Smallest Clinically Meaningful Improvement in Amputation-Related Pain and Brief Pain Inventory Scores as Defined by Patient Reports of Global Improvement After Cryoneurolysis: a Retrospective Analysis of a Randomized, Controlled Clinical Trial

BACKGROUND

The smallest meaningful improvement in pain scores (minimal clinically important difference [MCID]) after an analgesic intervention is essential information when both interpreting published data and designing a clinical trial. However, limited information is available for patients with chronic pain conditions, and what is published is derived from studies involving pharmacologic and psychological interventions. We here calculate these values based on data collected from 144 participants of a previously published multicenter clinical trial investigating the effects of a single treatment with percutaneous cryoneurolysis.

METHODS

In the original trial, we enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis, who had no subsequent participant interaction. At both baseline and 4 months (primary end point), participants rated their phantom limb pain based on a numeric rating scale (NRS) and their interference of pain on physical and emotional functioning as measured with the Brief Pain Inventory's interference subscale. They subsequently qualitatively defined the change using the 7-point ordinal Patient Global Impression of Change (PGIC). The smallest clinically meaningful improvements in phantom limb pain and Brief Pain Inventory scores were calculated using an anchor-based method based on the PGIC.

RESULTS

The median (interquartile range [IQR]) phantom pain NRS (0-10) improvements at 4 months considered small, medium, and large were 1 [1-1], 3 [3-4], and 4 [3-6], respectively. The median improvements in the Brief Pain Inventory interference subscale (0-70) associated with a small, medium, and large analgesic changes were 16 [6-18], 24 [22-31], and 34 [22-46]. The proportions of patients that experienced PGIC ≥5 were 33% and 36% in the active and placebo groups, respectively. The relative risk of a patient experiencing PGIC ≥5 in the active group compared to the sham group with 95% confidence interval was 0.9 (0.6-1.4), P = .667.

CONCLUSIONS

Amputees with phantom limb pain treated with percutaneous cryoneurolysis rate analgesic improvements as clinically meaningful similar to pharmacologic treatments, although their MCID for the Brief Pain Inventory was somewhat larger than previously published values. This information on patient-defined clinically meaningful improvements will facilitate interpretation of available studies and guide future trial design.

Ultrasound-guided Percutaneous Cryoneurolysis to Treat Chronic Postamputation Phantom Limb Pain: A Multicenter Randomized Controlled Trial

BACKGROUND

Postamputation phantom pain is notoriously persistent with few validated treatments. Cryoneurolysis involves the application of low temperatures to reversibly ablate peripheral nerves. The authors tested the hypothesis that a single cryoneurolysis treatment would decrease phantom pain 4 months later.

METHODS

The authors enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. The primary outcome was the change in average phantom pain intensity between baseline and 4 months as measured with a numeric rating scale (0 to 10), after which an optional crossover treatment was offered. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis, who had no subsequent participant interaction.

RESULTS

Pretreatment phantom pain scores were similar in both groups, with a median [quartiles] of 5.0 [4.0, 6.0] for active treatment and 5.0 [4.0, 7.0] for sham. After 4 months, pain intensity decreased by 0.5 [-0.5, 3.0] in patients given cryoneurolysis (n = 71) versus 0 [0, 3] in patients given sham (n = 73), with an estimated difference (95% CI) of -0.1 (-1.0 to 0.7), P = 0.759. Following their statistical gatekeeping protocol, the authors did not make inferences or draw conclusions on secondary endpoints. One serious adverse event occurred after a protocol deviation in which a femoral nerve cryolesion was induced just below the inguinal ligament-instead of the sensory-only saphenous nerve-which resulted in quadriceps weakness, and possibly a fall and clavicle fracture.

CONCLUSIONS

Percutaneous cryoneurolysis did not decrease chronic lower extremity phantom limb pain 4 months after treatment. However, these results were based upon the authors' specific study protocol, and since the optimal cryoneurolysis treatment parameters such as freeze duration and anatomic treatment location remain unknown, further research is warranted.

EDITOR’S PERSPECTIVE

Fluoroscopically Guided vs Landmark-Guided Sacroiliac Joint Injections: A Randomized Controlled Study

OBJECTIVES

To determine the prevalence of intra- and extra-articular sacroiliac joint (SIJ) pain, which injection is more beneficial, and whether fluoroscopy improves outcomes.

PATIENTS AND METHODS

This patient- and evaluator-blinded comparative effectiveness study randomized 125 participants with SIJ pain from April 30, 2014, through December 12, 2017, to receive fluoroscopically guided injections into the joint capsule (group 1) or "blind" injections to the point of maximum tenderness using sham radiographs (group 2). The primary outcome was average pain on a 0 to 10 scale 1 month after injection. A positive outcome was defined as at least a 2-point decrease in average pain score coupled with positive (>3) satisfaction on a Likert scale from 1 to 5.

RESULTS

For the primary outcome, no significant differences were observed between groups (mean ± SD change from baseline, -2.3±2.4 points in group 1 vs -1.7±2.3 points in group 2; 95% CI, -0.33 to 1.36 points for adjusted difference; P=.23), nor was there a difference in the proportions of positive blocks (61% vs 62%) or 1-month categorical outcome (48% vs 40% in groups 1 and 2, respectively; P=.33). At 3 months, the mean ± SD reductions in average pain (-1.8±2.1 vs -0.9 ± 2.0 points; 95% CI, 0.11 to 1.58 points for adjusted difference; P=.02) and worst pain (-2.2±2.5 vs -1.4±2.0 points; 95% CI, 0.01 to 1.66 points for adjusted difference; P=.049) were greater in group 1 than 2, with other outcome differences falling shy of statistical significance.

CONCLUSION

Although fluoroscopically guided injections provide greater intermediate-term benefit in some patients, these differences are modest and accompanied by large cost differences.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02096653.

The effectiveness of proprioceptive and neuromuscular training compared to bracing in reducing the recurrence rate of ankle sprains in athletes: A systematic review and meta-analysis

BACKGROUND

Ankle sprains are common musculoskeletal injuries in which the ligaments of the ankle partially or completely tear due to sudden stretching.

OBJECTIVES

To critically appraise, evaluate and establish the best available evidence to determine the effectiveness of proprioceptive and neuromuscular training (PNT) compared to bracing in reducing the recurrence rate of ankle sprains in athletes.

METHODOLOGY

The following seven databases were searched in June 2017: PubMed, Cochrane Library, PEDro, ScienceDirect, Scopus, SPORTDiscus, EBSCO Host: CINAHL. The main search terms used were "ankle sprains", "proprioceptive training", "neuromuscular training" and "bracing". The quality of the trials were critically appraised according to the PEDro scale. The RevMan 5© software was used to pool results.

