Hypofibrinolytic Activity after Total Joint Replacement

Tissue-type plasminogen activator (t-PA), tissue-type plasminogen activator inhibitor (t-PAI), and other factors (platelets, fibrinogen, fibrinogen degrada tion products, antithrombin-III, plasminogen, and α2-plasmin inhibitor [α2-PI]) related to the fibrinolytic system were studied in 21 patients undergoing total joint replacement.

Seventeen of the 21 patients revealed an impaired fibrinolytic activity from the first to seventh postoperative day and a subsequent return to the preopera tive level by the fourteenth postoperative day. There were accompanying increases in the level of α2-PI and in the t-PAI/t-PA ratio, and there was decrease in plas minogen level. Such hypofibrinolytic states may be related to a higher incidence of postoperative thrombosis in total joint replacement patients.

Direct Detection of Pure ac Spin Current by X-Ray Pump-Probe Measurements

Despite recent progress in spin-current research, the detection of spin current has mostly remained indirect. By synchronizing a microwave waveform with synchrotron x-ray pulses, we use the ferromagnetic resonance of the Py (Ni_{81}Fe_{19}) layer in a Py/Cu/Cu_{75}Mn_{25}/Cu/Co multilayer to pump a pure ac spin current into the Cu_{75}Mn_{25} and Co layers, and then directly probe the spin current within the Cu_{75}Mn_{25} layer and the spin dynamics of the Co layer by x-ray magnetic circular dichroism. This element-resolved pump-probe measurement unambiguously identifies the ac spin current in the Cu_{75}Mn_{25} layer.

Inulin significantly improves serum magnesium levels in proton pump inhibitor-induced hypomagnesaemia

BACKGROUND

Proton pump inhibitors (PPI) are among the most widely prescribed drugs to treat gastric acid-related disorders. PPI-induced hypomagnesaemia, a defect in intestinal absorption of Mg(2+) , can be a severe side effect of chronic PPI use.

AIM

To restore serum Mg(2+) concentrations in PPI-induced hypomagnesaemia patients by dietary supplementation with inulin fibres.

METHODS

Eleven patients with PPI-induced hypomagnesaemia and 10 controls were treated with inulin (20 g/day). Each trial consisted of two cycles of 14-day inulin treatment followed by a washout period of 14 days. Patients continued to use their PPI. Serum Mg(2+) levels served as the primary endpoint.

RESULTS

Inulin significantly enhanced serum Mg(2+) levels from 0.60 to 0.68 mmol/L in PPI-induced hypomagnesaemia patients, and from 0.84 to 0.93 mmol/L in controls. As a consequence 24 h urinary Mg(2+) excretion was significantly increased in patients with PPI-induced hypomagnesaemia (0.3-2.2 mmol/day). Symptoms related to hypomagnesaemia, including muscle cramps and paraesthesia, were reduced during intervention with inulin.

CONCLUSION

Inulin increases serum Mg(2+) concentrations under PPI maintenance in patients with PPI-induced hypomagnesaemia.

Civilian blast-related burn injuries

There is limited English literature describing the experience of a civilian hospital managing blast-related burn injuries. As the largest regional burn unit, we reviewed our cases with the aim of identifying means to improve current management. A 6-year retrospective analysis of all patients coded as sustaining blast-related burns was conducted through the unit's burns database. Medical case notes were reviewed for information on burn demographics, management and outcomes. 42 patients were identified. Male to female ratio was 37:5. Age range was 12-84 years, (mean=33 years). Total body surface area (%TBSA) burn ranged from 0.25% to 60%, (median=1%). The most common burn injury was flame (31/42, 73.8%). Gas explosions were the most common mechanism of injury (19 cases; 45.2%). 7/42 cases (16.7%) had full ATLS management pre-transfer to the burns unit. The Injury Severity Score (ISS) ranged from 0-43 (median=2). 17/42 (40.4%) patients required admission. 37/36 (88.1%) patients were managed conservatively of which 1 patient later required surgery due to deeper burns. 5/42 (11.9%) patients required surgical management at presentation and these were noted to be burns with >15% TBSA requiring resuscitation. One case required emergency escharotomies and finger amputations. All patients survived their burn injuries. Blast-related burn injuries are generally uncommon in the civilian setting. Following proper assessment, most of these cases can be deemed as minor injuries and managed conservatively. Improvement in burns management education and training at local emergency departments would provide efficient patient care and avoid unnecessary referrals to a burns unit.

