A Novel Minimally Invasive Technique for Treatment of Unicameral Bone Cysts

Management of unicameral bone cysts (UBC) remain controversial. These cysts seldom heal spontaneously or even after pathological fracture. Sometimes these cysts can be very large and incredibly troublesome to the patient. Various treatments exist with variable success rates. We present our experience of treating these lesions by continuous drainage. Over a seven year period, six patients with unicameral bone cysts were treated by inserting a modified drain into the wall of the cyst. The aim of surgery was to place the drain in a dependent area of the cyst, through the cortex allowing for continuous drainage. This was achieved through a small incision under radiographic control. A cement restrictor (usually used for femoral canal plugging during total hip replacements) was modified and inserted to prevent closure of the drain site. A redivac drain was passed through the plug into the cyst. The drain was left in place for a week to establish an epithelialized pathway which hopefully would remain patent, into the subcutaneous tissues, after the drain had been removed. There were four males and two females in the group and the age range was 6 -12 years. Four of the lesions were in the upper humerus, one in the proximal femur and the other one in the proximal tibia. Healing was rated according to the modified Neer classification. Grade 1 (healed) and Grade 2 (healed with defect) was defined as excellent outcome. Persistent /Recurrent cysts (Grade 3 and 4) were noted as unsatisfactory. Five cases were completely healed. Only one had a further fracture and there were no recurrent fractures. All the patients reported complete comfort and they all were able to re-engage in recreational activities without restriction. We think that reducing the intra-medullary pressure in these lesions will lead to healing. We report a safe and minimally invasive technique for the management of UBC.

Mid-term equivalent survival of medial and lateral unicondylar knee replacement: an analysis of data from a National Joint Registry

Current analysis of unicondylar knee replacements (UKRs) by national registries is based on the pooled results of medial and lateral implants. Consequently, little is known about the differential performance of medial and lateral replacements and the influence of each implant type within these pooled analyses. Using data from the National Joint Registry for England and Wales (NJR) we aimed to determine the proportion of UKRs implanted on the lateral side of the knee, and their survival and reason for failure compared with medial UKRs. By combining information on the side of operation with component details held on the NJR, we were able to determine implant laterality (medial versus lateral) for 32 847 of the 35 624 unicondylar replacements (92%) registered before December 2010. Of these, 2052 (6%) were inserted on the lateral side of the knee. The rates of survival at five years were 93.1% (95% confidence interval (CI) 92.7 to 93.5) for medial and 93.0% (95% CI 91.1 to 94.9) for lateral UKRs (p = 0.49). The rates of failure remained equivalent after adjusting for patient age, gender, American Society of Anesthesiologists (ASA) grade, indication for surgery and implant design using Cox's proportional hazards method (hazard ratio for lateral relative to medial replacement = 0.88 (95% CI 0.69 to 1.13); p = 0.32). Aseptic loosening/lysis and unexplained pain were the main reasons for revision in both groups, although the reasons did vary depending on whether a mobile- or a fixed-bearing design was used. At a maximum of eight years the mid-term survival rates of medial and lateral UKRs are similar.

Cobalt from metal-on-metal hip replacements may be the clinically relevant active agent responsible for periprosthetic tissue reactions

Some types of metal-on-metal (MOM) hip replacements have unacceptably high rates of failure, such as the Ultima TPS MOM hip, with 13.8% failure at 5 years. This has been attributed to an inflammatory reaction following the release of cobalt (Co) and chromium (Cr) from the bearing surfaces and modular junctions. There is in vitro evidence that Co is more important than Cr in the inflammatory process, but there are no reported human tissue studies of the analysis of implant-derived metals.

Unintended diagnosis of Von Hippel Lindau syndrome using Array Comparative Genomic Hybridization (CGH): counseling challenges arising from unexpected information

Array Comparative Genomic Hybridization (array CGH) is a powerful tool for identifying genomic imbalances and providing a diagnosis in individuals with a normal karyotype. It has been particularly useful in the investigation of individuals with developmental delay +/-, dysmorphic features and/or multiple congenital abnormalities. However, this non-targeted method of scanning the whole genome can reveal unexpected information. We present a case where array CGH identified the cause of a proband's moderate mental retardation by discovery of a de novo deletion of chromosome 3p25.3. This deletion was shown to contain at least 25 genes including the VHL gene, the deletion or mutation of which leads to Von Hippel Lindau (VHL) syndrome. Presymptomatic testing for VHL is usually offered after appropriate genetic counseling about the implications of this condition. Therefore, scanning the genome by array CGH presents a number of challenges for the genetic counselor. We suggest that further understanding of the psychosocial effects of array CGH is needed in order for appropriate pre- and post-test counseling to be provided.

