Continental variations in preoperative and postoperative management of patients with anterior cruciate ligament repair

AIM

Surgeon decision making for non-operative anterior cruciate ligament (ACL) treatment and postoperative rehabilitation is influenced by a myriad of factors. The aim of this study was to investigate intercontinental differences in surgeon decision making for care of the ACL deficient patient. The authors hypothesized that significant variation in clinical decision of ACL deficient patients existed among surgeons in different continents.

METHODS

This study involved a survey design, which met the checklist for reporting results of internet e-surveys (CHERRIES) guidelines. The survey was administered to orthopedic surgeons in 15 countries and involved standardized follow up and design. Questions related to non-operative care management and postoperative/rehabilitative management were provided to each respondent. Statistical analyses included multivariate comparisons among continents and regression findings for likelihood of targeting longer term non-operative treatment.

RESULTS

Over six hundred (634) surgeons completed the survey, representing six continents. Continental variations were found in non-operative surgical decision making and postoperative/rehabilitative management. Significant differences were noted in nearly all clinical decision making categories.

CONCLUSION

Variations do exist across continents in the non-operative and postoperative/rehabilitative management of patients with an ACL tear. Continental variations and disparate emphases such as activity level, age during injury, and bracing influenced treatment decision making, which could lead to variations in outcomes, costs, and appropriate care.

A study of changes in the body composition components in the patients with pulmonary tuberculosis

The present study deals with the analysis of body composition components of 86 randomly selected patients with confirmed pulmonary tuberculosis aged 16- 70 years collected from the District Tuberculosis Centre and Hospital, Amritsar. An adequate number of controls were also taken for comparison. The findings of the present study showed highly significant differences (p < or = 0.001) in all the twelve kinanthropometric variables except height. When the data was further analyzed between sputum negative and sputum positive patients with pulmonary tuberculosis, highly significant differences (p < or = 0.001) were found only in total body fat and statistically significant differences (p < or = 0.05) were observed in weight, chest circumference in normal position, abdominal circumference, right calf and buttock circumferences. It may be concluded that TB patients were more malnourished than normal people. Thus, special nutritional care should be taken to the TB patients to give them a better quality of life.

Complex-shaped platinum coils for brain aneurysms: higher packing density, improved biomechanical stability, and midterm angiographic outcome

BACKGROUND AND PURPOSE

Five to 60% of coiled brain aneurysms recanalize, generally because of coil compaction. In vitro exclusive use of complex-shaped coils allows better packing of the aneurysmal sac and the neck as compared with helical coils. We report a single-center, prospective study using complex coils. Safety, packing density, and recanalization rate were evaluated.

MATERIALS AND METHODS

Seventy-seven aneurysms were embolized using complex coils alone. Aneurysms had a volume of 265 mm3 (diameter: 7.1+/-3.3 mm) and a neck size of 4.1+/-1.8 mm (range: 1.5-12 mm). Average follow-up available in 31 patients was 10.5+/-7.6 months (range: 3-36 months). Primary angiographic endpoints included aneurysmal recanalization and (re)rupture. Primary adverse events included stroke or death.

RESULTS

Complete or near-complete occlusion was achieved in all of the aneurysms but required balloon assistance in 24.6%. The packing density was computed as 37%+/-13%. No rerupture was observed during the follow-up interval. Recanalization was seen in 4 (12.9%) of 31. Two basilar tip aneurysms underwent a safe and complete recoiling. Periprocedural nondevice-related neurologic deficits were seen in 2 (2.9%) of 69 patients.

CONCLUSIONS

The use of complex-shaped coils allows higher packing density, which may improve the recanalization rate. Basilar tip aneurysms remain a challenge.

