The influence of pain, kinesiophobia and psychological comorbidities on the accuracy of rating of perceived exertion in UK military spinal rehabilitation

INTRODUCTION

Chronic low back pain (CLBP) is a leading cause of disability in the UK Military. Pain and psychological comorbidities have been reported to influence the rating of perceived exertion (RPE). Exercise rehabilitation can be monitored using RPE; however, the accuracy of RPE in inpatient CLBP rehabilitation is unknown.

METHODS

A prospective cohort correlation study of 40 UK Military inpatients with CLBP was completed. Disability (ODI), kinesiophobia (TSK), anxiety (GAD-7) and depression (PHQ-9) were subjectively reported at the beginning and end of a 3 week intervention. Pain (VAS) and HR were recorded in the first aerobic exercise (AE) session (T1) and the final aerobic exercise session (T2). RPE was reported for each AE session.

RESULTS

At T1, a positive correlation was observed between RPE accuracy (-7.2±20.9), and pre-exercise pain (2.7 mm ±1.6 mm) (p>0.001) and ODI (31.0±16.9) (p>0.05), and a negative relationship between RPE accuracy and average HR (135 bpm ±22 bpm) (p>0.001) was observed. At T2, there was no significant correlation between RPE accuracy (-4.4±22.6) and pre-exercise pain (2.8 mm ±1.6 mm) or ODI (34.0±16.5) (p>0.05). The strong negative relationship between RPE accuracy and average HR (137 bpm ±20 bpm) remained at T2. Improved RPE accuracy over the 3-week rehabilitation programme was correlated to the change in average HR (r=-0.314, p<0.05).

CONCLUSIONS

Comorbidities may negatively affect RPE accuracy in CLBP, but the magnitude of the influence reduces over intensive rehabilitation.

Experiences with learning and confirming in drug and biological development

Since the 1997 landmark article by Dr. Lewis Sheiner in Clinical Pharmacology & Therapeutics, biopharmaceutical development in phases I-IIA has become more targeted toward learning (i.e., establishing proof of concept), then subsequently confirming that regulated standards are met. The purpose and importance of the learning-proof-of-concept phase is subjective but typically uses traditional statistics (which were developed for use in confirming). Two examples from development are presented to illustrate learning in practice. Suggestions for how to improve and embed the learn-confirm concept and how to enhance the contributions of clinical pharmacology and statistics are considered.

Analysis of cell surface erythropoietin receptor (EpoR) expression and function in human epithelial tumor tissues

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Background: EpoR mRNA and protein expression have been reported at low levels in human tumors implying EpoR may be functional in tumor cells with inferred implications for the use of erythropoiesis stimulating agents in the Oncology setting. However, mRNA studies use bulk tumor tissue which ignores contribution from the stroma and IHC studies have all used Abs that have since been shown to not be specific for EpoR. Therefore this important question remains unresolved. Methods: EpoR expression and function was investigated in viable, non-apoptotic primary human tumor cells (using tumor specific Abs) that were disaggregated from at least 30 patients from each of the following tumor types: breast (incl. metastases), NSC lung, colorectal, and ovarian. Additional tumor types included head and neck, GBM, pancreatic and gastric. Analysis was performed under conditions that were shown to preserve EpoR expression and function in positive control tissues (primary human erythroid progenitors from bone marrow and UT-7 cells). Cell surface EpoR expression was evaluated by flow cytometry using novel EpoR-specific Abs. EpoR function was investigated by analysis of EpoR signaling using phospho-specific Abs specific for STAT5, Erk, Akt etc following ex vivo Epo stimulation (0U- 300U/mL; for 5 and 30 min). Results: No expression of cell surface EpoR was detected in tumor cells in any of the over 130 tumors. In contrast, high levels of expression were observed in positive controls analyzed in parallel. No induction of EpoR signaling was observed in tumor cells at any [Epo], whereas activation was readily detected in tumor cells treated in parallel with a cocktail of known tumor growth factors. Positive controls treated in parallel, showed robust Epo concentration-dependent signaling. No evidence of EpoR expression or function was observed in tumor endothelial cells. Conclusions: These data demonstrate that epithelial tumor cells do not express functional cell surface EpoR and are not responsive to physiological, therapeutic or indeed very high levels of Epo (300U/mL).

No significant financial relationships to disclose.

Frequencies of plasma protease inhibitor alleles in Australian horse breeds and the recognition of two new alleles

Investigation of the plasma protease inhibitor system (Pi) in the Arabian and quarter horse breeds and re-examination of the standardbred breed resulted in the recognition of two new Pi alleles, designated E and L2. PiE is rare and has been found in only three quarter horses. In contrast, PiL2 is relatively common in the standardbred (0.107) and allowed subdivision of PiL into PiL and PiL2. Splitting of PiL resulted in an exclusion probability (PE) of 0.649 for the standardbred Pi system. Frequencies of the Pi genes have now been determined for four breeds (thoroughbred, standardbred, quarter horse and Arabian) of horses in Australia.

ISO-DALT characterization of 12 'new' equine plasma protease inhibitor (Pi) alleles

Twelve equine protease inhibitory alleles, PiE, H, J, K, L2, O, P, Q, R, V, X, Z, have been characterized in terms of isoelectric point, molecular mass and inhibitory activity to bovine trypsin and chymotrypsin by ISO-DALT electrophoresis. Protein maps for 20 Pi alleles including those of the eight 'Thoroughbred' alleles (PiF, G, I, L, N, S1, S2, U) have now been determined. Five pairs of alleles, S1/S2, G/K, L/L2, P/R and U/Z, possessed varying numbers of common proteins ranging from one protein in the case of G/K and L/L2 to six in the case of U/Z. Based on these results and studies of the abnormal expressions of PiF, PiL and PiS1, a theory of at least three closely linked loci has been postulated to account for the marked heterogeneity of the equine protease inhibitory system.

