Early results of the Acclaim total elbow replacement in patients with primary osteoarthritis

This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4).

Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved.

This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow.

Phase II study of vincristine sulfate liposomes injection in patients with metastatic uveal melanoma

9067

Background: Preclinical and clinical studies showed that liposomal encapsulation of vincristine sulfate (VCR) results in increased drug circulation time and accumulation of VCR at the tumor site. Marqibo has been administered safely at 2.25 mg/m2, a dose exceeding that typically employed for VCR ( dose capped at 2 mg), with tolerable clinical toxicities consistent with VCR. Of the 27 previously treated patients with metastatic melanoma in the Marqibo pharmacokinetic studies, 3 patients had a tumor response, including one patient with uveal melanoma metastatic to the lung that experienced a complete response. Methods: Patients with metastatic uveal melanoma with no more than one prior systemic therapy were enrolled. Patients with controlled brain metastases were allowed. Marqibo (2.25 mg/m2 by 1-hour intravenous infusion, no dose capping) was administered every 14 days until tumor progression. Responses were assessed every 6 weeks using the Response Evaluation Criteria in Solid Tumors (RECIST). Toxicity was assessed at least as frequently as before each dose. Results: Preliminary data is available for 22 enrolled patients (73% female). Median age was 65 years (range 38–79), 23% were previously treated with systemic chemotherapy, 86% had liver metastasis and 96% had M1c disease. Baseline serum LDH levels were elevated in 73% and were more than 2 × ULN in 37% of the patients. Twenty-one patients were evaluable for response; one patient discontinued the treatment after a single dose of therapy for toxicity without tumor progression. No patients died of drug toxicity while on the study. Twelve patients (57%) had stable disease. Estimated median survival is 6.4 months. Fourteen patients are alive, 2 for more than 12 months. Treatment related side effects were mostly grade 1 or 2; peripheral neuropathy was the only grade 3 toxicity, seen in 18% of the patients. The hematologic toxicities were minor; no neutropenia or thrombocytopenia was seen. Conclusions: Marqibo is well tolerated as single agent therapy in patients with advanced stage IV uveal melanoma. Its impact on the progression-free and overall survival of these critically ill patients will be presented.

No significant financial relationships to disclose.

Association of ADH2 and ALDH2 Gene Polymorphisms with Alcohol Dependence: A Pilot Study from India

Background:

Functional polymorphism in ADH2 and ALDH2 genes are considered most important among several genetic determinants of alcohol dependence (AD), a complex disorder.

Aims:

There is no report on the widely studied Arg47His and Glu487Lys polymorphisms from Indian alcohol dependent population. We, for the first time, report allelic and genotypic frequencies of Arg47His and Glu487Lys SNPs in North Indian alcohol dependent subjects.

Methods:

A total of n=174 alcohol dependent males, recruited using DSM IV criteria, were genotyped using PCR-RFLP method.

Results:

Data obtained from genetic analysis was correlated with clinical parameters using T test or Mann Whitney's U test. ADH2 gene polymorphism was found to be largely monomorphic with minor allele frequency (ADH2*2) < 0.001. For the ALDH2 Glu487Lys SNP, genotypic frequencies were 0.73 (2*1/*1), 0.16 (2*1/*2) and 0.11 (2*2/*2), with minor allele frequency (ALDH2*2) = 0.19. Various clinical parameters were found to be significantly associated with ALDH2 polymorphism.

Conclusions:

The highlight of the study is a clear association of ALDH2 gene polymorphism with delayed onset and shorter duration of alcohol consumption among ALDH2*2/*2 individuals. Our finding bolsters the protection conferring property of the ALDH2*2 allele of Glu487Lys SNP of ALDH2 gene.

Valgus extension overload syndrome of the elbow in a test cricket fast bowler

No Abstract South African Journal of Sports Medicine Vol. 20 (4) 2008: pp. 119-120

An unusual cutaneous-polyposis syndrome stabilized with acitretin

We present a patient with an unusual enterocutaneous syndrome. Long-term, low-dose acitretin treatment has stabilized the development of gastrointestinal lesions while synchronously reducing cutaneous morbidity.

The relationship between specific tissue lesions and pain severity in persons with knee osteoarthritis

INTRODUCTION

Pain is the most common symptom in knee osteoarthritis (OA), a leading cause of chronic disability, and a major source of the disability attributable to OA in general. Pain severity in knee OA is variable, ranging from barely perceptible to immobilizing. The knee lesions that contribute to pain severity have received little attention.

OBJECTIVE

To examine whether worse pathology of specific knee tissues - i.e. cartilage, bone (attrition, cysts, bone marrow lesions, and osteophytes), menisci (tears and subluxation), ligaments, and synovium (synovitis/effusion) - is associated with more severe knee pain.

METHODS

One hundred and forty-three individuals were recruited from the community with primary (idiopathic) knee OA, with definite tibiofemoral osteophytes in at least one knee, and at least some difficulty with knee-requiring activity. Knee magnetic resonance (MR) images were acquired using coronal T1-weighted spin-echo (SE), sagittal fat-suppressed dual-echo turbo SE, and axial and coronal fat-suppressed, T1-weighted 3D-fast low angle shot (FLASH) sequences. The whole-organ magnetic resonance imaging (MRI) scoring (WORMS) method was used to score knee tissue status. Since summing tissue scores across the entire joint, including regions free of disease, may dilute the ability to detect a true relationship between that tissue and pain severity, we used the score from the worst compartment (i.e. with the poorest cartilage morphology) as our primary approach. Knee pain severity was measured using knee-specific, 100 mm visual analogue scales. In analyses to evaluate the relationship between knee pain severity and lesion score, median quantile regression was used, adjusting for age and body mass index (BMI), in which a 95% CI excluding 0 is significant.

