Validation of a one-stop carpal tunnel clinic including nerve conduction studies and hand therapy

INTRODUCTION

Carpal tunnel syndrome is the most common hand disorder. We describe a pathway that includes clinical assessment, neurophysiological testing, surgery and physical therapy all at the same visit.

METHODS

All referrals for carpal tunnel syndrome were screened for inclusion in a 'one-stop' surgeon-led clinic. Prospective clinical data collected included patient reported outcome measures and satisfaction scores, touch threshold, pinch and grip strength. Patients were assessed clinically, underwent nerve conduction studies and surgery as indicated, all on the same day. Baseline and one-year follow-up data were analysed for 57 patients (62 hands).

RESULTS

There was significant improvement in all domains of the Boston Carpal Tunnel and Michigan hand Outcomes questionnaires, grip strength and touch threshold. There were no adverse events. The total mean operating time was 12.8 minutes (range: 5-15 minutes) and the mean tourniquet time was 2.5 minutes (range: 1-11 minutes). Using a dual theatre model produced a short mean turnaround time of 14.8 minutes (range: 2-37 minutes). Patient satisfaction as judged using a Picker questionnaire was very high.

CONCLUSIONS

A highly efficient clinical service involving both diagnostics and treatment can be delivered at a single hospital visit while maintaining optimal outcomes and high patient satisfaction.

P5-13-10: Discordance of Estrogen Receptor and HER-2/neu Status Can Be Seen between First and Subsequently Biopsied Metastatic Lesions in Breast Cancer

Background

We have previously reported discordance between primary and first metastasis for both estrogen receptor (ER) and HER-2/neu (HER 2) status (Breast Cancer Res Treat 2005;90:65–70 and Breast Cancer Res Treat 2009;113:301–6). Because biomarker status is the primary determinant for targeted therapy, changes in biomarkers can impact recommendations for systemic treatment.

Materials and Methods: In order to evaluate the possibility of further discordance with the development of additional metastatic sites, we examined the ER and HER 2 status of primary and first and subsequently biopsied breast cancer metastasis. In most cases, the subsequent site of metastasis was the second detected metastasis. Pathology reports were reviewed from 65 patients with biopsy proven first and additional metastasis; however, immunostain results were not available for all three timepoints for all patients. Sites of biopsied metastasis included lung, liver, bone, chest wall, and central nervous system.

Results: The time between the initial diagnosis and first metastasis was 102 (3-676) months [Median (Range)], and the time between the first and subsequent metastasis was 60 (6-273) months. For ER, there was discordance between the primary lesion and either the first or subsequent metastasis in 18 of 65 cases (27.7%). Discordance of the ER occurred between the first and subsequent metastasis in 12 (18%) of cases. Three patterns of ER discordance occurred in these 12 cases: 4 cases of both primary and first metastasis negative with subsequent metastasis positive; 3 cases of primary positive, first metastasis negative, and subsequent metastasis positive, and 5 cases of primary and first metastasis positive and subsequent metastasis negative. For HER 2, discordance was detected between the primary and either first or subsequent metastasis in 11 of 36 cases (30.6%). Further discordance between the first and subsequent metastatic lesions occurred in 8 of 51 (16%) of cases.

Conclusions: A significant level of discordance for either ER or HER 2 was detected between first and subsequent metastatic breast cancer lesions. For breast cancer patients with new metastasis, consideration of reevaluating ER and HER-2/neu status may be worthwhile.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-10.

Hepatitis B virus genotype, HBsAg mutations and co-infection with HCV in occult HBV infection

BACKGROUND

The association between mutations in the hepatitis B surface antigen (HBsAg) gene and the occurrence of occult HBV (OBI) in patients has not been studied adequately to determine if the two are correlated. The current study was aimed to investigate HBsAg mutations, the genotype of HBV and co-infection with HCV in OBI in the central part of Iran to determine any possible associations.

MATERIAL AND METHODS

In this study, 3700 plasma samples were examined for the presence of HBsAg, anti-HBc and HBV-DNA. All HBsAg(-)/anti-HBc(+)/HBV-DNA(+) samples were regarded as OBI. The genotype of HBV was identified using Gap-PCR and RT-PCR was used to determine possible co-infection with HCV. Finally, direct sequencing was performed to analyse mutations within the surface antigen gene of HBV in occult versus acute HBV infection.

RESULTS

Of the 3700 patient samples analysed, 352 (9.5%) cases were determined to be HBsAg(-)/anti-HBc(+) in which HBV-DNA was detected in 57 (16.1%), these latter patients were classified as OBI. All of the patients studied carried the D genotype. Direct sequencing of the S-gene from occult and acute HBV patients revealed one silent and one glycine to arginine mutation but the acute HBV patients showed an additional mutation (alanine to threonine). All the mutations were outside the range of the α-determinant. Furthermore, none of the OBI patients were co-infected with HCV.

