dynamic tensile experiments were performed on fresh, unfrozen porcine and human renal capsules at deformation rates ranging from 0.0001 to 7 m/s (strain-rates of 0.005-250 s(-1)). Single stroke, dynamic tests were performed on samples of porcine renal capsule at strain-rates of 0.005 s(-1) (n = 33), 0.05 s(-1) (n = 17), 0.5 s(-1) (n = 38), 2 s(-1) (n = 10), 4 s(-1) (n = 10), 50 s(-1) (n = 21), 100 s(-1) (n = 18), 150 s(-1) (n = 17), 200 s(-1) (n = 10), and 250 s(-1) (n = 17). Due to limited availability of human tissues, only quasi-static tests were performed (0.005 s(-1), n = 25). Porcine renal capsule properties were found to match the material properties of human capsular tissue sufficiently well such that porcine tissue material can be used as a human test surrogate. The apparent elastic modulus and breaking stress of the porcine renal capsule were observed to increase significantly with increasing strain-rate (p < 0.01). Breaking strain was inversely related to strain-rate (p < 0.01). The effect of increasing strain-rate on material properties diminished appreciably at rates exceeding 150 s(-1). Empirically derived mathematical models of constitutive behavior were developed using a hyperelastic/viscoelastic Ogden formulation, as well as a Cowper-Symonds law material curve multiplication.

Development and calibration of a load sensing cervical distractor capable of withstanding autoclave sterilization

In surgery of the cervical spine, a Caspar pin distractor is often used to apply a tensile load to the spine in order to open up the disc space. This is often done in order to place a graft or other interbody fusion device in the spine. Ideally a tight interference fit is achieved. If the spine is over distracted, allowing for a large graft, there is an increased risk of subsidence into the endplate. If there is too little distraction, there is an increased risk of graft dislodgement or pseudoarthrosis. Generally, graft height is selected from preoperative measurements and observed distraction without knowing the intraoperative compressive load. This device was designed to give the surgeon an assessment of this applied load. Instrumentation of the device involved the application of strain gauges and the selection of materials that would survive standard autoclave sterilization. The device was calibrated, sterilized and once again calibrated to demonstrate its suitability for surgical use. Results demonstrate excellent linearity in the calibration, and no difference was detected in the pre- and post-sterilization calibrations.

Lactoferrin works as a new LPS-binding protein in inflammatory activation of macrophages

Though lactoferrin (LF) is a glycoprotein that is involved in immunomodulation, its action mechanism has not been fully elucidated. Previous studies have suggested that lipopolysaccharide (LPS) activity is inhibited by direct binding between LPS and LF. However, here we show that when LPS and purified LF was mixed, and formed a complex (termed as LF-LPS), it was found to induce production of inflammatory mediators in macrophages to some extent, rather than inhibit LPS activity. Moreover, when macrophages were pretreated with LF-LPS, cells were rendered a tolerant state to LPS challenge. These macrophage-activating effects were mediated by Toll-like receptor 4 (TLR4)-NF-kappaB pathway. Comparative studies with C3H/HeN and C3H/HeJ mice demonstrated the strong dependency of the LF-LPS signal on TLR4. These findings suggest that the immunomodulatory properties of LF could be due, in part, to LPS binding.

A new method to investigate in vivo knee behavior using a finite element model of the lower limb

Several finite element models have been developed for estimating the mechanical response of joint internal structures, where direct or indirect in vivo measurement is difficult or impossible. The quality of the predictions made by those models is largely dependent on the quality of the experimental data (e.g. load/displacement) used to drive them. Also numerical problems have been described in the literature when using implicit finite element techniques to simulate problems that involve contacts and large displacements. In this study, a unique strategy was developed combining high accuracy in vivo three-dimensional kinematics and a lower limb finite element model based on explicit finite element techniques. The method presents an analytical technique applied to a dynamic loading condition (impact during hopping on one leg). The validation of the lower limb model focused on the response of the whole model and the knee joint in particular to the imposed 3D femoral in vivo kinematics and ground reaction forces. The approach outlined in this study introduces a generic tool for the study of in vivo knee joint behavior.