RESULTS

Three studies met the inclusion criteria and the quality according to the PEDro scale ranged from 4/10-7/10. The pooled data showed no difference between PNT and bracing in reducing the recurrence rate of ankle sprains in athletes at 12 months after initiation of the study.

CONCLUSION

This systematic review of the overall effect suggested that current evidence (Level II) does not favour the use of PNT over bracing in reducing the recurrence rate of ankle sprains. Physiotherapists are advised to use either PNT or bracing according to the patients preference and their own expertise.

Consequences of mitochondrial injury induced by pharmaceutical fatty acid oxidation inhibitors is characterized in human and rat liver slices

Inhibition of liver mitochondrial beta-oxidation by pharmaceuticals may lead to safety concerns including mitochondrial dysfunction, lipid accumulation, inflammation and necrosis. In this study, the consequences of mitochondrial beta-oxidation inhibition by pharmaceuticals is investigated in human and rat liver slices. The fatty acid oxidation inhibitors Etomoxir and CPI975, inhibit the rate limiting mitochondrial beta-oxidation enzyme carnitine palmitoyltransferase I, while FOX988 and SDZ51-641, sequester mitochondrial coenzyme A to inhibit carnitine palmitoyltransferase II. Mitochondrial dysfunction was evident by a significant decrease of liver slice ATP levels and mitochondrial injury was verified by ultrastructural changes in morphology, manifested as enlarged mitochondria, C- or O-shaped mitochondria, and granular or crystalline inclusions. Gene expression changes were evident prior to changes in mitochondrial morphology. Time- and concentration dependent changes in mitochondrial genes linked with respiration and mitochondrial fatty acid beta-oxidation were associated with an up-regulation of peroxisome fatty acid oxidation genes, likely as a compensatory mechanism for the inhibition of the mitochondrial pathways. Gene expression changes preceding the decline of liver slice ATP and GSH levels included an up-regulation of stress response and oxidative stress gene expression, as well as genes linked with transcription, transporters, proliferation, cell matrix and signaling. In association with the decline of liver slice ATP and GSH was increased apoptosis and inflammation. Caspase activity, a functional indicator of apoptosis, was significantly increased as well as an up-regulation of genes linked with apoptosis. The increased gene and protein expression of the pro-inflammatory cytokine IL-8, produced by endothelial cells, is likely in response to the manifestation of oxidative stress and GSH depletion; further amplifying the oxidative stress response induced by the fatty acid oxidation inhibitors and triggering an inflammatory response. In summary, human and rat liver slices exhibited similar effects to the inhibitors of mitochondrial beta-oxidation, and the mitochondrial injury is associated with apoptosis and inflammation in the liver slices.

Precision-cut tissue slices from transgenic mice as an in vitro toxicology system

In these experiments precision-cut tissue slices from two existing transgenic mouse strains, with transgenes that couple promoting or binding elements to a reporter protein, were used for determination of reporter induction. This approach combines the power of transgenic animals with the practicality of in vitro systems to investigate the biological impact of xenobiotics. Additionally, the normal cellular architecture and heterogeneity is retained in precision-cut tissue slices. Two transgenic mouse strains, one of which couples the promoting region of CYP 1A1 to beta-galactosidase, and another which couples two forward and two backward 12-O-tetradecanoyl phorbol-13-acetate (TPA) repeat elements (TRE) to luciferase (termed AP-1/luciferase), were used to determine the feasibility of this approach. Precision-cut kidney and liver slices from both transgenic strains remain viable as determined by slice K(+) ion content and LDH enzyme release. Liver slices harvested from the CYP 1A1/beta-galactosidase transgenic mice exhibit a 14-fold increase in beta-galactosidase activity when incubated with beta-napthoflavone for 24 h. Kidney and liver slices obtained from the AP-1/luciferase transgenic mice demonstrate induction of luciferase (up to 2.5-fold) when incubated with phorbol myristate acetate (PMA or TPA) up to 4 h. These data indicate that precision-cut tissue slices from transgenic mice offer a novel in vitro method for toxicity evaluation while maintaining normal cell heterogeneity.

Impact of energy intake and pregnancy status on rate and efficiency of gain and backfat changes of sows postweaning

A collaborative study was conducted to evaluate factors related to determining optimal feeding and management programs for increasing net returns from marketing cull sows. A total of 269 multiparous sows averaging 192 kg of body weight were weaned, moved to individual gestation crates, and assigned to one of eight treatment combinations in a 2 x 2 x 2 factorial arrangement for a 42-d postweaning feeding experiment. Factors included limited (L) (1.8 kg/sow/d) or ad libitum (AL) access to feed during wk 1 postweaning, a corn-soybean meal (corn) or barley-sunflower meal (barley) diet, and pregnant or nonpregnant status. All sows were provided ad libitum access to feed from wk 2 to 6 postweaning. Gain and feed intake (FI) data were collected weekly for each sow and used to calculate gain:feed (G/F). Ultrasonic backfat (BF) data were collected on d 0, 21, and 42 postweaning. Sows on the AL treatment had greater FI (P < 0.05) but similar gain (P = 0.80) for the 42-d postweaning period compared to sows on the L treatment. Most of this response was due to lower sow body weight loss during wk 1 postweaning (P < 0.01) when sows were provided AL (-7.2 kg) vs L (-13.2 kg) access to feed. Sows fed the corn diet had higher gain (P < 0.01), improved G/F (P < 0.01), and increased BF (P < 0.01) over the 42-d feeding period than sows fed barley. The corn diet resulted in less sow BW loss (P < 0.01) during wk 1 (-8.8 kg) than the barley diet (-11.6 kg). Pregnant sows had higher gain, FI, G/ F, and BF (P < 0.01) than nonpregnant sows over the 42-d feeding period. Most of this advantage occurred during wk 4 postweaning when FI and gain of nonpregnant sows was lower (P < 0.01) than for pregnant sows. An economic analysis indicated that, when cull sow prices are relatively high and feed prices are moderate to low, maintaining and managing cull sows for an additional 6 wk postweaning may be economically advantageous compared to 0 or 3 wk. Pregnant sows fed the corn diet produced the greatest economic return. These results suggest that mating sows as they return to estrus postweaning and providing ad libitum access to a corn-soybean meal diet improves growth performance and feed efficiency, and may thereby provide increased returns when marketing cull sows.