Diet-induced obesity resistance of Kv1.3-/- mice is olfactory bulb dependent

Gene-targeted deletion of the voltage-gated potassium channel, Kv1.3 (Kv1.3-/-), increases olfactory sensitivity and discriminatory ability, and causes resistance to diet-induced obesity (DIO) in mice. The present study aimed to determine whether the enhanced olfactory ability of the Kv1.3-/- mouse contributes to the resistance to DIO. Kv1.3+/+ and Kv1.3-/- mice were subject to bilateral olfactory bulbectomy (OBX) or sham surgery at 9 weeks of age and placed on either a control chow diet or a 32% moderately high-fat diet (MHF). Caloric and water intake, locomotor activity and oxygen consumption were monitored after 5 weeks of diet treatment. At the end of 26 weeks of diet treatment, fat pad weight and blood chemistry were evaluated. Kv1.3+/+ mice exhibited a significant increase in weight, adiposity, fasting glucose and fasting leptin in response to the MHF-diet, with or without OBX. When treated with a MHF-diet, Kv1.3-/- mice gained significantly less weight than Kv1.3+/+ mice and exhibited a significant increase in light phase metabolism. OBX of Kv1.3-/- mice prevented the resistance to DIO and concomitant up-regulation of light phase metabolism at the same time as decreasing dark phase metabolism and total energy expenditure. These findings suggest that pathways activated in Kv1.3-/- that increased energy expenditure and led to resistance to DIO are olfactory bulb dependent. Thus, these findings add to a growing body of evidence suggesting that the olfactory system can modulate the pathways involved in the regulation of energy balance.

MAT1A variants modulate the effect of dietary fatty acids on plasma homocysteine concentrations

BACKGROUND AND AIM

Dietary n-3 polyunsaturated fatty acids (PUFAs) are associated with decreased plasma homocysteine (Hcy), an important biomarker for cardiovascular disease. The S-adenosylmethionine synthetase type-1 (MAT1A), an essential enzyme in the conversion of methionine to S-adenosylmethionine, plays a key role in homocysteine metabolism. This study investigated the interaction between dietary fatty acids and MAT1A genotypes on plasma Hcy concentrations among Boston Puerto Ricans.

METHODS AND RESULTS

Plasma Hcy and MAT1A genotypes were determined in 994 subjects of the Boston Puerto Rican Health Study. Dietary fatty acid intakes were assessed by interviews using a questionnaire adapted from the NCI/Block food frequency form.

RESULT

In the cross-sectional analysis, genetic variant MAT1A 3U1510 displayed a significant interaction with dietary n-3:n-6 PUFA ratio in determining plasma Hcy (p-value for interaction = 0.025). 3U1510G homozygotes had significantly lower plasma Hcy concentration than major allele homozygotes and heterozygotes (AA + AG) (p-value for trend = 0.019) when the n-3:n-6 ratio was >0.09. Two other MAT1A variants, d18777 and i15752, also showed significant interactions with different constituents of dietary fat influencing Hcy concentrations. Furthermore, haplotypes consisting of three variants displayed a strong interaction with n3:n6 ratio influencing Hcy concentrations.

CONCLUSIONS

Our results suggest that MAT1A genotypes appear to modulate effects of dietary fat on plasma Hcy.

Are we being overly cautious? A qualitative inquiry into the experiences and perceptions of treatment-focused germline BRCA genetic testing amongst women recently diagnosed with breast cancer

PURPOSE

Women with breast cancer, who are found to be BRCA1/2 mutation carriers, have a high risk of ovarian cancer and metachronous breast cancer. Treatment-focused genetic testing (TFGT), offered around the time of diagnosis, allows genetic test results to inform surgical treatment decisions. However, concern has been raised that offering TFGT at this time may overly increase psychological burden. This study aimed to qualitatively explore women's attitudes and experiences of TFGT.

METHODS

Women who had been diagnosed with breast cancer at age 50 years or less undertook a semi-structured telephone interview (n = 26). The sample included women who had been offered TFGT, based on family history and/or other risk criteria (n = 14), and women who had been diagnosed within the past 6-12 months and had not been offered TFGT (n = 12). Interviews explored women's attitudes towards TFGT, perceived benefits and disadvantages, implications of TFGT and impact on surgical decision making. Interviews were transcribed verbatim and thematically analysed.

RESULTS

Women expressed positive attitudes towards TFGT and felt it was highly relevant to their surgical decision making. They did not feel that an offer of TFGT shortly after, or at the time of diagnosis, added undue psychological burden. The majority of women interviewed felt that TFGT should be incorporated into standard clinical care.

CONCLUSIONS

TFGT is viewed favourably by women newly diagnosed with breast cancer. Future randomized controlled trials are needed to examine the long-term impact of TFGT. We conclude that an offer of TFGT is not perceived as 'too much, too soon' by relevant patients.

