A systematic review of the clinical effectiveness and cost-effectiveness and economic modelling of minimal incision total hip replacement approaches in the management of arthritic disease of the hip

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of minimal incision approaches to total hip replacement (THR) for arthritis of the hip.

DATA SOURCES

Major electronic databases were searched from 1966 to 2007. Relevant websites were also examined and experts in the field were consulted.

REVIEW METHODS

Studies of minimal (one or two) incision THR compared with standard THR were assessed for inclusion in the review of clinical effectiveness. A systematic review of economic evaluations comparing a minimal incision approach to standard THR was also performed and the estimates from the systematic review of clinical effectiveness were incorporated into an economic model. Utilities data were sourced to estimate quality-adjusted life-years (QALYs). Due to lack of data, no economic analysis was conducted for the two mini-incision surgical method.

RESULTS

Nine randomised controlled trials (RCTs), 17 non-randomised comparative studies, six case series and one registry were found to be useful for the comparison of single mini-incision THR with standard THR. One RCT compared two mini-incision THR with standard THR, and two RCTs, five non-randomised comparative studies and two case series compared two mini-incision with single mini-incision THR. The RCTs were of moderate quality. Most had fewer than 200 patients and had a follow-up period of less than 1 year. The single mini-incision THR may have some perioperative advantages, e.g. blood loss [weighted mean difference (WMD) -57.71 ml, p<0.01] and shorter operative time, of uncertain practical significance. It may also offer a shorter recovery period and greater patient satisfaction. Evidence on long-term outcomes (especially revision) is too limited to be useful. Lack of data prevented subgroup analysis. With respect to the two-incision approach, data were suggestive of shorter recovery compared with single-incision THR, but conclusions must be treated with caution. The costs to the health service, per patient, of single mini-incision THR depend upon assumptions made, but are similar at one year (7060 pounds sterling vs 7350 pounds sterling for standard THR). For a 40-year time horizon the costs were 11,618 pounds sterling for mini-incision and 11,899 pounds sterling for standard THR. Two existing economic evaluations were identified, but they added little, if any, value to the current evidence base owing to their limited quality. In the economic model, mini-incision THR was less costly and provided slightly more QALYs in both the 1- and 40-year analyses. The mean QALYs at 1 year were 0.677 for standard THR and 0.695 for mini-incision THR. At 40 years, the mean QALYs were 8.463 for standard THR and 8.480 for mini-incision. At 1 year the probabilistic sensitivity analyses indicate that mini-incision THR has a 95% probability of being cost-effective if society's willingness to pay for a QALY were up to 50,000 pounds sterling. This is reduced to approximately 55% for the 40-year analysis. The results were driven by the assumption of a 1-month earlier return to usual activities and a decreased hospital length of stay and operation duration following mini-incision THR. If mini-incision THR actually required more intensive use of resources it would become approximately 200 pounds sterling more expensive and would only be cost-effective (cost per QALY>30,000 pounds sterling) if recovery was 1.5 weeks faster. A threshold analysis around risk of revision showed, using the same cost per QALY threshold, mini-incision THR would have to have no more than a 7.5% increase in revisions compared with standard THR for it to be no longer considered cost-effective (one more revision for every 200 procedures performed). Further sensitivity analysis involved relaxing assumptions of equal long-term outcomes where possible. and broadly similar results to the base-case analysis were found in this and further sensitivity analyses.

CONCLUSIONS

Compared with standard THR, minimal incision THR has small perioperative advantages in terms of blood loss and operation time. It may offer a shorter hospital stay and quicker recovery. It appears to have a similar procedure cost to standard THR, but evidence on its longer term performance is very limited. Further long-term follow-up data on costs and outcomes including analysis of subgroups of interest to the NHS would strengthen the current economic evaluation.