Human liver quality is a dominant factor in the outcome of in vitro studies

Donated human liver in the form of precision-cut tissue slices or isolated hepatocytes, is increasingly being used to predict metabolism and toxicity of xenobiotics in man. These tissue slices or hepatocytes can also be cold-preserved and cryopreserved to prolong their use for biological experiments. The viability of human liver could substantially affect the outcome of such experimentation. The goal of this investigation was to assess the viability of donated human livers, in the form of tissue slices, as they were received and to determine how varying degrees of liver quality affect experimental outcomes. Over one hundred human livers were categorized according to initial viability, as assessed by ATP content, K+ retention, protein synthesis, and LDH leakage. Each liver was placed in a low-, a medium-, or a high-quality group. The results showed that 76% of transplant-grade tissue (procured for transplantation) fell into the high-viability classification while the majority of research-grade tissue (not procured for transplantation) fell into the lowest viability classification. It was also found that only tissue slices prepared from highly viable human liver could be cold-preserved and cryopreserved. Dichlorobenzene metabolism was also greater in slices from highly viable human livers as compared to less viable livers. This study showed that human liver tissue acquired for medical research substantially varies in its viability and that these differences will affect the experimental data obtained.

Correlation between self-reported adherence to highly active antiretroviral therapy (HAART) and virologic outcome

The Patient Medication Adherence Questionnaire Version 1.0 (PMAQ-V1.0) is a patient-reported adherence instrument to assess medication-taking behaviors and identify barriers to adherence with antiretroviral therapy. To assess the correlation between adherence and virologic outcome, the PMAQ-V1.0 was administered to 194 antiretroviral-experienced adults with HIV infection enrolled in a 16-week evaluation of protease inhibitor-containing regimens featuring a lamivudine/zidovudine combination tablet. At baseline, plasma HIV-1 RNA levels were less than 10,000 copies/mL and CD4(+)-cell counts were equal to or greater than 300 x 10(6)/L; patients had been receiving a conventional regimen of lamivudine + zidovudine (separately) plus a protease inhibitor for at least 10 weeks immediately prior to the study. Forty-eight percent of patients who reported missing at least one dose of a nucleoside reverse-transcriptase inhibitor (NRTI) during the study had detectable plasma HIV-1 RNA, compared with 26% of patients who reported no missed doses (P = .002). Patients who missed at least one dose of an NRTI or protease inhibitor were 2.5 times more likely to have quantifiable HIV-1 RNA than those who reported no missed doses. Patients who reported fewer barriers and more motivators to adherence had better virologic outcomes (P = .001). Several dimensions of the PMAQ-V1.0 did not function as well as hypothesized. In this study, self-reported adherence derived from the PMAQ-V1.0 predicted virologic outcomes, but further refinement of the dimensions appears warranted.

Twice-daily triple nucleoside intensification treatment with lamivudine-zidovudine plus abacavir sustains suppression of human immunodeficiency virus type 1: results of the TARGET Study

This open-label, multicenter, single-arm clinical trial assessed the 48-week efficacy of a twice-daily triple nucleoside reverse-transcriptase inhibitor regimen containing a lamivudine (150 mg)-zidovudine (300 mg) combination tablet (COM) and abacavir (ABC; 300 mg) in 87 antiretroviral therapy-experienced, protease inhibitor-naive patients infected with human immunodeficiency virus type 1 (HIV-1). At baseline, the median plasma HIV-1 RNA level was 3.10 log(10) copies/mL, and the median CD4 cell count was 506 cells/mm(3). An intent-to-treat&rcolon;observed analysis showed that, at weeks 24 and 48 of treatment, HIV-1 RNA level was <400 copies/mL in 48 (76%) of 63 and 45 (82%) of 55 patients, respectively, and <50 copies/mL in 37 (59%) of 63 and 31 (56%) of 55 patients, respectively. Previous zidovudine or lamivudine use and presence at baseline of the M184V reverse-transcriptase mutation did not impact virologic response. Median CD4 cell counts were maintained above baseline throughout the study. COM plus ABC was generally well tolerated.

Efficacy, safety, and adherence with a twice-daily combination lamivudine/zidovudine tablet formulation, plus a protease inhibitor, in HIV infection

OBJECTIVE

A randomized, open-label, multicenter study to establish clinical equivalence (non-inferiority) of a regimen employing a lamivudine 150 mg/zidovudine 300 mg combination tablet, administered twice daily, plus a marketed protease inhibitor, compared with a conventional regimen of 150 mg lamivudine twice daily, 600 mg zidovudine daily, and a protease inhibitor, in antiretroviral-experienced patients infected with HIV-1.

PATIENTS

Adults who were seropositive for HIV-1 infection with plasma HIV-1 RNA levels < 10000 copies/ml (Roche Amplicor polymerase chain reaction assay, lower limit of quantitation (LLOQ) 400 copies/ml) and CD4+ cell counts > or = 300 x 10(6)/l). All patients had been receiving the conventional lamivudine/zidovudine/protease inhibitor regimen for > or = 10 weeks immediately prior to the study.

INTERVENTION

Patients were randomized to the conventional regimen (n = 113) or combination tablet regimen (n = 110) for 16 weeks. The primary study endpoint was treatment failure, defined as an increase in HIV-1 RNA > or = 0.5 log10 above baseline in patients with viral load > LLOQ at randomization and as HIV-1 RNA increasing to > or = 1250 copies/ml in patients with viral load < LLOQ at randomization.

RESULTS

The combination tablet regimen was associated with a 3.5% greater success rate than the conventional regimen (96.4 versus 92.9%), with four and eight patients failing treatment due to increases in HIV-1 RNA levels, respectively. The lower limit of the associated confidence interval for the difference was -2.4%, which was well within the -10% margin predefined as clinically unimportant. This establishes the clinical equivalence (non-inferiority) of the combination tablet regimen to the conventional regimens regarding virologic response. The combination tablet and conventional regimens were similar with respect to percentage of patients maintaining HIV-1 RNA levels < LLOQ at the end of study or improving from baseline to undetectability (94 versus 91%; P= 0.063), overall incidence of drug-related adverse events (21 versus 19%) (P=0.868), and mean area under the curve for CD4+ cell counts [treatment difference, 5.9 cells (95% confidence interval, -15.8 to 27.6 x 10(6) cells/l)]. A self-reported adherence questionnaire indicated that patients in the combination tablet group were less likely to miss doses of nucleoside analogue medication at weeks 8 (P= 0.007) and 16 (P= 0.046).

CONCLUSIONS

The combination lamivudine/zidovudine tablet/protease inhibitor regimen is clinically equivalent (non-inferior) to the conventional regimen with respect to virologic response and may offer adherence advantages.