A multinational assessment of metal-on-metal bearings in hip replacement

There is emerging evidence that many metal-on-metal (MoM) bearings, when used with large femoral heads in conventional hip replacement and some resurfacing prostheses, are associated with increased rates of revision arthroplasty. Registries are the main sources of data on MoM prostheses. At the recent International Consortium of Orthopaedic Registries (ICOR) meeting, data were presented from the Australian, England and Wales, and New Zealand registries. All registries reported an increased rate of revision for large femoral head MoM prostheses when prostheses were aggregated compared with the aggregated data of hip prostheses with other bearing surfaces. There was also evidence, however, that the outcome varied, depending on the type of prostheses used, in both large femoral head MoM conventional hip replacement as well as resurfacing hip replacement.The relevance of the recent isolated case reports on systemic metal toxicity was also discussed at the ICOR meeting. Although systemic metal toxicity appears to be a rare occurrence, there is a need to undertake appropriately designed studies to define the true prevalence of this phenomenon. There may be advantages in nesting these studies within registries. The ICOR meeting highlighted the implications of the MoM experience for the orthopaedic industry, regulators, and surgeons.

Monitoring the introduction and performance of a joint replacement: the United Kingdom metal-on-metal alert

Recent events have made us question our ability to monitor the introduction and performance of a new prosthetic joint replacement. These concerns are mirrored in many other countries, even those with joint registries and other systems for detecting poorly performing implants. In the United Kingdom, as is the case in most European Union countries, we have assessment processes in place, particularly the CE (Conformité Européenne) mark, the National Joint Registry, and the Orthopaedic Data Evaluation Panel. It is important to realize that these organizations can only react to poor performance; it is not within their power as monitoring agencies to prevent a poor implant from entering the market. When an implant has been shown to perform badly, it is referred to the Medicines and Healthcare products Regulatory Agency (MHRA), which then discusses the report with the manufacturer. When it is deemed that there is unequivocal evidence of a serious problem with the implant, the MHRA issues alerts to all hospitals and practitioners. We have continuing concerns about how to assess and monitor modifications to already existing devices. Suggestions are made for improvements to this system, and the authors will welcome feedback.

Can choices between alternative hip prostheses be evidence based? a review of the economic evaluation literature

Background

Total hip replacement surgery places a considerable financial burden on health services and society. Given the large number of hip prostheses available to surgeons, reliable economic evidence is crucial to inform resource allocation decisions. This review summarises published economic evidence on alternative hip prostheses to examine the potential for the literature to inform resource allocation decisions in the UK.

Methods

We searched nine medical and economics electronic databases. 3,270 studies were initially identified, 17 studies were included in the review. Studies were critically appraised using three separate guidelines.

Results

Several methodological problems were identified including a lack of observed long term prosthesis survival data, limited up-to-date and UK based evidence and exclusion of patient and societal perspectives.

Conclusions

More clinical trials including long term follow-up and economic evaluation are needed. These should compare the cost-effectiveness of different prostheses with longer-term follow-up and including a wider perspective.

Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study

OBJECTIVE

To evaluate the role of targeted prostate cancer screening in men with BRCA1 or BRCA2 mutations, an international study, IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls), was established. This is the first multicentre screening study targeted at men with a known genetic predisposition to prostate cancer. A preliminary analysis of the data is reported.

PATIENTS AND METHODS

Men aged 40-69 years from families with BRCA1 or BRCA2 mutations were offered annual prostate specific antigen (PSA) testing, and those with PSA > 3 ng/mL, were offered a prostate biopsy. Controls were men age-matched (± 5 years) who were negative for the familial mutation.

RESULTS

In total, 300 men were recruited (205 mutation carriers; 89 BRCA1, 116 BRCA2 and 95 controls) over 33 months. At the baseline screen (year 1), 7.0% (21/300) underwent a prostate biopsy. Prostate cancer was diagnosed in ten individuals, a prevalence of 3.3%. The positive predictive value of PSA screening in this cohort was 47·6% (10/21). One prostate cancer was diagnosed at year 2. Of the 11 prostate cancers diagnosed, nine were in mutation carriers, two in controls, and eight were clinically significant.

CONCLUSIONS

The present study shows that the positive predictive value of PSA screening in BRCA mutation carriers is high and that screening detects clinically significant prostate cancer. These results support the rationale for continued screening in such men.

National comparative audit of blood use in elective primary unilateral total hip replacement surgery in the UK

INTRODUCTION

Blood is a scarce and expensive product. Although it may be life-saving, in recent years there has been an increased emphasis on the potential hazards of transfusion as well as evidence supporting the use of lower transfusion thresholds. Orthopaedic surgery accounts for some 10% of transfused red blood cells and evidence suggests that there is considerable variation in transfusion practice.

PATIENTS AND METHODS

NHS Blood and Transplant, in collaboration with the Royal College of Physicians, undertook a national audit on transfusion practice. Each hospital was asked to provide information relating to 40 consecutive patients undergoing elective, primary unilateral total hip replacement surgery. The results were compared to indicators and standards.

