Morbidity associated with anterior iliac crest bone graft harvesting in children undergoing orthopaedic surgery: a prospective review

PURPOSE

Autologous iliac crest bone grafting is an integral part of many orthopaedic surgical procedures. Several studies have documented morbidity and prolonged pain following iliac crest bone graft harvesting in adults; however, in children there is a paucity of information. The purpose of the present study was to quantify the degree of pain and morbidity associated with anterior iliac crest graft harvesting in children undergoing non-spinal orthopaedic surgery.

METHODS

Patients were prospectively enrolled prior to orthopaedic surgery. A patient self-reported visual analogue score was used to record pain at specified time points following surgery. In addition, the patients were reviewed at 2 and 6 weeks, 3 months and 1 year after surgery to record any complications.

RESULTS

Data was collected on 33 patients (34 graft sites). Only one patient (2.94 %) had a complication, namely an injury to the lateral femoral cutaneous nerve. This resolved 3 months after surgery. 89 % of patients had no pain at the iliac crest graft harvest site 3 months after surgery. The three patients who had pain at 3 months had visual analogue scores of 1.0, 1.1 and 1.3, respectively.

CONCLUSION

This series reveals a very low complication rate and minimal iliac crest graft harvest site pain in children undergoing non-spinal orthopaedic surgery. In addition, the pain experienced is short-lived.

Social anxiety in orthognathic patients

There is evidence that patients seeking orthognathic treatment may be motivated by social anxiety disorder (SAD). The aim of this study was to investigate SAD in orthognathic patients using the Brief Fear of Negative Evaluation Scale (BFNES) and to compare these findings with those of the general population. This was a cross-sectional, questionnaire study conducted in two parts. Firstly, a national survey was conducted to yield data for the BFNES from a large, random sample of the UK general population. Secondly, orthognathic patients completed the BFNES. The BFNES scores are reported in two formats: the original 12-item scale (O-BFNES) and a shorter eight-item version (S-BFNES). With regards to the national survey, 1196 individuals participated. The mean O-BFNES score was 29.72 (standard deviation (SD) 9.39) and S-BFNES score was 15.59 (SD 7.67). With regards to the orthognathic sample, 61 patients participated. The mean O-BFNES score was 39.56 (SD 10.35) and the mean S-BFNES score was 24.21 (SD 8.41). Orthognathic patients had significantly higher scores than the general UK population (P<0.001), and multiple linear regression revealed that age, gender, and patient status were all independent predictors of BFNES scores. From the results of this study, orthognathic patients experience significantly higher levels of social anxiety than the general population.

Pharmacokinetic and Pharmacodynamic Comparison of Once-Daily Efavirenz (400 mg vs. 600 mg) in Treatment-Naïve HIV-Infected Patients: Results of the ENCORE1 Study

Daily efavirenz 400 mg (EFV400) was virologically noninferior to 600 mg (EFV600) at 48 weeks in treatment‐naïve patients. We evaluated EFV400 and EFV600 pharmacokinetics (NONMEM v. 7.2), assessing patient demographics and genetic polymorphisms (CYP2B6, CYP2A6, CYP3A4, NR1I3) as covariates and explored relationships with efficacy (plasma HIV‐RNA (pVL) <200 copies/mL) and safety outcomes at 48 weeks in 606 randomized ENCORE1 patients (female = 32%, African = 37%, Asian = 33%; EFV400 = 311, EFV600 = 295). CYP2B6 516G>T/983T>C/CYP2A6*9B/*17 and weight were associated with efavirenz CL/F. Exposure was significantly lower for EFV400 (geometric mean ratio, GMR; 90% confidence interval, CI: 0.73 (0.68–0.78)) but 97% (EFV400) and 98% (EFV600) of evaluable pVL was <200 copies/mL at 48 weeks (P = 0.802). Four of 20 patients with mid‐dose concentrations <1.0 mg/L had pVL ≥200 copies/mL (EFV400 = 1; EFV600 = 3). Efavirenz exposure was similar between those with and without efavirenz‐related side effects (GMR; 90% CI: 0.95 (0.88–1.02)). HIV suppression was comparable between doses despite significantly lower EFV400 exposure. Comprehensive evaluation of efavirenz pharmacokinetics/pharmacodynamics revealed important limitations in the accepted threshold concentration.