Cytochrome P-450-dependent bioactivation of 1,1-dichloroethylene to a reactive epoxide in human lung and liver microsomes

We investigated the cytochrome P-450-dependent metabolism of 1, 1-dichloroethylene (DCE) by human lung and liver microsomes and compared the results from analogous experiments in mice. Metabolites were identified by HPLC analysis of their glutathione conjugates and/or hydrolyzed products and were detected by using [14C]DCE. The role of human CYP2E1 in the metabolic reactions was examined by comparing p-nitrophenol hydroxylase activities with levels of metabolites formed and by using the CYP2E1-selective inhibitor diallyl sulfone. The major products formed in microsomal incubations containing NADPH were the DCE-epoxide-derived glutathione conjugates 2-(S-glutathionyl)acetyl glutathione and 2-S-glutathionyl acetate. Lower levels of the acetal of 2,2-dichloroacetaldehyde were also detected. In lung samples from eight patients, the amounts of epoxide-derived conjugates formed ranged from 15.6 +/- 4.23 to 34.9 +/- 12.75 pmol/mg protein/min. The levels in murine lung were higher at 40.0 +/- 3.8 pmol/mg protein/min. In liver samples from five patients, conjugate levels ranged from 46.5 +/- 8.3 to 240.0 +/- 10. 5 pmol/mg protein/min, whereas levels in murine liver were 83.0 +/- 6.2 pmol/mg protein/min. Conjugate levels formed in human liver correlated with the relative levels of p-nitrophenol hydroxylase activity present, but this relationship was equivocal in human lung. Diallyl sulfone inhibited the formation of the glutathione conjugates (20-65%) in liver samples from all four patients, whereas only one of five human lung samples exhibited this inhibition (27%). These results demonstrated that the DCE-epoxide is a major metabolite formed by human microsomes and is mediated by CYP2E1 in liver and in some individuals in lung.

Arthroscopic ankle fusion

Experience at Hartford Hospital with arthroscopic ankle fusion would indicate that the procedure is safe and effective, and offers far less patient morbidity than the traditional open procedures. Thirteen of 15 ankles operated developed successful arthrodeses. All but four patients had outpatient surgery.

Human and rat lung biotransformation of cyclosporin A and its derivatives using slices and bronchial epithelial cells

Lung biotransformation of the immunosuppressants, cyclosporin A (CSA), the hydroxyethyl derivative SDZ IMM 125 (IMM), and the methylcarbonate derivative SDZ SCP 764 (SCP), was demonstrated in slices from human and rat. The major biotransformation pathway for CSA and IMM (0.1-10 microM) was hydroxylation at amino acid 1 to form AM1 or IMM1, while for SCP it was an esterase cleavage of the methylcarbonate group to form AM1 in both species. The initial rate (0-1 hr) of human total metabolite formation increased proportionally with substrate concentration. AM1 formation was five times greater from SCP, an esterase pathway, than CSA, an oxidative pathway which was inhibited (50%) by ketoconazole. At 24 hr human lung CSA metabolite formation was greater than IMM (3-fold) or SCP (2-fold), whereas rat lung and liver and human bronchial epithelial cell SCP metabolite formation generally exceeded CSA or IMM metabolism. CSA biotransformation is expected to occur throughout the human lung as demonstrated by the similar metabolite profile and extent of metabolism by slices derived from five different regions. The scaling of slice total metabolism to organ metabolism revealed that initially lung CSA metabolite formation would be equal to liver but with time liver metabolism would exceed lung for human and rat. This study has demonstrated that human and rat lung are metabolically active, exhibiting oxidative and esterase pathways toward cyclosporin derivatives. The lung will play an important role in this metabolism, particularly when administered via inhalation; however, the liver will also be a major organ involved in the total clearance of these compounds.

Increased resistance to acetaminophen-induced hepatotoxicity in retrovirus-infected mice

In this research we examined the influence of chronic retrovirus infection on the hepatic metabolism of a model substrate, acetaminophen (APAP), and its induced liver injury in mice inoculated with LP-BM5 murine leukemia viruses. Female C57BL/6 mice at 15-17 wks after LP-BM5 retrovirus inoculation and age-matched control animals were used in the studies. APAP treatment (300 mg kg-1, p.o.) resulted in moderate to severe centrilobular necrosis in control animals, with the necrotic area accounting for 40-60% of the total area. In contrast, the APAP-treated (300 mg kg-1, p.o.) infected animals exhibited mild zonal necrosis with the necrotic area accounting for 1-6% of the total area. In the same study, a statistically significant higher percentage of APAP glucuronide and a lower percentage of unchanged APAP were recovered from the urine of the LP-BM5-inoculated animals than from that of controls. No statistically significant differences between infected and uninfected animals in the urinary recovery of APAP sulfate, APAP cysteine, or APAP mercapturate were observed. The formation of APAP metabolites and APAP-associated biochemical changes were also determined from liver slice preparation to avoid in vivo complicating factors. Consistently more significant depletion of the intracellular glutathione levels and K+ content were observed in slices from the uninfected animals at high concentrations of APAP (1 and 2 mM) than in slices from the retrovirus-infected animals. The differences in APAP-associated biochemical changes were accompanied by a 1.4-1.5-fold increase in the formation of APAP glucuronide, sulfate, and glutathione metabolites in slices prepared from animals inoculated with LP-BM5. We concluded that, based on histological examination and hepatic biochemical measurements, the retrovirus-infected animals were more resistant to APAP-induced liver injury. This could be due, in part, to alterations in the detoxification and activation metabolic pathways of APAP.

Protein arylation precedes acetaminophen toxicity in a dynamic organ slice culture of mouse kidney

Acetaminophen (APAP) is an analgesic and antipyretic agent which may cause hepatotoxicity and nephrotoxicity with overdose in man and laboratory animals. In vivo studies suggest that in situ activation of APAP contributes to the development of nephrotoxicity. Associated with target organ toxicity is selective arylation of proteins, with a 58-kDa acetaminophen binding protein (58-ABP) being the most prominent cytosolic target. In this study a mouse kidney slice model was developed to further evaluate the contribution of in situ activation of APAP to the development of nephrotoxicity and to determine the selectivity of protein arylation. Precision cut kidney slices from male CD-1 mice were incubated with selected concentrations of APAP (0-25 mM) for 2 to 24 hr. APAP caused a dose- and time-dependent decrease in nonprotein sulfhydryls (NPSH), ATP content, and K+ retention. Preceding toxicity was arylation of cytosolic proteins, the most prominent one being the 58-ABP. The association of 58-ABP arylation with APAP toxicity in this mouse kidney slice model is consistent with earlier, in vivo results and demonstrates the importance of in situ activation of APAP for the development of nephrotoxicity. Precision cut renal slices and dynamic organ culture are a good model for further mechanistic studies of APAP-induced renal toxicity.