Cochlear Function in Chronic Kidney Disease and Renal Transplantation: A Longitudinal Study

Hearing loss on pure-tone and brainstem-evoked response audiometry is well documented in chronic kidney disease patients, but there are only scant data in renal allograft recipients. The aim of this study was to evaluate cochlear function on pure-tone and brainstem-evoked response audiometry among patients of chronic kidney disease to document changes after renal transplantation. The study included 20 healthy controls and 40 patients: 10 each at stage 3 and 4 and 20 with stage 5 chronic kidney disease. Patients with known causes for hearing loss were not included. Patients with stage 5 chronic kidney disease were reevaluated 1 year after renal transplantation. Compared with healthy controls, chronic kidney disease patients showed a highly significant bilateral sensorineural hearing loss at all frequencies of 0.25 to 8.0 kHz, which was more marked in higher frequencies. A highly significant delay in the latencies of waves I, III, and V and interpeak latencies of I to III and I to V was also noted on brainstem-evoked response audiometry. Compared with their pretransplant values, there was a significant improvement in the delay in absolute latencies of I, III, and V among renal allograft recipients. There was no correlation of audiometry findings with gender, degree of renal failure, and serum sodium. Hearing loss was seen in 70% of stage 3 and 4 chronic kidney disease and 60% in stage 5. The intensity of hearing loss was variable. In conclusion, chronic kidney disease patients shows definitive audiologic dysfunction with some improvement in hearing and wave latencies after successful renal transplantation.

Mitochondrial DNA analyses of Indian water buffalo support a distinct genetic origin of river and swamp buffalo

Water buffalo (Bubalus bubalis) is broadly classified into river and swamp categories, but it remains disputed whether these two types were independently domesticated, or if they are the result of a single domestication event. In this study, we sequenced the mitochondrial D-loop region and cytochrome b gene of 217 and 80 buffalo respectively from eight breeds/locations in northern, north-western, central and southern India and compared our results with published Mediterranean and swamp buffalo sequences. Using these data, river and swamp buffalo were distinguished into two distinct clades. Based upon the existing knowledge of cytogenetic, ecological and phenotypic parameters, molecular data and present-day distribution of the river and swamp buffalo, we suggest that these two types were domesticated independently, and that classification of the river and swamp buffalo as two related subspecies is more appropriate.

The impact of childhood body mass index on timing of puberty, adult stature and obesity: a follow-up study based on adolescent anthropometry recorded at Christ's Hospital (1936-1964)

OBJECTIVE

To examine the impact of childhood body mass index (BMI) on timing of puberty, adult stature and obesity.

DESIGN

A retrospective school-based cohort follow-up study.

SUBJECTS

A total of 1520 men born between 1927 and 1956 with serial height and weight measurements from the age of 9 to 18, followed up in adulthood at a mean age of 63 years.

MEASUREMENTS

Prepubertal (child) BMI; age at peak height velocity (APHV); adult leg length, waist and hip circumference (self-reported), and height and weight (measured).

RESULTS

Boys with a higher childhood BMI tended to have an earlier puberty (per s.d. increase in child BMI: -0.31 years, 95% confidence interval (CI): -0.23 to -0.39, P < 0.001). Childhood BMI correlated strongly and positively with adult adiposity, as measured by BMI (1.24 kg/m(2), 95% CI: 1.04-1.45, P < 0.001), waist (1.94 cm, 95% CI: 1.50-2.37, P < 0.001) and hip (1.91 cm, 95% CI: 1.55-2.28, P < 0.001). It correlated inversely with leg length (-0.40 cm, 95% CI: -0.68 to -0.12, P = 0.005), but not significantly with height or trunk length. Boys with a later puberty tended to be taller (per s.d. increase in APHV: 0.57 cm, 95% CI: 0.17-0.97, P = 0.006) and less adipose as adults (-0.55 kg/m(2), 95% CI: -0.33 to -0.77, P < 0.001).

CONCLUSION

The long-term consequences of childhood obesity into adulthood are well known, but the potential impact on early pubertal maturation is less well appreciated. The factors that contribute to the onset and persistence of childhood obesity require more public health focus.

Diabetic retinopathy before and after renal transplantation: a longitudinal study

Retinal evaluation was performed in 20 consecutive type 2 diabetics before and after renal transplantation. This included 19 men and 1 woman of mean age 52 years (range 30 to 60 years). Before renal transplantation, 95% of these patients showed diabetic retinopathy (50% nonproliferative and 45% proliferative diabetic retinopathy). There was no change in retinopathy at 3 months after renal transplantation. At 1 year, two patients (10%) showed deterioration in their diabetic retinopathy, while the remaining 90% did not show any change. Also 25% of renal allograft recipients developed posterior capsular cataracts.

