Can cobalt levels estimate in-vivo wear of metal-on-metal bearings used in hip arthroplasty?

High levels of cobalt and chromium ions are detected in the blood and urine of patients with metal-on-metal (MoM) hip replacement. These elements are released as a result of wear at the bearing surfaces. Wear rates depend on a multitude of factors, which include the bearing geometry, carbon content, manufacturing processes, lubrication, speed and direction of sliding of the surfaces, pattern of loading, and orientation of the components. In-vivo wear of MoM bearings cannot be reliably measured on X-rays because no distinction can be made between the bearing surfaces. Hip simulator studies have shown that wear rates are higher during the initial bedding-in phase and subsequently drop to very low levels. Accordingly, metal ion levels would be expected to decrease with the use of the bearing, measured as implantation time following surgery. However, several clinical studies have found that metal ion levels either gradually rise or fluctuate instead of decreasing to lower levels. Moreover, hip simulator studies predict that large-diameter bearings have lower wear rates than small-diameter bearings. In clinical studies, however, metal levels in patients with large-diameter bearings are unexpectedly higher than those in patients with small-diameter bearings.

As a consequence, high cobalt ion levels in patients do not necessarily imply that their MoM bearings produce much wear debris at the time that their levels were measured; it may simply be due to accumulation of wear debris from the preceding time. Exercise-related cobalt rise may overcome this limitation and give a better assessment of the current wear status of a MoM bearing surface than a measure of cobalt levels only.

Is crow's feet sign a reliable indicator of corneal injury in facial burns?

Facial burns occur commonly, although they rarely result in serious ophthalmological injuries. Despite this, failure to identify and manage minor eye injuries can have serious consequences. When the blink reflex is forcibly suppressed, the cornea is left exposed, resulting in serious injury. One indicator of possible corneal injury is the absence of 'Crow's feet sign'. Crow's feet sign describes the sparing of the skin creases or crow's feet around the eye with forced eyelid closure. The implication is that the patient was conscious at the time of injury and therefore able to protect the eye from ocular injury. We present a consecutive series of 145 people with facial burns attending the burns unit at Selly Oak Hospital, Birmingham over a 2-year period. Demographics, cause, presence of inhalational injury and outcome were examined for all patients. Eleven patients were diagnosed with ocular injury, and none of these patients had crow's feet sign. To date, we have found 100% correlation between the presence of crow's feet sign and the absence of ocular injury. We would recommend that clinicians are alert to the absence of this sign as a marker of possible eye injury.

Hypnosis for schizophrenia

BACKGROUND

Many people with schizophrenia continue to experience symptoms despite conventional treatments being used. Alternative therapies such as hypnosis, in conjunction with conventional treatments, may be helpful.

OBJECTIVES

To investigate the use of hypnosis for people with schizophrenia or schizophrenia-like illnesses compared with standard care and other interventions.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (October 2006), contacted the Cochrane Complementary Medicine Field for additional searching (January 2003), hand searched references of included or excluded studies and made personal contact with authors of relevant trials.

SELECTION CRITERIA

We included all randomised or double blind controlled trials that compared hypnosis with other treatments or standard care for people with schizophrenia.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality assessed them and extracted data. We excluded data where more than 50% of participants in any group were lost to follow up. For binary outcomes we calculated a fixed effects risk ratio (RR) and its 95% confidence interval (CI).

MAIN RESULTS

We included three studies (total n=149). When hypnosis was compared with standard treatment no one left the studies between 1-8 weeks (n=70, 2 RCTs, Risk Difference 0.00 CI -0.09 to 0.09). Mental state scores were unaffected (n=60, 1 RCT, MD BPRS by one week -3.6 CI -12.05 to 4.8) as were measures of movement disorders and neurocognitive function. Compared with relaxation, hypnosis was also acceptable (n=106, 3 RCTs, RR leaving the study early 2.00 CI 0.2 to 2.15) and had no discernable effect on mental state (n=60, 1 RCT, MD BPRS by one week -3.4 CI -11.4 to 4.6), movement disorders or neurocognitive function. Hypnosis was as acceptable as music (Sibelius) by four weeks (n=36, RR leaving the study early 5.0, CI 0.3 to 97.4).