Pouchitis: pathogenesis, diagnosis, and management

The current treatment of choice for patients requiring colectomy for ulcerative colitis or familial adenomatous polyposis (FAP) is ileoanal anastomosis with pouch creation. Symptomatic inflammation of this pouch, a condition known as pouchitis, will develop in up to 40% of patients who undergo this surgery. Patients will present with crampy abdominal pain, fever, rectal bleeding, and diarrhea, and they may have either acute intermittent attacks or a chronic pouchitis syndrome. Most reported cases of pouchitis have occurred in patients with a previous history of ulcerative colitis, whereas complications develop in only a handful of patients with FAP. The etiology of pouchitis is probably a multifactorial event involving genetic, immune, microbial, and toxic mediators. The initial medical management of pouchitis usually relies on metronidazole; however, other drugs that are useful for ulcerative colitis have been found to be beneficial for pouchitis. Studying the etiology and management of pouchitis may help elucidate the pathogenesis of inflammatory bowel disease.

Cold- and cryopreservation of dog liver and kidney slices

The use of tissue slices in culture could decrease the number of animals used in health-related research and decrease experimental variation. This reduction may come about particularly if the methods of cold- and cryopreserving tissue slices are perfected, and one can conduct sequential in vitro experiments into xenobiotic metabolism, organ-specific toxicity, or organ-specific biochemical processes with tissue slices. With this goal in mind, dog liver and kidney slices were placed in cold storage at 0 degrees C using Viaspan (UW), Euro-Collins (EC), Sacks + prostacyclin (SP), and V-7 (V7) cold-preservation solutions for 10 days. Viability was assessed each day by measuring K+ content and protein synthesis after 4 h of incubation in Waymouth + 10% fetal calf serum (FCS). Dog liver slices can be cold-preserved in V7 for up to 7 days using K+ retention as the viability criterion but only up to 4 days using protein synthesis. Dog kidney slices can be cold-preserved in UW, EC, and V7 for up to 10 days using K+ retention, but only V7 could maintain protein synthesis for 10 days. Cryopreserved dog liver and kidney slices retained 63-68% of control viability after 4 h of incubation in FCS. The cryopreservation regimen included using 10% dimethyl sulfoxide in FCS as the cryoprotectant, a freezing rate of 0.5 degrees C/min for liver slices and 12 degrees C/min for kidney slices, and thawing in 37 degrees C FCS. Continued development of cold- and cryopreserving tissue slices could reduce the numbers of animals used and provide accurate and reproducible data.

Antidepressants for children. Is scientific support necessary?

This article is concerned with issues pertaining to the degree to which clinical therapeutic decisions can reasonably depart from the best available scientific data. There is a tension between the traditions of practitioner autonomy and the boundaries set by research findings. Ambiguity exists as to how much freedom practitioners have to accept or reject the existing scientific paradigm. The nature of the dilemma is explored by analyzing the current problems confronting child psychiatrists and pediatricians who choose to treat depressed children with antidepressants. Despite unanimous literature of double-blind studies indicating that antidepressants are no more effective than placebos in treating depression in children and adolescents, such medications continue to be in wide use. The strategies used to resolve this sort of contradiction are considered, and certain ethical puzzles are appraised.

Use of tissue slices in chemical mixture toxicology and interspecies investigations

Precision-cut tissue slices have proven to be a useful in vitro system for biotransformation and toxicity studies. Since tissue slices can be readily prepared from a variety of tissues and species, they can easily be used for interspecies investigations and comparisons. Furthermore, slices can be readily prepared from human tissue, thus comparisons (extrapolation) can be made between laboratory animals and humans. Slices can also be used to examine the toxic interactions of chemicals in vitro. It is important to use the correct experimental design to demonstrate toxic interactions and to assure that the tissue slices are properly exposed to the chemicals. Overall, tissue slices offer a valid in vitro system for performing species comparisons and chemical-chemical interaction studies.

Comparative metabolism and toxicity of dichlorobenzenes in Sprague-Dawley, Fischer-344 and human liver slices

1. Precision-cut liver slices, prepared from Sprague-Dawley and Fischer-344 rats and donated human liver tissue, were used to identify differences in 1,2-dichlorobenzene (1,2-DCB), 1,3-dichlorobenzene (1,3-DCB) and 1,4-dichlorobenzene (1,4-DCB) metabolism and how it may relate to toxicity. 2. Rat and human liver slices were incubated with 1 mM of either dichlorobenzene to determine metabolism and toxicity, at 2 and 6 h of organ culture. 3. The human liver slices metabolised the dichlorobenzenes to a greater extent than those from either of the rat strains. Liver slices from the Fischer-344 strain had a higher metabolic rate than the slices from the Sprague-Dawley rat strain. 4. The metabolic rate of dichlorobenzene isomers did not consistently correlate with its toxicity. For example, human slices did not exhibit any hepatoxicity, even though they metabolised these compounds to a greater extent than either rat strain. 5. Cross species covalent binding did not correlate with toxicity endpoints measured in this study. 6. The phase two metabolite profiles for each of the isomers in human and rat slices were similar in that the glutathione-cysteine conjugate was the major metabolite. 7. The use of an in vitro system which utilises human liver slices might provide an important bridge between animal derived data and the human situation.

Stress-related mucosal disease. Pathophysiology, prevention, and treatment

The advent of gastrointestinal endoscopy has allowed us to follow the morphologic results of severe stress on the gastrointestinal mucosa. It has become clear, however, that the presence of mucosal abnormalities does not always correlate with the presence of overt bleeding, or with the effect of bleeding on the overall outcome of such patients. In fact, the incidence of severe gastrointestinal hemorrhage, secondary to stress-related mucosal disease, has been decreasing over the past decade, as the care of these critically ill patients has improved. In patients who do have overt hemorrhage, however, the mortality rate is extremely high. It therefore remains the duty of the clinician to identify patients who are at high risk of having overt hemorrhage, and ensure that they receive adequate prophylactic therapy.