CONCLUSIONS

The absence of conformational mutations in the α-determinant of HBsAg confirmed that this antigen could be detected by commercial Elisa kits and therefore was not responsible for false negatives during blood screening. However, it can be concluded that suitable amounts of HBsAg were not expressed by HBV in the OBI patients to be detected by Elisa. Low level expression of HBsAg might be related to the D genotype of the virus. Furthermore, our results suggest that OBI is not related to co-infection with HCV.

Polymorphisms within exon 9 but not intron 8 of the vitamin D receptor are associated with the nephropathic complication of type-2 diabetes

The impact of several environmental and genetic factors on diabetes and its complications is well documented but there is an urgent need to understand more about genetic risk factors associated with this disease. The present study was aimed at examining the two single nucleotide polymorphisms (SNP) in intron 8 and exon 9 of the vitamin D receptor (VDR) gene in nephropathic and non-nephropathic type-2 diabetic patients. In this clinical study, peripheral blood samples were obtained from 100 type-2 diabetic patients, 100 nephropathic type-2 diabetic patients and 100 healthy controls. DNA was extracted and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was performed to examine two SNP polymorphisms within the VDR gene. Our results showed a significant difference in the Taq-1 evaluated genotypes of exon 9 in the VDR gene of diabetic individuals with (P=0.012) and without (P ≤ 0.001) nephropathy. Analysis of the Taq-1 evaluated alleles of nephropathic (P=0.917) and non-nephropathic (P=1.000) did not show a significant difference. We also evaluated the intron 8 Apa-1 alleles in patients with (P=0.480) and without nephropathy (P=0.543) and determined there were no differences between these groups. Our results also showed that the frequency of Apa-1 genotypes did not differ in nephropathic (P=0.224) and non-nephropathic (P=0.236) diabetic patients. Based on our results, it can be concluded that VDR and its functional polymorphism in exon 9 may play an important role in pathogenesis of type-2 diabetes and more investigations are required to clarify their role in nephropathy.

Detecting and defining the anatomic extent of large nerve perineural spread of malignancy: comparing "targeted" MRI with the histologic findings following surgery

BACKGROUND

The accurate preoperative identification of the extent of perineural spread (PNS) of malignancy along a cranial nerve is vital to the design of an appropriate surgical resection. Our purpose was to determine the sensitivity of targeted MRI in predicting the presence of disease and the anatomic extent of spread when compared with histologic findings.

METHODS

A retrospective review was performed of 25 patients with PNS who had targeted MRI and surgery to excise perineural tumor (2002-2008).

RESULTS

MRI detected PNS in 30 of 30 nerves (100%) with 1 false positive. MRI correctly identified the extent of spread based on histology in 25 of 30 nerves (83.3%). In 4 of 30 cases (13.3%) MRI underestimated the extent of spread proximal to the Gasserian ganglion that, if diagnosed preoperatively, may have deemed the patient inoperable.

CONCLUSIONS

MRI demonstrated the presence and anatomic extent of PNS in the majority of cases. MRI may underestimate microscopic spread proximal to the Gasserian ganglion.

The development and implementation of an obstetric cell salvage service

Cell salvage in obstetric haemorrhage is now endorsed by a number of organisations. Most of the literature has focused on isolated case series and safety. We describe how cell salvage, including a quality assurance process conducted prior to clinical implementation, was introduced to our stand-alone obstetric hospital which had no previous experience of this technique. An implementation committee was established and 25 quality assurance and familiarisation cases were initially conducted. As part of this process the alpha fetoprotein, haematocrit, free plasma haemoglobin, potassium and Kleihauer tests were performed when enough blood was available for processing. Our guidelines for clinical use included women at greatly increased risk of obstetric haemorrhage and women at increased risk of haemorrhage who refused traditional transfusion. After the successful completion of this process, cell salvage was signed off for clinical use in March 2007 and was used on 51 occasions between March 2007 and July 2009. Twenty-one patients had salvaged blood re-transfused and for seven patients this was their only red blood cell replacement. The median blood loss in patients re-transfused was 3000 ml (range <500 to 8500 ml), with the median volume re-transfused 359 mi (range 60 to 1300 ml). There was one episode of unexplained hypotension associated with administration of salvaged blood. We have successfully introduced obstetric cell salvage into clinical practice. A quality assurance process prior to implementation was beneficial for the staff involved. Despite targeting a high-risk obstetric population, our re-transfusion rates are approximately 40%. No serious adverse events have been recorded. We recommend that in units that already provide intraoperative cell salvage in a non-obstetric setting, extending the service into obstetric situations should be considered. Units that routinely care for high-risk obstetric patients should also consider the introduction of such a service. Post transfusion Kleihauer testing should be performed as soon as possible in Rhesus-negative mothers who deliver a Rhesus-positive foetus, so that appropriate anti-D prophylaxis can be administered.

Adding gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty

BACKGROUND

Gabapentin (GPN) is effective in reducing post-operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre-operative administration of gabapentin is more effective than post-operative administration.