AUTHORS' CONCLUSIONS

The studies in this field are few, small, poorly reported and outdated. Hypnosis could be helpful for people with schizophrenia. If we are to find this out, better designed, conducted and reported randomised studies are required. This current update has not revealed any new studies in this area since 2003.

Interplay of reactive oxygen species and nitric oxide in the pathogenesis of experimental lead-induced hypertension

1. Lead is a common environmental and industrial toxin that can cause a variety of acute and chronic illnesses. For example, chronic exposure to low levels of lead has been shown to raise arterial pressure and promote renal and cardiovascular complications. 2. Several mechanisms have been identified by which chronic lead exposure can cause hypertension and cardiovascular disease. In recent years, increasing evidence has emerged pointing to the role of oxidative stress as a major mediator of lead-induced hypertension. 3. The present article provides an overview of the published studies on this subject.

Co-inoculation of nitrogen-fixing and phosphate-solubilizing bacteria to promote growth, yield and nutrient uptake in chickpea

A total of 32 bacterial isolates includingMesorhizobium(N=10),Azotobacter(N=12) and phosphate-solubilizing bacteria (N=10) were isolated and tested for siderophore, HCN, ammonia, indole acetic acid production and phosphate solubilizationin vitro. The bacterial cultures were positive for siderophore, HCN and ammonia. Among the isolates,M. ciceriRC3 andA. chrococcumA4 displayed 35 and 14 μg ml−1of IAA, respectively, whereasBacillusproduced 19 (BacillusPSB1) and 17 μg ml−1(BacillusPSB10) of IAA in Luria Bertani broth. The diameter of the P solubilization zone varied between 4 (BacillusPSB1) and 5 mm (BacillusPSB10) and a considerable amount of tricalcium phosphate (7 and 8 μg ml−1byBacillusPSB1 andBacillusPSB10, respectively) was released in liquid medium, with a concomitant drop in pH. The effects of N2-fixing and PS bacteria on the growth, chlorophyll content, seed yield, grain protein and N uptake of chickpea plants in field trials varied considerably between the treatments. Nodule number and biomass were significantly greater at 90 days after sowing (DAS), decreasing by 145 DAS. Seed yield increased by 250% due to inoculation withM. ciceriRC3 +A. chroococcumA4 +BacillusPSB10, relative to the control treatment. Grain protein content ranged from 180 (BacillusPSB1) to 309 ng g−1(M. ciceriRC3 +A. chroococcumA4 +BacillusPSB10) in inoculated chickpea. The N contents in roots and shoots differed considerably among the treatments.

A phase II trial of RAD001 in patients (Pts) with metastatic renal cell carcinoma (MRCC)

5107

Background: RAD001 is an oral mammalian target of Rapamycin (mTOR) inhibitor. Three mechanisms of anti-tumor activity; shuts down tumor response to nutrients and growth factors; cell cycle arrest at late G1 and anti-angiogenesis via VEGF. Molecular alterations in the mTOR modular pathway increase sensitivity in PTEN deficient tumors such as RCC. Endpoints: time-to-progression (TTP), response rate (RR), overall survival (OS), toxicity, and to assess changes in metabolic imaging utilizing CT-PET. Methods: Eligibility included; predominant clear cell, progressive measurable MRCC, adequate organ/marrow function, zubrod performance status (ZPS) = 2, no more than 1 prior therapy, and no active CNS involvement. RAD001 is given orally at a dose of 10mg daily without an interruption (28-day cycle), with dose modifications for toxicity. Re-evaluation was assessed every 2 cycles (8 weeks). RECIST criteria is utilized. TTP and OS are determined from entry into the study. Results: 41 pts have been enrolled. 37 pts are evaluable for response/toxicity. 2 pts toxicity only. 2 pts screened failures. 31 were male/8 female, median age 60 (38–80) years. 31 pts received prior therapy. 23 pts had a ZPS of 0, 13 /1 and 3/2. Sites of disease included; lung, nodal, liver, bone, adrenal, and kidney. 9 pts had 1 metastatic site, 17 pts/2 and 13 pts/3 or more. 15 pts continue to receive RAD001. 12 pts had partial responses, 19 pts were stable for 3+ months. Median duration of therapy is 8+ (range 01–20+) months. Treatment related adverse events; mucositis, skin rash, pneumonitis, hypophosphatemia, hyperglycemia, hypertriglyceridemia, hypercholesterolemia, thrombocytopenia, anemia and elevated LFTs. PET scans have demonstrated decreased metabolic activity in responding or stable pts. Median overall survival is 11.5+ months (range 01–20+). Conclusion: RAD001 has promising anti-tumor activity in pts with MRCC demonstrated by partial response rate. Anti-tumor activity is further suggested by prolonged TTP =3 months. Anti-tumor activity, toxicity and metabolic imaging correlation will be presented. An additional 40 pts who failed prior sunitinib or sorafenib therapy are being enrolled.