Sites of biotransformation for the cyclosporin derivative SDZ IMM 125 using human liver and kidney slices and intestine. Comparison with rat liver slices and cyclosporin A metabolism

SDZ IMM 125 (IMM), the hydroxyethyl derivative of cyclosporin A (CSA), is metabolized by human liver slices to analogous primary metabolites, hydroxylated IMM1 and IMM9 and N-demethylated IMM4N, as for CSA (M17/AM1, M1/AM9, and M21/AM4N), but the rate and extent of IMM biotransformation is less than for CSA. Initial rates of IMM metabolite formation in the human liver slice cultures are 6.6 +/- 2.8 nmol/hr/g liver at 1 microM IMM and 24.3 +/- 22.9 nmol/hr/g liver at 10 microM IMM, whereas the rate of CSA metabolite formation is 1.8-fold faster at both concentrations. The percentage of unchanged IMM is 73% at 1 microM and 80% at 10 microM after 24 hr, reflecting the lower extent of IMM metabolism, about one-third (1 microM) and one-half (10 microM) that of CSA. In rat liver slices, IMM is metabolized to the same primary metabolites as in human liver slices, but more slowly and remains 90% unchanged at 24 hr. Human jejunum formed the same primary metabolites of IMM and CSA as in liver. Upscaling the slice rate of biotransformation revealed that human jejunum would contribute considerably to the first-pass of IMM and CSA, being approximately 2 to 3-fold slower than the rate in liver. The inhibition of both IMM and CSA biotransformation by triacetyloleandomycin implicates the involvement of cytochrome P4503A proteins. Human kidney cortex slices metabolized IMM to IMM1 and IMM9, accounting for approximately 75% of the total metabolites. Total metabolite formation represented approximately 64% of liver metabolite formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Nutrition support in inflammatory bowel disease

The mechanisms of nutritional therapy in inflammatory bowel disease have not been thoroughly established. It is likely that a further understanding of the underlying disease process will allow better understanding of these forms of therapy, with a sounder rationale for the construction of specific diet constituents for therapy. Regardless, nutritional therapy is likely to be multidimensional, and various forms may affect different aspects of the disease process. Decreased inflammatory factors, decreased antigenic stimuli, provision of essential nutrients, improved immune function, and other factors may all be of varying importance in different patients with inflammatory bowel disease. Little work has been done on the role of diet therapy in the long-term treatment of patients with inflammatory bowel disease as a method of preventing relapse. Parenteral nutrition and elemental diets appear to have limited roles in this area. Some investigation has been done to see if minor modifications of the normal diet can prolong remission periods. Low-fiber diets are frequently recommended for patients with strictures. Whether this has any significant effect on symptoms, inflammation, or complications is unclear. Heaton et al suggested that a high-fiber, unrefined carbohydrate diet resulted in fewer and shorter hospitalizations. In a prospective follow-up study by Ritchie et al, however, these results were not able to be reproduced. Exclusion diets have also been suggested as a means of reducing relapse rates in patients with Crohn's disease. In a small, randomized, controlled trial of an exclusion diet versus an unrefined carbohydrate, fiber-rich diet, there were significantly fewer relapses among the patients treated with the exclusion diet at 6 months. These diets require intensive patient cooperation, but the potential side effects are minimal. Clearly, these findings need to be reproduced in large, prospective, randomized, controlled studies before widespread use can be advocated. A great deal of data exists on the use of nutritional supplementation in the treatment of inflammatory bowel disease, although little of it is in the form of large, randomized, controlled studies. Nutritional manipulation currently has a limited role in patients with ulcerative colitis; a much broader role exists in patients with Crohn's disease. The mechanisms by which nutritional therapy affects these diseases may include a combination of factors--decreased antigenic exposure, improved immune function, and provision of essential nutrients and calories needed for bowel regeneration.(ABSTRACT TRUNCATED AT 400 WORDS)

Toxicity of cisplatin and mercuric chloride in human kidney cortical slices

1. Organ specific toxicity such as nephrotoxicity is often investigated with the use of in vivo or in vitro animal models. 2. It would be beneficial if these findings could be verified in a human in vitro system which utilizes non-transplantable human kidneys. 3. Non-transplantable human kidneys were decapsulated, cut in half along the long axis, cores made perpendicular to the hemisphere, and precision-cut renal cortical slices produced. 4. These human kidney slices were incubated for 3, 6, 12, 18 and 24 h, viability assessed using intracellular K+ content, protein synthesis and organic ion transport and the potential nephrotoxicity of cisplatin (0.25, 0.5 and 1.0 mM) and mercuric chloride (10, 50 and 100 microM) on these slices were examined. 5. Control human kidney slices were viable for up to 24 h using all viability parameters while a dose- and time-dependent toxic response was seen using both cisplatin and mercuric chloride. 6. Cisplatin was more nephrotoxic in this human in vitro system than in previously investigated in vitro animal systems whereas mercuric chloride was similar in both systems. 7. These results indicate that human renal cortical slices are useful in predicting and verifying potentially nephrotoxic compounds in man.

The use of human lung slices in toxicology

1. Successful use of agar-filled precision-cut rat lung slices in dynamic organ culture prompted the use of this technology with human lung. 2. The larger tissue mass of a human lung required that the trachea be cannulated with a balloon catheter and subsequently inflated with 4 liters of warm agar/medium mixture and then cooled before being precision-cut into 500 microns thick slices. 3. To characterize the human lung slices, viability and the effects of acrolein and nitrofurantoin were assessed over a period of 24 h using protein synthesis and nonprotein sulfhydryl content. 4. Control human lung slices synthesized protein at a linear rate and maintained a stable nonprotein sulfhydryl content for 24 h. 5. Slices incubated with acrolein exhibited no significant decrease in protein synthesis or nonprotein sulfhydryl levels until 24 h. 6. Incubation with nitrofurantoin exhibited a definite time- and dose-dependent inhibition of protein synthesis, and depletion of the cellular thiol pool. 7. These results indicate that this human lung tissue slice system may be used as an in vitro model to identify and screen pneumotoxicants.

Transient regional osteoporosis of the ankle and foot. A report of four cases and review of the literature

Transient regional osteoporosis of the ankle and foot is an uncommon clinical entity characterized by local tenderness over the involved area. Plain radiographs demonstrate osteopenia of the involved bone and technetium diphosphonate bone imaging shows increased tracer uptake at the same location. This disorder is benign and self-limiting, and treatment is conservative.

Cold- and cryopreservation of human liver and kidney slices

Tissue slices may provide a rapid and economical way of determining cold ischemic effects on human liver and kidney cell viability and metabolism. In contrast to isolated hepatocyte cultures, tissue slices offer an in vitro system which more closely resembles the in vivo situation because of the differentiation and functional heterogeneity of the slice. In this study, human liver and kidney slices were cold stored for 10 days in Belzers University of Wisconsin (UW), Euro-Collins, and Modified Sacks solutions. Another set of slices was cryopreserved at 1 degree C/min for liver and 12 degrees C/min for kidney using a 10% dimethyl sulfoxide/fetal calf serum (FCS) cryoprotectant solution. The cold- and cryopreserved slices were incubated in roller culture for 4 h using FCS as the media. Liver slice viability was assessed by K+ content, protein synthesis, gluconeogenesis, and urea synthesis. Kidney slice viability was assessed using K+ content, protein synthesis, and organic ion transport (PAH and TEA). Human kidney slices were cold preserved in UW for 4-6 days, while the human liver slices were preserved for 12-24 h depending on the viability parameter. Following cryopreservation, human liver slice viability was retained at between 65 and 90% of control values, while kidney slice viability was maintained between 70 and 90% of control values depending on the viability parameter. These results indicate that this human in vitro tissue slice system can be used to optimize preservation solutions and methods. The ability to cold- and cryopreserve human slices could facilitate the more efficient utilization of human tissue.

