Tralokinumab for moderate-to-severe atopic dermatitis: results from two 52-week, randomized, double-blind, multicentre, placebo-controlled phase III trials (ECZTRA 1 and ECZTRA 2)

Background

Tralokinumab, a fully human monoclonal antibody, specifically neutralizes interleukin‐13, a key cytokine driving peripheral inflammation in atopic dermatitis (AD). In phase II studies, tralokinumab combined with topical corticosteroids provided early and sustained improvements in AD signs and symptoms.

Objectives

To evaluate the efficacy and safety of tralokinumab monotherapy in adults with moderate‐to‐severe AD who had an inadequate response to topical treatments.

Methods

In two 52‐week, randomized, double‐blind, placebo‐controlled, phase III trials, ECZTRA 1 and ECZTRA 2, adults with moderate‐to‐severe AD were randomized (3 : 1) to subcutaneous tralokinumab 300 mg every 2 weeks (Q2W) or placebo. Primary endpoints were Investigator’s Global Assessment (IGA) score of 0 or 1 at week 16 and ≥ 75% improvement in Eczema Area and Severity Index (EASI 75) at week 16. Patients achieving an IGA score of 0 or 1 and/or EASI 75 with tralokinumab at week 16 were rerandomized to tralokinumab Q2W or every 4 weeks or placebo, for 36 weeks. The trials were registered with ClinicalTrials.gov: NCT03131648 and NCT03160885.

Results

At week 16, more patients who received tralokinumab vs. placebo achieved an IGA score of 0 or 1: 15·8% vs. 7·1% in ECZTRA 1 [difference 8·6%, 95% confidence interval (CI) 4·1–13·1; P = 0·002] and 22·2% vs. 10·9% in ECZTRA 2 (11·1%, 95% CI 5·8–16·4; P < 0·001) and EASI 75: 25·0% vs. 12·7% (12·1%, 95% CI 6·5–17·7; P < 0·001) and 33·2% vs. 11·4% (21·6%, 95% CI 15·8–27·3; P < 0·001). Early improvements in pruritus, sleep interference, Dermatology Life Quality Index, SCORing Atopic Dermatitis and Patient‐Oriented Eczema Measure were observed from the first postbaseline measurements. The majority of week 16 tralokinumab responders maintained response at week 52 with continued tralokinumab treatment without any rescue medication (including topical corticosteroids). Adverse events were reported in 76·4% and 61·5% of patients receiving tralokinumab in ECZTRA 1 and ECZTRA 2, respectively, and in 77·0% and 66·0% of patients receiving placebo in ECZTRA 1 and ECZTRA 2, respectively, in the 16‐week initial period.

Conclusions

Tralokinumab monotherapy was superior to placebo at 16 weeks of treatment and was well tolerated up to 52 weeks of treatment.

What is already known about this topic?

Atopic dermatitis (AD) is a chronic interleukin (IL)‐13‐mediated disease.

There is a need for safe and effective long‐term treatment options for AD.

Tralokinumab is a fully human monoclonal antibody that binds specifically to IL‐13 with high affinity, thereby preventing receptor interaction and subsequent downstream signalling.

Tralokinumab combined with topical corticosteroids showed early and sustained efficacy and safety in a 12‐week, phase IIb trial in moderate‐to‐severe AD.

What does this study add?

These are the first pivotal phase III trials demonstrating that by specifically targeting IL‐13 alone, patients can achieve significant improvements in AD signs and symptoms and quality of life, and maintain these improvements over time without the requirement for topical corticosteroids.

These trials provide evidence that tralokinumab offers a long‐term, well‐tolerated treatment option for patients with moderate‐to‐severe AD.

Linked Comment: Morra and Drucker. Br J Dermatol 2021; 184:386–387.

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Fibronectin and fibrinogen contribute to the enhanced binding of Staphylococcus aureus to atopic skin

BACKGROUND

Staphylococcus aureus colonizes the skin lesions of more than 90% of patients with atopic dermatitis (AD). The mechanism for increased S aureus colonization in AD is unknown. However, the initial event in colonization requires adherence of S aureus to the skin.

OBJECTIVE

The purpose of this study was to examine the roles of various bacterial adhesins on S aureus binding to AD skin.

METHODS

In an attempt to delineate the mechanism behind this adherence process, an in vitro bacterial binding assay was developed to quantitate the adherence of various S aureus strains to AD, psoriatic, and normal skin sections. S aureus strains used in this study were obtained either from cultures of AD skin lesions or from genetically manipulated strains of S aureus that lacked specific microbial surface components recognizing adhesive matrix molecules (MSCRAMMs)--namely, fibronectin-binding protein (Fnbp), fibrinogen-binding protein (Clf), collagen-binding protein (Cna), and their parent strains. In addition, S aureus strains from patients with AD were pretreated with fibronectin or fibrinogen to block MSCRAMM receptors and interfere with binding.