No significant financial relationships to disclose.

Multi-center phase II/III randomized controlled clinical trial using TNFerade combined with chemoradiation in patients with locally advanced pancreatic cancer (LAPC)

4518

Background: TNFerade is a replication-deficient adenoviral vector carrying the transgene for human TNF-a protein, regulated by the radiation-inducible promoter Egr-1. A 50 patient (pt) phase II dose-escalation study in LAPC showed a possible dose-dependent improvement in survival. To confirm these findings, the randomized Pancreatic Cancer Clinical Trial with TNFerade (PACT) study was developed. PACT is a 330 pt study, powered to detect a 20% absolute increase in the primary efficacy endpoint (overall survival at 1 year) compared to standard of care (SOC) chemoradiation. An interim analysis of safety and efficacy was planned after the first 51 pts were randomized. Survival data to 11/15/06 has been evaluated and are reported here. Methods: The TNFerade arm pts received a five- wk treatment of weekly injections of 4 x 1011 pu TNFerade, continuous infusion 5-FU (200 mg/m2/day x 5 days/wk) and 50.4 Gy radiation. TNFerade was administered by percutaneous CT-guided transabdominal injection. The SOC arm received the same regimen, without TNFerade injections. Patients were randomized 2:1 to the TNFerade and SOC arms. The first 51 randomized pts were assessed for evidence of objective response (OR) and overall survival Results: Assessment of response data is still ongoing. TNFerade + SOC was well tolerated. One year survival, the primary endpoint of the study, was 70.5% in the TNFerade + SOC arm versus 28.0% in the SOC arm, an absolute increase of 42.5%. The median survival for TNFerade + SOC pts was 515 days compared to 335 days for the SOC pts. The logrank statistic for comparison between the two arms is X2 = 2.014 (p=0.16). Conclusions: The interim survival data is preliminary. The magnitude of the difference in survival in favor of the TNFerade + SOC arm, however, is encouraging. The data appears to corroborate previous findings from the dose-escalation study, which showed an apparent survival advantage in the 4×1011 pu dose group compared to 4 x 109 pu group. A second interim analysis is planned with larger patient numbers to determine whether this early positive trend is confirmed.

No significant financial relationships to disclose.

A phase II trial of intra-patient dose-escalated sorafenib in patients (pts) with metastatic renal cell cancer (MRCC)

