[Avulsion fracture of the lesser trochanter]

An avulsion fracture of the lesser trochanter is a very rare injury often misdiagnosed as a muscle lesion or hip distortion. This report concerns the avulsion fracture of the lesser trochanter of a 13-year-old boy, suffered on a runway preparing for a long jump. Conservative treatment without weight-bearing was indicated for 6 weeks. Twelve weeks after the injury the patient resumed his normal sport activities.

[The mature twoplane and triplane fracture. Transitional fractures of the distal tibia combined with typical fracture patterns of adults]

Physiologic closure of the growth plate of the distal tibia occurs between the ages of 12 and 14 years in girls and 1 year later in boys. The closure of the tibial physis starts eccentrically at the ventrolateral zone of the medial malleolus extending dorsally and ends laterally. Therefore, the anterolateral zone is the last to ossify. The process of closure lasts about 18 months. During this period the growth plate loses its joint-protective function and transitional fractures may occur. The more the closure progresses the more lateral the location of the fracture. In addition to the typical transitional fractures, typical fracture patterns of adults in the ossified physis are possible due to a mature bone structure. We report two cases of transitional fractures combined with typical fracture patterns of adults due to a dorsomedial ossified physis in the distal tibia.

Destruction of the Kondo effect in the cubic heavy-fermion compound Ce3Pd20Si6

How ground states of quantum matter transform between one another reveals deep insights into the mechanisms stabilizing them. Correspondingly, quantum phase transitions are explored in numerous materials classes, with heavy-fermion compounds being among the most prominent ones. Recent studies in an anisotropic heavy-fermion compound have shown that different types of transitions are induced by variations of chemical or external pressure, raising the question of the extent to which heavy-fermion quantum criticality is universal. To make progress, it is essential to broaden both the materials basis and the microscopic parameter variety. Here, we identify a cubic heavy-fermion material as exhibiting a field-induced quantum phase transition, and show how the material can be used to explore one extreme of the dimensionality axis. The transition between two different ordered phases is accompanied by an abrupt change of Fermi surface, reminiscent of what happens across the field-induced antiferromagnetic to paramagnetic transition in the anisotropic YbRh2Si2. This finding leads to a materials-based global phase diagram--a precondition for a unified theoretical description.

Immunogenicity of a combined schedule of 7-valent pneumococcal conjugate vaccine followed by a 23-valent polysaccharide vaccine in adult recipients of heart or lung transplants

A combined schedule of 7-valent pneumococcal conjugate vaccine (PCV7) followed by 23-valent pneumococcal polysaccharide vaccine (PPV23) was evaluated retrospectively in 26 adult recipients of heart or lung transplants. PCV7 was immunogenic in these patients but there appeared to be no benefit from the additional PPV23 dose.

Chemical pressure, dilution and disorder in the heavy fermion compounds Ce(3-x)La(x)Pd₂₀Si₆ (x=1/3, 2/3)

The heavy fermion compound Ce3Pd20Si6 is one of the rare examples of a cubic system with a readily accessible quantum critical point. Ce atoms at the two different sites 4a and 8c of the crystal structure have recently been shown to have different crystal field ground states (Γ7 and Γ8, respectively) and are assumed to be responsible for the two different low-temperature phase transitions at T(L) and T(U), which have been tentatively attributed to antiferromagnetic and antiferroquadrupolar order, respectively. Here we present electrical resistivity measurements in a wide temperature range (50 mK-300 K) on two new representatives of the La substitution series Ce(3 - x)La(x)Pd20Si6, x=1/3 and 2/3. Put in the context of previously published data our results indicate that La preferentially occupies the 4a site and that Ce ions at the 8c site have a sizably larger Kondo temperature. Low-temperature resistivity measurements in applied magnetic fields suggest that (disorder smeared) quantum critical points exist in the x=1/3 and 2/3 samples at fields below 1 T.

[Preclinical prediction of prehospital injury severity by emergency physicians : approach to evaluate validity]

BACKGROUND

The prognosis of polytraumatized patients is basically dependent on the quality of emergency room (ER) management and a smooth transition from prehospital emergency therapy to ER therapy is essential. The accurate prediction of the prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. Furthermore it helps to provide medical resources on time. Overestimation of injury severity wastes resources, underestimation puts patients at risk. Prehospital misjudgement of injury severity is common. The aim of this study was to evaluate reliability of the injury severity estimated by emergency physicians.

MATERIALS AND METHODS

For comparison of the prehospital and hospital injury severity the Injury Severity Score (ISS) and Trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the Revised Trauma Score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the Abbreviated Injury Scale (AIS). The concordance of prehospital and hospital injury severity at different ranges and according to different body regions was evaluated. A difference of more than 25% between the prehospital injury severity and the injury severity calculated after ER diagnostics was considered as being relevant and judged as overestimation or underestimation. The documented injury severity in the emergency physician protocol was judged as detailed, satisfactory and poor.