METHODS

After REB approval and informed consent, 126 patients were enrolled in a double-blinded, randomized-controlled study. Patients received acetaminophen 1 g per os (p.o.), celecoxib 400 mg p.o. and dexamethasone 8 mg intravenously, 1-2 h pre-operatively. Patients were randomly assigned to one of three treatment groups (G1: Placebo/Placebo; G2: GPN/Placebo; G3: Placebo/GPN). Patients received gabapentin 600 mg (G2) or placebo (G1 and G3) 2 h before surgery. All patients had spinal anesthesia [15 mg (3cc) of 0.5% hypobaric bupivacaine with 10 microg of fentanyl]. In the post-anesthetic care unit, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). On the ward, patients received acetaminophen 1000 mg p.o. q6h, celecoxib 200 mg p.o. q12h and a morphine PCA device. Patients were interviewed 6 months post-surgery to determine the incidence and severity of chronic post-surgical pain.

RESULTS

Mean+/-SD cumulative morphine (mg) consumption (G1=49.4+/-24.8, G2=47.2+/-30.1 and G3=56.1+/-38.2) at 48 h and pain scores at 12, 24, 36 and 48 h post-surgery were not significantly different among the groups [G1 (n=38), G2 (n=38) and G3 (n=38)]. Side effect profiles were similar across groups. Six months after surgery, the number of patients who reported chronic post-surgical pain (G1=10, G2=12 and G3=9) and the severity of the pain (G1=4.2+/-2.9, G2=4.1+/-2.2 and G3=4.9+/-2.2) did not differ significantly among the groups (P>0.05).

CONCLUSIONS

A single 600 mg dose of gabapentin given pre-operatively or post-operatively does not reduce morphine consumption or pain scores in hospital or at 6 months after hip arthroplasty within the context of spinal anesthesia and a robust multimodal analgesia regimen.

Evaluation of thickness and appearance of anterior talofibular and calcaneofibular ligaments in normal versus abnormal ankles with MRI

Injuries to the lateral ligaments of the ankle are common in medical practice. The most commonly injured ligaments are the anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments. When undertaking MRI evaluation of ankle injuries it is important to understand the normal dimensions, appearance and variations of these ligaments. Twenty-eight consecutive patients referred for MRI of the ankle underwent bilateral scanning. The thickness of normal and abnormal ATFL and CFL was determined. The mean thickness of the ATFL was 2.19 +/- 0.6 mm and the CFL measured 2.13 +/- 0.5 mm. One normal ankle had an extremely thin ATFL (0.8 mm) with an otherwise normal appearance, whereas two ankles had an ATFL with a high attachment, both of which were deemed to be normal variants. Nineteen per cent of normal CFLs were noted to consist of a lateral hypointense band with a medial isointense medial band. Two variations of normal ATFL, one normal variant CFL and a measurement of the normal thickness of the ATFL and CFL have been presented in this paper. These variations have not been described previously by other authors. It is envisaged that these findings will assist in the MRI assessment of the lateral ankle ligaments.

Modulation of p53 and MDM2 activity by novel interaction with Ras-GAP binding proteins (G3BP)

Inactivation of the p53 tumor suppressor pathway is a critical step in human tumorigenesis. In addition to mutations, p53 can be functionally silenced through its increased degradation, inhibition of its transcriptional activity and/or its inappropriate subcellular localization. Using a proteomic approach, we have found that members of the Ras network of proteins, Ras-GTPase activating protein-SH3-domain-binding proteins 1 and 2 (G3BP1 and 2), bind to p53 in vitro and in vivo. Our data show that expression of G3BPs leads to the redistribution of p53 from the nucleus to the cytoplasm. The G3BP2 isoform additionally associated with murine double minute 2 (MDM2), a negative regulator of p53. G3BP2 expression resulted in significant reduction in MDM2-mediated p53 ubiquitylation and degradation. Interestingly, MDM2 was also stabilized in G3BP2-expressing cells and its ability to ubiquitylate itself was compromised. Accordingly, short hairpin RNA (shRNA)-mediated knockdown of G3BP2 caused a reduction in MDM2 protein levels. Furthermore, expression of shRNA targeting either G3BP1 or G3BP2 in human cancer cell lines resulted in marked upregulation of p53 levels and activity. Our results suggest that both G3BP isoforms may act as negative regulators of p53.

The effect of pressure loading on the blood flow rate in human skin

The effect of pressure on the blood flow in skin is of considerable clinical interest. Methods are described for the estimation of skin blood flow from the disappearance rate of an injection of 133Xe in saline. The flow rate may be monitored for a period long enough to establish the normal flow and the reduced flow resulting from a constant pressure load. Initial results indicate that the flow is reduced greatly by pressures up to 10 mmHg. This result is interpreted as a demonstration of an auto regulatory mechanism of skin blood flow. Above 30 mmHg the flow continues to decrease essentially to zero as systolic pressure is approached.