RESULTS

The increase in median pain from median quantile regression, adjusting for age and BMI, was significant for bone attrition (1.91, 95% confidence interval (CI) 0.68, 3.13), bone marrow lesions (3.72, 95% CI 1.76, 5.68), meniscal tears (1.99, 95% CI 0.60, 3.38), and grade 2 or 3 synovitis/effusion vs grade 0 (9.82, 95% CI 0.38, 19.27). The relationship with pain severity was of borderline significance for osteophytes and cartilage morphology and was not significant for bone cysts or meniscal subluxation. Ligament tears were too infrequent for meaningful analysis. When compared to the pain severity in knees with high scores for both bone attrition and bone marrow lesions (median pain severity 40 mm), knees with high attrition alone (30 mm) were not significantly different, but knees with high bone marrow lesion without high attrition scores (15 mm) were significantly less painful.

CONCLUSION

In persons with knee OA, knee pain severity was associated with subarticular bone attrition, bone marrow lesions, synovitis/effusion, and meniscal tears. The contribution of bone marrow lesions to pain severity appeared to require the presence of bone attrition.

Absorption characteristics of EC-MPS – an enteric-coated formulation of mycophenolic sodium

Enteric-coated mycophenolate sodium is an advanced formulation delivering mycophenolic acid (MPA), designed to improve MPA-related upper gastrointestinal adverse events by delaying MPA release until the small intestine.

OBJECTIVE

Two studies were undertaken to identify the absolute bioavailability and dose-proportionality of enteric-coated mycophenolate sodium in stable renal transplant patients receiving cyclosporine.

METHODS

Study 1: The mean MPA AUC(0-t) was shown to be greater after MPA infusion than after oral enteric-coated mycophenolate sodium (42.1 vs. 28.9 microg x h/ml). Mean absolute bioavailability was 0.71 +/- 0.21 (SD). Study 2: The AUC(0-t) and C(max) for MPA were proportional to the dose of enteric-coated mycophenolate sodium, similarly mean AUC(0-infinity) and C(max) for MPA glucuronide were proportional to dose administered.

RESULTS AND CONCLUSIONS

In patients receiving cyclosporine the absolute bioavailability of MPA provided by enteric-coated mycophenolate sodium is equivalent to that provided by mycophenolate mofetil when administered in combination with cyclosporine, and exhibits dose-proportionality. Enteric-coated mycophenolate sodium was well tolerated from 180 - 2,160 mg with no serious adverse events reported.

Evaluation of the pharmacokinetic interaction between fluvastatin XL and cyclosporine in renal transplant recipients

OBJECTIVE

To assess the pharmacokinetic interaction between cyclosporine and extended-release fluvastatin (fluvastatin XL), 80 mg for 7 days, in stable renal transplant recipients.

METHODS

This was a single-center, open-label study. 17 renal transplant recipients received their standard cyclosporine therapy (Days 1 - 9) plus a once-daily single oral dose of fluvastatin XL, 80 mg (Days 2 - 8). Blood samples were collected and cyclosporine (whole blood) and fluvastatin (plasma) concentrations determined by radioimmunoassay and HPLC fluorescence detection, respectively. Pharmacokinetic parameters were calculated using non-compartment analysis and fluvastatin results were compared with historical controls.

RESULTS

Treatment with fluvastatin XL, 80 mg for 7 days, had no significant effect on either the AUC0-12 (3,644 ng x h/ml in the absence of fluvastatin vs. 3,534 ng x h/ml in the presence of fluvastatin) or the Cmax of cyclosporine (983 ng/ml in the absence of fluvastatin vs. 945 ng/ml in the presence of fluvastatin). Co-administration of fluvastatin XL also had no effect on the tmax, t1/2 or apparent clearance (CL/F) of cyclosporine in renal transplant patients. The AUC and Cmax for fluvastatin XL in the presence of cyclosporine (AUC0-24 1,192 ng. x h/ml, Cmax 271 ng/ml) were approximately 2-fold higher compared with historical data for fluvastatin XL alone in healthy volunteers (AUC0-24 630 ng x h/ml, Cmax 102 ng/ml) but lower than the historical data for fluvastatin IR, 40 mg b.i.d. alone in healthy volunteers (AUC0-24 1,340 ng x h/ml, Cmax 443 ng/ml). Tmax, t1/2 and trough levels of fluvastatin in the presence of cyclosporine were also similar to the historical controls. Concomitant administration of cyclosporine and fluvastatin XL was well tolerated by renal transplant recipients.

CONCLUSIONS

Fluvastatin XL, 80 mg, and cyclosporine do not show clinically relevant pharmacokinetic interactions.

A database of simple sequence repeats from cereal and legume expressed sequence tags mined in silico: survey and evaluation

Simple sequence repeats (SSRs) or microsatellites are an important class of molecular markers for genome analysis and plant breeding applications. In this paper, the SSR distributions within ESTs from the legumes soybean (Glycine max, representing 135.86 Mb), medicago (Medicago truncatula, 121.1 Mb) and lotus (Lotus japonicus, 45.4 Mb) have been studied relative to the distributions in cereals such as sorghum (Sorghum bicolor, 98.9 Mb), rice (Oryza sativa, 143.9 Mb) and maize (Zea mays, 183.7 Mb). The relative abundance, density, composition and putative annotations of di-, tri-, tetra- and penta-nucleotide repeats have been compared and SSR containing ESTs (SSR-ESTs) have been clustered to give a non-redundant set of EST-SSRs, available in a database. Further, a subset of such candidate EST-SSRs from sorghum have been tested for their ability to detect polymorphism between Striga-susceptible, stay-green drought tolerant mapping population parent 'E 36-1' and its Striga-resistant, non-stay-green counterpart 'N13'. Primer sets for 64% of the EST-SSRs tested produced a clear and specific PCR product band and 34% of these detected scorable polymorphism between the N13 and E 36-1 parental lines. Over half of these markers have been genotyped on 94 RILs from the (N13 x E 36-1)-based mapping population, with 42 markers mapping onto the ten sorghum linkage groups. This establishes the value of this database as a resource of molecular markers for practical applications in cereal and legume genetics and breeding. The primer pairs for non-redundant EST-SSRs have been designed and are freely available through the database (http://intranet.icrisat.org/gt1/ssr/ssrdatabase.html).