RESULTS

Under all experimental conditions, binding of S aureus was localized primarily to the stratum corneum. Immunocytochemical staining of AD skin sections showed a redistribution of fibronectin to the cornified layer, an observation not seen in normal skin. S aureus binding to uninvolved AD skin was significantly greater than the binding to uninvolved psoriatic skin (P <.0001) and normal skin (P <.0005). The Fnbp-negative S aureus showed a significant reduction in binding to the AD skin (P <.0001) but not to the psoriatic and normal skin. In the AD skin, a significant reduction in the binding of S aureus was also observed in the Clf-negative strain (P <.0001) but not in the Cna-negative S aureus. Preincubation of S aureus with either fibronectin or fibrinogen also inhibited bacterial binding to AD skin (P <.0001).

CONCLUSION

These data suggest that fibronectin and fibrinogen--but not collagen--play a major role in the enhanced binding of S aureus to the skin of patients with AD.

Gender differences in three dimensional gait analysis data from 98 healthy Korean adults

OBJECTIVES

The research hypothesis was that healthy adults would walk differently according to their gender when walked barefoot at their comfortable speed. The aim of this study was to prove the hypothesis in healthy Korean adults.

DESIGN

Between-gender statistical comparisons of the gait analysis data including spatiotemporal, three-dimensional joint kinematic and kinetic data.

BACKGROUND

There have been few attempts to identify the significant gender differences in gait pattern and to explore their possible causes.

METHODS

Healthy 98 Korean adults (47 females and 51 males) volunteered. Gait analysis data was obtained with opto-electric system and force plates. Normalization was used to avoid the body size effect. Gender difference was tested with independent t-test, ancova, and two-way repeated anova.

RESULTS

Females were shorter, both in height and leg length ( P < 0.05 ). The cadence and pelvic width were as great as in males. They walked slower than males due to shorter stride length ( P < 0.05 ). The females had still shorter stride length and narrower step width ( P < 0.05 ), and they walked as fast as the males. Females walked with their pelvis tilted more anteriorly and more up and down oblique motion, hip joints more flexed-adducted-internally rotated, knee joint in more valgus angles ( P = 0.05 ).

CONCLUSIONS

The gait analysis data had significant gender differences. We assume that the difference is due to gender features of the gait-related anatomy and habits. Comparison with other research shows some evidence for racial differences.

Electrogenerated Chemiluminescence from Tris(2,2‘-bipyridyl)ruthenium(II) Immobilized in Titania−Perfluorosulfonated Ionomer Composite Films

Electrochemical behavior and electrogenerated chemiluminescence (ECL) of tris(2,2'-bipyridyl)ruthenium(II) (Ru(bpy)3(2+)) immobilized in sol-gel-derived titania TiO2)-Nafion composite films coated on a glassy carbon electrode have been investigated. The electroactivity of Ru(bpy)3(2+) ion exchanged into the composite films and its ECL behavior were strongly dependent upon the amount of Nafion incorporated into the TiO2-Nafion composite films. The ECL sensor of Ru(bpy)32+ immobilized in a TiO2-Nafion composite with 50% Nafion content showed the maximum ECL intensities for both tripropylamine (TPA) and sodium oxalate in 0.05 M phosphate buffer solution at pH 7. Detection limits were 0.1 microM for TPA and 1.0 microM for oxalate (S/N = 3) with a linear range of 3 orders of magnitude in concentration. The present ECL sensor showed improved ECL sensitivity and long-term stability, as compared to the ECL sensors based on pure Nafion films. The present Ru(bpy)3(2+) ECL sensor based on TiO2-Nafion (50%) composite films was applied as an HPLC detector for the determination of erythromycin in human urine samples. The present Ru(bpy)3(2+) ECL sensor was stable in the mobile phase containing a high content of organic solvent (30%, v/v), in contrast to a pure Nafion-based Ru(bpy)3(2+) ECL sensor. The detection limit for erythromycin was 1.0 microM, with a linear range of 3 orders of magnitude in concentration.

Role of ABA and ABI3 in desiccation tolerance

We show in bryophytes that abscisic acid (ABA) pretreatment of moss (Physcomitrella patens) cells confers desiccation tolerance. In angiosperms, both ABA and the transcriptional regulator ABSCISIC ACID INSENSITIVE 3 (ABI3) are required to protect the seed during desiccation. ABA was not able to protect moss cells in stable deletion lines of ABI3 (DeltaPpabi3). Hence, moss has the same functional link between ABA, ABI3, and the desiccation tolerance phenotype that is found in angiosperms. Furthermore, we identified 22 genes that were induced during ABA pretreatment in wild-type lines. When their expression was compared with that of DeltaPpabi3 during ABA pretreatment and immediately after desiccation, a new target of ABI3 action appears to be in the recovery period.