Secretion expression of recombinant glucagon inEscherichia coli

A novel approach for the preparation of recombinant human glucagon was described. An expression vector pAGluT, containing phoA promoter, phoA signal peptide and glucagon gene, was constructed by means of genetic engineering.Escherichia coli strain YK537 was transformed with pAGluT. High-level secretory expression of recombinant human glucagon was achieved. The expression yield of recombinant human glucagon was found to be 80 mg/L, approximately 30% of the total proteins in supernatant. The biological activities and the physicochemical properties of the purified recombinant human glucagon were found to be the same as that of native glucagon. In addition, our results suggested that phoA expression system may be suitable for the expression of other small peptides.

Seed yield of near-isogenic soybean lines with introgressed quantitative trait loci conditioning resistance to corn earworm (Lepidoptera: Noctuidae) and soybean looper (Lepidoptera: Noctuidae) from PI 229358

The development of superior soybean, Glycine max (L.) Merr., cultivars exhibiting resistance to insects has been hindered due to linkage drag, a common phenomenon when introgressing alleles from exotic germplasm. Simple-sequence repeat (SSR) markers were used previously to map soybean insect resistance (SIR) quantitative trait loci (QTLs) in a'Cobb' X PI 229358 population, and subsequently used to create near-isogenic lines (NILs) with SIR QTL i n a 'Benning' genetic background. SIR QTLs were mapped on linkage groups (LGs) M (SIRQTL-M), G (SIRQTL-G), and H (SIRQTL-H). The objectives of this study were to 1) evaluate linkage drag for seed yield by using Benning-derived NILs selected for SIRQTL-M, SIRQTL-H, and SIRQTL-G; 2) assess the amount of PI 229358 genome surrounding the SIR QTL in each Benning NIL; and 3) evaluate the individual effects these three QTLs on antibiosis and antixenosis to corn earworm, Helicoverpa zea (Boddie), and soybean looper, Pseudoplusia includens (Walker). Yield data collected in five environments indicated that a significant yield reduction is associated with SIRQTL-G compared with NILs without SIR QTL. Overall, there was no yield reduction associated with SIRQTL-M or SIRQTL-H. A significant antixenosis and antibiosis effect was detected for SIRQTL-M in insect feeding assays, with no effect detected in antixenosis or antibiosis assays for SIRQTL-G or SIRQTL-H without the presence of PI 229358 alleles at SIRQTL-M. These results support recent findings concerning these loci.

C/EBPbeta represses p53 to promote cell survival downstream of DNA damage independent of oncogenic Ras and p19(Arf)

CCAAT/enhancer-binding protein-beta (C/EBPbeta) is a mediator of cell survival and tumorigenesis. When C/EBPbeta(-/-) mice are treated with carcinogens that produce oncogenic Ras mutations in keratinocytes, they respond with abnormally elevated keratinocyte apoptosis and a block in skin tumorigenesis. Although this aberrant carcinogen-induced apoptosis results from abnormal upregulation of p53, it is not known whether upregulated p53 results from oncogenic Ras and its ability to induce p19(Arf) and/or activate DNA-damage response pathways or from direct carcinogen-induced DNA damage. We report that p19(Arf) is dramatically elevated in C/EBPbeta(-/-) epidermis and that C/EBPbeta represses a p19(Arf) promoter reporter. To determine whether p19(Arf) is responsible for the proapoptotic phenotype in C/EBPbeta(-/-) mice, C/EBPbeta(-/-);p19(Arf-/-) mice were generated. C/EBPbeta(-/-);p19(Arf-/-) mice responded to carcinogen treatment with increased p53 and apoptosis, indicating p19(Arf) is not essential. To ascertain whether oncogenic Ras activation induces aberrant p53 and apoptosis in C/EBPbeta(-/-) epidermis, we generated K14-ER:Ras;C/EBPbeta(-/-) mice. Oncogenic Ras activation induced by 4-hydroxytamoxifen did not produce increased p53 or apoptosis. Finally, when C/EBPbeta(-/-) mice were treated with differing types of DNA-damaging agents, including alkylating chemotherapeutic agents, they displayed aberrant levels of p53 and apoptosis. These results indicate that C/EBPbeta represses p53 to promote cell survival downstream of DNA damage and suggest that inhibition of C/EBPbeta may be a target for cancer cotherapy to increase the efficacy of alkylating chemotherapeutic agents.