In vivo comparison of suburethral sling materials

In vivo tissue responses were compared for three commercially available polypropylene suburethral slings that differ markedly in fabric structure and in size of resulting interstices and pores. All three elicited the same basic inflammatory response; however, individual fabric structures produced distinct differences in tissue formation within each mesh. The presence of numerous, closely spaced, small diameter filaments prevented formation of extensive fibrous connective tissue within two slings (ObTape and IVS Tunneller mesh). The much larger diameter monofilament and open knit structure of the Monarc sling permitted the most extensive fibrous tissue integration. These differences may be of interest to physicians considering clinical use.

Effects of Short-Term Training on Sensory and Motor Function in Severed Nerves of Long-Term Human Amputees

Much has been studied and written about plastic changes in the CNS of humans triggered by events such as limb amputation. However, little is known about the extent to which the original pathways retain residual function after peripheral amputation. Our earlier, acute study on long-term amputees indicated that central pathways associated with amputated peripheral nerves retain at least some sensory and motor function. The purpose of the present study was to determine if these functional connections would be strengthened or improved with experience and training over several days time. To do this, electrodes were implanted within fascicles of severed nerves of long-term human amputees to evaluate the changes in electrically evoked sensations and volitional motor neuron activity associated with attempted phantom limb movements. Nerve stimulation consistently resulted in discrete, unitary, graded sensations of touch/pressure and joint-position sense. There was no significant change in the values of stimulation parameters required to produce these sensations over time. Similarly, while the amputees were able to improve volitional control of motor neuron activity, the rate and pattern of change was similar to that seen with practice in normal individuals on motor tasks. We conclude that the central plasticity seen after amputation is most likely primarily due to unmasking, rather than replacement, of existing synaptic connections. These results also have implications for neural control of prosthetic limbs.

Sonographic evaluation of renal allograft

Sonography has become an integral part of the care of renal allograft recipients. It is a simple, inexpensive and readily available non-invasive imaging modality. It is indicated as the initial investigation in patients presenting with decreased urine output, pain, infection and hematuria and for doing a percutaneous allograft biopsy. While sonography confirms the diagnosis of obstructive nephropathy and perinephric fluid collections, Doppler is an effective screening modality for the detection of post-transplant vascular complications.

Smoking--a renal risk factor

Smoking has adverse effects on health, causing ischemic heart disease, stroke, chronic obstructive lung disease and cancers of the respiratory, gastrointestinal, pancreas, kidney and urinary tract. Smoking causes an acute increase in mean arterial pressure and heart rate. Chronic smoking reduces the renal plasma flow. There is clinical evidence that smoking has adverse effects on renal outcome in essential hypertension, diabetic nephropathy, primary glomerular diseases, systemic diseases involving the kidney and renal allograft recipients.

Isolation of human single chain antibodies (scFv) against human TNF-alpha from human peripheral blood lymphocyte-SCID mice

By developing an appropriate immunization protocol for SCID (hu-PBL-SCID) mice engrafted with human peripheral blood lymphocytes in combination with scFv phage display library, we were able to establish an efficient strategy to obtain human scFv clones against a human self-antigen, TNF-alpha. The mice pretreated with gamma-radiation (3Gy) and anti-asialo GM1 antibody were immunized with a mixture of human TNF-alpha-keyhole limpet hemocyanin and Freund's adjuvant. Human antibody maturation was suggested to be induced in the mice with the immunization protocol. The scFv clones obtained from the mice were shown to exhibit binding affinities in the range of 10(7)-10(8) M(-1). Together with our previously published work on the isolation of respiratory syncytial virus neutralizing scFvs, the results of this study have implicated that this combined approach is one of the effective alternatives for the cloning of human monoclonal antibodies specific for a wide range of antigens of interest.

Lipid profile before and after renal transplantation--a longitudinal study

BACKGROUND

The data on lipid profile in renal transplant recipients from the Indian subcontinent is scant.