Novel BRAF and KRAS Mutations in Papillary Thyroid Carcinoma Arising in Struma Ovarii

Papillary carcinomas of thyroid type rarely arise within struma ovarii. There are limited data on the immunohistochemical and molecular features of these tumors. Three cases of papillary carcinoma arising in struma ovarii (PCSO) were identified. The clinicopathological features were reviewed and immunohistochemical staining for HBME-1, cytokeratin (CK) 19, and CD56 was performed. Tumor DNA was sequenced for somatic mutations using a panel of 26 oncogenes, with a particular focus on BRAF and KRAS mutations. The patients were aged 22, 48, and 55 years. All cases were FIGO stage IA. Two tumors were of classical histological type, and one was a follicular variant papillary carcinoma. All tumors expressed HBME-1 and two were positive for CK19. CD56 was negative in all three cases. One tumor demonstrated a BRAF G469A mutation in exon 11, and in a second case, a KRAS Q61K double base mutation in exon 3 was detected. These mutations have not been described previously in PCSO. No mutations were detected in the benign follicular components of the tumors adjacent to the malignant papillary tissue. None of the patients had tumor recurrence on clinical follow-up (range 11 months to 8½ years). HBME-1, CK19, and CD56 are useful immunohistochemical markers of PCSO. Novel BRAF and KRAS mutations were identified in two of three tumors suggesting that mutations in PCSO may differ from those commonly identified in papillary carcinoma of the eutopic thyroid. The clinical significance of these mutations is uncertain but follow-up data in this small series support the generally good prognosis of PCSO.

Durability of giant hiatus hernia repair in 455 patients over 20 years

INTRODUCTION

The surgical management of symptomatic giant hiatus hernia (GHH) aims to improve quality of life (QoL) and reduce the risk of life threatening complications. Previous reports are predominantly those with small sample sizes and short follow-up periods. The present study sought to assess a large cohort of patients for recurrence and QoL over a longer time period.

METHODS

This was a follow-up study of a prospectively collected database of 455 consecutive patients. Primary repair of GHH was evaluated by endoscopy/barium meal for recurrence and a standardised symptom questionnaire for QoL. Recurrence was assessed for size, elapsed time, oesophagitis and symptoms.

RESULTS

Objective and subjective review was achieved in 91.9% and 68.6% of patients. The median age was 69 years (range: 15-93 years) and 64% were female. Laparoscopic repair was completed in 95% (mesh in 6% and Collis gastroplasty in 7%). The 30-day mortality rate was 0.9%. The proportion of patients alive at five and ten years were 90% and 75% respectively. Postoperative QoL scores improved from a mean of 95 to 111 (p<0.01) and were stable over time (112 at 10 years). The overall recurrence rate was 35.6% (149/418) at 42 months; this was 11.5% (48/418) for hernias >2cm and 24.2% (101/418) for <2cm. The rate of new recurrence at 0-1 years was 13.7% (>2cm = 3.4%, <2cm = 10.3%), at 1-5 years it was 30.8% (>2cm = 9.5%, <2cm = 21.3%), at 5-10 years it was 40.1% (>2cm = 13.8%, <2cm = 26.3%) and at over 10 years it was 50.0% (>2cm = 25.0%, <2cm = 25.0%). Recurrence was associated with oesophagitis but not decreased QoL. Revision surgery was required in 4.8% of cases (14.8% with recurrence). There were no interval major GHH complications.

CONCLUSIONS

Surgery has provided sustained QoL improvements irrespective of recurrence. Recurrence occurred progressively over ten years and may predispose to oesophagitis.

Self-inflicted Burns: 10 year review and comparison to national guidelines

INTRODUCTION

There is an increasing trend of self-inflicted burns noted in the literature, often seen in patients with complex psychosocial backgrounds. These patients are challenging to manage as the recovery from the acute burn may be compounded by difficult rehabilitation and suboptimal coping strategies. We aimed to review patients presenting to our burns unit with self-inflicted burns, the management strategies and examine the complexities surrounding their management. We assessed patient outcomes with a particular interest in psychosocial support given.

METHODS

A retrospective review of all patients presenting with self-inflicted burns over a 10 year period (2005-2014 inclusive) was conducted. Patients were identified through IBID database coded as either 'self-inflicted' or 'suicidal.' We reviewed patient and burn demographics, the clinical management, psychosocial management and patient outcomes such as wound healing, re-admission rates, and survival.

RESULTS

We identified 118 self-inflicted burns in total. 50/118 (42%) were admitted. 64 (54%) were male and the total body surface burn area ranged from <0.5% to 99% with a median of 14%. 60/118 (51%) had TBSA <10% and 58/118 (49%) had TBSA >10%. 24 (48%) underwent admission to the Burn Intensive Care Unit (BITU). All patients admitted to BITU had TBSA >10%. Of those admitted to BITU 6 were palliative, 18 had full resuscitation and surgical management. Of those 18 patients who had active treatment, 10/18 (56%) died. Mean total length of stay was 31 days, range 1-130 days. 9% of patients sustained injuries whilst being a current inpatient at a psychiatric institution. Of all patients reviewed, 16% (n=19) had a previous history of deliberate self-harm through burns. Of those patients admitted, 98% of were reviewed by the mental health team during their admission with time to psychological review varying depending on fitness for assessment. The overall mean length of stay for all admitted patients who were actively treated but who subsequently died was 53 days. 84% of admitted patients were managed surgically.