Protection against lipopolysaccharide-induced sepsis and inhibition of interleukin-1β and prostaglandin E2 synthesis by silymarin

Silymarin is known to have hepatoprotective and anticarcinogenic effects. Recently, anti-inflammatory effect of silymarin is attracting an increasing attention, but the mechanism of this effect is not fully understood. Here, we report that silymarin protected mice against lipopolysaccharide (LPS)-induced sepsis. In this model of sepsis, silymarin improved the rate of survival of LPS-treated mice from 6 to 38%. To further investigate the mechanism responsible for anti-septic effect of silymarin, we examined the inhibitory effect of silymarin on interleukin-1beta (IL-1beta) and prostaglandin E2 (PGE2) production in macrophages. Silymarin dose-dependently suppressed the LPS-induced production of IL-1beta and PGE2 in isolated mouse peritoneal macrophages and RAW 264.7 cells. Consistent with these results, the mRNA expression of IL-1beta and cyclooxygenase-2 was also completely blocked by silymarin in LPS-stimulated RAW 264.7 cells. Moreover, the LPS-induced DNA binding activity of nuclear factor-kappaB/Rel was also inhibited by silymarin in RAW 264.7 cells. Taken together, these results demonstrate that silymarin has a protective effect against endotoxin-induced sepsis, and suggest that this is mediated, at least in part, by the inhibitory effect of silymarin on the production of IL-1beta and PGE2.

2-Acetylaminofluorene inhibits interleukin-1β production in LPS-stimulated macrophages by blocking NF-κB/Rel activation

In the present study, we demonstrate the inhibitory effect of 2-acetylaminofluorene (AAF) on interleukin-1beta (IL-1beta) gene expression in lipopolysaccharide (LPS)-stimulated macrophages. Acetylaminofluorene inhibited IL-1 production in LPS-stimulated splenic macrophages and RAW 264.7 cells. Additionally, AAF also suppressed LPS-induced mRNA expression of IL-1beta in macrophages. To further characterize the molecular mechanism responsible for AAF-mediated suppression of IL-1beta, we investigated the effect of AAF on LPS-mediated activation of transcription factors, such as NF-kappaB, AP-1, CRE and NF-IL6, which are known to be important for LPS-induced gene expression of IL-1beta. Treatment of AAF caused a dose-related inhibition of LPS-induced NF-kappaB/Rel transcriptional activation, while the transcriptional activation of AP-1, CRE and NF-IL6 was not affected by AAF. Furthermore, LPS-induced NF-kappaB/Rel DNA binding was also suppressed by AAF treatment. These results suggest that AAF inhibits IL-1beta gene expression by blocking NF-kappaB/Rel activation.

Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella

Comminuted and displaced fractures of the inferiorole of the patella are not easy to reduce and it is difficult to fix the fragments soundly enough to allow early movement of the knee. We have evaluated the clinical effectiveness of the separate vertical wiring technique in acute comminuted fractures of the inferior pole of the patella. A biomechanical study was also performed using ten pairs of embalmed cadaver knees. A four-part fracture was made on the inferior pole of the patella and fixed by two separate vertical wires on one side and two pull-out sutures after partial patellectomy on the other. The ultimate load to failure in the first group was significantly higher than in the second (250.1+/- 109.7 N v 69.7 +/- 18.9 N, p < 0.002), as was the stiffness (279.9 +/- 76.4 N/mm v 23.2 +/- 11.4 N/mm, p < 0.001). The separate wire technique was used in 25 patients with comminuted fractures of the inferior pole of the patella who were followed up for a mean period of 22 months (10 to 50). All the fractures healed at a mean of seven weeks (6 to 10). No breakage of a wire or infection occurred. The mean grading at the final follow-up was 29.5 points (27 to 30) using the Böstman method. This technique preserved the length of the patella, fixed the comminuted fragments of the inferior pole and avoided long-term immobilisation of the knee.

Silymarin inhibits TNF-alpha-induced expression of adhesion molecules in human umbilical vein endothelial cells

Silymarin is known to have an anti-atherosclerotic activity, but the mechanism responsible for it remains unclear. Here, we demonstrate a possible mechanism involved in the anti-atherosclerotic activity of silymarin. Silymarin inhibited THP-1 cell adhesion to human umbilical vein endothelial cells (HUVECs). Silymarin also suppressed the TNF-alpha-induced protein and mRNA expression of adhesion molecules, such as VCAM-1, ICAM-1 and E-selectin, in HUVECs. Moreover, silymarin suppressed the TNF-alpha-induced DNA binding of NF-kappaB/Rel in HUVECs. Taken together, these results demonstrate that silymarin exerts an anti-atherosclerotic activity, at least in part, by inhibiting the expression of adhesion molecules.