5026

Background: Sorafenib has demonstrated activity with limited toxicity at a dose of 400 mg bid in MRCC pts. This presents an opportunity to explore a more intensive drug administration. This study allowed individual pt titration designed to evaluate the ability for pts to dose escalate. Response rate (RR), time to progression (TTP) and overall survival (OS) will be assessed. Methods: Eligibility included; pathologic diagnosis of a component of clear cell, progressive measurable MRCC, no more than 1 prior therapy, karnofsky performance status (KPS) = 70%, adequate organ/marrow function and no active CNS involvement. Initial dose 400 mg bid, daily. Dose escalation defined in the table below: Re-evaluation is performed every 8 weeks. RECIST criteria is utilized. Results: 46 patients have been enrolled. 44 are evaluable. 37 male/7 female, median age 50 years (43–79). 19 pts received prior therapy. 39 pts had a KPS of 100%, 5/90%. Sites of disease included; lung, nodal, liver, bone, adrenal, pancreas and kidney. 26 pts 1 metastatic site, 12 /2, 6/3 or more. 22 pts continue to receive sorafenib therapy; 2/800 mg, 7/1,200 mg, and 13/1,600 mg. 8 pts complete response (CR), 14 pts/partial response (PR) and 14 pts stable for 3+ months. Median duration of therapy is 6+ (range 0.2+ - 12+) months. 2 pts have not been reevaluated. Treatment related adverse events to-date; hand/foot syndrome, skin rash, diarrhea, alopecia, fatigue, hypertension, hypophosphatemia, and elevated amylase/lipase. Conclusion: 91% of pts were escalated to 1,200 mg or 1,600 mg per day. Dose escalated sorafenib has promising anti-tumor activity in pts with MRCC as demonstrated by a 52% CR/PR rate. Anti-tumor activity is further suggested by prolonged TTP = 3 months for 33% of pts. Independent radiology review is in progress. Intra-patient dose escalation data in association with anti-tumor activity and toxicity will be presented.

[Table: see text]

[Table: see text]

Pregnancies complicated by multidrug-resistant tuberculosis and HIV co-infection in Durban, South Africa

SETTING

Tertiary hospitals in KwaZulu Natal, South Africa.

OBJECTIVE

To study the impact of multidrug-resistant tuberculosis (MDR-TB) and human immunodeficiency virus-1 (HIV-1) co-infection during pregnancy on maternal and perinatal outcome.

DESIGN

Prospective study performed between 1996 and 2001. Symptomatic pregnant women were investigated for TB. Those with confirmed MDR-TB were reported on.

RESULTS

Three of five pregnant women with MDR-TB were HIV-1 co-infected. One woman decided to terminate the pregnancy and one experienced pre-term labour. Two neonates had features of growth restriction.

CONCLUSION

Management of pregnant women with MDR-TB in an HIV-endemic area is possible in developing countries.

Microcytosis, iron deficiency and thalassaemia in a multi-ethnic community: a pilot study

The high prevalence of microcytosis (defined here as mean cell haemoglobin<27 pg) with no other abnormality is a principal cause of confusion in screening for haemoglobin disorders. Here we report the results of a small pilot study aiming to resolve this confusion by routinely proceeding to plasma ferritin and HPLC assay, using the original sequestrene blood sample, when microcytosis is detected. Participants comprised a random sample of 1,302 people referred for a full blood count by their General Practitioner (GP) to the laboratory of a North London district general hospital serving a multi-ethnic inner-city population. Ethnicity was established by questionnaire. In North Europeans, microcytosis was present in 3% of males (half were iron-deficient) and 11% of females (most were iron-deficient). Among ethnic minorities, microcytosis was present in 35% of males (one tenth were iron-deficient), and 45% of females (less than half were iron-deficient): an exclusion diagnosis of "probable alpha thalassaemia" could be made in the remainder. We conclude that when microcytosis is present, routine further analysis of the original sequestrene sample by plasma ferritin assay and haemoglobinopathy screening could lead to a more efficient and cost-effective laboratory service for primary care and maternity services.

Detection of Entamoeba histolytica DNA from liver abscess aspirate using polymerase chain reaction (PCR): a diagnostic tool for amoebic liver abscess