METHODS

Lipid profile was studied in 30 consecutive patients of end stage renal disease before renal transplantation (0 month) and prospectively posttransplantation at 1, 3, and 6 months. The results were compared with 30, age and sex matched, healthy controls. All the patients received triple immunosuppression (prednisolone, azathioprine and cyclosporine).

RESULTS

Pretransplantation, the hypertriglyceridemia and hypercholesterolemia was present in 20% and 7% of the patients and the difference (elevation) in the mean values of various lipid fractions was not significant compared to healthy controls except a fall in HDL (p < .01). After renal transplantation, there was a significant elevation in the mean values of total cholesterol, triglycerides, VLDL, and LDL cholesterol at 1, 3, and 6 months. HDL cholesterol levels remained significantly lower as compared to healthy controls. Although, the mean values of serum triglycerides and cholesterol were significantly higher in diabetic end stage renal disease compared to nondiabetic ESRD, however there was insignificant difference in the lipid profile amongst diabetic and nondiabetic renal allograft recipients.

CONCLUSION

Our data shows distinct elevation in the lipids and lipoproteins after renal transplantation and immunosuppressive drugs seem to be the culprit.

Mutations of the UMOD gene are responsible for medullary cystic kidney disease 2 and familial juvenile hyperuricaemic nephropathy

INTRODUCTION

Medullary cystic kidney disease 2 (MCKD2) and familial juvenile hyperuricaemic nephropathy (FJHN) are both autosomal dominant renal diseases characterised by juvenile onset of hyperuricaemia, gout, and progressive renal failure. Clinical features of both conditions vary in presence and severity. Often definitive diagnosis is possible only after significant pathology has occurred. Genetic linkage studies have localised genes for both conditions to overlapping regions of chromosome 16p11-p13. These clinical and genetic findings suggest that these conditions may be allelic.

AIM

To identify the gene and associated mutation(s) responsible for FJHN and MCKD2.

METHODS

Two large, multigenerational families segregating FJHN were studied by genetic linkage and haplotype analyses to sublocalise the chromosome 16p FJHN gene locus. To permit refinement of the candidate interval and localisation of candidate genes, an integrated physical and genetic map of the candidate region was developed. DNA sequencing of candidate genes was performed to detect mutations in subjects affected with FJHN (three unrelated families) and MCKD2 (one family).

RESULTS

We identified four novel uromodulin (UMOD) gene mutations that segregate with the disease phenotype in three families with FJHN and in one family with MCKD2.

CONCLUSION

These data provide the first direct evidence that MCKD2 and FJHN arise from mutation of the UMOD gene and are allelic disorders. UMOD is a GPI anchored glycoprotein and the most abundant protein in normal urine. We postulate that mutation of UMOD disrupts the tertiary structure of UMOD and is responsible for the clinical changes of interstitial renal disease, polyuria, and hyperuricaemia found in MCKD2 and FJHN.

Amplified delivery of indium-111 to EGFR-positive human breast cancer cells

A method is described to amplify the delivery of 111In to human breast cancer cells utilizing a novel human serum albumin-human EGF (HSA-hEGF) bioconjugate substituted preferentially in the HSA domain with multiple DTPA metal chelators for 111In. 111In-DTPA-HSA-hEGF exhibited a lower receptor-binding affinity than 111In-DTPA-hEGF but was rapidly and specifically bound, internalized and translocated to the nucleus in EGFR-positive MDA-MB-468 breast cancer cells. 111In-DTPA-HSA-hEGF was cytotoxic in vitro mainly through the emission of short-range Auger electrons and partially through the effects of the hEGF moiety to MDA-MB-468 cells overexpressing EGFR (1-2 x 10(6) receptors/cell) but not towards MCF-7 breast cancer cells with a 100-fold lower level of EGFR on their surface. The cytotoxicity in vitro against MDA-MB-468 cells of 111In-DTPA-HSA-hEGF substituted with nine DTPA chelators was enhanced 4-fold compared to 111In-DTPA-hEGF monosubstituted with DTPA. Studies are planned to further evaluate 111In-DTPA-HSA-hEGF in vivo as a new imaging and targeted radiotherapeutic agent for breast cancer.