Subdivision of equine Tf into H1 and H2

Subdivision of equine TfH into two variants, designated H1 (faster) and H2 (slower), has been accomplished by high voltage, thin layer polyacrylamide gel electrophoresis at pH 7.9. Transferrin H1 and H2 have been shown to be controlled by codominant alleles and gene frequencies of the Tf alleles have been determined in the Australian Thoroughbred, Standardbred. Quarter Horse and Arabian Horse breeds.

Protein identification and characterization by mass spectrometry

This overview describes some of the new technologies that can be employed to facilitate rapid identification and characterization of proteins, including the use of correlative approaches for protein identification, rapid posttranslational modification analysis, identification of components in complex mixtures, and direct mass analysis of gel-separated proteins. The mass spectrometric methods referred to in this overview include matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) and electrospray ionization mass spectrometry (ESI-MS).

Does the serum peptidome reveal hemostatic dysregulation?

There is a significant need for markers that are diagnostic of disease, particularly cancer. For these biomarkers to be useful they would need to be able to detect disease early in its progression with high sensitivity and specificity. Many approaches are being undertaken to attempt to find such biomarkers using the tools of systems biology, i.e., parallel measurement techniques including proteomics (parallel protein measurements). Often the premise behind such an approach was to cast a wide net and then design an assay for specific elements that were found to be diagnostic. One such approach has utilized matrix-assisted laser desorption/ionization-mass spectrometry to interrogate the low-molecular-weight component of serum (the fluid component of blood following clotting), the serum peptidome. This approach has the appealing characteristic of speed of analysis but has a number of shortcomings mostly due to signal:noise and mass resolution in some instruments, making peak analysis difficult. Of course, experimental design and statistical analysis have to be conducted with the system limitations in mind. These points have been addressed by others, but few have focused on a potentially larger issue with serum peptidome analysis - are the signals being measured informing us about the disease state directly or indirectly through measurement of another physiological process such as hemostatic dysregulation? This article will present evidence that points to careful measures of the serum peptidome revealing differences in clotting time in disease states and not direct measures of tumor proteolytic activity on blood proteins.

The detection of loose bodies in the elbow

Our aim was to determine the clinical value of MRI and CT arthrography in predicting the presence of loose bodies in the elbow.

A series of 26 patients with mechanical symptoms in the elbow had plain radiography, MRI and CT arthrography, followed by routine arthroscopy of the elbow. The location and number of loose bodies determined by MRI and CT arthrography were recorded. Pre-operative plain radiography, MRI and CT arthrography were compared with arthroscopy.

Both MRI and CT arthrography had excellent sensitivity (92% to 100%) but low to moderate specificity (15% to 77%) in identifying posteriorly-based loose bodies. Neither MRI nor CT arthrography was consistently sensitive (46% to 91%) or specific (13% to 73%) in predicting the presence or absence of loose bodies anteriorly. The overall sensitivity for the detection of loose bodies in either compartment was 88% to 100% and the specificity 20% to 70%. Pre-operative radiography had a similar sensitivity and specificity of 84% and 71%, respectively.

Our results suggest that neither CT arthrography nor MRI is reliable or accurate enough to be any more effective than plain radiography alone in patients presenting with mechanical symptoms in the elbow.

Osteoblastoma of the clavicle

A 14-year-old female with a 1-year history of a painful clavicle mass underwent resection and reconstruction with an intercalated autograft and rigid plate fixation. The histopathology was diagnostic for osteoblastoma. Although a clavicle mass is a common entity following clavicle trauma, less common disorders such as bone tumors need to be considered in the differential diagnosis. Osteoblastoma is an uncommon, benign bone tumor representing 1% of all primary bone tumors. An extensive review of the literature reveals only one reported case of clavicular osteoblastoma.

Ligamentous stabilizers against posterolateral rotatory instability of the elbow

BACKGROUND

The lateral ulnar collateral ligament, the entire lateral collateral ligament complex, and the overlying extensor muscles have all been suggested as key stabilizers against posterolateral rotatory instability of the elbow. The purpose of this investigation was to determine whether either an intact radial collateral ligament alone or an intact lateral ulnar collateral ligament alone is sufficient to prevent posterolateral rotatory instability when the annular ligament is intact.

METHODS

Sequential sectioning of the radial collateral and lateral ulnar collateral ligaments was performed in twelve fresh-frozen cadaveric upper extremities. At each stage of the sectioning protocol, a pivot shift test was performed with the arm in a vertical position. Passive elbow flexion was performed with the forearm maintained in either pronation or supination and the arm in the varus and valgus gravity-loaded orientations. An electromagnetic tracking device was used to quantify the internal-external rotation and varus-valgus angulation of the ulna with respect to the humerus.

RESULTS

Compared with the intact elbow, no differences in the magnitude of internal-external rotation or maximum varus-valgus laxity of the ulna were detected with only the radial collateral or lateral ulnar collateral ligament intact (p > 0.05). However, once the entire lateral collateral ligament was transected, significant increases in internal-external rotation (p = 0.0007) and maximum varus-valgus laxity (p < 0.0001) were measured. None of the pivot shift tests had a clinically positive result until the entire lateral collateral ligament was sectioned.

CONCLUSIONS

This study suggests that, when the annular ligament is intact, either the radial collateral ligament or the lateral ulnar collateral ligament can be transected without inducing posterolateral rotatory instability of the elbow.

Non-traditional study designs to demonstrate average bioequivalence for highly variable drug products

OBJECTIVE

To demonstrate average bioequivalence, the ninety-percent confidence intervals (CI) on the ratio of geometric means for area under the concentration-time curve (AUC) and maximum observed plasma concentration (Cmax) must lie within 0.80-1.25. Demonstration of average bioequivalence (ABE) for highly variable drug products requires large numbers of subjects in a standard, adequately powered, two-period crossover.