Preferential binding of Staphylococcus aureus to skin sites of Th2-mediated inflammation in a murine model

Staphylococcus aureus is found on over 90% of atopic dermatitis skin lesions and is thought to contribute to skin inflammation via the production of potent exotoxins. In contrast, less than 5% of normal subjects harbor S. aureus. This suggests that an atopic immune response itself may play a role in preferential binding of S. aureus to the skin. To examine this issue more directly, we analyzed the S. aureus binding characteristics of skin in mice undergoing different T helper type 1 cell versus T helper type 2 cell inflammatory responses using a novel in vitro bacterial binding assay. BALB/C female mice were first sensitized to ovalbumin with alum or ovalbumin with complete Freund's adjuvant to induce T helper type 2 or T helper type 1 responses, respectively. Mice were then challenged intradermally with either saline (control) or ovalbumin. Forty-eight hours later, skin specimens were obtained from the challenge sites, and the number of S. aureus binding to each skin section was quantitated. Bacterial binding was found to be significantly greater at skin sites of BALB/C mice that had been ovalbumin/alum sensitized compared with ovalbumin/complete Freund's adjuvant sensitized (p < or = 0.01). When compared to the ovalbumin sensitized/challenged skin of wild type BALB/C mice or interferon-gamma gene knockout mice, interleukin-4, but not interferon-gamma, gene knockout mice had significantly less S. aureus binding at their ovalbumin sensitized/challenged skin sites. Mutant S. aureus strains that lacked either fibronectin- or fibrinogen-binding protein expression showed significantly reduced S. aureus binding compared with the parent wild type strain (p < 0.005). Moreover, preincubation of the wild type bacteria with fibronectin or fibrinogen, but not collagen, resulted in significantly less skin binding of S. aureus (p < 0.01). Incubation of skin with interleukin-4, and less so with interferon-gamma, led to more binding of wild type S. aureus but not of an S. aureus mutant deficient in fibronectin binding protein expression. After interleukin-4 incubation, but not interferon-gamma, epidermal immunoreactivity for fibronectin was observed in murine skin explants. These results show that a T helper type 2 inflammatory environment can promote skin binding by S. aureus and that this binding is mediated by fibronectin and fibrinogen.

Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty

Twenty-two patients with infected total hip arthroplasty were treated with 2-stage arthroplasty, using a cement spacer impregnated with a combination of 3 thermostable antibiotics (vancomycin, gentamicin, and cefotaxime). Initially, implants were removed, and a spacer was inserted. Six to 12 weeks later, the spacer was removed, and the patients underwent reconstruction using cementless components. The patients were followed for an average of 41 months. One patient had a recurrence of infection and was treated with resection arthroplasty. The remaining 21 patients (95%) had no evidence of infection at the final follow-up. We recommend using the combination of these 3 antibiotics in the cement spacer for 2-stage reconstruction in infected hip arthroplasty when the causative organism is not identified in the culture of preoperative aspiration.

Tibial bone defects treated by internal bone transport using the Ilizarov method

We reviewed 27 cases of tibial bone defects treated by internal bone transport using the Ilizarov method. The causes of the bone defects were open fractures in 14 segments and infected non-unions in 13. The average length of the defects was 8.3 cm (range, 3-20 cm). There were 21 one-level tibial transports, 3 two-level tibial transports, 1 one-level tibial transport with fibular transport, and 2 fibular transports. At the docking site, 25 segments underwent bone grafting. Eleven of the 25 were Papineau-type open cancellous bone grafts. Acute shortening or docking was performed in 10 segments. Bone union was obtained in every instance. The average time of external fixation was 8 months and the average time to union was 7.1 months. Bone grafting at the docking site is recommended in order to shorten the duration of treatment and to prevent refracture and non-union.

Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images

PURPOSE

To determine whether the marrow edema around focal osteonecrosis on magnetic resonance (MR) images is associated with clinical symptoms.

MATERIALS AND METHODS

Thirty-three patients with 37 hips showing early stage osteonecrosis of the femoral head were followed up at 3-month intervals with clinical evaluation, conventional radiography, and serial MR imaging.