CONCLUSION

Self-inflicted burns patients would benefit from a more complex pathway of treatment as their management aims to achieve not only physical health but also psychological health. They would benefit from enhanced care to manage the acute burn but also psychiatric support to ensure patients do not re-offend.

Endpoint comparison for bone mineral density measurements in North Central Cancer Treatment Group cancer clinical trials N02C1 and N03CC (Alliance)

Bone mineral density (BMD) measurement can vary depending upon anatomical site, machine, and normative values used. This analysis compared different BMD endpoints in two clinical trials. Trial results differed across endpoints. Future clinical trials should consider inclusion of multiple endpoints in sensitivity analysis to ensure sound overall study conclusions.

INTRODUCTION

Methodological issues hamper efficacy assessment of osteoporosis prevention agents in cancer survivors. Osteoporosis diagnosis can vary depending upon which bone mineral density (BMD) anatomical site and machine is used and which set of normative values are applied. This analysis compared different endpoints for osteoporosis treatment efficacy assessment in two clinical studies.

METHODS

Data from North Central Cancer Treatment Group phase III clinical trials N02C1 and N03CC (Alliance) were employed involving 774 patients each comparing two treatments for osteoporosis prevention. Endpoints for three anatomical sites included raw BMD score (RawBMD); raw machine-based, sample-standardized, and reference population-standardized T scores (RawT, TSamp, TRef); and standard normal percentile corresponding to the reference population-standardized T score (TPerc). For each, treatment arm comparison was carried out using three statistical tests using change and percentage change from baseline (CB, %CB) at 1 year.

RESULTS

Baseline correlations among endpoints ranged from 0.79 to 1.00. RawBMD and TPerc produced more statistically significant results (14 and 19 each out of 36 tests) compared to RawT (11/36), TSamp (8/36), and TRef (7/36). Spine produced the most statistically significant results (26/60) relative to femoral neck (20/60) and total hip (13/60). Lastly, CB resulted in 44 statistically significant results out of 90 tests, whereas %CB resulted in only 15 significant results.

CONCLUSIONS

Treatment comparisons and interpretations were different across endpoints and anatomical sites. Transforming via sample statistics provided similar results as transforming via reference or machine-based norms. However, RawBMD and TPerc may be more sensitive to change as clinical trial endpoints.

Tailoring the magnetic anisotropy of Py/Ni bilayer films using well aligned atomic steps on Cu(001)

Tailoring the spin orientation at the atomic scale has been a key task in spintronics technology. While controlling the out-of-plane to in-plane spin orientation has been achieved by a precise control of the perpendicular magnetic anisotropy at atomic layer thickness level, a design and control of the in-plane magnetic anisotropy has not yet been well developed. On well aligned atomic steps of a 6° vicinal Cu(001) surface with steps parallel to the [110] axis, we grow Py/Ni overlayer films epitaxially to permit a systematic exploration of the step-induced in-plane magnetic anisotropy as a function of both the Py and the Ni film thicknesses. We found that the atomic steps from the vicinal Cu(001) induce an in-plane uniaxial magnetic anisotropy that favors both Py and Ni magnetizations perpendicular to the steps, opposite to the behavior of Co on vicinal Cu(001). In addition, thickness-dependent study shows that the Ni films exhibit different magnetic anisotropy below and above ~6 ML Ni thickness.

Targeted assessment of fracture risk in women at midlife

This study establishes a profile for women at midlife, referred for a dual energy X-ray absorptiometry (DXA), most likely to have osteoporosis, and from this, a pre-DXA screening tool has been developed. These findings inform much needed evidence-based guidelines for targeted and effective screening for osteoporosis and osteoporotic fracture prevention in women at midlife.

INTRODUCTION

There is no consensus as to whether women at midlife should undergo screening dual energy X-ray absorptiometry (DXA) to identify osteoporosis (T-score < -2.5).

METHODS

We investigated the prevalence of osteoporosis in women, aged 40-65 years, referred to 42 community-based Australian radiology centres, and identified the characteristics that best predict osteoporosis in women having a screening DXA.