Is endosonography guided fine needle aspiration (EUS-FNA) for sarcoidosis as good as we think?

BACKGROUND

Preliminary data show that endosonography guided fine needle aspiration (EUS-FNA) may be an accurate method for diagnosing sarcoidosis. However, these data were obtained in a small selected group of patients with a very high pretest probability of sarcoidosis. This retrospective study reports on the use of EUS-FNA in an unselected group of patients with mediastinal lymphadenopathy of unknown origin.

METHODS

The EUS database of a single tertiary referral centre was reviewed for patients who underwent EUS-FNA for mediastinal lymphadenopathy of unknown origin. Clinical presentation and imaging studies of each case were carefully reviewed and the diagnosis "sarcoidosis" or "no sarcoidosis" attributed if possible. The diagnoses were compared with the result of EUS-FNA.

RESULTS

One hundred and twenty four patients were investigated. In 35 cases EUS-FNA identified granulomas (group 1); in the other 89 cases (group 2) no granulomas were detected. The definite diagnoses in group 1 were sarcoidosis (n = 25), indefinite (n = 7), no sarcoidosis (n = 3). The definite diagnoses in group 2 were sarcoidosis (n = 3), indefinite (n = 9), no sarcoidosis (n = 77). Of the 77 cases with no sarcoidosis, 44 were diagnosed with other diseases. The other 33 showed non-specific changes in the FNA and sarcoidosis was excluded by negative non-EUS pathology (n = 17) and clinical presentation. The sensitivity and specificity for EUS-FNA were 89% (95% CI 82 to 94) and 96% (95% CI 91 to 98), respectively, after exclusion of the indefinite cases in both groups.

CONCLUSIONS

EUS-FNA is an accurate method for diagnosing sarcoidosis in an unselected group of patients with mediastinal lymphadenopathy. The reported sensitivity and specificity must be appreciated in the context of the difficult and often incomplete clinical diagnosis of sarcoidosis.

Steatosis and fibrosis in patients with chronic hepatitis C

BACKGROUND

Steatosis is present on liver biopsy in approximately 50% of patients with hepatitis C; its association with stage of fibrosis has been reported, but its relation to other fibrosis associated factors is unknown.

AIM

To study the relation between steatosis and other histological features in patients with hepatitis C, and changes in steatosis with time.

METHODS

Cross sectional study: 233 routine liver biopsies from 219 patients with hepatitis C; hepatectomy specimens from 65 patients transplanted for hepatitis C cirrhosis. Longitudinal study: 41 patients with two biopsies and 10 patients with three biopsies performed over 2-8 years. Biopsies were scored by the Ishak scheme, and degree of steatosis assessed subjectively. Multivariate analysis was used to study the interaction of fibrosis associated factors. Changes in steatosis over time in individual patients were explored in the longitudinal study.

RESULTS

Steatosis was present in 50% of biopsies. It correlated strongly with fibrosis in non-cirrhotic samples, but declined in cirrhosis, and was unusual in transplant hepatectomy specimens. On multivariate analysis of non-cirrhotic biopsies, steatosis was associated with increasing patient age and remained significantly associated with fibrosis independent of portal inflammation and interface hepatitis. In the longitudinal study, steatosis persisted and increased over time, except in patients developing cirrhosis.

CONCLUSIONS

Steatosis is associated with fibrosis independently of necroinflammation, but declines in cirrhosis. It may represent a pathogenic pathway distinct from necroinflammatory activity in the generation of liver fibrosis, and should be included in the assessment of biopsies for clinical and research purposes.

Correlation of percutaneous liver biopsy fragmentation with the degree of fibrosis

BACKGROUND

Although fragmentation of a liver biopsy specimen has been considered to be suggestive of cirrhosis, the evidence for this is difficult to find in the published literature.

AIM

To determine whether fragmentation of percutaneous liver biopsy specimens correlates with the degree of fibrosis.

METHODS

One hundred and eighty-six patients underwent percutaneous liver biopsy prospectively. The specimens were measured for the length and number of fragments. The extent of fibrosis was scored by a pathologist blind to the clinical data. Length and fragmentation data were compared between the different stages.

RESULTS

The overall median fragment length was 1.85 cm and the median fragment number was four. Specimens with advanced fibrosis (stages III-IV) had more fragments than those with no or mild fibrosis (stages 0-II) (P < 0.0001). The aggregate fragment length decreased with increasing stage of fibrosis (P < 0.0001). Specimens with greater than 12 fragments were seen only with advanced fibrosis.

CONCLUSIONS

Fragmentation of percutaneous liver biopsy specimens is common and increases with progression from early to advanced fibrosis. Fibrotic specimens fragment more often and more extensively.

Training in radial EUS: what is the best approach and is there a role for the nurse endoscopist?

BACKGROUND AND STUDY AIMS

The aim of this study was to determine the relative contribution of previous endoscopic experience, case observation, and hands-on experience to skill acquisition in radial EUS.