RESULTS

Seven (50%) of 14 symptomatic hips showed marrow edema around focal osteonecrosis on initial MR images, whereas only one (4%) of 23 asymptomatic hips showed edema (P < .01). Six (86%) of seven hips that were moderately to severely painful were associated with surrounding marrow edema. All eight hips showing osteonecrosis with marrow edema at the initial MR examination had joint effusion and exhibited intense radionuclide uptake in the proximal femur, which corresponded to the extent of edema on MR images. In all eight hips, the marrow edema resolved on follow-up MR images, and the pain subsided with the resolution of edema.

CONCLUSION

The results of this study suggest that the combination of marrow edema of the proximal femur and focal osteonecrosis of the femoral head are strongly associated with hip pain in early stage osteonecrosis, even prior to collapse. Pain improvement usually parallels the resolution of edema.

Production of plasminogen activator inhibitor-1 by human mast cells and its possible role in asthma

The plasminogen activator inhibitor type 1 (PAI-1) has an essential role in tissue remodeling. The PAI-1 gene was induced by a combination of phorbol ester and calcium ionophore at the highest level among the inducible human mast cell genes that we have analyzed on a DNA microarray. PAI-1 was secreted by both a human mast cell line (HMC)-1 and primary cultured human mast cells upon stimulation, whereas PAI-1 was undetectable in either group of unstimulated cells. The secretion of PAI-1 was due to de novo synthesis of PAI-1 rather than secretion of preformed PAI-1. The functional significance of PAI-1 secretion was demonstrated by complete inhibition of tissue-type plasminogen activator activity with supernatants of stimulated HMC-1 cells. Furthermore, we were able to regulate PAI-1 gene expression in HMC-1 cells by known therapeutic agents. High-dose (1 microM) dexamethasone induced PAI-1 mRNA expression. Cyclosporin down-regulated the expression of the PAI-1 gene. Cycloheximide abrogated PAI-1 mRNA expression, suggesting that transcription of the PAI-1 gene requires de novo synthesis of early gene products, including transcription factors. Finally, we demonstrated PAI-1 in lung mast cells from a patient with asthmatic attack by double-immunofluorescence study. This is the first report demonstrating that activated human mast cells release a striking amount of functionally active PAI-1. These results suggest that PAI-1 could play an important role in airway remodeling of asthma, and inhibition of PAI-1 activity could represent a novel therapeutic approach in the management of airway remodeling.

Primary total hip arthroplasty with a cementless porous-coated anatomic total hip prosthesis: 10- to 12-year results of prospective and consecutive series

We performed a prospective study in 108 consecutive patients (116 hips) who were followed for a minimum of 10 years (10-12 years) after primary total hip arthroplasty using an uncemented porous-coated anatomic (PCA) hip prosthesis. The average age of the patients at operation was 48.4 years (range, 19-85 years), and the diagnosis was avascular necrosis of the femoral head in 46 hips, neglected femoral neck fracture in 27, osteoarthrosis secondary to childhood pyogenic arthritis in 24, childhood tuberculous arthritis in 5, and miscellaneous in 14. The average preoperative Harris Hip Score was 55 points, which improved to 87 points at 11 years. Seventy-five hips (65%) were excellent, 11 (9%) were good, and 30 (39%) were poor. The overall rate of revision was 15% (17 of 116 hips). The rate of revision of the femoral component was 11% (13 of 116 hips), and the rate of revision of the acetabular component was 15% (17 of 116 hips). The prevalence of thigh pain was 28% at 11 years. The increase in the incidence of aseptic loosening of the femoral component was found to explain the high incidence of severe thigh pain at 11 years' follow-up. At 11 years, there was femoral osteolysis in 69 hips (59%) and acetabular osteolysis in 65 hips (56%). At 6 years, 20 hips (17%) showed definite wear of the polyethylene liner. At 11 years, 81 hips (70%) showed definite wear of the polyethylene liner. Because the complication rate of the PCA hip prosthesis with respect to loosening, osteolysis, and excessive wear in the polyethylene liner is high, we abandoned the use of this implant.

The vascular manifestations of Behçet's disease: angiographic and CT findings

The purpose was to evaluate angiographic and CT manifestations of vascular Behçet's disease. The medical records of 64 patients with Behçet's disease, treated in our hospital during the last 4 years, were reviewed. 37 patients underwent angiography or CT in the symptomatic regions because of symptoms or clinical signs of vascular involvement by Behçet's disease. 33 (male:female ratio 28:5; mean age 35 years) of the 37 patients demonstrated vascular involvement, which was surgically proven (18 patients) or diagnosed on angiography (15 patients). Angiograms and CT images of these 33 patients were retrospectively analysed for lesion type, location, extent and other characteristic findings of vascular involvement. 12 patients had only venous lesions, 11 had only arterial lesions and 10 had both arterial and venous lesions. The major angiographic findings of vascular Behçet's disease were acute or chronic thrombosis in deep veins of the lower extremities (19 patients), in the inferior vena cava (4 patients) and in the superior vena cava (2 patients), pseudoaneurysms of large or medium sized arteries (11 patients), and occlusions/ stenoses of distal run-off arteries (13 patients). Common CT findings were obliterated deep veins (8 patients) and non-calcified thickened aneurysmal walls (9 patients), with or without contrast enhancement. The combination of these angiographic and CT findings with clinical manifestations are helpful in distinguishing vascular Behçet's disease from other vasculitides.