Biomechanical Properties of the Condyle Created by Osteodistraction

A new condyle can be reconstructed by osteodistraction, but the biomechanical properties of the neocondyle remain unknown. This study examined the hypothesis that the biomechanical properties of neocondylar cancellous bone could reach control levels 24 weeks after its creation by osteodistraction. The right mandibular condyles were removed and reconstructed by osteo-distraction in 16 adult goats. Their contralateral condyles served as controls. Microstructural and mechanical properties were examined by microcomputed tomography and mechanical testing. At 24 weeks after distraction, the neocondyle grew larger in size, but the shape and histological features were similar to those of the controls. The cancellous bone of the neocondyle even appeared to be more dense and stiffer in comparison with the control condyle. The results of this study suggest that the neocondyle created by osteodistraction develops nearly normal biomechanical properties for functional loading by 24 weeks after creation.

Positive selection targeting the cathelin-like domain of the antimicrobial cathelicidin family

The cathelin-like domain (CLD) of cathelicidins is grouped in the same superfamily with cystatins, natural cysteine protease inhibitors, due to their structural similarity. Intriguingly, human hCAP-18/LL37 and pig protegrin-3 (PG3) CLDs exhibit opposite effects against cathepsin L. Here, I evaluated the functional importance of the CLD through identifying whether positive selection has driven adaptive evolution of this domain. As a result, four positively selected sites were detected and three of them are located on a loop region previously recognized as a key determinant of the activating effect of the PG3 CLD. Analysis of amino acid variability of the CLD led to the discovery of a conserved region and three highly variable regions, in which two are subjected to positive selection. Positive selection targeting the variable regions provides a starting point for experimentally establishing a direct link between the observed amino acid changes and functional divergence of the CLD family.

Effects of defoliating insect resistance QTLs and a cry1Ac transgene in soybean near-isogenic lines

The crystal proteins coded by transgenes from Bacillus thuringiensis (Bt) have shown considerable value in providing effective insect resistance in a number of crop species, including soybean, Glycine max (L.) Merr. Additional sources of soybean insect resistance would be desirable to manage the development of tolerance/resistance to crystal proteins by defoliating insects and to sustain the deployment of Bt crops. The objective of this study was to evaluate the effects and interactions of three insect resistance quantitative trait loci (QTLs; QTL-M, QTL-H, and QTL-G) originating from Japanese soybean PI 229358 and a cry1Ac gene in a "Benning" genetic background. A set of 16 BC(6)F(2)-derived near isogenic lines (NILs) was developed using marker-assisted backcrosses and evaluated for resistance to soybean looper [SBL, Pseudoplusia includens (Walker)] and corn earworm [CEW, Helicoverpa zea (Boddie)] in field cage, greenhouse, and detached leaf assays. Both Bt and QTL-M had significantly reduced defoliation by both SBL and CEW and reduced larval weight of CEW. The antibiosis QTL-G had a significant effect on reducing CEW larval weight and also a significant effect on reducing defoliation by SBL and CEW in some assays. The antixenosis QTL-H had no main effect, but it appeared to function through interaction with QTL-M and QTL-G. Adding QTL-H and QTL-G further enhanced the resistance of the Bt and QTL-M combination to CEW in the field cage assay. These results should help guide the development of strategies for effective management of insect pests and for sustainable deployment of Bt genes.

Evaluation of thermal properties of food materials at high pressures using a dual-needle line-heat-source method