RESULTS

Of the patients 73% reached the ER during on-call hours. The mean ER-ISS was 19 (1-50). At a range of ±25% referring to the ER-ISS, 30% overestimation and 36% underestimation of the prehospital injury severity was observed. A concordance of 34% was found. At a range of ±50% the concordance between the prehospital injury severity and the injury severity calculated after ER diagnostics was 57%, at a range of ±75% the concordance was 73%. The mean ER-TRISS was 6.9 points (0.3-98.6) and the mean ER-RTS was 7.569 points (0-7.841). Using the TRISS with a range of ±25% a concordance of 28% was observed. A high concordance of the prehospital and hospital injury severity was found in the region of the face (70%) and external soft tissue injuries (80%). The concordance in the body region of the abdomen was 55%, of the thorax 40%, of the extremities and pelvis 37% and of the head 33%. Underestimation in the region of the abdomen was 32%, of the head 37%, of the thorax 42% and of the extremities and pelvis 47%. Missed injuries were the reason for underestimation in the body region of extremities and pelvis in half of the cases. Of the patients 61% suffered a traffic accident, 25% a fall of less than 3 m and 8% of more than 3 m. In 5% of the cases other mechanisms of injury were observed. Injury severity was documented in a detailed manner in 61% and satisfactory in 26%.

CONCLUSIONS

The prediction of prehospital injury severity is difficult and less reliable. Relevant underestimation of injury severity was observed in visceral cavities. In order to evaluate injury severity the use of anatomical trauma scores alone might be not sufficient. In addition, the mechanism of injury and the deduced consequences, such as prehospital therapy, the choice of destination hospital and the need of ER treatment should be taken into account.

[The painful os intermetatarseum]

The os intermetatarseum is an uncommon accessory bone of the foot, usually found between the bases of the first and second metatarsal bones. Two cases of a painful os intermetatarseum in athletes are reported. Surgical excision of the os intermetatarseum relieved the pain in both patients. Case reports concerning athletes with a painful os intermetatarseum are rare. An os intermetatarseum should be taken under consideration when evaluating dorsal midfoot pain.

Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones

PURPOSE

To report our approach for treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL).

PATIENTS AND METHODS

Twenty-two symptomatic patients (11 men and 11 women, age range 51 to 88 years) with intrahepatic or common bile duct calculi underwent PTBL. Nine patients had undergone previous gastrectomy and small-bowel anastomosis, thus precluding endoscopic retrograde cholangiopancreatography. In the other 13 patients, stone removal attempts by ERCP failed due to failed access or very large calculi. We used a 7.5F flexible ureteroscope and a 200-μm holmium laser fiber by way of a percutaneous transhepatic tract, with graded fluoroscopy, to fragment the calculi with direct vision. Balloon dilatation was added when a stricture was seen. The procedure was performed with the patient under general anaesthesia. A biliary drainage tube was left at the end of the procedure.

RESULTS

All stones were completely fragmented and flushed into the small bowel under direct vision except for one patient in whom the procedure was aborted. In 18 patients, 1 session sufficed, and in 3 patients, 2 sessions were needed. In 7 patients, balloon dilatation was performed for benign stricture after Whipple operation (n = 3), for choledochalenteric anastomosis (n = 3), and for recurrent cholangitis (n = 1). Adjunctive "balloon push" (n = 4) and "rendezvous" (n = 1) procedures were needed to completely clean the biliary tree. None of these patients needed surgery.

CONCLUSION

Complicated or large biliary calculi can be treated successfully using PTBL. We suggest that this approach should become the first choice of treatment before laparoscopic or open surgery is considered.

Phase I and pharmacological study of the broad-spectrum tyrosine kinase inhibitor JNJ-26483327 in patients with advanced solid tumours

Background:

JNJ-26483327 is an oral, potent, multi-targeted tyrosine kinase inhibitor, inhibiting kinases of epidermal growth factor receptor (EGFR)-1, -2 and -4, rearranged during transfection (RET) receptor, vascular endothelial growth factor receptor (VEGFR)-3 and Src family (Lyn, Fyn, Yes) at low nanomolar concentrations. This phase I, accelerated titration study assessed maximum tolerated dose, safety, pharmacokinetics and pharmacodynamic effects of JNJ-26483327.

Methods:

Nineteen patients with advanced cancers received JNJ-26483327 continuous twice daily (BID) in escalating dose cohorts ranging from 100 to 2100 mg. Pharmacodynamic effects were assessed in paired skin biopsies and blood.

Results:

JNJ-26483327 was well tolerated in doses up to 1500 mg BID, with target-inhibition-related toxicity such as diarrhoea and skin rash, and other common reported toxicities being nausea, vomiting, anorexia and fatigue. At 2100 mg, two episodes of dose-limiting toxicity were observed, consisting of grade 3 anorexia and a combination of grade 3 anorexia and fatigue, respectively. Pharmacokinetics were dose proportional up to 1500 mg in which plasma levels were obtained showing anti-tumour activity in xenograft mouse models. Pharmacodynamic analysis did not show a substantial effect on expression of Ki-67, p27^kip1, phosphorylated mitogen-activated protein kinase, phosphorylated Akt and EGFR, and serum levels of sVEGFR-2, VEGF-C and VEGF-D remained unchanged. Stable disease was noted in six patients (32%).