Effects of ambient air pollution on daily mortality in a cohort of patients with congestive heart failure

This study was planned to test the hypothesis that patients with congestive heart failure are more susceptible to the harmful effects of ambient air pollution than the general population. We used both general additive Poisson regression and the case-crossover approach to test the hypothesis. The effect of air pollution on daily mortality of patients with congestive heart failure among residents of Seoul, South Korea, during the period 1994--1998 was compared with that of the general population in the same area and the same period. The odds ratios and 95% confidence intervals (95% CIs) estimated from general additive models in the general population for an interquartile range increase of particulate matter less than 10 microm in diameter (42.1 microg/m(3)), carbon monoxide (0.59 ppm), nitrogen dioxide (14.6 ppb), sulfur dioxide (9.9 ppb), and ozone (20.5 ppb) were 1.014 (95% CI = 1.006- 1.022), 1.022 (95% CI = 1.017- 1.029), 1.021 (95% CI = 1.014- 1.029), 1.020 (95% CI = 1.012--1.028), and 1.010 (95% CI = 1.002--1.017), respectively. The estimated effects appeared larger among the congestive heart failure patients than among the general population (2.5 approximately 4.1 times higher depending on the pollutants). The results from the case-crossover analysis were similar. The finding of a stronger association in the patients with congestive heart failure reinforces the evidence that a harmful effect of air pollution is mediated by cardiovascular mechanisms.

High prevalence of current asthma and active smoking effect among the elderly

BACKGROUND

Although asthma is a common cause of morbidity in adults, relatively few objectively measured population studies of asthma prevalence in adult populations have been conducted.

OBJECTIVE

To evaluate the prevalence of asthma, based on both a questionnaire and methacholine bronchial provocation test, and to determine the risk factors of asthma prevalence in an adult population.

METHODS

A total of 2,467 adults, who were randomly selected from metropolitan urban, non-metropolitan urban and rural areas, responded to the modified ISAAC questionnaire, and underwent methacholine bronchial provocation tests and skin prick tests to locally common aeroallergens.

RESULTS

The prevalence of current asthma based on the questionnaire and the methacholine challenge was 2.0% in adults younger than 40, 3.8% in 40- to 54-year-olds, 7.7% in 55- to 64-year-olds and 12.7% in those aged 65 or higher. For subjects of 55-64 years, active smoking was found to be significantly related with the prevalence of current asthma and bronchial hyper-responsiveness, although smoking was positively associated with percentage predictive value of forced expiratory volume of 1 s (FEV1).

CONCLUSION

The prevalence of current asthma is common among the elderly, and active smoking may play an important role in the development of asthma and bronchial hyper-responsiveness among the elderly.

Urinary 1-hydroxypyrene and 2-naphthol concentrations in male Koreans

OBJECTIVE

Urinary 1-hydroxypyrene (1-OHP) has been used as a biological marker of exposure to polycyclic aromatic hydrocarbons (PAHs), and urinary 2-naphthol is suggested as a new marker for route-specific exposure to airborne PAHs. We analyzed urinary 1-OHP and 2-naphthol concentrations in 292 male Koreans (129 university students and 163 shipyard workers) to define the distribution pattern in Koreans with no or low occupational exposure to PAHs.

METHOD

Histories of cigarette smoking and the eating of PAH-containing foods were obtained by a self-administered structured questionnaire. Urine samples were collected and urinary 1-OHP and 2-naphthol concentrations were measured using high-performance liquid chromatography (HPLC).

RESULTS

The arithmetic (geometric) means of urinary 1-OHP and 2-naphthol concentrations for all students, expressed as micromoles per mole of creatinine, were 0.04 (0.04) and 3.12 (2.22), for non-smokers 0.03 (0.03) and 1.78 (1.30) and for smokers 0.05 (0.03) and 4.36 (3.62), respectively. Among shipyard workers, the arithmetic (geometric) means of urinary 1-OHP and 2-naphthol concentrations were 0.69 (0.31) and 4.37 (2.62) for all, 0.27 (0.18) and 2.46 (1.16) for nonsmokers, and 0.97 (0.44) and 5.60 (4.44) for smokers, respectively. Mean urinary 1-OHP and 2-naphthol concentrations differed significantly between nonsmokers and smokers both in students and in shipyard workers. In smokers, some variables related to smoking habit were positively correlated with urinary 1-OHP and with 2-naphthol concentrations. The latter showed better correlations with the variables related to smoking amount than the former. None of the food-related factors was significantly correlated with urinary 1-OHP or 2-naphthol concentration.