METHODS

In EUS trainees, four senior gastroenterology fellows, and a nurse endoscopist, the ability to reproduce set views from the mediastinum, stomach, and duodenum was assessed. Points were ascribed to static and dynamic stations and to the use of console controls.

RESULTS

Trainees observed 55 - 170 cases and conducted 25 - 124 examinations. Competence was demonstrated after performing approximately 25 examinations in the mediastinum, 35 examinations in the stomach, and 78 examinations in the duodenum. The number of previous examinations conducted correlated with the ability to scan the duodenum ( P < 0.01). Observation of 100 or more further procedures early in training did not accelerate learning. The nurse endoscopist showed a comparable degree of competence in mediastinal scanning to that of the other trainees after performing a similar number of examinations.

CONCLUSIONS

Proficiency in radial endosonography is greatly influenced by the numbers of examinations performed. Observing large numbers of cases early in training does not appear to translate into competence. A background in advanced therapeutic endoscopy is not a prerequisite for acquiring endoscopic ultrasound skills. Nurse endoscopists may be expected to train successfully in mediastinal imaging at the same pace as senior gastroenterology fellows.

Upper gastrointestinal endoscopy performed by nurses: scope for the future?

BACKGROUND

Previous researchers have shown that non-medical endoscopists can perform lower gastrointestinal endoscopy as safely and effectively as medical staff. However, it is not known if upper gastrointestinal endoscopy performed by medical and non-medical endoscopists in clinical practice yields similar results in terms of performance, patient discomfort, and satisfaction.

AIM

To determine differences in the yield of diagnosis for significant disease during upper gastrointestinal endoscopy performed by nurse and medical endoscopists and to measure patient discomfort, satisfaction, and attitudes towards future endoscopy.

PATIENTS

This two part study included 3009 patients in a retrospective analysis and 480 in a prospective study.

METHODS

The first part of the study assessed indications for endoscopy, diagnoses, and procedures performed by medical and nurse endoscopists. In a second prospective study, 480 patients were included to determine the association between endoscopist type and sedation, patient anxiety, discomfort, satisfaction, and attitudes towards future sedation.

RESULTS

No patient refused endoscopy by either a nurse or medical endoscopist and there were no complications in either group. Nurses performed 1487 procedures and reported fewer endoscopies as "normal" than medical staff (p=0.006). Multivariate analysis showed that male sex, older age, inpatient status, dysphagia, and gastrointestinal bleeding, but not endoscopist type, were all associated with significant disease. In relation to discomfort and satisfaction, a similar proportion of patients received sedation in both groups (p=0.81). There were no differences in pre-procedure anxiety (p=0.61), discomfort during intubation (p=0.97), discomfort during examination (p=0.90), or post-procedure examination rating (p=0.79) in patients examined by medical or nurse endoscopists.

CONCLUSION

Experienced nurses perform routine diagnostic gastroscopy safely in everyday clinical practice and with as little discomfort and as much patient satisfaction as medical staff.

Safe administration of etoposide phosphate after hypersensitivity reaction to intravenous etoposide

Etoposide is commonly used in a variety of malignancies. A well known but rare toxicity are hypersensitivity reactions, usually manifested by chest discomfort, dyspnoea, bronchospasm and hypotension. We report the details of a patient who developed hypersensitivity reactions to intravenous etoposide, but subsequently tolerated the administration of intravenous etoposide phosphate with no sequelae.

The effects of skull thickness variations on human head dynamic impact responses

Variations in human skull thickness affecting human head dynamic impact responses were studied by finite element modeling techniques, experimental measurements, and histology examinations. The aims of the study were to better understand the influences of skull thickness variations on human head dynamic impact responses and the injury mechanisms of human head during direct impact. The thicknesses of the frontal bone of seven human cadaver skulls were measured using ultrasonic technology. These measurements were compared with previous experimental data. Histology of the skull was recorded and examined. The measured data were analyzed and then served as a reference to vary the skull thickness of a previously published three-dimensional finite element human head model to create four models with different skull thickness. The skull thicknesses modeled are 4.6 mm, 5.98 mm, 7.68 mm, and 9.61 mm. These models were impacted by a cylinder with a mass of 5.23 kg and an initial velocity of 6.33 m/s. Model responses were compared between models in terms of intracranial pressures, head impact accelerations, brain shear stresses, and skull von Mises stresses. It has been shown that the thickness of the skull influenced the dynamic responses of the head during direct impact. As skull thickness increased, skull deformation decreased as the skull absorbed less impact energy. However, this relationship cannot be linearly interpolated to the other parameters such as head acceleration and intracranial pressure responses. Based on model responses to half-sine wave pulses, skull and brain iso-stress curves were constructed for the thicker and thinner skulls. Thresholds for skull fracture and reversible concussion were established for the population represented by these skulls.

Comparison of echocardiography with technetium 99m-gated single photon emission computed tomography as diagnostic tools for left ventricular ejection fraction

Left ventricular ejection fractions (LVEF) are routinely measured and result in critical decision-making algorithms in cardiology. This study was conducted to compare the accepted standard two-dimensional (2-D) echocardiogram ejection fraction (EF(ECHO)) with single photon emission computed tomography rest ejection fraction (EF(SPECT)). Data were acquired and analyzed from 51 inpatients. EF(ECHO) was obtained using modified Simpson's rule in the four-chamber apical view, and gated EF(SPECT) was computed by an automated method (Siemens ICON software). Comparison between EF(ECHO) and EF(SPECT) was done by linear regression, Bland-Altman, and receiver operator characteristic (ROC) analyses. Linear regression analysis revealed EF(SPECT) = 1.12 x EF(ECHO) - 3.6%, r = 0.93, n = 51, P < 0.0001. Bland-Altman analysis showed that the limits of 95% confidence for the difference between EF(SPECT) and EF(ECHO) were - 12% to 18%. Ninety-eight percent of the datapoints were within the limits of confidence. The ROC analysis showed that the sensitivity and specificity for detecting abnormal EF (< or = 50%) were 85% and 86% with EF(SPECT), and 91% and 90% with EF(ECHO). This study showed good correlation as well as agreement between SPECT and two-dimensional echocardiograms in measuring EF.