Conclusion:

JNJ-26483327 is well tolerated and shows a predictable pharmacokinetic profile; the recommended dose for further studies is 1500 mg BID.

Wing pointedness associated with migratory distance in common-garden and comparative studies of stonechats (Saxicola torquata)

Migration promotes utilization of seasonal resources, and the distance flown is associated with specific morphologies, yet these relationships can be confounded by environmental factors and phylogeny. Understanding adaptations associated with migration is important: although migration patterns change rapidly, it is unclear whether migratory traits track behavioural shifts. We studied morphometrics of four stonechat populations representing a migratory gradient and raised under common-garden conditions. With multivariate analyses, we identified wing traits that differed clearly from general size trends, and used phylogenetic comparative methods to test the prediction that these traits correlated with migratory distance in captive and wild populations. Pointedness differed among populations, changed independently from overall body size, and was correlated with migration distance. Migration in stonechats may lead to deviations from allometric size changes, suggesting that birds may adapt morphologically to selection pressures created by their own behaviour in response to changing environmental conditions.

Laparoscopic surgery for renal stones: is it indicated in the modern endourology era?

PURPOSE

To report the outcomes of laparoscopic surgery combined with endourological assistance for the treatment of renal stones in patients with associated anomalies of the urinary tract. To discuss the role of laparoscopy in kidney stone disease.

MATERIALS AND METHODS

Thirteen patients with renal stones and concomitant urinary anomalies underwent laparoscopic stone surgery combined with ancillary endourological assistance as needed. Their data were analyzed retrospectively including stone burden, associated malformations, perioperative complications and outcomes.

RESULTS

Encountered anomalies included ureteropelvic junction obstruction, horseshoe kidney, ectopic pelvic kidney, fussed-crossed ectopic kidney, and double collecting system. Treatment included laparoscopic pyeloplasty, pyelolithotomy, and nephrolithotomy combined with flexible nephroscopy and stone retrieval. Intraoperative complications were lost stones in the abdomen diagnosed in two patients during follow up. Mean number of stones removed was 12 (range 3 to 214). Stone free status was 77% (10/13) and 100% after one ancillary treatment in the remaining patients. One patient had a postoperative urinary leak managed conservatively. Laparoscopic pyeloplasty was successful in all patients according to clinical and dynamic renal scan parameters.

CONCLUSIONS

In carefully selected patients, laparoscopic and endourological techniques can be successfully combined in a one procedure solution that deals with complex stone disease and repairs underlying urinary anomalies.

Phase I pharmacokinetic (PK) and pharmacodynamic (PD) study of HDM-2 antagonist JNJ-26854165 in patients with advanced refractory solid tumors

3514

Background: JNJ-26854165 is a novel first-in-clinic oral Human Double Minute-2 (HDM-2) ubiquitin ligase antagonist. It increases the level of HDM-2 client proteins (e.g. p53) by inhibiting the association of HDM-2-client protein complex with the proteosome. Preclinical studies have demonstrated potent anti-proliferative and apoptosis-inducing activity of JNJ-26854165 in a broad range of p53 wild type and mutant tumor models. Methods: A 3+3 dose escalation study with the primary objectives to determine the adverse event (AE) profile, dose limiting toxicities (DLT) and maximum tolerated dose of JNJ-26854165 is ongoing. Secondary objectives include evaluation of PK and PD activity. Eligible patients have ECOG PS≤2 and adequate hematological, renal and hepatic function. JNJ-26854165 is administered orally once daily on a continuous schedule (21-day cycles). Sequential skin and tumor biopsies are taken, and evaluations for HDM-2, p53 and other pathway related markers are performed, including further molecular analyses for HDM-2 activity. Results: 37 pts have been treated at 9 dose levels (DL), 4–300 mg qd. AEs included nausea, vomiting, fatigue, anorexia, insomnia, electrolyte disturbances, liver function tests and creatinine elevations, and asymptomatic QTc prolongation, mostly grade 1–2. A DLT, grade 3 QTcF prolongation, was observed in one patient at DL 9. The patient was asymptomatic and the QTc prolongation recovered after treatment discontinuation. PK data showed dose-proportionality. After dosing at 300 mg, steady state Cmax and AUC0–24h were 2–3 μg/mL and ≈50 μg.h/mL, respectively, well exceeding the expected effective exposure modeled by preclinical studies. PD data showed engagement of the targeted pathway such as dose-dependent p53 upregulation in skin, upregulation of HDM-2 levels in tumors after treatment, and an increase in plasma MIC-1 levels. No objective responses have been observed so far. Conclusions: JNJ-26854165 was well tolerated at doses beyond the expected effective exposure modeled by preclinical studies. PD activity was observed at the 150–300 mg dose levels. The trial continues with cohort expansion at 300 mg. Updated results will be presented.

[Table: see text]

One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics

Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts. Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.