CONCLUSION

These results suggest that urinary 2-naphthol concentration is more sensitively affected by smoking status than urinary 1-OHP concentration and that urinary 2-naphthol is a sensitive marker for low-level inhalation of PAHs.

Echocardiographic and morphologic characteristics of left atrial myxoma and their relation to systemic embolism

We examined the relation between the echocardiographic morphology of cardiac myxoma and systemic embolism in 25 patients. Two distinct types of myxoma could be identified by echocardiography: round type characterized by solid and round shape with nonmobile surface (n = 13, 52%), and polypoid type characterized by soft and irregular shape with mobile surface (n = 12, 48%); multiple regression analysis revealed the polypoid type of tumor was the only independent predictor of systemic embolism (p = 0.0029).

Missed rib fractures on evaluation of initial chest CT for trauma patients: pattern analysis and diagnostic value of coronal multiplanar reconstruction images with multidetector row CT

OBJECTIVE

The objective of this study was to review the prevalence and radiological features of rib fractures missed on initial chest CT evaluation, and to examine the diagnostic value of additional coronal images in a large series of trauma patients.

METHODS

130 patients who presented to an emergency room for blunt chest trauma underwent multidetector row CT of the thorax within the first hour during their stay, and had follow-up CT or bone scans as diagnostic gold standards. Images were evaluated on two separate occasions: once with axial images and once with both axial and coronal images. The detection rates of missed rib fractures were compared between readings using a non-parametric method of clustered data. In the cases of missed rib fractures, the shapes, locations and associated fractures were evaluated.

RESULTS

58 rib fractures were missed with axial images only and 52 were missed with both axial and coronal images (p=0.088). The most common shape of missed rib fractures was buckled (56.9%), and the anterior arc (55.2%) was most commonly involved. 21 (36.2%) missed rib fractures had combined fractures on the same ribs, and 38 (65.5%) were accompanied by fracture on neighbouring ribs.

CONCLUSION

Missed rib fractures are not uncommon, and radiologists should be familiar with buckle fractures, which are frequently missed. Additional coronal imagescan be helpful in the diagnosis of rib fractures that are not seen on axial images.

The Drosophila gene Medea demonstrates the requirement for different classes of Smads in dpp signaling

Signals from transforming growth factor-beta (TGF-beta) ligands are transmitted within the cell by members of the Smad family, which can be grouped into three classes based on sequence similarities. Our previous identification of both class I and II Smads functioning in a single pathway in C. elegans, raised the issue of whether the requirement for Smads derived from different classes is a general feature of TGF-beta signaling. We report here the identification of a new Drosophila class II Smad, Medea, a close homolog of the human tumor-suppressor gene DPC4. Embryos from germline clones of both Medea and Mad (a class I Smad) are ventralized, as are embryos null for the TGF-beta-like ligand decapentaplegic (dpp). Loss of Medea also blocks dpp signaling during later development, suggesting that Medea, like Mad, is universally required for dpp signaling. Furthermore, we show that the necessity for these two closely related, non-redundant Smads, is due to their different signaling properties - upon activation of the Dpp pathway, Mad is required to actively translocate Medea into the nucleus. These results provide a paradigm for, and distinguish between, the requirement for class I and II Smads in Dpp/BMP signaling.

Drainage versus nondrainage in simultaneous bilateral total hip arthroplasties

A prospective study of 48 patients (96 hips) who had undergone primary simultaneous bilateral total hip arthroplasty was conducted to assess the effect of postoperative suction drainage on wound healing and infection. A suction drain was placed by randomization of the drained versus undrained side. The same surgical technique was used in all total hip arthroplasty wounds. Statistical analysis of the results showed significant differences with respect to drainage from the wound, soaked dressings requiring reinforcements, ecchymosis, and erythema about the wound in the group without drainage. There was no specific correlation between the incidence of wound complications and infection after total hip arthroplasty and the use or nonuse of closed-suction drainage. The hip score and range of motion of the hip were unaffected by the use or nonuse of the drains. The cost of 1 set of hemovac drains is $135 and the cost for 4-5 dressings and bed sheet changes is about $50. Although the hemovac is more expensive, the authors recommend the routine use of suction drains for wounds after primary total hip arthroplasty to reduce drainage, soaked dressings requiring reinforcement, ecchymosis and erythema around the wound, and psychological impact on the patient's fear of bleeding.