Thermal properties of food systems at high pressure (HP) are important in the design and operation of HP processing equipment. Available techniques for thermal property evaluation under HP conditions are still very limited. In this study, a dual-needle line-heat-source (DNL) device was installed in an HP vessel to evaluate thermal conductivity (k), diffusivity (alpha), and volumetric heat capacity (C(pV)) of foods at high pressure. The DNL probe was calibrated using glycerin (0.1 MPa) and 2% (w/w) agar gel (0.1 to 350 MPa) at 5 and 25 degrees C. Calibration results showed a good correlation with the reference data of pure water: R(2)= 0.966 for thermal conductivity and R(2)= 0.837 for diffusivity, and a small standard deviation of relative error (3.18%) for the volumetric heat capacity. Fresh potato and cheddar cheese were used as test samples at 5 degrees C at selected pressure levels (0.1 to 350 MPa). The potato samples gave thermal properties very close to those of pure water, but much higher than those of the cheese. The k and alpha values of both potato and cheese increased with pressure and a 2nd-order polynomial well fitted their pressure dependency. The volumetric heat capacity data did not show a clear pressure-dependency trend. The experimental system worked well for the evaluation of thermal properties at pressures up to 350 MPa.

From chiral vibration to static chirality in (135)Nd

Electromagnetic transition probabilities have been measured for the intraband and interband transitions in the two sequences in the nucleus (135)Nd that were previously identified as a composite chiral pair of rotational bands. The chiral character of the bands is affirmed and it is shown that their behavior is associated with a transition from a vibrational into a static chiral regime.

Molecular phylogenetic diversity of bacteria and its spatial distribution in composts

AIMS

To investigate microbial diversity of swine manure composts in the initial stage and the spatial distribution due to gradient effect.

METHODS AND RESULTS

Samples in different locations of a composting pile were taken and analysed by using a culture-independent approach. Total community DNA was extracted and bacterial 16S rRNA genes were subsequently amplified, cloned, restriction fragment length polymorphism-screened and sequenced. Thirty-three unique sequence types were found among the 110 analysed positive clones from superstratum sample; 56 among 122 from middle-level sample and 32 among 114 from substrate sample, respectively. The sequences related to Clostridium sp. were most common in the composts. One hundred and thirteen out of 121 16S rDNA sequence types displayed homology with those in the GenBank database. Seven 16S rDNA sequence types were not closely related to any known species. The middle-level sample had the highest microbial diversity, containing unique sequences related to Lactosphaera pasteurii, Firmicutes sp., Aerococcus sp., Megasphaera sp. and Stenotrophomonas sp.

CONCLUSIONS

Pile temperature significantly affected microbial community in the initial stage of the composting. Microbial community in different locations is quite different resulting from gradient effect.

SIGNIFICANCE AND IMPACT OF THE STUDY

Results of this study reveal high bacterial diversity in manure composts, and provide molecular evidence to support gradient effect on microbial diversity in initial stage as well.

Characterization of intestinal inflammation and identification of related gene expression changes in mdr1a(-/-) mice

Multidrug resistance targeted mutation (mdr1a (-/-) ) mice spontaneously develop intestinal inflammation. The aim of this study was to further characterize the intestinal inflammation in mdr1a (-/-) mice. Intestinal samples were collected to measure inflammation and gene expression changes over time. The first signs of inflammation occurred around 16 weeks of age and most mdr1a (-/-) mice developed inflammation between 16 and 27 weeks of age. The total histological injury score was the highest in the colon. The inflammatory lesions were transmural and discontinuous, revealing similarities to human inflammatory bowel diseases (IBD). Genes involved in inflammatory response pathways were up-regulated whereas genes involved in biotransformation and transport were down-regulated in colonic epithelial cell scrapings of inflamed mdra1 (-/-) mice at 25 weeks of age compared to non-inflamed FVB mice. These results show overlap to human IBD and strengthen the use of this in vivo model to study human IBD. The anti-inflammatory regenerating islet-derived genes were expressed at a lower level during inflammation initiation in non-inflamed colonic epithelial cell scrapings of mdr1a (-/-) mice at 12 weeks of age. This result suggests that an insufficiently suppressed immune response could be crucial to the initiation and development of intestinal inflammation in mdr1a (-/-) mice.