RESULTS

Information was analysed relating to 7465 operations performed in 223 hospitals. Almost all hospitals had a system for referring abnormal pre-operative blood results to a doctor and 73% performed a group-and-save rather than a cross-match before surgery. Of hospitals, 47% had a transfusion policy. In 73%, the policy recommended a transfusion threshold at a haemoglobin concentration of 8 g/dl or less. There was a wide variation in transfusion rate among hospitals. Of patients, 15% had a haemoglobin concentration less than 12 g/dl recorded in the 28 days before surgery and 57% of these patients were transfused compared to 20% with higher pre-operative values. Of those who were transfused, 7% were given a single unit and 67% two units. Of patients transfused two or more units during days 1-14 after surgery, 65% had a post transfusion haemoglobin concentration of 10 g/dl or more.

CONCLUSIONS

Pre-operative anaemia, lack of availability of transfusion protocols and use of different thresholds for transfusion may have contributed to the wide variation in transfusion rate. Effective measures to identify and correct pre-operative anaemia may decrease the need for transfusion. A consistent, evidence-based, transfusion threshold should be used and transfusion of more than one unit should only be given if essential to maintain haemoglobin concentrations above this threshold.

End-of-life care: Empowering cancer patients with information and choices

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Background: Terminally ill patients want information and choices, including aid in dying, as they confront death due to cancer and other terminal illnesses. Physicians treating such patients want to feel safe in having candid conversations with patients about their wishes and to provide aid in dying when appropriate. Methods: Review the law governing end of life decision making, including aid in dying. Review the data from Oregon, which has more than 10 years experience with a regulated practice. Review what has been learned in OR, and how that is transferring to other states making aid in dying an end of life option. Results: Oregon's experience shows that when aid in dying is a legal option for mentally competent terminally ill patients overall end of life care improves. Conversations between physicians and patients are more open and candid; Referrals to hospice increase and occur earlier; clinician enrollment in CE for pain and symptom management increase; rx of strong pain medication increase; more patients die at home; patients are comforted to have aid in dying as an option; there is no negative impact on the practice of medicine. Conclusions: Terminally ill patients should be able to recieve comprehensive counseling about all end of life options. There is a growing trend of support for expanding end of life options to include aid in dying for mentally competent terminally ill patients who find themselves trapped in an unbearable dying process.

No significant financial relationships to disclose.

Community-based orthopaedic follow-up. Is it what doctors and patients want?

INTRODUCTION

The objective of this study was to investigate how patients, general practitioners (GPs) and orthopaedic trainees, feel about the proposed governmental changes to reduce orthopaedic out-patient clinics by having GPs and specialist nurses follow-up postoperative orthopaedic patients in the community.

SUBJECTS AND METHODS

The design was a cross-sectional questionnaire study including a teaching hospital and general practitioners in the Norfolk primary care trust. Participants were 73 orthopaedic postoperative patients who attended out-patients over a 1-week period in July 2007 who all responded. Of 250 GPs, 239 responded. Of 38 orthopaedic trainees at the level of senior house officer (post MRCS) and specialist registrar (Eastern Deanery Rotation and Pott Rotation), 30 responded

RESULTS

Of the 73 patients, 56 (77%) felt the surgeon was best suited to manage them postoperatively. Of these, 47 felt that it was very important that the surgical team saw them postoperatively. Also, 53 felt that their GP did not have sufficient knowledge and experience to deal with their current orthopaedic problem adequately. Only 12 GPs of 239 (5%) felt very confident assessing postoperative patients. Inadequate resources available to diagnose and treat postoperative complications was noted by 74% as the reason for not performing follow-up in primary care, and only 18% felt they should follow-up postoperative patients. All trainees felt that following up their own postoperative patients was important to their training.

CONCLUSIONS

Most patients, GPs, and orthopaedic trainees had serious doubts about the proposed governmental changes to reduce orthopaedic out-patient clinics by having GPs and specialist nurses follow-up postoperative orthopaedic patients in the community.

Measuring, and identifying predictors of women's perceptions of three types of breast cancer risk: population risk, absolute risk and comparative risk

Although a key function of cancer genetics services is to provide risk information, to date there has been little consistency in the way in which breast cancer risk perception has been measured. The aims of the study were to measure estimates of (i) population risk, (ii) absolute risk and (iii) comparative risk of developing breast cancer for Ashkenazi Jewish women, and to determine predictors of breast cancer risk perception. Of 152 women, 107 (70%) completed all questions. The mean (s.d.) estimates for population risk, absolute risk and comparative risk were 22.7% (15.9), 31.8% (20.6) and 1.9-fold (1.9), respectively. Most women overestimated population risk. Women at population risk generally overestimated the population risk and their own absolute risk, yet understood they are at the same risk as the population. Those with a family history understood that they are at increased risk, but underestimated the extent to which their familial risk is increased. Anxiety, high estimation of population risk and lesser family history predicted overestimation of absolute risk, whereas high estimation of population risk and a strong family history predicted underestimation of comparative risk.