New therapies for idiopathic ulcerative colitis

Medical and surgical management of ulcerative colitis has advanced far in the last decade. New time-released ASA compounds and enemas have decreased the side effects of sulfasalazine and allowed delivery of higher doses of the active compound to the site of action. New steroid compounds have reduced the potential for systemic adrenal glucocorticoid suppression. However, therapy is still directed only against secondary immune and inflammatory responses. Until the cause of UC is discovered, well-designed and well-performed clinical trials must continue to try to identify agents that combine low toxicity with high therapeutic potential.

Culture medium composition affects the relative toxicities of chlorobenzenes in rat liver slices and the isolated perfused liver

The effects of different media composition on the hepatotoxicity produced by monochlorobenzene (MCB), 1,2-dichlorobenzene (1,2-DCB), 1,3-dichlorobenzene (1,3-DCB) and 1,4-dichlorobenzene (1,4-DCB) were examined in two different in vitro systems. The toxicity of these chlorobenzenes was investigated in the perfused rat liver and liver slices using Krebs-Henseleit buffer. Significant differences between the chlorobenzenes were apparent in the perfused liver but not in the tissue slices. However, a dose and time related response of rat liver slices to the chlorobenzenes was observed. Partial amelioration of the chlorobenzene toxicity was observed when the Krebs-Henseleit buffer was supplemented with vitamins, amino acids, and/or bovine serum albumin. 1,2-DCB and 1,3-DCB toxicity was affected by amino acids and vitamins. The toxicity produced by 1,4-DCB was suppressed by amino acids, vitamins and 1% BSA. MCB hepatoxicity could only be suppressed by 1% BSA. This data suggests that tissue culture media composition plays a major role in the hepatotoxicity of the chlorobenzenes.

Cyclosporin A metabolism in human liver, kidney, and intestine slices. Comparison to rat and dog slices and human cell lines

This study assesses the contribution of cyclosporin A (CsA) metabolism at sites of CsA-induced toxicity: kidney and liver, and a site of absorption, the intestine. With organ slice cultures (8 mm phi), it has been possible to demonstrate that the extrahepatic metabolism of CsA is significant. Both human kidney and colonic mucosal tissue metabolize CsA (1 microM, 24 hr) as analyzed by HPLC. The major metabolite M17 was formed in the kidney at an initial rate of 3 pmol/hr/mg slice protein, which was comparable to M17 formation in the liver slices (5 pmol/hr/mg slice protein). The rate of total CsA metabolism by human kidney slices represents about 42% the rate in liver slices. The metabolism of CsA to M17 was the same in the human kidney cell line 293; however, CsA metabolism was not detectable using human kidney microsomes, nor was metabolism clearly evident in either rat or dog kidney slice cultures. The metabolism of CsA by human colonic mucosal slices to at least three metabolites and the metabolism of CsA by the human intestinal cell line FHs74 Int indicates that the intestinal metabolism of CsA contributes to the first-pass effect of the drug. The liver proved to be the major site of CsA biotransformation in terms of the complexity of metabolites produced, whereas the human liver HepG2 cell line proved not to be a suitable model for CsA metabolism. A time course revealed that the first metabolites formed in the liver slice cultures were the monohydroxylated, M1 and M17, and N-demethylated, M21, followed by the secondary metabolites (including M8, M13, and M18).(ABSTRACT TRUNCATED AT 250 WORDS)

The lack of relationship between hepatotoxicity and lithocholic-acid sulfation in biliary bile acids during chenodiol therapy in the National Cooperative Gallstone Study

To test whether hepatotoxicity occurring in National Cooperative Gallstone Study patients was caused by a toxic effect of chenodiol per se or of lithocholate caused by defective sulfation, bile samples were analyzed using a new high-performance liquid chromatography method that measures the proportions of the four individual lithocholate amidates (sulfated and unsulfated lithocholylglycine and lithocholyltaurine) and all common bile acid amidates. Samples were obtained from National Cooperative Gallstone Study patients (n = 17) with abnormal light microscopic liver biopsy results or major aminotransferase elevations and from a matched control group of patients (n = 14) who received similar chenodiol doses but had no evidence of liver injury. Bile samples from 45 healthy subjects were also analyzed. The analytical method was validated by showing that the percentage of chenodiol and cholic and deoxycholic acid obtained by high-performance liquid chromatography correlated highly (r greater than 0.94) with previous gas-liquid chromatography analyses of these samples by the National Cooperative Gallstone Study Reference Laboratory. No significant differences were seen between gallstone patients with and without evidence of liver injury for percent total lithocholate amidates, percent sulfated or unsulfated lithocholate amidates or percent chenodiol amidates. Lithocholate was partially sulfated in all bile samples (52% +/- 17% [mean +/- S.D., n = 50]), but the extent of sulfation varied widely between and within patients during the course of therapy. Mean values of healthy subjects were similar and also showed a wide range in the extent of lithocholate sulfation. It is concluded that (a) liver injury caused by these doses of chenodiol could not be attributed to the accumulation of unsulfated lithocholate per se in circulating bile acids; (b) liver injury appeared to be, directly or indirectly, caused by enrichment in circulating bile acids with chenodiol or chenodiol together with lithocholate, suggesting that the hepatocytes of those patients with hepatotoxicity were injured by the change induced in bile-acid metabolism by the feeding of chenodiol; and (c) about half of lithocholate amidates in bile samples were sulfated, but the extent of sulfation was highly variable both in gallstone patients and healthy subjects.

Home parenteral nutrition for patients with inoperable malignant bowel obstruction

The use of home parenteral nutrition (HPN) in patients with inoperable malignant bowel obstruction (IMBO) is controversial. The efficacy, safety, and indications for HPN in these patients is uncertain, and its benefit is difficult to demonstrate. The records of 17 patients (9, ovarian cancer; 4, colon cancer; 4, other) with IMBO receiving HPN managed by the Nutrition Support Team (NST) at Yale-New Haven Hospital from 1980 to 1989 were reviewed. Median survival was 53 days and was longest in the two patients with appendiceal carcinomatosis (208 and 159 days), intermediate in patients with colon cancer (median 90 days), and shortest in patients with ovarian cancer (median 39 days). Survival was unrelated to age or sex. All patients died of their underlying disease; 82% of deaths occurred at home. Only one treatment-related complication requiring readmission occurred. Fourteen patients and their families (82%) perceived their therapy as highly beneficial or beneficial. The NST agreed with this assessment in 11 patients but did not share this perception in three patients. These three patients had a short duration of HPN (less than 25 days) or minimal rehabilitation. It is concluded that HPN for patients with IMBO is associated with a low complication rate, may be most beneficial for those patients with gastrointestinal tract primary tumors, and is usually perceived by patients and care providers as beneficial. HPN has palliative benefit and facilitates compassionate home care for carefully selected patients with IMBO.