Lower Limb: Advanced FE Model and New Experimental Data

The Lower Limb Model for Safety (LLMS) is a finite element model of the lower limb developed mainly for safety applications. It is based on a detailed description of the lower limb anatomy derived from CT and MRI scans collected on a subject close to a 50th percentile male. The main anatomical structures from ankle to hip (excluding the hip) were all modeled with deformable elements. The modeling of the foot and ankle region was based on a previous model Beillas et al. (1999) that has been modified. The global validation of the LLMS focused on the response of the isolated lower leg to axial loading, the response of the isolated knee to frontal and lateral impact, and the interaction of the whole model with a Hybrid III model in a sled environment, for a total of nine different set-ups. In order to better characterize the axial behavior of the lower leg, experiments conducted on cadaveric tibia and foot were reanalyzed and experimental corridors were proposed. Future work will include additional validation of the model using global data, joint kinematics data, and deformation data at the local level.

The influence of superficial soft tissues and restraint condition on thoracic skeletal injury prediction

The purpose of this study is to evaluate the hard tissue injury-predictive value of various thoracic injury criteria when the restraint conditions are varied. Ten right-front passenger human cadaver sled tests are presented, all of which were performed at 48 km/h with nominally identical sled deceleration pulses. Restraint conditions evaluated are 1) force-limiting belt and depowered airbag (4 tests), 2) non-depowered airbag with no torso belt (3 tests), and 3) standard belt and depowered airbag (3 tests). Externally measured chest compression is shown to correspond well with the presence of hard tissue injury, regardless of restraint condition, and rib fracture onset is found to occur at approximately 25% chest compression. Peak acceleration and the average spinal acceleration measured at the first and eighth or ninth thoracic vertebrae are shown to be unrelated to the presence of injury, though clear variations in peaks and time histories among restraint conditions can be seen. The maximum viscous criterion is found to correspond with injury, but only because it increases with the maximum chest compression. A simple analytical study is presented to elucidate the observed restraint condition dependence of rib fracture location and the restraint insensitivity of injurious maximum chest compression. Computed tomography images of a loaded torso are presented to show the load-distributing effect of the soft tissues superficial to the rib cage.

Safety, tolerability, and pharmacokinetics of an extended-release formulation of fluvastatin administered once daily to patients with primary hypercholesterolemia

Fluvastatin sodium (Lescol, Novartis Pharmaceutical Corp., East Hanover, NJ, U.S.A.), a potent 3-hydroxy-3-methylglutaryl coenzyme A (HMG Co-A) reductase inhibitor that limits cholesterol biosynthesis, is available as a 40-mg immediate-release formulation capsule. An extended-release formulation for once-daily administration has been developed for patients with primary hypercholesterolemia who may benefit from doses higher than 40 mg/day. This phase I study evaluated the safety, tolerability, and pharmacokinetics of a new fluvastatin extended-release formulation at doses ranging from 80-640 mg/day in 40 hypercholesterolemic patients. After a 2-week dietary stabilization phase, patients (Fredrickson type IIa/IIb), 18-55 years of age, were randomly assigned to four groups to receive oral fluvastatin extended-release (80, 160, 320, or 640 mg) or matching placebo once daily for 13 days. Fluvastatin extended-release was generally safe and well tolerated at doses of 80-320 mg/day. Within this dose range, linear pharmacokinetics was observed after single and multiple dosing. At 640 mg, fluvastatin extended-release was not well tolerated. Six of the seven actively treated patients at this dose experienced adverse events, including diarrhea, headache, and clinically relevant elevations in serum transaminase concentrations. In addition, nonlinear pharmacokinetics, possibly due to saturation of first-pass metabolism, was observed at this dose, causing higher than expected serum drug concentrations. Once-daily administration of fluvastatin extended-release at doses of 80-320 mg/day was generally safe and well tolerated in patients with primary hypercholesterolemia over a 13-day dosing period.

Single-stage lumbar sympathectomy and omentopexy: a new surgical approach towards patients with Buerger's disease

Single-stage lumbar sympathectomyand omentopexy were performed in six patients with Buerger's disease at the Department of Surgery, Jawahar Lal Nehru Medical College and Hospital, Ajmer, India, between January 1994 and December 1996. All were male smokers and had limb coldness, intermittent claudication and rest pain. Four had limb discoloration and three had ulcers of toes unresponsive to medical treatment. Postoperatively there was relief of symptoms in all, with improvement of tissue oxygen saturation and increase in claudication distance. We conclude that single-stage lumbar sympathectomy and omentopexy is an effective new surgical approach towards patients with Buerger's disease.

Abdominal tuberculosis in children: an Indian experience

The hospital records of 125 children, aged 14 years or less treated for abdominal tuberculosis (TB) at Jawahar Lal Nehru Medical College and Hospital, Ajmer, India between January 1987 and December 1996, were studied to analyse the various patterns of abdominal TB in children and to evaluate the role of various investigations in researching a diagnosis. Abdominal pain was the presenting symptom in 100 (80 per cent) patients. Detectable ascites was present in 55 (44 per cent) and visible peristalsis in 45 (36 per cent) cases. Laboratory investigations and radiographs were not conclusive in the majority of the patients. In 45 (36 per cent) patients in whom no tissue diagnosis was available, the diagnosis was based on a dramatic clinical response to anti-tuberculous chemotherapy. Fifty (40 per cent) patients were treated conservatively with anti-tuberculous drugs alone; the remaining patients underwent laparotomy for diagnosis and relief of bowel obstruction. There were no post-operative deaths and on follow-up, good recovery was observed in these patients. Abdominal TB in children is of a non-specific nature and defies diagnosis with non-invasive investigations; laparotomy is required for a definitive diagnosis in the majority of the patients. However, if a high index of suspicion is maintained in endemic areas, a therapeutic trial of anti-tuberculous chemotherapy is justified.