Compound K, a metabolite of ginseng saponin, induces apoptosis via caspase-8-dependent pathway in HL-60 human leukemia cells

BACKGROUND

Compound K [20-O-beta-(D-glucopyranosyl)-20(S)-protopanaxadiol], a metabolite of the protopanaxadiol-type saponins of Panax ginseng C.A. Meyer, has been reported to possess anti-tumor properties to inhibit angiogenesis and to induce tumor apoptosis. In the present study, we investigated the effect of Compound K on apoptosis and explored the underlying mechanisms involved in HL-60 human leukemia cells.

METHODS

We examined the effect of Compound K on the viabilities of various cancer cell lines using MTT assays. DAPI assay, Annexin V and PI double staining, Western blot assay and immunoprecipitation were used to determine the effect of Compound K on the induction of apoptosis.

RESULTS

Compound K was found to inhibit the viability of HL-60 cells in a dose- and time-dependent manner with an IC50 of 14 muM. Moreover, this cell death had typical features of apoptosis, that is, DNA fragmentation, DNA ladder formation, and the externalization of Annexin V targeted phosphatidylserine residues in HL-60 cells. In addition, compound-K induced a series of intracellular events associated with both the mitochondrial- and death receptor-dependent apoptotic pathways, namely, (1) the activation of caspases-3, -8, and -9; (2) the loss of mitochondrial membrane potential; (3) the release of cytochrome c and Smac/DIABLO to the cytosol; (4) the translocation of Bid and Bax to mitochondria; and (5) the downregulations of Bcl-2 and Bcl-xL. Furthermore, a caspase-8 inhibitor completely abolished caspase-3 activation, Bid cleavage, and subsequent DNA fragmentation by Compound K. Interestingly, the activation of caspase-3 and -8 and DNA fragmentation were significantly prevented in the presence of cycloheximide, suggesting that Compound K-induced apoptosis is dependent on de novo protein synthesis.

CONCLUSIONS

The results indicate that caspase-8 plays a key role in Compound K-stimulated apoptosis via the activation of caspase-3 directly or indirectly through Bid cleavage, cytochrome c release, and caspase-9 activation.

Two-year survival: preoperative adjuvant chemotherapy in the treatment of cervical cancer stages Ib and II with bulky tumor

The effect of preoperative adjuvant chemotherapy on the 2-year survival rate of patients with locally advanced cervical cancer (stages Ib and II with bulky tumour) was evaluated. The 54 patients first received initial chemotherapy of vinblastine, bleomycin, and cis-platinum in a combined regimen (VBP) and then radical hysterectomy. The overall histologic response rate to chemotherapy of the primary tumor confirmed in the surgical specimen was 81% including microscopic or no evidence of disease (41%, Grade III or IV). A lower than expected incidence of lymph node metastasis (20%) was found. All nodal metastasis was noted in patients with Grades I or II (P = 0.0034). Median follow-up was 36 months (range 26-60 months). Three recurrences (6%) appeared and those patients died of the disease within 24 months. Thus the 2-year tumour-free survival rate was 94%. The patients who had positive nodes more often experienced recurrence (27 vs 0%) and a lower 2-year survival rate (72 vs 100%) (P = 0.0067). All of these recurrences were found in patients with three or more positive nodes. This preliminary study suggest that preoperative adjuvant chemotherapy (VBP) is effective (1) in reducing tumour volume or the stage of the disease, (2) in curing the lymph node involvement, and (3) in improving the 2-year tumour-free survival rate. A prospective randomized study comparing radical surgery alone with preoperative adjuvant chemotherapy followed by radical surgery is in progress.

Lavender oil inhibits immediate-type allergic reaction in mice and rats

We studied the effects of lavender oil on mast cell-mediated immediate-type allergic reactions in mice and rats. Lavender oil (1:500, 1:100, 1:10, 1:1, 1:0) inhibited concentration-dependently mast cell-dependent ear swelling response induced by compound 48/80 in mice by both topical and intradermal application. Lavender oil (1:500, 1:100, 1:10, 1:1, 1:0) inhibited concentration-dependently passive cutaneous anaphylaxis induced by anti-dinitrophenyl (DNP) IgE in rats by both topical and intradermal application. Lavender oil (1:500, 1:100, 1:10, 1:1, 1:0) also inhibited concentration-dependently the histamine release from the peritoneal mast cells by compound 48/80 or anti-DNP IgE. Moreover, lavender oil (1:1000, 1:100, 1:10, 1:0) had a significant inhibitory effect on anti-DNP IgE-induced tumour necrosis factor-alpha secretion from peritoneal mast cells. These results indicate that lavender oil inhibits immediate-type allergic reactions by inhibition of mast cell degranulation in-vivo and in-vitro.