METHODS

Application of non-traditional study designs can help to meet this hurdle. Study design and analysis for replicate and group sequential-replicate study designs are presented and illustrated using examples. It is demonstrated how to use such approaches to meet the difficult regulatory hurdle of average bioequivalence for a highly variable drug product.

RESULTS

To illustrate, data are provided from three separate ABE studies for a highly variable drug product at three dosage strengths. In all three studies, a replicate study design was used to compensate for high intrasubject variation. Additionally, for the last study, a group sequential study design was imposed to provide early evidence of conclusive results.

CONCLUSION

Replicate designs and group-sequential designs in bioequivalence should be used to demonstrate average bioequivalence for highly variable drug products or when uncertain of true intrasubject variability in order to ensure conclusive study results.

Outcome of plate fixation of olecranon fractures

OBJECTIVES

To evaluate the functional outcome of plate fixation for displaced olecranon fractures, both simple and comminuted.

DESIGN

Retrospective patient, chart, and radiographic review.

SETTING

Academic teaching hospital.

PATIENTS

Twenty-five patients who underwent plate fixation of displaced olecranon fractures by two surgeons were independently reviewed at an average follow-up of thirty-four months (range, 15-69 months).

MAIN OUTCOME MEASUREMENTS

Physical capability was assessed by measuring range of motion and isometric elbow strength. Patient-rated outcomes were evaluated using the SF-36, DASH, Mayo Elbow Performance Index (MEPI), and visual analogue scales for patient satisfaction and pain. Radiographs were evaluated preoperatively, postoperatively, and at the time of final review.

RESULTS

The average patient age was fifty-four years (range, 14-81 years). The Mayo classification of fractures was fourteen Type II and eleven Type III. An adequate reduction was maintained in all elbows until union. Physical capability measures indicated nonsignificant side-to-side differences in motion or strength, except for supination motion, which was reduced in the injured arm (p = 0.003). The MEPI-rated outcome was twenty-two excellent or good. Patient satisfaction was high (9.7/10), with a low pain rating (1/10). The mean DASH score was consistent with almost normal upper extremity function. The SF-36 showed no difference in physical health as compared with the average American population. Twenty percent of patients required plate removal because of prominence of the internal fixation. The outcome was not influenced by fracture pattern.

CONCLUSION

Plate fixation is an effective treatment option for displaced olecranon fractures with a good functional outcome and a low incidence of complications.

Arthroplasty with a metal radial head for unreconstructible fractures of the radial head

BACKGROUND

Treatment of unreconstructible comminuted fractures of the radial head remains controversial. There is limited information on the outcome of management of these injuries with arthroplasty with a metal radial head implant.

METHODS

The functional outcomes of arthroplasties with a metal radial head implant for the treatment of twenty-five displaced, unreconstructible fractures of the radial head in twenty-four consecutive patients (mean age, fifty-four years) were evaluated at a mean of thirty-nine months (minimum, two years). There were ten Mason type-III and fifteen Mason-Johnston type-IV injuries. Two of these injuries were isolated, and twenty-three were associated with other elbow fractures and/or ligamentous injuries.

RESULTS

At the time of follow-up, Short Form-36 (SF-36) summary scores suggested that overall health-related quality of life was within the normal range (physical component = 47 +/- 10, and mental component = 49 +/- 13). Other outcome scales indicated mild disability of the upper extremity (Disabilities of the Arm, Shoulder and Hand score = 17 +/- 19), wrist (Patient-Rated Wrist Evaluation score = 17 +/- 21 and Wrist Outcome Score = 60 +/- 10), and elbow (Mayo Elbow Performance Index = 80 +/- 16). According to the Mayo Elbow Performance Index, three results were graded as poor; five, as fair; and seventeen, as good or excellent. The poor and fair outcomes were associated with concomitant injury in two patients, a history of a psychiatric disorder in three, comorbidity in two, a Workers' Compensation claim in two, and litigation in one. Subjective patient satisfaction averaged 9.2 on a scale of 1 to 10. Elbow flexion of the injured extremity averaged 140 degrees +/- 9 degrees; extension, -8 degrees +/- 7 degrees; pronation, 78 degrees +/- 9 degrees; and supination, 68 degrees +/- 10 degrees. A significant loss of elbow flexion and extension and of forearm supination occurred in the affected extremity, which also had significantly less strength of isometric forearm pronation (17%) and supination (18%) as well as significantly less grip strength (p < 0.05). Asymptomatic bone lucencies surrounded the stem of the implant in seventeen of the twenty-five elbows. Valgus stability was restored, and proximal radial migration did not occur. Complications, all of which resolved, included one complex regional pain syndrome, one ulnar neuropathy, one posterior interosseous nerve palsy, one episode of elbow stiffness, and one wound infection.

CONCLUSIONS

Patients treated with a metal radial head implant for a severely comminuted radial head fracture will have mild-to-moderate impairment of the physical capability of the elbow and wrist. At the time of short-term follow-up, arthroplasty with a metal radial head implant was found to have been a safe and effective treatment option for patients with an unreconstructible radial head fracture; however, long-term follow-up is still needed.