Development and validation of a pedestrian lower limb non-linear 3-d finite element model

Lower limb injury is becoming an increasingly important concern in vehicle safety for both occupants and pedestrians. To enable vehicle manufacturers to better understand the biomechanical effects of design changes, it is deemed beneficial to employ a biomechanically fidelic finite element model of the human lower limb. The model developed in this study includes long bones (tibia, fibula, femur) and flat bone (patella) as deformable bodies. The pelvis and foot bones are modeled as rigid bodies connected to the femur and tibia/fibula via rotational spring-dashpots. The knee is defined by scanned bone surface geometry and is surrounded by the menisci, major ligaments, and patellar tendon. Finite elements used to model include 6- and 8-node solids for cartilage, menisci, surrounding muscles, and cancellous bone; 3- and 4-node shells for skin and cortical bone; and nonlinear spring-dashpots for ligaments. Anatomical, physiological, and material properties data are from the literature while the bone surface geometry was scanned by a commercial source. Validation against published cadaver test results consisted of tibia and femur 3-point bending (lateralmedial and anterior-posterior) and whole limb lateral knee shear. Validation was performed under both static and dynamic loading conditions, until bone failure or ligament rupture. Additional dynamic validation with the lower limb in a seated orientation has not been completed, limiting current applications to the pedestrian impact condition. The validated models were employed to examine the effect of axial compressive force (the physiological condition) on tibia and femur lateral-medial and anterior-posterior bending under static conditions.

Improved neck injury risk curves for tension and extension moment measurements of crash dummies

This paper describes improvements made to the injury risk curves for peak neck tension, peak neck extension moment and a linear combination of tension and extension moment that produce peak stress in the anterior-longitudinal ligament at the head-to-neck junction. Data from previously published experiments that correlated neck injuries to 10-week-old, anesthetized pigs and neck response measurements of a 3-year-old child dummy that were subjected to similar airbag deployments are updated and used to generate Normal probability curves for the risk of AIS >/= 3 neck injury for the 3-year-old child. These curves are extended to other sizes and ages by normalizing for neck size. Factors for percent of muscle tone and ligamentous failure stress as a function of age are incorporated in the risk analysis. The most sensitive predictor of AIS > 3 neck injury for this data set is peak neck tension. If two possible outliers are deleted from the data set, then the combined criterion of extension moment and axial force becomes the most sensitive predictor which is consistent with expectations.

Effect of intra-tracheal instillation and inhalation of silicon dioxide on some biochemical variables in broncho-alveolar lavage fluid and lung histopathology in rats

In the present study, the bronchial alveolar lavage fluid (BALF) biochemical and lung histopathological changes occurring in response to single large intra-tracheal exposure to silica have been compared to the changes seen after continued chronic exposure via inhalation. Male albino rats (200-250gms) were exposed to silicon dioxide via intratracheal instillation (8mg/0.05ml saline) and whole body inhalation (200mg/m3, 6 hours/day for 2 and 4 weeks) in separate groups . The respective control animals were instilled with normal saline (0.05ml) or exposed to fresh air in simulation chamber for the same duration. BALF was analyzed for total protein, elastase, malondialdehyde (MDA) levels and catalase activity and histopathology of right lung was carried out after 4 weeks post-exposure in intra-tracheal model and after 2 and 4 weeks of exposure in the inhalation model. The levels of total protein, elastase and malondialdehyde (MDA) were significantly elevated, while catalase activity was significantly decreased in the BALF of exposed animals as compared to controls. The histopathological studies of lungs, showed exudates of inflammatory cells, chiefly of macrophages in the alveolar spaces and interstitial septa with multifocal nodular granulomatous lesions. The biochemical findings in BALF of both the models indicate inflammatory changes, lipid peroxidation and fibrosis. However, comparatively lower catalase activity and higher elastase levels in the 4 week inhalationally exposed group than the 4 week post intratracheally exposed group, suggests that these parameters may be affected by acute and chronic exposure and require further confirmation.

Effects of furosemide on medullary oxygenation in younger and older subjects

Renal medullary hypoxia is characteristic of mammalian kidneys and can be assessed noninvasively in animals and humans by blood oxygen level-dependent magnetic resonance imaging (BOLD MRI). Water diuresis has been shown to improve medullary oxygenation in young human subjects but not in elderly subjects, a difference attributed to a decline in renal prostaglandin production with age. Loop diuretics such as furosemide also increase medullary oxygenation in experimental animals, by inhibiting active transport and oxygen consumption in the medullary thick ascending limb. We examined, using BOLD MRI, this response to furosemide in eight younger (23 to 34 years) and eight elderly (64 to 81 years) healthy women. We also attempted to assess the role of prostaglandins in age-related differences, using ibuprofen to inhibit prostaglandin E2 synthesis. Renal medullary oxygenation, initially low, increased during furosemide diuresis in younger subjects. In the older population, however, furosemide usually elicited little or no change in oxygenation of the renal medulla, despite profuse diuresis. Ibuprofen did not inhibit the action of furosemide to improve medullary pO2 in younger subjects.