Amoebic liver abscess is common in Bangladesh. It is usually diagnosed by suggestive clinical features, ultrasound findings and positive serology. However, none of these are definitive and the picture overlaps with pyogenic liver abscess. It is critical to differentiate amoebic liver abscess from pyogenic liver abscess as the treatment are different. This study was designed to evaluate the feasibility of using polymerase chain reaction (PCR) for detection of Entamoeba histolytica (E.histolytica) DNA in liver abscess pus for confirmatory diagnosis of amoebic liver abscess. This study was carried out in the department of Hepatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Thirty patients of amoebic liver abscess were included in this study. PCR was done to detect E.histolytica DNA in liver abscess aspirate of all patients by real time PCR method, using oligonucleotide primer containing small-subunit rRNA gene of E.histolytica. Real time PCR detected E.histolytica in liver abscess aspirate in 29 cases out of 30 cases and the sensitivity was 97% (p<0.001). This study also showed that antigen detection by ELISA in liver abscess aspirate was positive in 12 cases only and sensitivity was 40%. The study indicates that detection of E.histolytica by PCR is more sensitive than amoebic antigen detection and PCR assay can be successfully used to confirm the diagnosis of amoebic liver abscess.

Antagonism of antinociceptive effect of hydro-ethanolic extract of Hypericum perforatum Linn. by a non selective opioid receptor antagonist, naloxone

Hydro-ethanolic crude extract of Hypericum perforatum Linn. family hypericaceae (St. John's Wort) aerial parts (Hp. Cr) was studied for its possible antinociceptive effect against acetic acid-induced abdominal constriction assay in mice. Hp. Cr (10-20 mg kg(-1)), opium (10-30 mg kg(-1)), morphine (0.75-3.0 mg kg(-1)) and aspirin (50-100 mg kg(-1)) showed dose-dependent antinociceptive effect. In animals treated with naloxone (0.5 mg kg(-1)), the antinociceptive effect of Hp. Cr was significantly reduced similar to that of opium, while effect of aspirin remained unchanged. These results suggest that the antinociceptive effect of Hypericum perforatum may be mediated through activation of opioid receptors.

Gingival temperature measurements with fluoride and nonfluoride elastomeric ligatures

INTRODUCTION

Little is known about the effect of fluoridated elastomerics on gingival health. The aim of this in-vivo study was to compare subgingival temperature measurements near brackets with fluoridated elastomerics with nonfluoridated elastomerics.

METHODS

This was a prospective, longitudinal, crossover study, involving 12 volunteers. Data, including gingival temperature, gingival crevicular fluid volume, and gingival index scores, were collected weekly from the buccal aspects of 8 teeth for 8 weeks (except for a 1-week washout period). A baseline examination was carried out at week 1. This was repeated at week 2, immediately before placement of orthodontic brackets on all 4 first premolars, which were randomly allocated to receive either fluoridated or nonfluoridated elastomerics. Examinations were repeated at weeks 3 and 4, when the elastomerics were removed. After the washout period, the contrary elastomerics (either fluoridated or nonfluoridated) were placed. Examinations were repeated at weeks 5 and 6 when the elastomerics and brackets were removed. A final examination was performed at week 7.

RESULTS

There was a small, but statistically significant, increase in the gingival temperature (P = .002) after placement of the fluoridated elastomerics. There were no other differences in the markers for gingival health.

CONCLUSIONS

The mean increase in gingival temperature with fluoridated elastomers was small (0.3 degrees C) and unlikely to be clinically significant, but the implications are discussed.

Intraoperative cholangiography facilitates simple transcystic clearance of ductal stones in units without expertise for laparoscopic bile duct surgery

BACKGROUND

In the absence of facilities and expertise for laparoscopic bile duct exploration (LBDE), most patients with suspected ductal calculi undergo preoperative endoscopic duct clearance. Intraoperative cholangiography (IOC) is not performed at the subsequent laparoscopic cholecystectomy. This study aimed to investigate the rate of successful duct clearance after simple transcystic manipulations.

METHODS

This prospective study investigated 1,408 patients over 13 years in a unit practicing single-session management of biliary calculi. For the great majority, IOC was attempted. Abnormalities were dealt with by flushing of the duct, glucagon injection, Dormia basket trawling, choledochoscopic transcystic exploration, or choledochotomy.