Population and individual bioequivalence: lessons from real data and simulation studies

The Food and Drug Administration (FDA) has proposed replacing the 1992 average bioequivalence (ABE) with population and individual bioequivalence (PBE & IBE), as outlined in the preliminary draft guidance of December 1997, which was subsequently replaced by the draft guidances of August 1999 and resolved in the final guidance of October 2000. This has led to considerable public debate among regulatory, academic, and industry experts at numerous conferences (e.g., FDA/AAPS March 1998, FDA/AAPS August-September 1999, FDA Pharmaceutical Sciences Advisory Committee September 1999) and in the literature. The final guidance calls for ABE to remain as the primary criterion by which new formulations may be judged ready for access to the marketplace. In addition, the FDA recommends the use of replicate study designs for the specific drug classes of controlled-release formulations and highly variable drugs. The final guidance also alludes to the possibility of a sponsor requesting alternative criteria such as PBE and IBE following consultation with the FDA. This procedure amounts to a data collection period during which data suitable to evaluate the operating characteristics of PBE and IBE would be generated, analyzed, and discussed among interested parties. A comprehensive review of currently available databases is useful in determining the ultimate value of this data collection period. This report provides an update to the previous publication by the authors. In all, 28 data sets from 20 replicate cross-over bioequivalence studies have been analyzed (n = 12-96) using the statistical methodology in the most recent FDA draft guidance. The results are presented below. ABE Pass: ABE Fail: Total: AUC/Cmax AUC/Cmax AUC/Cmax AUC/Cmax Pass PBE & IBE 20/14 1/3 21/17 Pass IBE only 1/0 0/0 1/0 Fail PBE and IBE 0/2 0/1 0/3 Fail IBE only 2/3 4/5 6/8 Total 23/19 5/9 28/28 Review of the database reveals many interesting features, most notably the lack of consistent results within a given data set across all three criteria. The sensitivity of subject-by-formulation interaction to sample size and inherent variability of the compounds is further explored through simulation studies. It is concluded that additional simulation assessments must be considered when evaluating the value of a data collection period for PBE and IBE assessment. It will be shown that definitive conclusions regarding some of the operating characteristics of PBE and IBE can be achieved through a combination of data-driven hypotheses followed by simulation studies to further evaluate the hypotheses. Some recommendations for further data collection will be made.

Muscle forces and pronation stabilize the lateral ligament deficient elbow

The influence of muscle activity and forearm position on the stability of the lateral collateral ligament deficient elbow was investigated in vitro, using a custom testing apparatus to simulate active and passive elbow flexion. Rotation of the ulna relative to the humerus was measured before and after sectioning of the joint capsule, and the radial and lateral ulnar collateral ligaments from the lateral epicondyle. Gross instability was present after lateral collateral ligament transection during passive elbow flexion with the arm in the varus orientation. In the vertical orientation during passive elbow flexion, stability of the lateral collateral ligament deficient elbow was similar to the intact elbow with the forearm held in pronation, but not similar to the intact elbow when maintained in supination. This instability with the forearm supinated was reduced significantly when simulated active flexion was done. The stabilizing effect of muscle activity suggests physical therapy of the lateral collateral ligament deficient elbow should focus on active rather than passive mobilization, while avoiding shoulder abduction to minimize varus elbow stress. Passive mobilization should be done with the forearm maintained in pronation.

Triple "E" syndrome: bilateral locked posterior fracture dislocation of the shoulders

Bilateral locked posterior fracture dislocation of the shoulders is one of the least common injuries of the shoulder, and this injury has been suggested to be pathognomonic of seizures when diagnosed in the absence of trauma. The authors present a case of idiopathic bilateral locked posterior fracture dislocations of the shoulder, along with a review of the medical literature. The authors also present the "triple E syndrome," describing the possible etiologies of this injury: epilepsy (or any convulsive seizure), electrocution, or extreme trauma.

Lack of effect of rosiglitazone on the pharmacokinetics of oral contraceptives in healthy female volunteers

The effect of rosiglitazone (Avandia [BRL 49653C]) on the pharmacokinetics of ethinylestradiol and norethindrone was evaluated after repeat dosing of rosiglitazone with an oral contraceptive (OC; Ortho-Novum 1/35 containing norethindrone 1 mg and ethinylestradiol 0.035 mg) in a randomized, double-blind, placebo-controlled crossover study. Thirty-four healthy female volunteers received oral rosiglitazone (RSG) 8 mg + OC or matched placebo (P) + OC daily on days 1 to 14 of a 28-day OC dosing cycle; the alternate regimen was administered during a second cycle. Ethinylestradiol and norethindrone pharmacokinetics were determined from plasma concentrations on day 14. Lack of pharmacokinetic effect was prospectively defined as 90% CI for the point estimate (PE) of the ratio (RSG + OC):(P + OC) contained within a 20% equivalence range for both ethinylestradiol and norethindrone (analyzed by ANOVA). For RSG + OC and P + OC, respectively, mean ethinylestradiol AUC(0-24) was 1126 and 1208 pg.h/mL (PE: 0.92; 90% CI: 0.88-0.97), and mean norethindrone AUC(0-24) was 178 and 171 ng.h/mL (PE: 1.04; 90% CI: 1.00-1.07). Thus, rosiglitazone had no significant effects on the pharmacokinetics of ethinylestradiol or norethindrone. Coadministration of rosiglitazone with OCs does not induce metabolism of these synthetic sex steroids and is not expected to impair the efficacy of OCs or hormone replacement therapy.

Automated LC-LC-MS-MS platform using binary ion-exchange and gradient reversed-phase chromatography for improved proteomic analyses

A simple multidimensional liquid chromatography system utilizing an isocratic pump and a HPLC system is described for the comprehensive proteomic analysis of complex peptide digest mixtures by coupled LC-LC-MS-MS techniques. A binary ion-exchange separation was achieved through the use of a strong cation-exchange column followed by a reversed-phase column for data-dependent LC-MS-MS analysis of the unbound analytes, and following salt elution (and concomitant column reequilibration), the bound analytes. Off-line validation of the platform showed near quantitative recovery of fractionated peptides and essentially complete ion-exchange partitioning. In comparative analyses of a highly complex peptide digest mixture a >40% increase in the number of peptide and protein identifications was achieved using this multidimensional platform compared to an unfractionated control.