Revision rates after primary hip and knee replacement in England between 2003 and 2006

BACKGROUND

Hip and knee replacement are some of the most frequently performed surgical procedures in the world. Resurfacing of the hip and unicondylar knee replacement are increasingly being used. There is relatively little evidence on their performance. To study performance of joint replacement in England, we investigated revision rates in the first 3 y after hip or knee replacement according to prosthesis type.

METHODS AND FINDINGS

We linked records of the National Joint Registry for England and Wales and the Hospital Episode Statistics for patients with a primary hip or knee replacement in the National Health Service in England between April 2003 and September 2006. Hospital Episode Statistics records of succeeding admissions were used to identify revisions for any reason. 76,576 patients with a primary hip replacement and 80,697 with a primary knee replacement were included (51% of all primary hip and knee replacements done in the English National Health Service). In hip patients, 3-y revision rates were 0.9% (95% confidence interval [CI] 0.8%-1.1%) with cemented, 2.0% (1.7%-2.3%) with cementless, 1.5% (1.1%-2.0% CI) with "hybrid" prostheses, and 2.6% (2.1%-3.1%) with hip resurfacing (p < 0.0001). Revision rates after hip resurfacing were increased especially in women. In knee patients, 3-y revision rates were 1.4% (1.2%-1.5% CI) with cemented, 1.5% (1.1%-2.1% CI) with cementless, and 2.8% (1.8%-4.5% CI) with unicondylar prostheses (p < 0.0001). Revision rates after knee replacement strongly decreased with age.

INTERPRETATION

Overall, about one in 75 patients needed a revision of their prosthesis within 3 y. On the basis of our data, consideration should be given to using hip resurfacing only in male patients and unicondylar knee replacement only in elderly patients.

Kv1.3 gene-targeted deletion alters longevity and reduces adiposity by increasing locomotion and metabolism in melanocortin-4 receptor-null mice

OBJECTIVE

Gene-targeted deletion of the voltage-gated potassium channel, Kv1.3, results in 'super-smeller' mice that have altered firing patterns of mitral cells in the olfactory bulb, modified axonal targeting to glomerular synaptic units, and behaviorally have an increased ability to detect and discriminate odors. Moreover, the Kv1.3-null mice weighed less than their wild-type counterparts, have modified ingestive behaviors, and are resistant to fat deposition following a moderately high-fat dietary regime. In this study, we investigate whether or not gene-targeted deletion of Kv1.3 (Shaker family member) can abrogate weight gain in a genetic model of obesity, the melanocortin-4 receptor-null mouse (MC4R-null).

DESIGN

Mice with double gene-targeted deletions of Kv1.3 and MC4R were generated by interbreeding Kv1.3 (Kv)- and MC4R-null mouse lines to homozygosity. Developmental weights, nose to anus length, fat pad weight, fasting serum chemistry, oxygen consumption, carbon dioxide respiration, locomotor activity and caloric intake were monitored in control, Kv-null, MC4R-null and Kv/MC4R-null mice. Physiological and metabolic profiles were acquired at postnatal day 60 (P60) in order to explore changes linked to body weight at the reported onset of obesity in the MC4R-null model.

RESULTS

Gene-targeted deletion of Kv1.3 in MC4R-null mice reduces body weight by decreasing fat deposition and subsequent fasting leptin levels, without changing the overall growth, fasting blood glucose or serum insulin. Gene-targeted deletion of Kv1.3 in MC4R-null mice significantly extended lifespan and increased reproductive success. Basal or light-phase mass-specific metabolic rate and locomotor activity were not affected by genetic deletion of Kv1.3 in MC4R-null mice but dark-phase locomotor activity and mass-specific metabolism were significantly increased resulting in increased total energy expenditure.

CONCLUSIONS

Gene-targeted deletion of Kv1.3 can reduce adiposity and total body weight in a genetic model of obesity by increasing both locomotor activity and mass-specific metabolism.

Open reduction of developmental hip dysplasia using a medial approach: a review of 24 hips

The results of the Ferguson medial approach for reduction of developmental hip dysplasia were reviewed for 24 hips. The mean age at surgery was 4.8 months and the mean length of clinical follow-up was 59 months. Clinically all hips were normal in follow-up and radiologically the acetabular index was within normal limits. There was the need for further surgery in two cases with loss of concentric reduction. There were two cases showing evidence of vascular insult post operatively according to the classification of Kalmachi and MacEwan. We conclude that the Ferguson medial approach is a safe and effective form of treatment for open reduction of developmental hip dysplasia in cases where closed reduction either has failed or is inappropriate. The age of the child or the presence of the upper femoral ossific nucleus does not appear to affect outcome. The procedure can safely be performed before six months of age.

Development of a communication aid to facilitate risk communication in consultations with unaffected women from high risk breast cancer families: a pilot study

The literature on risk perception in women from high-risk breast cancer families reveals persistent over-estimation of risk, even after counseling. In this study, a communication aid was designed to facilitate discussion of risk between clinical geneticists and genetic counselors and women from this high-risk population.