Anxiolytic actions of the substance P (NK1) receptor antagonist L-760735 and the 5-HT1A agonist 8-OH-DPAT in the social interaction test in gerbils

The gerbil social interaction test has previously detected anxiolytic effects of nicotine and diazepam. In the present study, the high affinity substance P (NK(1)) receptor antagonist L-760735 (3 mg/kg) significantly increased the time spent in social interaction, whereas its low affinity analogue L-781773 (3 mg/kg) was without effect. Diazepam (0.1 mg/kg) and the 5-HT(1A) receptor agonist 8-OH-DPAT (0.003 and 0.01 mg/kg) also increased social interaction, whereas an acute dose of the selective serotonin re-uptake inhibitor fluoxetine (10 mg/kg) decreased the time spent in social interaction. Diazepam (0.1 mg/kg) significantly increased locomotor activity, but this effect was independent of the increase in social interaction. The other drugs tested were without effect on locomotor activity. The present findings suggest that the gerbil social interaction may well provide a useful assay for detecting both anxiolytic and anxiogenic compounds, and suggests that the high affinity NK(1) receptor antagonist L-760735 may prove to be useful as an anxiolytic therapy.

Stem cell properties and repopulation of the rat liver by fetal liver epithelial progenitor cells

The potential of embryonal day (ED) 14 fetal liver epithelial progenitor (FLEP) cells from Fischer (F)344 rats to repopulate the normal and retrorsine-treated liver was studied throughout a 6-month period in syngeneic dipeptidyl peptidase IV (DPPIV-) mutant F344 rats. In normal liver, FLEP cells formed: 1) hepatocytic clusters ranging in size up to approximately 800 to 1000 cells; 2) bile duct structures connected to pre-existing host bile ducts; and 3) mixed clusters containing both hepatocytes and bile duct epithelial cells. Liver repopulation after 6 months was moderate (5 to 10%). In retrorsine-treated liver, transplanted cells formed large multilobular structures containing both parenchymal and bile duct cells and liver repopulation was extensive (60 to 80%). When the repopulating capacity of ED 14 FLEP cells transplanted into normal liver was compared to adult hepatocytes, three important differences were noted: 1) FLEP cells continued to proliferate at 6 months after transplantation, whereas adult hepatocytes ceased proliferation within the first month; 2) both the number and size of clusters derived from FLEP cells gradually increased throughout time but decreased throughout time with transplanted mature hepatocytes; and 3) FLEP cells differentiated into hepatocytes when engrafted into the liver parenchyma and into bile epithelial cells when engrafted in the vicinity of the host bile ducts, whereas adult hepatocytes did not form bile duct structures. Finally, after transplantation of ED 14 FLEP cells, new clusters of DPPIV+ cells appeared after 4 to 6 months, suggesting reseeding of the liver by transplanted cells. This study represents the first report with an isolated fetal liver epithelial cell fraction in which the cells exhibit properties of tissue-determined stem cells after their transplantation into normal adult liver; namely, bipotency and continued proliferation long after their transplantation.

In adolescence, female rats are more sensitive to the anxiolytic effect of nicotine than are male rats

Anxiety may play an important role in the onset of smoking, particularly in young girls. This study examined whether there were sex differences in the effects of nicotine on anxiety in adolescent rats and whether social isolation modified these effects. Male and female adolescent rats were housed in groups of the same sex or in social isolation for seven days prior to testing in the social interaction test of anxiety. Nicotine increased social interaction in both males and females, and because there was no concomitant change in locomotor activity, this indicated anxiolytic effects. However, there was a 5-fold sex difference in the lowest dose required to enhance social interaction, with an anxiolytic effect in females at 0.05 mg/kg, but in males only at 0.25mg/kg. Furthermore, in males the anxiolytic effect was seen only in socially isolated animals, whereas in the females it was present in both housing conditions. The depressant effect of nicotine on locomotor activity also depended on both the sex of the animal and on their housing conditions, with greater effects in singly housed animals and in males. This sex difference in sensitivity to nicotine's anxiolytic effects suggests there may be sex differences in the factors initiating and maintaining teenage smoking.