Ilizarov hybrid external fixation for fractures of the distal radius: Part I. Feasibility of transfixion wire placement

The advantages of Ilizarov external fixation, allowing early motion of adjacent joints during fixation of periarticular fractures, have not yet been applied to distal radius fractures. A magnetic resonance imaging study of 10 normal volunteers evaluated the safety of passing percutaneous transfixion pins across the distal radius in 3 forearm positions. Even in the optimal forearm position, the safe zones between the transfixion pin, vessel, nerve, or tendon was small, suggesting that open placement would be required. A cadaver study in 8 specimens demonstrated that the pins could be placed with an open technique using an aiming device and that the pins could be placed without limiting forearm rotation. The proximity of vital structures to transfixion pins dictates open placement to safely apply Ilizarov fixation to distal radius fractures.

Ilizarov hybrid external fixation for fractures of the distal radius: Part II. Internal fixation versus Ilizarov hybrid external fixation: Stability as assessed by cadaveric simulated motion testing

The in vitro stability of an Ilizarov hybrid external fixator was compared with that of a dorsal 3.5-mm AO T-plate in 8 unpaired, fresh-frozen upper extremities. A specially designed testing device that used computer-controlled pneumatic actuators was used to simulate active finger, wrist, and forearm motions by applying loads to relevant tendons. A comminuted extra-articular distal radius fracture was modelled using a dorsally based wedge osteotomy. Fracture stability was assessed using an electromagnetic tracking device to measure motion across the fracture site after randomized application of the plate and the hybrid fixator. During simulated finger and wrist motions with the forearm pronated or supinated, motion of the distal fragment with the hybrid fixator applied was comparable to or statistically less than with the AO plate applied. During simulated forearm rotation, the stability provided by the 2 fixation types was similar, although the plate allowed statistically less radial-ulnar deviation of the fragment. In this model of a 2-part extra-articular distal radius fracture, the clinically meaningful stability of the Ilizarov hybrid external fixator was comparable to that of the dorsal AO plate.

A biomechanical analysis of intrascaphoid compression using the 3.00 mm Synthes cannulated screw and threaded washer: an in vitro cadaveric study

This study evaluated the compressive capabilities of the 3.0 mm Synthes cannulated screw and threaded washer. A transverse osteotomy was performed at the waist of eight cadaveric scaphoids and a custom-designed load cell was inserted before internal fixion with a 3.0 mm cannulated screw and threaded washer. The mean intrascaphoid compression achieved was 108 (SD, 60) N. This compressive force is comparable to that produced by standard cortical screws.

An anthropometric study of the radial head: implications in the design of a prosthesis

The dimensions of the native radial head were measured in 28 cadaveric upper extremities and radiographs of the contralateral elbows of 40 patients who had received a radial head replacement. The mean difference between the maximum and minimum radial head diameters was 1.7 +/- 0.7 mm (range, 0.12-3.27 mm). This variability suggests that although the native radial head is not circular, it does not have a consistently elliptic shape. The native radial head also is variably offset from the axis of the neck (4.2 +/- 2.5 mm), suggesting that a radial head hemiarthroplasty that precisely replicates normal anatomy would be difficult to achieve. There was a poor correlation between the radial head diameter and the medullary canal of the radial neck, suggesting that a modular implant system should be considered.

Towards defining the urinary proteome using liquid chromatography-tandem mass spectrometry. I. Profiling an unfractionated tryptic digest

The proteome of normal male urine from a commercial pooled source has been examined using direct liquid chromatography-tandem mass spectrometry (LC-MS/MS). The entire urinary protein mixture was denatured, reduced and enzymatically digested prior to LC-MS/MS analysis using a hybrid-quadrupole time-of-flight mass spectrometer (Q-TOF) to perform data-dependent ion selection and fragmentation. To fragment as many peptides as possible, the mixture was analyzed four separate times, with the mass spectrometer selecting ions for fragmentation from a subset of the entire mass range for each run. This approach requires only an autosampler on the HPLC for automation (i.e, unattended operation). Across these four analyses, 1.450 peptide MS/MS spectra were matched to 751 sequences to identify 124 gene products (proteins and translations of expressed sequence tags). Interestingly, the experimental time for these analyses was less than that required to run a single two-dimensional gel.

Identification of incompletely processed potential carboxypeptidase E substrates from CpEfat/CpEfat mice

In an attempt to identify peptides that may be involved in the obese phenotype observed in CpEfat/CpEfat mice (deficient in Carboxypeptidase E, CpE) samples from fourteen neuroendocrine tissues in wild-type and CpEfat/CpEfat mice were obtained. Peptides were purified from these tissues and potential CpE substrate peptides were enriched using an anhydrotrypsin column that captures peptides with basic C-termini. Bound peptides were subjected to tryptic digestion and followed by liquid chromatography-mass spectrometry analysis. The relative levels of CpEfat/CpEfat versus wild-type peptides were determined by comparison of the ion intensities. Peptide ions elevated in the CpEfat/CpEfat samples were identified by targeted liquid chromatography-tandem mass spectrometry. From those ions, 27 peptides derived from known neuropeptides (including CpE substrates) were identified, together with another 25 peptides from proteins not known to be components of the neuropeptide processing pathway. The known CpE substrates identified included the recently discovered proSAAS, granin-like neuroendocrine peptide precursor that inhibits prohormone processing. The approach demonstrated the feasibility of using an affinity-based method for identifying differences in specific classes of peptides between normal and mutant mice.