METHOD

Stage 1. The aid was developed by an expert panel of clinical geneticists, genetic counselors, psychologists, an epidemiologist, an oncologist, linguists and a consumer. It was guided by the international literature on risk communication and a large multi-centre Australian study of risk communication. The 13 page full-color communication aid used varying formats of words, numbers, graphs and pie-charts to address (a) the woman's subjective risk; (b) the population risk of breast cancer; c) the risk of inherited breast cancer; (d) the cumulative risk for women with BRCA1 and BRCA2 mutations; (e) family risk factors; (f) the woman's suitability for genetic testing; (h) screening and management recommendations, and (i) a re-assessment of the woman's subjective risk. Stage 2: A before-after pilot study of 38 women who were unaffected with breast cancer and were attending four Australian familial cancer clinics was undertaken. Baseline and follow-up questionnaires were completed by 27 women. Outcomes were compared to those observed in 107 similar women undergoing genetic counseling without the communication aid in 2001.

RESULTS

The risk communication aid appears to be beneficial; breast cancer genetics knowledge improved in some areas and importantly, risk perceptions improved in the cohort receiving the communication aid. Psychological measures showed no difference in anxiety or depression between the group receiving the communication aid and the comparison cohort. Women and clinicians were very positive about the usefulness of the communication aid as an adjunct to the genetic counseling consultation.

Estimating the referral rate for cancer genetic assessment from a systematic review of the evidence

To estimate the optimal proportion of new patients diagnosed with cancer who require assessment and evaluation for familial cancer genetic risk, based on the best evidence available. We identified evidence of the patients who require assessment for familial genetic risk when diagnosed with cancer through extensive literature reviews and searches of guidelines. Epidemiological data on the distribution of cancer type, presence of a family history, age and other factors that influence referral for genetic assessment were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiological data to calculate the optimal proportion of patients who should be referred. We identified 'high probability' and 'moderate probability' groups for having a genetic susceptibility. The proportion of patients diagnosed with cancer in Australia who have a high probability of having a genetic predisposition and who should be referred for genetic assessment is 1%. If the moderate probability group is also assessed this proportion increases to 6%. This model has identified the proportion of new patients diagnosed with cancer who should be referred for genetic assessment. This data is the first step in determining the resources required for provision of an adequate cancer genetic service.

A comparison of community, clinician, and patient preferences for naming a cancer-related mutation

This study compared language preferences to describe a cancer-related mutation in three groups: 253 members of the general community, 20 clinicians working in cancer genetics, and 269 individuals at increased risk of carrying a cancer-related mutation (including 198 women with a strong family history of breast and/or ovarian cancer, and 71 individuals with a family history of hereditary non-polyposis colorectal cancer). In the community sample, 'faulty gene' was the preferred term to describe a cancer-related mutation, although females, those affected by cancer and those who felt cancer had a large impact on their lives were more likely to prefer the terms 'gene change' or 'altered gene'. In contrast, the clinicians' preference ratings for 'faulty gene' and 'gene change' were equal. When forced to choose between 'faulty gene' and 'altered gene', the high-risk patient group reported preferring 'faulty gene', although over 40% were happy with either term. Further research investigating individuals' understanding of the different terms that can be used to describe a cancer-related mutation, and the functional impact of these terms on patients' thoughts and feelings about their condition and on their health-related behavior after genetic counseling would be worthwhile.

A discrete choice experiment of preferences for genetic counselling among Jewish women seeking cancer genetics services

To determine which aspects of breast cancer genetic counselling are important to Ashkenazi Jewish women, a discrete choice experiment was conducted. Participants consisted of 339 Australian Ashkenazi Jewish women who provided a blood sample for research used to test for Ashkenazi Jewish ancestral mutations in the genes BRCA1 and BRCA2, and were offered their genetic test result through a cancer genetics service. Main outcome measures were women's preferences for, and trade-offs between, the genetic counselling aspects of providing cancer, gene, and risk information (information); giving advice about cancer surveillance (surveillance); preparing for genetic testing (preparation); and, assistance with decision-making (direction). Respondents most valued information, about twice as much as advice about surveillance, four times as much as preparation for testing, and nine times as much as assistance with decision-making, which was least valued. Women's preferences were consistent with the major goals of genetic counselling, which include providing information and surveillance advice, and avoiding direction by facilitating autonomous decision-making. There were differences between the women in which aspects they most favoured, suggesting that counselling that elicits and responds to clients’ preferences is more likely to meet clients’ needs.

The long-term outcome of tendon lengthening for chronic Achilles tendon pain

BACKGROUND

The purpose of this study was to assess the long-term results of tendon lengthening surgery for the treatment of chronic Achilles tendon pain.

METHODS

The results of 21 procedures in 18 patients were assessed. Each patient had an open Z-plasty to lengthen the Achilles tendon by 1 cm.