A comparison of polyethylene wear in hips with cobalt-chrome or zirconia heads. A prospective, randomised study

We have reviewed 70 patients with bilateral simultaneous total hip arthroplasties to determine the rate of failure and to compare polyethylene wear and osteolysis between an implant with a cobalt-chrome head and Hylamer liner with that of a zirconia head and Hylamer liner. The mean thickness of the polyethylene liner was 11.0 mm (8.8 to 12.2) in the hip with a zirconia head and 10.7 mm (8.8 to 12.2) in that with a cobalt-chrome head. At follow-up at 6.4 years no acetabular or femoral component had been revised for aseptic loosening and no acetabular or femoral component was loose according to radiological criteria in both the cemented and cementless groups. The mean rate of linear wear and annual wear rate were highest in the 22 mm zirconia femoral head (1.25 mm (SD 1.05) and 0.21 mm (SD 0.18), respectively) and lowest in the 22 mm cobalt-chrome femoral head (0.70 mm (SD 0.39) and 0.12 mm (SD 0.07), respectively). The mean volumetric wear was highest in the 28 mm zirconia femoral head (730.79 mm ) and lowest in the 22 mm cobalt-chrome femoral head (264.67 mm3), but if the results were compared by size of the femoral head and type of material there was no statistical difference (p > 0.05). Sequential measurements of annual wear showed that the zirconia femoral head had a relatively higher rate of penetration than the cobalt-chrome head over the first three years; thereafter the rate of wear was reduced and compared favourably with that of cobalt-chrome heads. There was a statistically significant relationship between the wear of the polyethylene liner and the age of the patient, male gender and the degree of abduction angle of the cup, but not diagnosis, weight, hip score, range of movement, or amount of anteversion. Osteolysis was identified on both sides of the acetabulum in six patients (9%). Of 12 hips with acetabular osteolysis, six had a 28 mm cobalt-chrome femoral head and the remaining six a 28 mm zirconia head. Osteolysis was observed in zones 1A and 7A of the femur in two hips (3%) with a 28 mm zirconia head (cemented hip) and in four (6%) with a 28 mm cobalt-chrome femoral head (cementless hip). Our findings suggest that although the performance of a zirconia femoral head with a Hylamer liner was not statistically different from that of a cobalt-chrome femoral head and Hylamer liner, there was a trend for the zirconia head to be worse than the cobalt-chrome femoral head.

Bone-protecting effect of safflower seeds in ovariectomized rats

Safflower (Carthamus tinctorius L.) seeds have long been clinically used in Korea to promote bone formation and prevent osteoporosis. However, the beneficial effect has not been scientifically evaluated. Thus, in the present study we investigated whether phytoestrogen rich safflower seeds reduce bone loss in ovariectomized rats. Female Sprague-Dawley rats were subjected to bilateral ovariectomy or sham surgery. One week after the operation, ovariectomized rats were either fed a diet containing defatted safflower seeds or injected with 17b-estradiol (E2) for 4 weeks. As expected, ovariectomy resulted in a dramatic reduction in trabecular bone mass of the proximal tibia, increase in deposition of marrow fat, and in uterine atrophy. E2 treatment almost completely prevented bone loss as well as marrow adiposity, as examined by scanning electron microscopy and histomorphometry. Safflower seeds partially prevented ovariectomy-induced bone loss and slightly reduced marrow adiposity. Safflower seeds, in contrast to E2, exerted very weak uterotrophic action. In an attempt to elucidate the underlying mechanisms, effect of polyphenolic compounds extracted from safflower seeds on proliferation of osteoblast-like cells was also assessed in vitro. The mixed polyphenolic compounds stimulated growth of ROS 17/2.8 osteoblast-like cells in a dose-dependent manner (5-100 mg/ml), as potently as E2 and genistein. The present data provide the first direct in vivo evidence that safflower seeds have a protecting effect on bone loss caused by estrogen deficiency, without substantial effect on the uterus. The beneficial effect of safflower seeds may be mediated, at least in part, by the stimulating effect of polyphenolic compounds on proliferation of osteoblasts.

Sub-two-cycle pulses from a Kerr-lens mode-locked Ti:sapphire laser

Pulses shorter than two optical cycles with bandwidths in excess of 400 nm have been generated from a Kerr-lens mode-locked Ti:sapphire laser with a repetition rate of 90 MHz and an average power of 200 mW. Low-dispersion prisms and double-chirped mirrors provide broadband controlled dispersion and high reflectivity. These pulse durations are to our knowledge the shortest ever generated directly from a laser oscillator.