Towards defining the urinary proteome using liquid chromatography-tandem mass spectrometry. II. Limitations of complex mixture analyses

With an emphasis on obtaining a multitude of high quality tandem mass spectrometry spectra for protein identification, instrumental parameters are described for the liquid chromatography-tandem mass spectrometry analysis of trypsin digested unfractionated urine using a hybrid quadrupole-time-of-flight (Q-TOF) mass spectrometer. Precursor acquisition rates of up to 20 distinct precursors/minute in a single analysis were obtained through the use of parallel precursor selection (four precursors/survey period) and variable collision induced dissociation integration time (1 to 6 periods summed). Maximal exploitation of the gas phase fractionated ions was obtained through the use of narrow survey scans and iterative data-dependent analyses incorporating dynamic exclusion. The impact on data fidelity as a product of data-dependent selection of precursor ions from a dynamically excluded field is discussed with regards to sample complexity, precursor selection rates, survey scan range and facile chemical modifications. Operational and post-analysis strategies are presented to restore data confidence and reconcile the greatest number of matched spectra.

Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation

Twenty-two consecutive patients (23 wrists) underwent open reduction internal fixation of dorsal perilunate dislocations and fracture-dislocations through combined dorsal and volar approaches. One of 5 experienced wrist surgeons performed these procedures within an average of 3 days of injury (range, 0-26 days) and intercarpal fixation was kept within the proximal carpal row. Motion was instituted an average of 10 weeks (range, 5-16 weeks) after injury. All patients were males. The average age at the time of injury was 32 years (range, 16-60 years). The average follow-up period was 37 months (range, 13-65 months). Average flexion-extension motion arc and grip strength in the injured wrist were 57% and 73%, respectively, compared with the contralateral wrist. The scapholunate angle increased and the revised carpal height ratio decreased over time, which was statistically significant for both measurements. Three patients (3 wrists) required wrist arthrodesis and a fourth patient had an immediate scaphoid excision and 4-corner arthrodesis secondary to an irreparable scaphoid fracture. One patient required a proximal row carpectomy to treat septic arthritis. Nine of the remaining 18 wrists had radiographic evidence of arthritis, most often at the capitolunate or scaphocapitate articulations. Short form-36 mental summary scores were significantly greater than age- and gender-matched US population values; physical summary scores were significantly less. The disabilities of arm, shoulder, and hand evaluation, Mayo wrist score, and patient-rated wrist evaluation all reflected loss of function. Seventy-three percent of all patients had returned to full duties in their usual occupations and a total of 82% were employed.

Case studies, practical issues and observations on population and individual bioequivalence

The FDA has proposed replacing the 1992 average bioequivalence (ABE) with population and individual bioequivalence (PBE and IBE). This has led to considerable public discussion between regulatory, academic and industry experts. At the heart of the discussion has been the relatively modest amount of available data to examine the behaviour of the PBE and IBE criteria. A retrospective analysis of 22 data sets from 15 replicate cross-over bioequivalence studies has been conducted (n=12-74). AUC and C(max) parameters from these studies were analysed using ABE, PBE and IBE methods. Of the 22 data sets for AUC, 19 pass ABE, all pass PBE and 20 pass IBE. Of the three data sets that failed ABE, all passed PBE and one passed IBE. The results for C(max) are more variable. Of the 16 data sets where ABE is demonstrated, one data set failed both PBE and IBE. Of the six data sets that failed ABE, two passed both PBE and IBE, three passed PBE but not IBE and one failed all three criteria. There were five data sets that passed ABE and PBE but not IBE. Additional practical issues involving the behaviour of the new criteria and its expected impact on sample size for highly variable drug products will be presented. The characterization of key parameters and their interrelationships will also be discussed with particular emphasis on the subject by formulation term in the IBE criteria. It is concluded that more studies and simulations are desirable before full-scale implementation of PBE and IBE criteria.

Functional outcome of semiconstrained total elbow arthroplasty

BACKGROUND

The objective of the present study was to review the results of primary total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. Two hypotheses were tested: (1) the results in patients with inflammatory arthritis would be superior to those in patients with a traumatic or posttraumatic condition, and (2) the isometric extensor torque after total elbow arthroplasty would be significantly less than that of the contralateral elbow.

METHODS

Forty-seven consecutive patients (fifty-one elbows) had the operation performed by one of three surgeons between November 1, 1989, and June 30, 1996. Thirty-six surviving patients (thirty-nine elbows) were available for follow-up. The mean duration (and standard deviation) of follow-up was 50 +/- 11 months (range, twenty-four to ninety-seven months). The mean age at the time of the operation was 64 +/- 11 years (range, twenty-seven to eighty-seven years). Eighteen patients (twenty-one elbows) had inflammatory arthritis. Eighteen patients (eighteen elbows) had an acute fracture or posttraumatic condition (posttraumatic osteoarthritis in eight, an acute fracture of the humerus in seven, nonunion of the distal aspect of the humerus in two, and primary osteoarthritis in one). The patients were evaluated with use of questionnaires (the Mayo elbow performance index, the Short Form-36 [SF-36], and the Disabilities of the Arm, Shoulder and Hand [DASH] Questionnaire); clinical examination by an orthopaedic surgeon who was not involved with the pre-operative, operative, postoperative, or follow-up care; radiographs; and elbow strength-testing with an isokinetic dynamometer.

RESULTS

The mean score (and standard deviation) on the Mayo elbow performance index for the group that had inflammatory arthritis (90 +/- 11 points) was significantly higher than that for the group with a traumatic or posttraumatic condition (78 +/- 18 points) at the time of the latest follow-up (p < 0.05). In both groups, the mean extensor torque of the involved elbow was significantly less than that of the contralateral elbow (p < 0.05). No significant difference between the groups was found with respect to the flexion-extension arc of motion. Ten elbows (26 percent) had ulnar nerve dysfunction (a transient deficit in six and a permanent deficit in four); nine (23 percent), an intraoperative fracture (of the humeral diaphysis in four, of the ulnar diaphysis in four, and of the olecranon in one); three (8 percent), a periprosthetic infection; three, a triceps disruption; and one (3 percent), a revision because of a fracture of the ulnar component. There were no other revisions. Of the thirty-four elbows with complete radiographic follow-up, twenty-three had no change in the bone-cement interface. Progressive radiolucency was noted around the ulnar prosthesis in eight elbows, around the humeral prosthesis in one elbow, and around both components in two elbows.