RESULTS

One thousand four hundred and two women completed the study questionnaire and had DXA reports available. After excluding women with an established indication for a DXA (58 %), users of bone-specific medication (10.5 %) and cancer (7.6 %), 466 women were classified as having a screening DXA. Forty of these women had osteoporosis at the lumbar spine (n = 32, 6.9 %) or femoral neck (n = 17, 3.6 %). Three predictors of osteoporosis (postmenopausal, nonuse of hormonal therapy and body mass index) were identified and incorporated into the Monash Osteoporosis Risk Score for women at midlife (MORS). In the screened study population, the MORS had a sensitivity of 70 % and specificity of 66 %, with a positive predictive value of 16.2 % and negative predictive value of 95.9 % for osteoporosis.

CONCLUSIONS

Very few women referred for a screening DXA scan will be found to have osteoporosis. The MORS, a simple decision tool, would have identified 70 % of the women in our screening DXA study population and would have eliminated over 60 % of the screening DXA studies. Hence, use of the MORS may reduce unnecessary DXA scans and facilitate identification of the majority of cases of osteoporosis in women aged 40 to 65 years.

Transgenic characterization of two testis-specific promoters in the silkworm, Bombyx mori

Sex-specific regulatory elements are key components for developing insect genetic sexing systems. The current insect genetic sexing system mainly uses a female-specific modification system whereas little success was reported on male-specific genetic modification. In the silkworm Bombyx mori, a lepidopteran model insect with economic importance, a transgene-based, female-specific lethality system has been established based on sex-specific alternative splicing factors and a female-specific promoter BmVgp (vitellogenin promoter) has been identified. However, no male-specific regulatory elements have yet been identified. Here we report the transgenic identification of two promoters that drive reporter gene expression in a testis-specific manner in B. mori. Putative promoter sequences from the B. mori Radial spoke head 1 gene (BmR1) and beta-tubulin 4 gene (Bmβ4) were introduced using piggybac-based germline transformation. In transgenic silkworms, expression of the reporter gene enhanced green fluorescent protein (EGFP) directed by either BmR1 promoter (BmR1p) or Bmβ4p showed precisely testis-specific manners from the larval to adult stage. Furthermore, EGFP expression of these two transgenic lines showed different localization in the testis, indicating that BmR1p or Bmβ4p might be used as distinct regulatory elements in directing testis-specific gene expression. Identification of these testis-specific promoters not only contributes to a better understanding of testis-specific gene function in insects, but also has potential applications in sterile insect techniques for pest management.

Severe ascites as the primary symptom of fulminant postpartum HELLP syndrome: a case report

Previous studies show that HELLP syndrome occurring in postpartum period was more dangerous to both fetus and the mother than if presented before delivery. So far, there is a lack of screening or predictive tests for postpartum HELLP syndrome in clinical practice.

CASE

Here the authors report a rare case of postpartum HELLP syndrome with severe ascites as the primary symptom. The patient was diagnosed with severe preeclampsia and fetal growth retardation at 34+2 weeks gestation and received anti-hypertensive therapy. Severe ascites were found intraoperatively during emergency caesarean section. On the second postoperative day, complete HELLP syndrome was diagnosed. This case gradually complicated by hypoproteinemia, acute renal failure, severe anaemia, and infection and required renal haemodialysis, blood transfusion, and other supportive treatments for about one month.

CONCLUSION

Although this case has a fulminant and long course, it has a well clinical prognosis and also shows that severe ascites may be a clue for postpartum HELLP syndrome in patient with severe preeclampsia.

Paget's disease of bone

Paget's disease of bone is a common disorder characterized by increased but disorganized bone remodelling. Some patients are asymptomatic but others present with bone pain or other complications such as fracture and deformity. Major advances have been made in understanding the pathophysiology of Paget's disease in recent years and highly effective agents are now available with which to suppress the abnormal bone turnover that causes the disease. Here we review recent advances in the epidemiology, pathogenesis, clinical features and management of Paget's disease. We also reflect upon the future challenges that remain to be overcome to explain the unusual distribution of the disease and to favourably alter the natural history and prevent the development of complications.

Chirality switching and winding or unwinding of the antiferromagnetic NiO domain walls in Fe/NiO/Fe/CoO/Ag(001)

Fe/NiO/Fe/CoO/Ag(001) single crystalline films were grown epitaxially and investigated by x-ray magnetic circular dichroism and x-ray magnetic linear dichroism. The bottom Fe layer magnetization is pinned through exchange coupling to the CoO layer and the top Fe layer magnetization can be rotated by an in-plane external magnetic field. We find that the NiO spins wind up to form a domain wall due to the perpendicular NiO/Fe interfacial coupling as the top layer Fe magnetization rotates from 0° to 90°, but switch wall chirality and unwind the wall as the Fe magnetization rotates from 90° to 180°. This observation shows that Mauri's 180° domain wall does not exist in perpendicularly coupled ferromagnetic-antiferromagnetic systems in the strong coupling regime.