CONCLUSIONS

The action of loop diuretics to improve medullary oxygenation, apparent in younger subjects, is blunted by normal aging. Inhibition of prostaglandin synthesis did not counteract the effect of furosemide in younger subjects, suggesting that a decline in prostaglandin E2 production with age is not the central cause of this age-related defect.

Pharmacokinetics, pharmacodynamics, and safety of microencapsulated octreotide acetate in healthy subjects

The pharmacokinetics, pharmacodynamics, and safety of the marketed formulation of microencapsulated octreotide acetate were evaluated in an open-label study in 22 healthy cholecystectomized subjects. Each subject received a single 30 mg dose of microencapsulated octreotide acetate intramuscularly (i.m.). Concentrations of octreotide, growth hormone (GH), insulin-like growth factor binding protein 3 (IGFBP-3), and insulin-like growth factor 1 (IGF-1) as well as clinical safety were evaluated over a period of 112 days (16 weeks). After the injection, mean serum octreotide concentration initially increased rapidly, reached the maximum (Cmax, day 1 = 0.96 +/- 0.25 ng/ml) approximately 1.5 hours after dosing, and declined thereafter until 24 hours postdose (Cmin, 24 h = 0.088 +/- 0.093 ng/ml). The octreotide concentration then increased and started a sustained release from day 7 onward. Plateau concentrations were maintained through day 70 and gradually declined to below the lower limit of quantification (LLOQ) by day 112. The plateau height (Cplateau (2-112d, 60%)) was 1.68 +/- 0.88 ng/ml, and the duration (delta plateau, 60%) was 30.2 +/- 15.7 days. The integrated concentration-time curve, AUC0-112d, was 2819 +/- 782 (ng.h/ml), and the apparent half-life (t1/2) was 169 hours. To assess the variability, the drug concentrations were determined hourly for 8 hours on day 28, and the mean octreotide concentration, Cavg, day 28' was 1.55 +/- 1.26 ng/ml. The suppression of IGF-1 was statistically significant compared to the baseline (p < 0.05) through day 63; however, there were no appreciable changes in GH and IGFBP-3 concentrations after a single injection of microencapsulated octreotide acetate. Simulation of a 28-day dose schedule suggested that steady-state octreotide concentrations would be reached by the third injection with steady-state concentrations about twofold greater than the first injection. There were no serious adverse events or clinically meaningful changes in vital signs, ECGs, or laboratory evaluations observed in this study, indicating that the 30 mg i.m. dose of microencapsulated octreotide acetate was well tolerated in this population.

A study of dapsone syndrome at a rural teaching hospital in South India

Dapsone syndrome or sulphone syndrome was noticed within four to six weeks of starting treatment in 10 out of 604 patients (1.6%) on MDT for leprosy treated at Rajah Muthiah Medical College Hospital, South Arcot District, Tamil Nadu State during the period 1995 - 1998. Patients developed either maculo papular rash or exfoliation along with fever and lymphadenopathy. Abnormal liver function tests was noticed in 50%. The patients with dapsone syndrome were treated with corticosteroids after withdrawing dapsone. There was complete resolution of skin lesion and other symptoms.

Pedicled omental transfer for limb salvage in Buerger's disease

We performed pedicled omental transfer in 62 patients with Buerger's disease at the Department of Surgery, J.L.N. Hospital, Ajmer between January 1990 and December 1996. All were male and had evidence of limb ischaemia. Post-operative results in these patients consisted of relief of intermittent claudication in 92%, disappearance of rest pain in 94%, disappearance of limb coldness in 83%, disappearance of discolouration in 82%, and healing of ischaemic ulcers in 83%. Tissue oxygen saturation in the affected limb improved from a mean of 84.8+/-3.6% in the preoperative period, to 89+/-1.5% at 12 h, 93.1+/-1.8% at 72 h and 96+/-1.2% at the end of 2 months of follow-up. Claudication distance improved from a mean of 75+/-20 m in the pre-operative period to 1000+/-110 m at 2 months of follow-up in 57 of 62 patients. Major amputations were not required in any patient, thus conserving the limb. We conclude that pedicled omental transfer offers promising results in patients with limb ischaemia due to Buerger's disease.

GFP chimeras of E-MAP-115 (ensconsin) domains mimic behavior of the endogenous protein in vitro and in vivo

E-MAP-115 (ensconsin) is a microtubule-associated protein (MAP) abundant in carcinoma and other epithelia-derived cells. We expressed chimeras of green fluorescent protein (GFP) conjugated to ensconsin's N-terminal MT-binding domain (EMTB), to study distribution, dynamics, and function of the MAP in living cells. We tested the hypothesis that behavior of expressed GFP-EMTB accurately matched behavior of endogenous ensconsin. Like endogenous MAP, GFP-EMTB was associated with microtubules in living or fixed cells, and microtubule association of either molecule was impervious to extraction with nonionic detergents. In cell lysates both GFP-EMTB and endogenous ensconsin were dissociated from microtubules by identical salt extraction conditions, and both molecules remained bound to a calcium-stable subset of Taxol-stabilized microtubules. These data show that microtubule association of ensconsin was affected neither by the absence of domains other than its microtubule-binding domain, nor by the presence of appended GFP. We took advantage of this finding to generate constructs in which additional GFP moieties were attached to EMTB, to obtain a more intensely fluorescent reporter of in vivo MAP binding. We show here that expression of chimeric proteins consisting of five GFP molecules attached to a single EMTB molecule produces brightly labeled microtubules without compromising the behavior of the MAP or the microtubules to which it is attached. Thus, we have demonstrated the utility of chimeric proteins containing GFP multimers as authentic reporters of ensconsin distribution and dynamics; expression of these GFP-EMTB chimeric molecules also provides a non-perturbing label of the microtubule system in living cells.