Incretin-based medications for type 2 diabetes: an overview of reviews

AIMS

To summarize evidence from and assess the quality of published systematic reviews evaluating the safety, efficacy and effectiveness of incretin-based medications used in the treatment of type 2 diabetes.

METHODS

We identified systematic reviews of randomized controlled trials or observational studies published in any language that evaluated the safety and/or effectiveness of glucagon-like peptide-1 (GLP-1) receptor agonists or dipeptidyl-peptidase-4 (DPP-4) inhibitors. Data sources used include the Cochrane Library, PubMed, EMBASE, Web of Science, International Pharmaceutical Abstracts, table of contents of diabetes journals, and hand-searching of reference lists and clinical practice guidelines. The methodological quality of systematic reviews was independently assessed by two reviewers using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist. Our study protocol was registered with PROSPERO (2013:CRD42013005149). The primary outcomes were pooled treatment effect estimates for glycaemic control, macrovascular and microvascular complications, and hypoglycaemic events.

RESULTS

We identified 467 unique citations of which 84 systematic reviews met our inclusion criteria. There were 51 reviews that evaluated GLP-1 receptor agonists and 64 reviews that evaluated DPP-4 inhibitors. The median (interquartile range) AMSTAR score was 6 (3) out of 11 for quantitative and 1 (1) for non-quantitative reviews. Among the 66 quantitative systematic reviews, there were a total of 718 pooled treatment effect estimates reported for our primary outcomes and 1012 reported pooled treatment effect estimates for secondary outcomes.

CONCLUSIONS

Clinicians and policy makers, when using the results of systematic reviews to inform decision-making with regard to round clinical care or healthcare policies for incretin-based medications, should consider the variability in quality of reviews.

Real-time oil-saturation monitoring in rock cores with low-field NMR

Nuclear magnetic resonance (NMR) provides a powerful suite of tools for studying oil in reservoir core plugs at the laboratory scale. Low-field magnets are preferred for well-log calibration and to minimize magnetic-susceptibility-induced internal gradients in the porous medium. We demonstrate that careful data processing, combined with prior knowledge of the sample properties, enables real-time acquisition and interpretation of saturation state (relative amount of oil and water in the pores of a rock). Robust discrimination of oil and brine is achieved with diffusion weighting. We use this real-time analysis to monitor the forced displacement of oil from porous materials (sintered glass beads and sandstones) and to generate capillary desaturation curves. The real-time output enables in situ modification of the flood protocol and accurate control of the saturation state prior to the acquisition of standard NMR core analysis data, such as diffusion-relaxation correlations. Although applications to oil recovery and core analysis are demonstrated, the implementation highlights the general practicality of low-field NMR as an inline sensor for real-time industrial process control.

A prolonged outbreak of invasive meningococcal disease in an extended Irish Traveller family across three Health Service Executive (HSE) areas in Ireland, 2010 to 2013

Between March 2010 and November 2013 eight laboratory-confirmed cases of serogroup B, invasive meningococcal disease (IMD) were identified in an extended Irish Traveller family across three Health Service Executive (HSE) areas of Ireland. Cases were aged between 5 and 46 months, and were either a cousin or sibling of another case. All eight cases survived. Chemoprophylaxis was given to relevant nuclear family members and close contacts on each occasion, but failed to prevent further cases. Neisseria meningitidis isolates from six cases were highly related, belonging to the ST-41/44 clonal complex, and shared the porA designation 7–2,4. In November 2013, the outbreak control team recommended that directly observed ciprofloxacin chemoprophylaxis be administered simultaneously to the extended family, and that the four component meningococcal B (4CMenB) vaccine be administered to family members aged 2 months to 23 years inclusive and relevant close contacts of the eighth case. Subsequently these recommendations were implemented at three regional clinics. Additionally pharyngeal swabs (n=112) were collected to assess carriage rates of N. meningitidis in this extended family. Pharyngeal carriage of N. meningitidis was detected in 15 (13%) family members. From the epidemiological investigation and carriage study overcrowding was the most likely risk factor identified in this outbreak. To date, the combination of directly observed ciprofloxacin chemoprophylaxis and use of 4CMenB vaccine have controlled the outbreak with no further cases diagnosed.