CONCLUSIONS

Patients who had a total elbow arthroplasty with use of a semiconstrained Coonrad-Morrey prosthesis were generally satisfied; the mean level of patient satisfaction was 9.2 of a possible 10 points for those who had inflammatory arthritis and 8.6 points for those who had a fracture or posttraumatic condition. The rates of complications involving the ulnar nerve, intraoperative fracture, triceps disruption, deep infection, and periprosthetic radiolucency are of concern.

Effect of screw placement on fixation in the humeral head

The objectives of this study were (1) to determine the most advantageous screw locations within the humeral head when plate and screw fixation is to be used and (2) to determine the effect of positioning the screw tip abutting the subchondral bone. Ten paired humeral heads were harvested with a monoplanar cut through the anatomic neck. Through use of a standardized template, 7 holes were drilled and tapped in each specimen for insertion of 6.5-mm fully threaded cancellous screws perpendicular to the plane of the cut. Paired specimens were randomized into 2 groups, one with the screw purchase in central cancellous bone and the other with the screw purchase up to the subchondral bone. Each screw was pulled out axially at a displacement rate of 10 mm/min through use of a servohydraulic testing machine. The length of thread purchase, position within the head, and screw pullout load to failure were recorded. The normalized pullout force to failure was calculated by dividing absolute pullout force to failure by length of screw purchase. Data were analyzed by means of a 2-way repeated measures analysis of variance and post hoc Student-Newman-Keuls test. The central position had a significantly higher absolute pullout force to failure than all other sites (P < .05). By virtue of the humeral head shape, the central position also had a significantly greater length of screw purchase than all other positions (P < .05). The central position had a significantly higher relative pullout force to failure than all other positions (P < .05). Subchondral bone abutment positioning improved both the absolute and the relative pullout forces to failure (P < .05). When screws and plates are used in open reduction and internal fixation of a proximal humerus fracture, a major mode of failure is loss of fixation within the humeral head. On the basis of this study, optimal screw purchase with respect to bone fixation can be achieved by including screws located in the center of the humeral head in the subchondral abutment position. To minimize screw fixation failure, the anterosuperior position should be avoided. The pattern of distribution of the relative pullout force as measured in this study is consistent with previous observational studies of patterns of trabecular density within the humeral head.

Proteomics: the industrialization of protein chemistry

Establishing a proteomics platform in the industrial setting initially required implementation of a series of robotic systems to allow a high-throughput approach to analysis and identification of differences observed on 2-D electrophoresis gels. Now, a simpler alternative approach employing chromatography-based systems is emerging for identification of many components of complex mixtures, which can also provide quantitative comparisons through the use of a new labeling methodology.

PhRMA perspective on population and individual bioequivalence

The Food and Drug Administration (FDA) issued a second-draft guidance in August 1999 on the subject of in vivo bioequivalence, which is based on the concepts of individual and population bioequivalence (IBE and PBE, respectively). The intention of this guidance is to replace the 1992 guidance that requires that in vivo bioequivalence be demonstrated by average bioequivalence (ABE). Although the concepts of population and individual bioequivalence are intuitively reasonable, a detailed review of the literature has not uncovered clinical evidence to justify the additional burden to the innovator and generic companies as well as the consumer that the new guidelines would impose. The criteria for bioequivalence described in the draft guidance employ aggregate statistics that combine information about differences in bioavailability between formulation means and differences in bioavailability variation of formulations between and within subjects. The purely technical aspects of the statistical approach are reasonably sound. However, PhRMA believes that important operational issues remain that need to be resolved before any changes to current practice are implemented. PhRMA believes that the ideals of prescribability and switchability are intuitively reasonable, but it is uncertain of the extent to which the proposed guidance can achieve these goals. It is not clear whether the attainment of such goals is necessary in the evaluation of bioequivalence given the role this plays in drug development, and the lack of clinical evidence argues against a pressing need to change current practice. PhRMA is concerned that the trade-off offered by the aggregate criteria may ultimately represent more harm than good to the public interest. PhRMA recommends more rigorous evaluation of methods based on two-way crossover designs before moving to methods that require more complex designs. One such method is identified herein and contains procedures for estimating prescribability and switchability. The possibility of a phase-in or trial period to collect replicate crossover data to further evaluate IBE and PBE and possibly allow market access based on these criteria as they are being evaluated has been proposed. PhRMA believes this is unprecedented and will offer little additional information beyond that which can be obtained by simulation or has already been collected by the FDA. Simulation studies have the advantage of allowing evaluation of the sensitivity of various procedures to represent the data patterns as created within the simulation. Operating characteristics by which proposed criteria can be adequately judged have not yet been defined. The limitations of ABE for highly variable drugs and narrow therapeutic drugs are well appreciated and may be addressed by means other than a wholesale change in the current criteria.

Early excision of heterotopic bone in the forearm

Five patients undergoing early excision of heterotopic bone in the forearm with radiation therapy and indomethacin were reviewed. Inciting causes of heterotopic ossification included distal biceps tendon repairs, ulna fractures, and a fracture of the radius and ulna. Preoperative forearm rotation arc averaged 17 degrees. Excision was performed at an average of 4 months after injury. Patients were administered 500 to 1,000 cGy of radiation after surgery and received indomethacin for 6 weeks. At an average of 37 months after surgery the forearm rotation arc averaged 136 degrees. All patients had resumed normal activities and had no radiographic recurrence of heterotopic bone or other treatment complications. In the past excision of heterotopic ossification after more than 12 months has been advocated to prevent recurrence. The results of this study suggest that early excision with radiation therapy and indomethacin is a viable option in treating and preventing recurrent heterotopic ossification in the forearm.