Tuberculous perforations of the small intestine

The hospital records of 58 patients operated on for tuberculous perforations of the small intestines at our hospital between 1987 and 1996 were reviewed. Clinical features were non-specific in the majority of the patients. Pneumoperitoneum on abdominal radiographs was present in only 28 (48.3%) patients. Forty-five (77.6%) were operated on within 36 hours of perforation. Surgical management consisted of resection and end-to-end anastomosis (n = 45); oval excision of the perforation and transverse anastomosis reinforced with an omental patch (n = 7); ileo-transverse colostomy (n = 5); and peritoneal drainage only (n = 1). There were 17 deaths (29.3%). Adverse prognostic factors were operation beyond 36 hours (p < 0.01), multiple perforations (p < 0.001), and faecal fistula formation (p < 0.01). Mortality was least with early resection and end-to-end anastomosis of the perforated bowel segment. We conclude that a high index of suspicion is essential for early diagnosis and optimal treatment of patients with tuberculous intestinal perforations.

Haemangiopericytoma of the adult male breast

Haemangiopericytoma is an uncommon, usually benign, soft tissue tumour which has been rarely reported to occur in the female breast. Haemangiopericytoma of the adult male breast has been reported only once before. We report another such case.

Trauma scoring in a developing country

AIM OF STUDY

The aim of the study was to evaluate the efficacy of trauma scoring systems in a developing country.

METHOD

Trauma Score (TS) and Trauma and Injury Severity Score (TRISS) were used to predict the survival of 462 trauma patients during the period January 1996 to July 1996.

RESULTS

TS had a sensitivity of 53.9% and a specificity of 98.8% whereas TRISS had a sensitivity of 46% and a specificity of 98.7%. Significant differences in mortality were observed compared with the baseline Major Trauma Outcome Study (MTOS) norms (Z = 4.17, p < 0.001).

CONCLUSION

Present injury severity instruments using MTOS coefficients do not accurately predict survival of trauma patients in a developing country, thus highlighting the need for developing new coefficients for trauma scoring in these countries.

Sigmoidopexy (tube sigmoidostomy) as definitive surgical procedure for sigmoid volvulus

BACKGROUND

Volvulus of the sigmoid colon is associated with high mortality and high recurrence rate following nonoperative decompression of the colon. Therefore definitive surgery is required for its management.

AIM

To evaluate the outcome following sigmoidopexy (tube sigmoidostomy) as a definitive surgical procedure to prevent recurrence of disease.

METHODS

Seventeen patients with sigmoid volvulus who presented with features of large gut obstruction were studied; 12 patients underwent elective and 5 underwent emergent exploratory laparotomy. Malecot catheter fixed to the sigmoid colon and abdominal wall acted as fixator for the colon and rent for drainage of fecal matter.

RESULTS

Sigmoidostomy started functioning the day following surgery and the stoma remained patent for approximately 12 days, although discharge started decreasing by the 5th postoperative day. No recurrence was noted over a period of 18 (5) months (range 13-23).

CONCLUSIONS

Tube sigmoidostomy is an alternative effective procedure to prevent recurrence of sigmoid volvulus in patients who present without gangrene.

Angiogenic potential of perivascularly delivered aFGF in a porcine model of chronic myocardial ischemia

A number of heparin-binding growth factors, including basic (bFGF) and acidic (aFGF) fibroblast growth factors have been shown to promote angiogenesis in vivo. In this study, we employed a sustained-release polymer extravascular delivery system to evaluate the angiogenic efficacy of a novel form of genetically modified aFGF in the setting of chronic myocardial ischemia. Fifteen Yorkshire pigs subjected to Ameroid occluder placement on the left circumflex (LCX) artery were treated with perivascularly administered aFGF in ethylene vinyl acetate (EVAc) polymer (10 micrograms, n = 7) or EVAc alone (controls, n = 8). Seven to nine weeks later, after coronary angiography to document Ameroid-induced coronary occlusion, all animals underwent studies of coronary flow and global and regional left ventricular function. Microsphere-determined coronary flow in the Ameroid-compromised territory was significantly increased in aFGF-treated compared with control animals, and this improvement in perfusion was maintained during ventricular pacing. Left ventricular function studies demonstrated improved global and regional function in aFGF-treated animals. We conclude that local perivascular delivery of genetically modified aFGF results in significant improvement in myocardial flow and regional and global left ventricular function.

Free versus pedicled omental grafts for limb salvage in Buerger's disease

BACKGROUND

Buerger's disease is a disabling and progressive disease that affects young smokers with a variable and unpredictable course. Free or pedicled omental transfer are the possible modes of management for these patients, and these modes are compared in the present study.

METHODS

Of the 43 patients who had Buerger's disease who were treated at the Department of Surgery, Jawahar Lal Nehru (JLN) Hospital, Ajmer, between January 1990 and December 1995, 15 patients underwent application of free omental grafts (group A); 28 patients underwent pedicled omental transplantation (group B). The clinical results obtained with the use of either technique were compared.

RESULTS

There were no statistically significant differences in the relief of intermittent claudication (80% vs 82%), rest pain (82% vs 91%), coldness (83% vs 87%), discolouration (80% vs 82%), ulceration (75% vs 78%) and post-amputation ulcer healing (75% vs 86%) in the two groups (P > 0.05); but the time taken for the relief of intermittent claudication, rest pain and coldness was significantly less in group B. Major amputations were not required in both the groups.

CONCLUSIONS

These findings suggest that the ultimate clinical benefits obtained with the use of either free or pedicled omental grafts in patients with Buerger's disease are similar, supporting a possible local action of the omentum.