RESULTS

Results showed a long-term (7.5 years) reduction in visual analogue pain scores for sporting activity in 20 of 21 procedures (median 50 point reduction, p < 0.0005). The tendon lengthening was apparent in a mean increase in dorsiflexion of 5 degrees. Two patients had minor gait abnormalities postoperatively. One patient had a reduction in plantarflexion power on the operated side, but five patients had improved power compared to the nonoperated limb. One major and five minor surgical complications were noted.

CONCLUSIONS

The retrospective nature of this study must be noted in drawing conclusions. However, the results suggest excellent long-term reduction of Achilles pain after tendon lengthening. This must be weighed against a relatively high complication rate for any procedure in this region. This treatment does not appear to cause long-term deficits in plantarflexion power or gait.

The effect of achilles tendon lengthening on ankle dorsiflexion: a cadaver study

BACKGROUND

Tendon lengthening is an important cause of morbidity after Achilles tendon rupture. However, direct measurement of the tendon length is difficult. Ankle dorsiflexion has, therefore, been used as a surrogate measure on the assumption that it is the Achilles tendon that limits this movement. The aim of this investigation was to assess the relationship between Achilles tendon length and ankle dorsiflexion. The primary question was whether or not the Achilles tendon is the structure that limits ankle dorsiflexion. The secondary purpose was to quantify the relationship between Achilles tendon lengthening and dorsiflexion at the ankle joint.

METHODS

Five cadaver specimens were dissected to expose the tendons and capsular tissue of the leg and hindfoot. Fixed bony reference points were used as markers for the measurements. In the first specimen, the Achilles tendon was intact and the other structures that may limit ankle dorsiflexion were sequentially divided. In the other specimens the Achilles tendon was lengthened by 1 cm intervals and the effect upon ankle dorsiflexion movement was recorded.

RESULTS

Division of the other tendons and the capsular tissue around the ankle joint did not affect the range of ankle dorsiflexion. When the Achilles was divided the foot could be dorsiflexed until the talar neck impinged upon the anterior aspect of the distal tibia. There was a mean increase of 12 degrees of dorsiflexion for each centimeter increase in tendon length.

CONCLUSION

The Achilles tendon is the anatomical structure that limits ankle dorsiflexion, even when the tendon is lengthened. There was a linear relationship between the length of the Achilles tendon and the range of ankle dorsiflexion in this cadaver model. Ankle dorsiflexion would appear to be a clinically useful indicator of tendon length.

Knowledge of risk management strategies, and information and risk management preferences of women at increased risk for ovarian cancer

Little research is available on the level of knowledge about ovarian cancer risk management options in women at increased risk for this disease. The study objectives were to evaluate this together with the information and ovarian cancer risk management preferences of high-risk women. One hundred and twenty-nine women were assessed after their attendance at one of six familial cancer clinics in relation to knowledge of surveillance and/or preventative strategies for reduction of ovarian cancer risk, preferences for particular strategies, and information preferences. Screening was selected by 57 (44%) women as the preferred risk management option. One hundred and five women (82%) indicated a wish for as much information as possible about ovarian cancer, including both good and bad outcomes and 114 (89%) reported a preference for sharing treatment decisions with their health professional. Participants' knowledge about ovarian cancer risk management options was significantly associated with educational levels (Z = -3.2, p=0.001) and whether or not ovarian cancer was included in the family history (Z = -2.3, p = 0.018). Findings from this present study indicate that women at increased risk of ovarian cancer who attend familial cancer clinics want as much information as possible about this disease and they want to be involved in the decision-making process. Women who reported a lower level of education (no post-school qualifications) may be most likely to benefit from additional educational strategies designed to supplement genetic counseling to improve their knowledge levels.

Comparative sequence analysis and radiation hybrid mapping of two epidermal type II keratin genes in the dog: keratin 1 and keratin 2e

In order to extend knowledge of the process of cornification across species and to be better able to recognize inborn errors in keratin synthesis in the dog, we describe the organization and chromosome mapping of canine KRT1 and KRT2E and compare these results to human and murine sequence data. The coding regions of KRT1 and KRT2E are 1,860 bp and 1,902 bp respectively, distributed over nine exons. Both genes are localized on the canine radiation hybrid map to chromosome 27 in the type II keratin gene cluster close to polymorphic markers. These genes are highly conserved across species and based on both genomic and amino acid sequences, canine KRT1 and KRT2E share greater homology with humans than with mice.