A simplified device for protein identification by microcapillary gradient liquid chromatography-tandem mass spectrometry

A simplified device and procedure have been developed for microcapillary gradient liquid chromatography-tandem mass spectrometry (LC-MS/MS). This procedure has proved useful in identifying low level quantities of proteins from sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) gel bands. Microelectrospray needles are packed with reversed-phase resin and function both as a high performance liquid chromatography (HPLC) column and a nanospray mass spectrometer tip when interfaced between an HPLC and ion trap mass spectrometer. Variable submicroliter flow rates are generated by flow splitting between the microelectrospray capillary and an HPLC system. A manual injector is used to inject a protein digest mixture that binds to the column and is then washed at a high flow rate (2 microL/min post split). Gradient elution of bound peptides was initiated by the injection of a filled loop of 70% v/v methanol (5 microL) concomitant with a reduction of flow rate (0.1 microL/min post split). This forms a diffusion-dependent gradient of variable length (typically 15-30 min in length) depending upon the final flow rate. Chromatographic separations of a standard solution digest demonstrate that this diffusion-dependent gradient provides reasonable separations such that multiple peptide identifications by MS/MS can be obtained. Application of this methodology to the analysis of several in-gel-digested gel-separated proteins is presented to demonstrate its utility.

Cloning and characterization of the murine glucosamine-6-phosphate acetyltransferase EMeg32. Differential expression and intracellular membrane association

N-Linked glycosylation is a post-translational modification occurring in many eukaryotic secreted and surface-bound proteins and has impact on diverse physiological and pathological processes. Similarly important is the generation of glycosylphosphatidylinositol linkers, which anchor membrane proteins to the cell. Both protein modifications depend on the central nucleotide sugar UDP-N-acetylglucosamine (UDP-GlcNAc). The enzymatic reactions leading to generation of nucleotide sugars are established, yet most of the respective genes still await cloning. We describe the characterization of such a gene, EMeg32, which we identified based on its differential expression in murine hematopoietic precursor cells. We further demonstrate regulated expression during embryogenesis. EMeg32 codes for a 184-amino acid protein exhibiting glucosamine-6-phosphate acetyltransferase activity. It thereby holds a key position in the pathway toward de novo UDP-GlcNAc synthesis. Surprisingly, the protein associates with the cytoplasmic side of various intracellular membranes, accumulates prior to mitosis, and copurifies with the cdc48 homolog p97/valosin-containing protein.

Mass spectrometric identification of proteins released from mitochondria undergoing permeability transition

Mitochondrial membrane permeabilization is a rate-limiting step of cell death. This process is, at least in part, mediated by opening of the permeability transition pore complex (PTPC) Several soluble proteins from the mitochondrial intermembrane space and matrix are involved in the activation of catabolic hydrolases including caspases and nucleases. We therefore investigated the composition of a mixture of proteins released from purified mitochondria upon PTPC opening. This mixture was subjected to a novel proteomics/mass spectrometric approach designed to identify a maximum of peptides. Peptides from a total of 79 known proteins or genes were identified. In addition, 21 matches with expressed sequence tags (EST) were obtained. Among the known proteins, several may have indirect or direct pro-apoptotic properties. Thus endozepine, a ligand of the peripheral benzodiazepin receptor (whose occupation may facilitate mitochondrial membrane permeabilization), was found among the released proteins. Several proteins involved in protein import were also released, namely the so-called X-linked deafness dystonia protein (DDP) and the glucose regulated protein 75 (grb75), meaning that protein import may become irreversibly disrupted in mitochondria of apoptotic cells. In addition, a number of catabolic enzymes are detected: arginase 1 (which degrades arginine), sulfite oxidase (which degrades sulfur amino acids), and epoxide hydrolase. Although the functional impact of each of these proteins on apoptosis remains elusive, the present data bank of mitochondrial proteins released upon PTPC opening should help further elucidation of the death process.

Identification and characterization of proSAAS, a granin-like neuroendocrine peptide precursor that inhibits prohormone processing

Five novel peptides were identified in the brains of mice lacking active carboxypeptidase E, a neuropeptide-processing enzyme. These peptides are produced from a single precursor, termed proSAAS, which is present in human, mouse, and rat. ProSAAS mRNA is expressed primarily in brain and other neuroendocrine tissues (pituitary, adrenal, pancreas); within brain, the mRNA is broadly distributed among neurons. When expressed in AtT-20 cells, proSAAS is secreted via the regulated pathway and is also processed at paired-basic cleavage sites into smaller peptides. Overexpression of proSAAS in the AtT-20 cells substantially reduces the rate of processing of the endogenous prohormone proopiomelanocortin. Purified proSAAS inhibits prohormone convertase 1 activity with an IC(50) of 590 nM but does not inhibit prohormone convertase 2. Taken together, proSAAS may represent an endogenous inhibitor of prohormone convertase 1.

The effectiveness of turnbuckle splinting for elbow contractures

We have treated 22 patients with an elbow contracture using a static progressive turnbuckle splint for a mean of 4.5 +/- 1.8 months. All had failed to improve with supervised physiotherapy and splinting. The mean range of flexion before splintage was from 32 +/- 10 degrees to 108 +/- 19 degrees and afterwards from 26 + 10 (p = 0.02) to 127 +/- 12 degrees (p = 0.0001). A total of 11 patients gained a 'functional arc of movement,' defined as at least 30 degrees to 130 degrees. In eight patients movement improved with turnbuckle splinting, but the functional arc was not achieved. Six of these were satisfied and did not wish to proceed with surgical treatment and two had release of the elbow contracture. In three patients movement did not improve with the use of the turnbuckle splint and one subsequently had surgical treatment. Our findings have shown that turnbuckle splinting is a safe and effective treatment which should be considered in patients whose established elbow contractures have failed to respond to conventional physiotherapy.