Antagonism of aryl hydrocarbon receptor-dependent induction of CYP1A1 and inhibition of IgM expression by di-ortho-substituted polychlorinated biphenyls

Halogenated aromatic hydrocarbons (HAHs) are ubiquitous environment contaminants that produce many of their toxic effects by binding to the aryl hydrocarbon receptor (AhR). However, several investigations have demonstrated that certain polychlorinated biphenyl (PCB) congeners, principally di-ortho-chlorinated PCB congeners, or mixtures containing multiple di-ortho-chlorinated PCBs, inhibit AhR-mediated responses induced by other toxic HAHs. Most relevant to the present study are past reports demonstrating antagonism by these uniquely acting PCB congeners on AhR agonist-mediated inhibition of humoral immune responses. The mechanism responsible for antagonism of AhR agonists by certain PCBs is presently unknown. The present study evaluated the antagonist activity of several di-ortho-substituted PCB congeners [PCB47 (2,2',4,4'), PCB52 (2,2',5,5'), PCB128 (2,2',3,3',4,4'), and PCB153 (2,2',4,4',5,5')] when present in combination with AhR agonists [TCDD (2,3,7,8,-tetrachlorodibenzo-p-dioxin), PCB126 (3,3',4,4',5), and PCB77 (3,3',4,4')] on CYP1A1 induction and inhibition of lipopolysaccharide (LPS)-induced immunoglobulin production in the CH12.LX B cell line. In contrast to non-ortho-substituted PCB (PCB77), which showed additive effects on CYP1A1 induction in combination with TCDD, all of the di-ortho-substituted PCBs examined produced antagonism. Di-ortho-substituted PCB (PCB52) also antagonized TCDD- or PCB126- mediated inhibition of IgM secretion and immunoglobulin heavy chain mRNA expression in the LPS-activated B cells. In addition, PCB52 inhibited TCDD-induced AhR DNA binding to a dioxin-responsive element. Collectively, these results suggest that the mechanism responsible for antagonism by di-ortho-substituted PCB congeners of AhR agonist-mediated CYP1A1 induction and inhibition of antibody responses in B cells occurs through interference with agonist activation of the cytosolic AhR complex.

Lower extremity injuries in lateral impact: a retrospective study

ABSTRACT A retrospective analysis of the NASS/CDS database from 1993 to 2000 was used to investigate lower extremity injury in lateral impact. The analysis includes the study of the injury patterns, crash characteristics and the interactions between the occupant and the vehicle interior, including injuries to the farside occupants. The findings include significantly different injury patterns for the nearside and farside impacts. In particular, while the proportion of pelvis/hip injuries, with respect to AIS2 and AIS3 lower extremity skeletal injuries and 2-4 and 10-8 o'clock side impacts, was higher in nearside (70.4%) than farside (38.3%), the opposite trend was observed for the thigh (2.8% vs 4.5%), knee (6.2% vs 16.7%), leg (10.1% vs 19.5%) and foot/ankle (5.6% vs 14.7) injuries. Analysis of the PDOF suggested that a large proportion the impacts occurred obliquely, at approximately 10 and 2 o'clock, with a rearward component of force. It is hoped that the findings of the current study can help to investigate injury mechanisms.

Inhibition of inducible nitric-oxide synthase expression by silymarin in lipopolysaccharide-stimulated macrophages

Silymarin, a polyphenolic flavonoid antioxidant, is known to have anti-inflammatory, hepatoprotective, and anticarcinogenic effects. In the present study, we report the inhibitory effect of silymarin on nitric oxide production and inducible nitric-oxide synthase (iNOS) gene expression in macrophages. In vivo administration of silymarin attenuated nitric oxide production by peritoneal macrophages in lipopolysaccharide (LPS)-treated mice. Silymarin also dose dependently suppressed the LPS-induced production of nitric oxide in isolated mouse peritoneal macrophages and RAW 264.7, a murine macrophage-like cell line. Moreover, iNOS mRNA and its protein expression were completely abrogated by silymarin in LPS-stimulated RAW 264.7 cells. To further investigate the mechanism responsible for the inhibition of iNOS gene expression by silymarin, we examined the effect of silymarin on LPS-induced nuclear factor-kappaB (NF-kappaB)/Rel activation, which regulates various genes involved in immune and inflammatory response. In RAW 264.7 cells, the LPS-induced DNA binding activity of NF-kappaB/Rel was significantly inhibited by silymarin, and this effect was mediated through the inhibition of the degradation of inhibitory factor-kappaB. Silymarin also inhibited tumor necrosis factor-alpha-induced NF-kappaB/Rel activation, whereas okadaic acid-induced NF-kappaB/Rel activation was not affected. NF-kappaB/Rel-dependent reporter gene expression was also suppressed by silymarin in LPS-stimulated RAW 264.7 cells. Further study showed that silymarin suppressed the production of reactive oxygen species generated by H(2)O(2) in RAW 264.7 cells. Collectively, these results suggest that silymarin inhibits nitric oxide production and iNOS gene expression by inhibiting NF-kappaB/Rel activation. Furthermore, the radical-scavenging activity of silymarin may explain its inhibitory effect on NF-kappaB/Rel activation.