The mechanism of phenylephrine-mediated [Ca(2+)](i) oscillations underlying tonic contraction in the rabbit inferior vena cava

1. We characterized the mechanisms in vascular smooth muscle cells (VSMCs) that produce asynchronous, wave-like Ca(2+) oscillations in response to phenylephrine (PE). Confocal imaging was used to observe [Ca(2+)](i) in individual VSMCs of intact inferior vena cava (IVC) from rabbits. 2. It was found that the Ca(2+) waves were initiated by Ca(2+) release from the sarcoplasmic reticulum (SR) via inositol 1,4,5-trisphosphate-sensitive SR Ca(2+) release channels (IP(3)R channels) and that refilling of the SR Ca(2+) store through the sarcoplasmic-endoplasmic reticulum Ca(2+)-ATPase (SERCA) was required for maintained generation of the repetitive Ca(2+) waves. 3. Blockade of L-type voltage-gated Ca(2+) channels (L-type VGCCs) with nifedipine reduced the frequency of PE-stimulated [Ca(2+)](i) oscillations, while additional blockade of receptor-operated channels/store-operated channels (ROCs/SOCs) with SKF96365 abolished the remaining oscillations. Parallel force measurements showed that nifedipine inhibited PE-induced tonic contraction by 27 % while SKF96365 abolished it. This indicates that stimulated Ca(2+) entry refills the SR to support the recurrent waves of SR Ca(2+) release and that both L-type VGCCs and ROCs/SOCs contribute to this process. 4. Application of the Na(+)-Ca(2+) exchanger (NCX) inhibitors 2',4'-dichlorobenzamil (forward- and reverse-mode inhibitor) and KB-R7943 (reverse-mode inhibitor) completely abolished the nifedipine-resistant component of [Ca(2+)](i) oscillations and markedly reduced PE-induced tone. 5. Thus, we conclude that each Ca(2+) wave depends on initial SR Ca(2+) release via IP(3)R channels followed by SR Ca(2+) refilling through SERCA. Na(+) entry through ROCs/SOCs facilitates Ca(2+) entry through the NCX operating in the reverse mode, which refills the SR and maintains PE-induced [Ca(2+)](i) oscillations. In addition some Ca(2+) entry through L-type VGCCs and ROCs/SOCs serves to modulate the frequency of the oscillations and the magnitude of force development.

Purine nucleoside phosphorylase inhibitor BCX-1777 (Immucillin-H)--a novel potent and orally active immunosuppressive agent

Patients with purine nucleoside phosphorylase (PNP) deficiency present a selective T-cell immunodeficiency. Inhibitors of PNP are, therefore, of interest as potential T-cell selective immunosuppressive agents. BCX-1777 is a potent inhibitor of PNP from various species including human, mouse, rat, monkey and dog, with IC50 values ranging from 0.48 to 1.57 nM. BCX-1777, in the presence of 2'-deoxyguanosine (dGuo, 3-10 microM), inhibits human lymphocyte proliferation activated by various agents such as interleukin-2 (IL-2), mixed lymphocyte reaction (MLR) and phytohemagglutinin (PHA) (IC50 values < 0.1-0.38 microM). BCX-1777 is a 10-100-fold more potent inhibitor of human lymphocyte proliferation than other known PNP inhibitors like PD141955 and BCX-34. Nucleotide analysis of human lymphocytes indicate that inhibition of proliferation by BCX-1777 correlates with dGTP levels in the cells. BCX-1777 has excellent oral bioavailability (63%) in mice. At a single dose of 10 mg/kg in mice, BCX-1777 elevates dGuo to approximately 5 microM. BCX-1777 was not effective in mouse T-cell models such as delayed type hypersensitivity (DTH) and splenomegaly because mouse T-cells do not accumulate dGTP as do human T-cells. However, in the human peripheral blood lymphocyte severe combined immunodeficiency (hu-PBL-SCID) mouse model, BCX-1777 was effective in prolonging the life span 2-fold or more. This is the first known example of a PNP inhibitor that elevates dGuo in mice similar to the levels observed in PNP-deficient patients. Furthermore, these dGuo levels are also required for in vitro T-cell inhibition by BCX-1777. Thus, BCX-1777 represents a novel class of selective immunosuppressive agents that could have therapeutic utility in various T-cell disorders.