RESULTS

Of 1,056 cholangiograms performed (75%), 287 were abnormal (27.2%). Surgical trainees, operating under supervision, successfully performed 24% of all cholangiograms. Of 396 patients admitted with biliary emergencies, 94.1% had abnormal cholangiograms. Of the 287 patients with abnormal IOCs, 9.4% required no intervention, 18% were clear after glucagon and flushing, and 13% were cleared using Dormia basket trawling under fluoroscopy. A total of 95 patients required formal LBDE, and 2 required postoperative endoscopic retrograde cholangiopancreatography (ERCP). No postoperative ERCP for retained stones was required after simple transcystic manipulation. Eight conversions occurred, one during a transcystic exploration. Follow-up evaluation continued for as long as 6 years in some cases. Two patients had recurrent stones after LBDE and a clear postoperative tube cholangiogram.

CONCLUSION

In this series, 10% of the abnormal cholangiograms occurred in patients without preoperative risk factors for bile duct stones. Altogether, 88 IOCs (31%) were cleared after either simple flushing or trawling with a Dormia basket. Formal LBDE was not required for 40% of abnormal cholangiograms. Simple transcystic manipulations to clear the bile ducts justify the use of routine IOC in units without laparoscopic biliary expertise.

Explaining union participation: The effects of union commitment and demographic factors

This study examined the relationship between trade union commitment and union participation among blue-collar workers in South Africa. Survey questionnaires were completed by 93 participants (response rate = 62 %). Findings are consistent with previous research and showed that after controlling for demographic factors, 43% of the variance in participation can be explained by union commitment. In this study, Black participants displayed significantly higher levels of commitment and participation than their Coloured counterparts did.

Impact of natural hosts and artificial adult diets on some quality parameters of the melon fly, Bactrocera cucurbitae (Coquillett) (Diptera: Tephritidae)

Experiments were conducted to evaluate the impact of different natural hosts and artificial adult diets on the pupal quality, adult emergence, ovariole number and longevity of the melon fly, Bactrocera cucurbitae (Coquillett) for two generations under laboratory condition. Pupal quality and percentage adult emergence was slightly higher in F2 generation than F1 generation from all tested hosts. B. cucurbitae fed on proteose-peptone sugar (1:4) produced twice as many as eggs when fed on yeast:sugar (1:3). The differences in fecundity can be explained by the higher number of ovarioles and source of protein ingested. Highly significant interaction between adult diets and natural hosts was observed in terms of ovariole number of B. cucurbitae. Experimental results indicated the importance of understanding the genetic traits in the variation of ovariole number among natural populations of the fly spp.

Coronary calcification, homocysteine, C-reactive protein and the metabolic syndrome in Type 2 diabetes: the Prospective Evaluation of Diabetic Ischaemic Heart Disease by Coronary Tomography (PREDICT) Study

AIMS

The PREDICT Study aims to determine: (i) the association between cardiovascular risk factors and coronary artery calcification score (CACS) obtained by electron beam tomography and (ii) the predictive value of CACS for coronary heart disease (CHD) events in Type 2 diabetes.

METHODS

Having previously reported relationships between CACS and conventional risk factors, we have now studied the novel risk factors, plasma high-sensitivity C-reactive protein (CRP) and homocysteine, insulin resistance, serum apoprotein A1 and B concentrations, the serum triglyceride/high-density lipoprotein cholesterol ratio and metabolic syndrome (International Diabetes Federation definition) in 573 subjects of the PREDICT Type 2 diabetes cohort.

RESULTS

In univariate analyses, the only significant positive novel correlate of CACS was homocysteine (P = 0.0004). CRP was increased in those with detectable calcification, but decreased with increasing calcification score (P = 0.006). In a multivariate model that included all significant univariate correlates, CACS was independently associated with age (P < 0.0001), waist-hip ratio (P < 0.02), male gender (P < 0.05) and duration of diabetes (P < 0.05), but the association with homocysteine was no longer significant. The negative association between CACS and CRP remained in multivariate analysis, and was independent of statin use.

CONCLUSIONS

Age was the major factor influencing CACS in Type 2 diabetes, with weaker contributions from waist hip-ratio and duration of diabetes. Other novel cardiovascular risk factors appear to have little positive effect.