Salivary cystatins influence ingestion of capsaicin-containing diets in the rat

Dietary capsaicin consumed by rats over several days induces cystatin-like substances in submandibular saliva. Yet the physiological role of these salivary proteins has not been thoroughly investigated. Salivary cystatins in the rat submandibular glands are known to be induced by chronic treatment with the sympathetic beta-agonist, isoproterenol. In the present study, the possible roles of the salivary proteins on food intake were examined by comparing consumption of a capsaicin-adulterated (0.05%) diet in rats with and without isoproterenol pretreatment (0.1 and 5.0 mg/kg, 5 days). Electrophoretic analysis performed prior to feeding trials revealed that the group pretreated with 5 mg/kg isoproterenol had large amounts of cystatin in the saliva compared with the group pretreated with 0.1 mg/kg isoproterenol and control group. The group treated with 5 mg/kg isoproterenol showed greater consumption of the capsaicin-adulterated diet than the other groups until the 3rd day of trials. Bilateral removal of the submandibular and sublingual glands neutralized the effects of isoproterenol. Induction of salivary cystatins by isoproterenol treatment was not mimicked by systemic and intragastric administration of capsaicin. These results suggest that cystatins are included in the salivary proteins induced by capsaicin and that they contribute to enhanced ingestion of the capsaicin diet. Induction of salivary cystatins may be triggered by irritation of the oral mucosa by capsaicin.

Aryl hydrocarbon receptor-dependent inhibition of AP-1 activity by 2,3,7,8-tetrachlorodibenzo-p-dioxin in activated B cells

B cells have been identified as sensitive cellular targets responsible for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)-mediated suppression of humoral immunity. In previous studies, TCDD was shown to produce a significant inhibition of IgM secretion and mu gene expression in LPS-activated CH12.LX B cells (AhR expressing) but not in BCL-1 B cells (AhR deficient). The present studies extend these previous findings by investigating the effect of TCDD on AP-1 and nuclear factor (NF)-kappaB, both of which play an important role in B-cell activation, differentiation, and immunoglobulin (Ig) gene expression. Electrophoretic mobility shift assays and chloramphenicol acetyl transferase reporter gene experiments demonstrated that lipopolysaccharide (LPS)-induced DNA binding and transcriptional activity of AP-1 was markedly inhibited by TCDD at 24, 48, and 72 h after cellular activation of CH12.LX cells. Conversely, TCDD treatment produced no significant change on the activity of NF-kappaB. Two AhR antagonists, alpha-naphthoflavone and 2,2',5,5'-tetrachlorobiphenyl, attenuated TCDD-induced inhibition of AP-1 binding in CH12.LX cells. Concordant with this result, TCDD did not inhibit LPS-induced AP-1 activity in BCL-1 B cells. Moreover, supershift analysis revealed the major component of the AP-1 complex in LPS-activated CH12.LX cells was c-Jun. Additional studies revealed that the nuclear c-jun and c-jun steady-state mRNA expression was inhibited by TCDD treatment. Collectively, these results suggest that TCDD-induced inhibition of IgM expression by B cells may be mediated, at least in part, through a down-regulation of AP-1 activity in an AhR-dependent manner.

Qi therapy as an intervention to reduce chronic pain and to enhance mood in elderly subjects: a pilot study

Qi therapy (or external Qi) is an oriental complementary therapy preventing, curing disease and strengthens health and improving the human potentiality through regulation of body. It is increasingly being used to improve the quality of life, but there is little direct evidence of its efficacy. This study assessed the effects of Qi therapy (QT) on reducing pain and enhancing mood states in elderly subjects with chronic pain. We studied 40 elderly participants with chronic pain, who were randomly allocated to receive QT (n=20) or standard care (n=20). The experimental group receives Qi therapy twice a week for 2 weeks (total 4 times), and control group received general care at the same time and the same amount of duration. We measured pain level and Profile of Mood State (POMS) to explore participants' response to Qi therapy. There was a significant reduction in pain (p<0.0001) after QT and an improved positive mood state (p<0.0001). These findings suggest that Qi therapy may have a role in helping the elderly to cope with their pain and mood disturbances.