Hepatobiliary abnormalities associated with total parenteral nutrition

Evidence of hepatic dysfunction (clinically, chemically, and morphologically) and biliary-tract abnormalities is common in patients receiving TPN. The entity might present as hepatocellular injury (fatty liver, steatonecrosis), intrahepatic cholestasis, acalculous cholecystitis, or cholelithiasis. Infants manifest primarily intrahepatic cholestasis, whereas adults manifest fatty liver early and intrahepatic cholestasis later in the course of therapy. Both groups are at risk for the development of biliary-tract abnormalities. Although most of these changes in the adult are mild and reversible, a small number of patients have recently been reported to develop progressive liver disease. In infants, however, the changes may be more severe, and lead more frequently to progressive liver disease and death. Although this progression to chronic liver disease is worrisome, it is uncertain whether, in patients on long-term therapy, it is due to the TPN or to other conditions or therapies associated with their clinical condition. The pathogenesis of each of these lesions may be multifactorial, including carbohydrate overfeeding, essential-fatty-acid deficiency, amino-acid deficiencies or imbalances, carnitine deficiency, bile-salt toxicity, lipid emulsions, bile-flow reduction, and gallbladder stasis. Therapies in these patients are aimed at alterations in the preceding etiologies (decreased glucose loads, contraction of the gallbladder). Further work is necessary to delineate the exact mechanisms of this entity, especially with regard to the causal relationships of TPN and this entity and to the development of chronic liver disease.

Endemic fluorosis with spinal cord compression. A case report and review

We report a case of spinal cord compression in a Mexican immigrant due to vertebral osteosclerosis from chronic fluoride intoxication. Endemic fluorosis is acquired through drinking water. Groundwater sources with high fluoride content occur worldwide. The epidemiology, metabolism, and clinical features of fluorosis are reviewed. Greater physician awareness of this entity is important to identify correctly patients with this unusual and potentially devastating clinical disorder.

Distal splenorenal vs. portal-systemic shunts after hemorrhage from varices: a randomized controlled trial

Between 1975 and 1983, 303 cirrhotic patients with endoscopically proven major variceal hemorrhage were admitted to the participating hospitals of the Boston-New Haven Collaborative Liver Group. Of these, 274 were evaluated for admission to a prospective, randomized controlled trial comparing portal-systemic shunts with distal splenorenal shunts. The criteria for inclusion were as follows: (i) a portohepatic pressure gradient greater than or equal to 12 mmHg; (ii) angiographic evidence of antegrade portal venous flow; (iii) angiographic demonstration that the inferior vena cava and portal, splenic and left renal veins were anatomically suitable for either a portal-systemic or distal splenorenal shunt, and (iv) the patient was a reasonable operative risk. Eighty-one patients from the six participating hospitals fulfilled the criteria and consented to participate. Thirty-eight patients were randomly assigned to have portal-systemic shunt and 43 to have distal splenorenal shunt. After a follow-up period of 11 years (mean = 3.5 years for all patients), survival was found to be similar in the two groups of patients. The 30-day operative mortality was 13% for the portal-systemic shunt group and 9% for the distal splenorenal shunt patients. Late mortality was 55% for the portal-systemic shunt and 37% for the distal splenorenal shunt group. Total mortality was 68% for the portal-systemic shunt and 46% for the distal splenorenal shunt group. None of these differences is statistically significant. In those patients who survived greater than 30 days after surgery, recurrent variceal hemorrhage occurred in four (12%) in the portal-systemic shunt group compared to seven in the distal splenorenal shunt group (18%) (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Duodenal ulcer. Incidence, risk factors, and predictive value of plasma pepsinogen

In 1958 the Yale freshman class gave blood samples as part of a study intended to determine the predictive value of plasma pepsinogen (PP) for the subsequent development of duodenal ulcer (DU). We report a long-term follow-up of this cohort. A self-administered questionnaire designed to ascertain information about the development of peptic ulcers, and the presence of risk factors was mailed to 861 subjects with "active" addresses. A second questionnaire was mailed to each respondent's physician(s) to verify the diagnosis of DU. Completed questionnaires were returned, after three mailings, by 604 (70%) of the subjects. They reported 18 documented DUs, 15 since 1958, for an incidence of 1.1/1000 person years. Only smoking (P less than 0.05) and undergraduate physical inactivity (P less than 0.01) were identified as risk factors for DU. Family history; blood type; blood antigen secretor status; ingestion of coffee, alcohol, milk, salicylates, soda, or tea; and COPD were not identified as risk factors for DU. Patients with DU had higher mean PP values than those who did not (391.6 +/- 99.6 vs 346.6 +/- 106.7, mean +/- SD) but this was not statistically significant (P greater than 0.05). The predictive value of an elevated PP (greater than 450) for the development of DU was 7.9%, but a low or normal PP predicted the absence of a DU in 97.5% of subjects over a 22-year span.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastrointestinal bleeding in competitive runners

Competitive runners have been shown to develop previously undescribed clinical conditions, including "runner's anemia." This has been shown to be an iron-deficiency anemia of several etiologies including gastrointestinal bleeding. Although 8-23% of runners have been shown to have guaiac-positive stools after a marathon, the incidence of significant and prolonged bleeding is unknown. We report four cases of competitive runners with iron-deficiency anemia, gastrointestinal bleeding coinciding with running, and no definitive gastrointestinal pathology despite extensive evaluation.

Chronic arthritis of the knee in Lyme disease. Review of the literature and report of two cases treated by synovectomy

The arthritis that may be a part of Lyme disease, a spirochetal infection transmitted by ticks, has not been widely reported in the orthopaedic literature. Established chronic arthritis in patients who have Lyme disease most commonly affects the knee and may cause erosive joint disease. Antibiotics given early in the course of the disease can prevent chronic arthritis. When the arthritis is established, penicillin administered intravenously is curative in as many as 55 per cent of patients, but medical therapy alone may be insufficient to successfully treat the chronic stage of arthritis.

Conservative treatment of patellofemoral pain

The vast majority of patients with patellofemoral pain respond to conservative treatment. Nonoperative management consists of rest and avoidance of activities producing increased patellofemoral pressure, combined with quadriceps strengthening exercises with the knee extended. Anti-inflammatory drugs and special braces may assist in the treatment program.