Cost effectiveness of total hip arthroplasty in osteoarthritis

Many different designs of total hip arthroplasty (THA) with varying performance and cost are available. The identification of those which are the most cost-effective could allow significant cost-savings. We used an established Markov model to examine the cost effectiveness of five frequently used categories of THA which differed according to bearing surface and mode of fixation, using data from the National Joint Registry for England and Wales. Kaplan–Meier analyses of rates of revision for men and women were modelled with parametric distributions. Costs of devices were provided by the NHS Supply Chain and associated costs were taken from existing studies. Lifetime costs, lifetime quality-adjusted-life-years (QALYs) and the probability of a device being cost effective at a willingness to pay £20 000/QALY were included in the models.

The differences in QALYs between different categories of implant were extremely small (<  0.0039 QALYs for men or women over the patient’s lifetime) and differences in cost were also marginal (£2500 to £3000 in the same time period). As a result, the probability of any particular device being the most cost effective was very sensitive to small, plausible changes in quality of life estimates and cost.

Our results suggest that available evidence does not support recommending a particular device on cost effectiveness grounds alone. We would recommend that the choice of prosthesis should be determined by the rate of revision, local costs and the preferences of the surgeon and patient.

Cite this article: Bone Joint J 2015;97-B:449–57.

Abstract 381: Characterizing the role of heterochromatin protein 1 gamma in normal intestinal homeostasis and tumorigenesis

Background: Epigenetic modifications are being increasingly recognized to contribute to colorectal cancer formation. Heterochromatin Protein 1 gamma (HP1gamma) has an important role in carcinogenesis and tumorigenesis by regulating several mechanisms, such as heterochromatin formation, gene silencing and DNA replication and repair. The aim of this study was to characterize the role of HP1gamma in normal intestinal homeostasis, tumorigenesis and cancer progression.

Methods: The Cbx3 gene (encoding the HP1gamma protein) was conditionally deleted in the murine small intestinal epithelium under normal intestinal homeostasis and in the context of aberrant Wnt signaling using transgenic mouse models. Furthermore, the effect of CBX3 depletion on Wnt activation was investigated using an in vitro system.

Results: The level of Cbx3 was significantly up-regulated in small intestinal cancer tissues of mouse models, consistent with our preliminary observations that CBX3 was highly expressed in tumor samples of colorectal cancer patients compared to matched normal tissues. We found a dramatic increase in the lifespan of our colorectal cancer mouse model following the loss of Cbx3. Both in vivo and in vitro studies demonstrated that depletion of Cbx3 leads to decreased transcription of a subset of Wnt target genes and Wnt signaling activity, respectively. Furthermore, marked epigenetic alternations were observed in association patterns of HP1gamma and the heterochromatin markers (H3K9me2, H3K9me3 and H4K20me3) in wild-type and mouse model of colorectal cancer.

Conclusions: HP1gamma may play direct or indirect roles in regulating Wnt target gene expression by binding H3K9me3 or H4K20me3 and altering heterochromatin formation. These data provide stepping stones for further investigation of the mechanistic role of HP1gamma in normal intestinal homeostasis, tumor initiation and progression.

Citation Format: Ka Ian Lio, Alan Clarke, Karen Reed. Characterizing the role of heterochromatin protein 1 gamma in normal intestinal homeostasis and tumorigenesis. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 381. doi:10.1158/1538-7445.AM2014-381