Recent advances in brain injury research: a new human head model development and validation

Many finite element models have been developed by several research groups in order to achieve a better understanding of brain injury. Due to the lack of experimental data, validation of these models has generally been limited. Consequently, applying these models to investigate brain responses has also been limited. Over the last several years, several versions of the Wayne State University brain injury model (WSUBIM) were developed. However, none of these models is capable of simulating indirect impacts with an angular acceleration higher than 8,000 rad/s(2). Additionally, the density and quality of the mesh in the regions of interest are not detailed and sensitive enough to accurately predict the stress/strain level associated with a wide range of impact severities. In this study, WSUBIM version 2001, capable of simulating direct and indirect impacts with a combined translational and rotational acceleration of the head up to 200 g and 12,000 rad/s(2) has been developed. This new finely meshed model, consisting of more than 314,500 elements and 281,800 nodes, also simulates an anatomically detailed facial bone model. An additional new feature of the model is the damageable material property representation of the facial bone and the skull, allowing it to simulate bony fractures. The model was subjected to extensive validation using published cadaveric test data. These data include the intracranial and ventricular pressure data reported by Nahum et al. (1977) and Trosseille et al. (1992), the relative displacement data between the brain and the skull reported by King et al. (1999) and Hardy et al. (2001), and the facial impact data reported by Nyquist et al. (1986) and Allsop et al. (1988). With the enhanced accuracy of model predictions offered by this new model, along with new experimental data, it is hoped that it will become a powerful tool to further our understanding of the mechanisms of injury and the tolerance of the brain to blunt impact.

Prodigiosin blocks T cell activation by inhibiting interleukin-2Ralpha expression and delays progression of autoimmune diabetes and collagen-induced arthritis

Prodigiosin (PDG) was previously reported to be a T cell-specific immunosuppressant. Here we describe the mechanism of action of PDG in T cells and the effect of PDG on autoimmune diseases. PDG selectively suppresses concanavalin A (Con A)-induced T cell proliferation, but has little effect on lipopolysaccharide-induced proliferation of B cells and nitric oxide production of macrophages. Although PDG does not block interleukin (IL)-2 production, it efficiently inhibits interleukin-2 receptor alpha-chain (IL-2Ralpha) expression, and this results in a disruption of the IL-2/IL-2R signaling pathway, on which a great part of the regulation of T cell activation depends. PDG blocks T cell differentiation into effector helper T cells secreting interferon-gamma and IL-4 as well as into effector cytotoxic T lymphocytes expressing perforin, which is at least in part resulting from inhibition of the IL-2/IL-2R signaling. PDG indirectly blocks signal transducer and activator of transcription activation by inhibiting cytokine signalings in Con A-activated T cells, although it does not inhibit the activation of nuclear factor-kappaB, nuclear factor of activated T cells, and activator protein-1. As direct evidence of immunosuppression in vivo, we show that PDG markedly reduced blood glucose levels and cellular infiltration into the pancreatic islets in nonobese diabetic mice, and that it also delays the onset of collagen-induced arthritis in DBA/1 mice. In conclusion, our results demonstrate that PDG has a unique mode of action, namely, that it blocks T cell activation by inhibiting primarily IL-2Ralpha expression in the IL-2/IL-2R signaling, and show that this compound represents a promising immunosuppressant candidate for the treatment of autoimmune diseases.

Development of a finite element model of the human abdomen

Currently, three-dimensional finite element models of the human body have been developed for frequently injured anatomical regions such as the brain, chest, extremities and pelvis. While a few models of the human body include the abdomen, these models have tended to oversimplify the complexity of the abdominal region. As the first step in understanding abdominal injuries via numerical methods, a 3D finite element model of a 50(th) percentile male human abdomen (WSUHAM) has been developed and validated against experimental data obtained from two sets of side impact tests and a series of frontal impact tests. The model includes a detailed representation of the liver, spleen, kidneys, spine, skin and major blood vessels. Hollow organs, such as the esophagus, stomach, small and large intestines, gallbladder, bile ducts, ureters, rectum and adrenal glands are grouped into three bodybags in order to provide realistic inertial properties and to maintain the position of the solid organs in their appropriate locations. Using direct connections, the model was joined superiorly to a partial model of the human thorax, and inferiorly to models of the human pelvis and the lower extremities that have been previously developed. Material properties for various tissues of the abdomen were derived from the literature. Data obtained in a series of cadaveric pendulum impact tests conducted at Wayne State University (WSU), a series of lateral drop tests conducted at Association Peugeot-Renault (APR) and a series of cadaveric lower abdomen frontal impact tests conducted at WSU were used to validate the model. Results predicted by the model match these experimental data for various impact speeds, impactor masses and drop heights. Further study is still needed in order to fully validate WSUHAM before it can be used to assess various impact loading conditions associated with vehicular crashes.