RhoA prevents apoptosis during zebrafish embryogenesis through activation of Mek/Erk pathway

RhoA small GTPase, as a key regulator for actin cytoskeletal rearrangement, plays pivotal roles during morphogenesis, cytokinesis, phagocytosis and cell migration, but little is known about its signaling mechanism that controls cell survival in vivo. Using zebrafish as a model, we show that non-overlapping antisense morpholinos that block either translation or splicing of rhoA lead to extensive apoptosis during embryogenesis, resulting in overall reduction of body size and body length. These defects are associated with reduced activation of growth-promoting Erk and decreased expression of anti-apoptotic bcl-2. Moreover, ectopic expression of rhoA, Mek or BCL-2 mRNA rescues such phenotypes. Consistently, combined suppression of RhoA and Mek/Erk or Bcl-2 pathways by sub-optimal dose of rhoA morpholino and pharmacological inhibitors for either Mek (U0126) or Bcl-2 (HA 14-1) can induce developmental abnormalities and enhanced apoptosis, similar to those caused by effective RhoA knockdown. Furthermore, U0126 abrogates the rescue by RhoA and MEK but not BCL-2. In contrast, HA 14-1 effectively abolishes all functional rescues by RhoA, MEK or BCL-2, supporting that RhoA prevents apoptosis by activation of Mek/Erk pathway and requiring Bcl-2. These findings reveal an important genetic and functional relationship between RhoA with Mek/Erk and Bcl-2 for cell survival control during embryogenesis.

The kinetics of Ringer's solution in young and elderly patients during induction of general anesthesia with propofol and epidural anesthesia with ropivacaine

BACKGROUND

Different fluid regimens are often adopted for elderly patients, but it is not known whether they handle infused fluids differently during the induction of anesthesia than young patients.

METHODS

Mean arterial pressure (MAP), plasma dilution (based on hemoglobin) and volume kinetics were assessed during an intravenous (i.v.) infusion of 1000 ml of lactated Ringer's solution over exactly 60 min in 29 patients given general anesthesia with propofol (15 < 65 years of age, and 14 > 65 years old) and in 16 patients receiving lumbar epidural anesthesia with titrated doses of ropivacaine (7 patients < 65 years of age and 9 > 65 years old).

RESULTS

General anesthesia caused a greater decrease in MAP than epidural anesthesia (mean 15% vs. 9%; P < 0.001) and was followed by a more pronounced plasma dilution (30% vs. 18%; P < 0.001); the maximum values reaching 50%. The fluid-induced hemodilution increased after the onset of anesthesia. The distribution rate constant (k(t)), which governs the preference for infused fluid to retain the plasma, was significantly reduced, with the lowest values being reached during general anesthesia (P < 0.002). However, only the reduction of MAP, and not the patient's age group or the type of anesthesia per se, had a statistically significant influence on k(t) after the induction.

CONCLUSION

Induction of anesthesia greatly increases fluid-induced hemodilution, the magnitude of which can be expressed as an acute reduction of the distribution rate constant for infused fluid. The post-induction value of this parameter was closely associated with MAP but not with the patient's age.

Hypoxia and Lactate Production in Trophoblast Cells

The etiology of preeclampsia is unknown but is thought to be related to hypoxia in the placenta. We previously reported that the enzyme lactate dehydrogenase (LDH) has increased activity and gene expression in placentas from preeclamptic pregnancies [Tsoi SCM, Zheng J, Xu F, Kay HH. Differential expression of lactate dehydrogenase isozymes (LDH) in human placenta with high expression of LDH-A(4) isozyme in the endothelial cells of pre-eclampsia villi. Placenta 2001;22:317-22]. LDH is responsible for pyruvate conversion to lactate through glycolysis. In this study, we further investigated the role of hypoxia in primary trophoblast cells and a cultured cell line, JEG3 cells, to obtain a better understanding of how it affects the activities of lactate dehydrogenase, lactate production and regulatory genes, as a possible model for preeclampsia. Primary trophoblast cells and JEG3 cells were cultured under 1% oxygen. At 6, 12 and 24h, cells were analyzed for LDHA and LDHB isozyme activities, mRNA and protein expression compared to standard culture conditions. Lactate was measured from cell medium. The hypoxia inducible transcription factor (HIF-1alpha) protein expression was confirmed by western blot. Two lactate transporters (MCT1 and MCT4) mRNA and protein expression were also studied under hypoxia. Finally, lactate was measured in plasma obtained from patients with severe preeclampsia. Under hypoxic conditions, LDHA mRNA is increased in primary trophoblast cells and JEG3 cells. The HIF-1alpha protein expression is higher in hypoxia-treated JEG3 cells than control. LDHA isozyme activity and its protein expression are increased most significantly at 24h of culture under hypoxia. However, LDHB protein is unchanged while its mRNA is decreased. Lactate secretion from JEG3 cells under hypoxia is increased, as is the lactate levels in the plasma from preeclampsia patients. Of the two lactate transporters studied, MCT4 mRNA and protein level are increased under hypoxia. Our findings support the role of hypoxia in inducing HIF-1alpha activity in trophoblasts and increasing LDH transcription as well as its activity. Higher levels of lactate are produced and secreted which may contribute to the higher lactate levels in plasma of preeclamptic patients. These mechanisms may be important in the pathophysiology of preeclampsia.