Synthesis and characterization of human alpha-defensins 4-6

Human alpha-defensins are small, Cys-rich, cationic proteins expressed predominantly in neutrophils and intestinal epithelia. They play important roles in innate and adaptive immunity against infection. Progress in studying these molecules can be accelerated by access to large quantities of high-quality materials, which have been obtained mainly from natural sources. Here, we report total synthesis of human alpha-defensins 4, 5, and 6, also known as HNP4, HD5, and HD6, using the optimized N,N-diisopropylethylamine (DIEA) in situ neutralization/2-(1 H-benzotriazolyl)-1,1,3,3-tetramethyluroniumhexafluorophosphate (HBTU) activation protocol for solid-phase Boc chemistry. Oxidative folding/disulfide formation was achieved directly using crude peptides, resulting in an overall synthetic yield of 10-16% with high purity. Antimicrobial activity assays were performed with Escherichia coli ATCC 25922 and Staphylococcus aureus ATCC 29213, using colony-counting methods, and the results demonstrated differential activity against these strains. Our report describes a highly efficient synthetic approach that enables thorough structural and functional studies of these three important immunologic molecules.

Somatic mutations of KIT in familial testicular germ cell tumours

Somatic mutations of the KIT gene have been reported in mast cell diseases and gastrointestinal stromal tumours. Recently, they have also been found in mediastinal and testicular germ cell tumours (TGCTs), particularly in cases with bilateral disease. We screened the KIT coding sequence (except exon 1) for germline mutations in 240 pedigrees with two or more cases of TGCT. No germline mutations were found. Exons 10, 11 and 17 of KIT were examined for somatic mutations in 123 TGCT from 93 multiple-case testicular cancer families. Five somatic mutations were identified; four were missense amino-acid substitutions in exon 17 and one was a 12 bp in-frame deletion in exon 11. Two of seven TGCT from cases with bilateral disease carried KIT mutations compared with three out of 116 unilateral cases (P=0.026). The results indicate that somatic KIT mutations are implicated in the development of a minority of familial as well as sporadic TGCT. They also lend support to the hypothesis that KIT mutations primarily take place during embryogenesis such that primordial germ cells with KIT mutations are distributed to both testes.

Kv1.3 channel gene-targeted deletion produces "Super-Smeller Mice" with altered glomeruli, interacting scaffolding proteins, and biophysics

Mice with gene-targeted deletion of the Kv1.3 channel were generated to study its role in olfactory function. Potassium currents in olfactory bulb mitral cells from Kv1.3 null mice have slow inactivation kinetics, a modified voltage dependence, and a dampened C-type inactivation and fail to be modulated by activators of receptor tyrosine signaling cascades. Kv1.3 deletion increases expression of scaffolding proteins that normally regulate the channel through protein-protein interactions. Kv1.3-/- mice have a 1,000- to 10,000-fold lower threshold for detection of odors and an increased ability to discriminate between odorants. In accordance with this heightened sense of smell, Kv1.3-/- mice have glomeruli or olfactory coding units that are smaller and more numerous than those of wild-type mice. These data suggest that Kv1.3 plays a far more reaching role in signal transduction, development, and olfactory coding than that of the classically defined role of a potassium channel-to shape excitability by influencing membrane potential.

Communication and information-giving in high-risk breast cancer consultations: influence on patient outcomes

This longitudinal study aimed to document (i) the information-giving and patient-communication styles of clinical geneticists and genetic counsellors (consultants) in familial breast cancer clinics and (ii) assess the effect of these styles on women's knowledge, whether their expectations were met, satisfaction, risk perception and psychological status. A total of 158 women from high-risk breast cancer families completed self-report questionnaires at 2 weeks preconsultation and 4 weeks postconsultation. The consultations were audiotaped, transcribed and coded. Multivariate logistic regressions showed that discussing prophylactic mastectomy (P=0.00) and oophorectomy (P=0.01) led to women having significantly more expectations met; discussing genetic testing significantly decreased anxiety (P=0.03) and facilitating understanding significantly decreased depression (P=0.05). Receiving a summary letter of the consultation significantly lowered anxiety (P=0.01) and significantly increased the accuracy of perceived risk (P=0.02). Women whose consultant used more supportive communications experienced significantly more anxiety about breast cancer at the 4 weeks follow-up (P=0.00). These women were not significantly more anxious before genetic counselling. In conclusion, this study found that consultants vary in the amount of information they give and the way they communicate; and this variation can result in better or worse psychosocial outcomes. Greater use of supportive and counselling communications appeared to increase anxiety about breast cancer. Identifying methods to assist consultants to address emotional issues effectively may be helpful.

Comparison of modulation of Kv1.3 channel by two receptor tyrosine kinases in olfactory bulb neurons of rodents

Activation of the receptor tyrosine kinase (RTK), insulin (IRK) or neurotrophin B (TrkB), was characterized and compared in olfactory bulb neuron (OBN) cultures from Sprague Dawley rats and sv129 B6 mice. Current suppression attributed to modulation of the delayed rectifier, Kv1.3, a voltage-gated potassium (Kv) channel of the Shaker family, was observed following acute application of the growth factors, insulin or brain-derived neurotrophic factor (BDNF), to mitral cells of either rodent model. Using site-directed mutagenesis of putative tyrosine phosphorylation recognition motifs in the channel, we find that stimulation of Kv1.3 with these growth factors causes multiple phosphorylation, albeit via different residue combinations that are RTK specific.