Investigation of Head Injury Mechanisms Using Neutral Density Technology and High-Speed Biplanar X-ray

The principal focus of this study was the measurement of relative brain motion with respect to the skull using a high-speed, biplanar x-ray system and neutral density targets (NDTs). A suspension fixture was used for testing of inverted, perfused, human cadaver heads. Each specimen was subjected to multiple tests, either struck at rest using a 152-mm-diameter padded impactor face, or stopped against an angled surface from steady-state motion. The impacts were to the frontal and occipital regions. An array of multiple NDTs was implanted in a double-column scheme of 5 and 6 targets, with 10 mm between targets in each column and 80 mm between columns. These columns were implanted in the temporoparietal and occipitoparietal regions. The impacts produced peak resultant accelerations of 10 to 150 g, and peak angular accelerations between 1000 and 8000 rad/s(2). For all but one test, the peak angular speeds ranged from 17 to 22 rad/s. The relative 3D displacements between the skull and the NDTs were analyzed. The localized motions of the brain generally followed loop or figure eight patterns, with peak displacements on the order of +/- 5 mm. These results can be used to further finite-element modeling efforts.

Lower Limb: Advanced FE Model and New Experimental Data

The Lower Limb Model for Safety (LLMS) is a finite element model of the lower limb developed mainly for safety applications. It is based on a detailed description of the lower limb anatomy derived from CT and MRI scans collected on a subject close to a 50th percentile male. The main anatomical structures from ankle to hip (excluding the hip) were all modeled with deformable elements. The modeling of the foot and ankle region was based on a previous model Beillas et al. (1999) that has been modified. The global validation of the LLMS focused on the response of the isolated lower leg to axial loading, the response of the isolated knee to frontal and lateral impact, and the interaction of the whole model with a Hybrid III model in a sled environment, for a total of nine different set-ups. In order to better characterize the axial behavior of the lower leg, experiments conducted on cadaveric tibia and foot were reanalyzed and experimental corridors were proposed. Future work will include additional validation of the model using global data, joint kinematics data, and deformation data at the local level.

Development of a computer model to predict aortic rupture due to impact loading

Aortic injuries during blunt thoracic impacts can lead to life threatening hemorrhagic shock and potential exsanguination. Experimental approaches designed to study the mechanism of aortic rupture such as the testing of cadavers is not only expensive and time consuming, but has also been relatively unsuccessful. The objective of this study was to develop a computer model and to use it to predict modes of loading that are most likely to produce aortic ruptures. Previously, a 3D finite element model of the human thorax was developed and validated against data obtained from lateral pendulum tests. The model included a detailed description of the heart, lungs, rib cage, sternum, spine, diaphragm, major blood vessels and intercostal muscles. However, the aorta was modeled as a hollow tube using shell elements with no fluid within, and its material properties were assumed to be linear and isotropic. In this study fluid elements representing blood have been incorporated into the model in order to simulate pressure changes inside the aorta due to impact. The current model was globally validated against experimental data published in the literature for both frontal and lateral pendulum impact tests. Simulations of the validated model for thoracic impacts from a number of directions indicate that the ligamentum arteriosum, subclavian artery, parietal pleura and pressure changes within the aorta are factors that could influence aortic rupture. The model suggests that a right-sided impact to the chest is potentially more hazardous with respect to aortic rupture than any other impact direction simulated in this study. The aortic isthmus was the most likely site of aortic rupture regardless of impact direction. The reader is cautioned that this model could only be validated on a global scale. Validation of the kinematics and dynamics of the aorta at the local level could not be done due to a lack of experimental data. It is hoped that this model will be used to design experiments that can reproduce field relevant aortic ruptures in the laboratory. Only after such experiments have been run, can local validation be examined and the model judged to be acceptable or unacceptable.