Single-neutron states in (101)Sn

The first data on the relative single-particle energies outside the doubly magic (100)Sn nucleus were obtained. A prompt 171.7(6) keV gamma-ray transition was correlated with protons emitted following the beta decay of (101)Sn and is interpreted as the transition between the single-neutron g(7/2) and d(5/2) orbitals in (101)Sn. This observation provides a stringent test of current nuclear structure models. The measured nug(7/2)-nud(5/2) energy splitting is compared with values calculated using mean-field nuclear potentials and is used to calculate low-energy excited states in light Sn isotopes in the framework of the shell model. The correlation technique used in this work offers possibilities for future, more extensive spectroscopy near (100)Sn.

Interaction of the acid soap of triethanolamine stearate and stearic acid with water

Stearic acid and triethanolamine (TEA) in a molar ratio of 2:1 were mixed in aqueous solution at 80 degrees C and subsequently cooled to ambient temperature. The structural evolution of the resultant sample during storage was characterized by using light microscopy, Cryo-SEM, differential scanning calorimetery, pH, infrared spectroscopy, elemental analysis, and simultaneous small and wide-angle X-ray diffraction. It was found that a lamellar liquid crystalline phase was formed when stearic acid and TEA solution were mixed at 80 degrees C and multilamellar spheres of a few microns diameter were formed initially after cooling. A hydrolysis reaction (i.e., the reverse reaction of neutralization between stearic acid and TEA) occurred thereafter that caused the breakdown of the lamellar gel phase and the formation of platelet stearic acid crystals. Three polymorphs of stearic acid (defined following previous work as the A, C, and E forms) were formed as the result of hydrolysis reaction, which gave rise to a strong optically pearlescent appearance.

Hyperdense intracranial epidermoid cysts: a study of 15 cases

BACKGROUND

Although intracranial epidermoid cysts generally appear as hypodense lesions on CT scans, occasionally, they may appear hyperdense, making diagnosis difficult. The aim was to study clinical features and possible pathogenesis of hyperdense intracranial epidermoid cysts (HIECs).

METHODS

Fifteen patients with HIECs were surgically treated in our department during a 21-year period (1985 up to 2005). We reviewed each patient's clinical records, radiological findings, operative reports, and pathological examinations, along with a review of the literature.

FINDINGS

The incidence of HIECs in our series was approximately 3.02%, with female predominance. The average age was 32 years and the average duration of complaints was nine months. The most common location was the parasellar area (6 cases), followed by cerebellum (4 cases), clival region (3 cases), cerebello-pontine angle (1 case) and lateral ventricle (1 case). Gross-total excision of the tumor was achieved in ten patients (66.7%). Four (26.7%) patients underwent subtotal resection; and one (6.6%) patient underwent partial resection. Aseptic meningitis that occurred postoperatively in two cases was controlled by lumbar drainage.

CONCLUSIONS

Recurrent leakage of the irritating cyst contents and subsequent chemical inflammatory response may be responsible for the high-density on CT scans and the cystic nature. A correct histological diagnosis is important because, in contrast to typical ECs and other lesions, HIECs are more prone to spread intra-operatively and result in severe aseptic meningitis.