A multicenter trial of selegiline transdermal system for HIV-associated cognitive impairment

BACKGROUND

Cognitive impairment continues to be a significant neurologic complication of HIV infection and has been associated with oxidative stress-induced neuronal injury. Selegiline is an MAO-B inhibitor with antioxidant and neurotrophic properties. This rationale has led to the design and implementation of this Selegiline Transdermal System (STS) study with the primary aims of assessing safety and tolerability of STS as well as improvement in cognitive performance.

METHODS

HIV-1 infected individuals with impaired cognitive functioning were enrolled in this placebo-controlled, three-arm study of STS across 17 sites. Cognitive impairment was determined using a standard battery of neuropsychological tests. Subjects were randomized to receive STS 3 mg/24 hours, STS 6 mg/24 hours, or matching placebo patches daily. The primary efficacy endpoint was defined as the change in neuropsychological composite Z-score (NPZ-6) from baseline to week 24. Measures of safety included frequencies of adverse experiences and abnormal results on laboratory tests.

RESULTS

A total of 128 subjects (88% men, 51% white) were enrolled, median age 45 years. Most subjects (62%) had mild to moderate AIDS dementia complex. The 24-week NPZ-6 median (interquartile range) changes were 0.22 (-0.28, 0.55) for the selegiline 3 mg/24 hours arm, 0.21 (-0.18, 0.62) for the selegiline 6 mg/24 hours arm, and 0.28 (-0.16, 0.64) for the placebo arm (a positive score indicates improvement from baseline) (p = 0.914). Severe laboratory abnormalities were few and occurred in similar proportion among the three treatment arms.

CONCLUSION

Selegiline was safe and well tolerated by HIV-infected individuals with cognitive impairment and mild to moderate immune suppression; however, no cognitive or functional improvement was observed in this phase II study.

Alpha decay of 109I and its implications for the proton decay of 105Sb and the astrophysical rapid proton-capture process

An alpha-decay branch of (1.4+/-0.4) x 10(-4) has been discovered in the decay of 109I, which predominantly decays via proton emission. The measured Q(alpha) value of 3918+/-21 keV allows the indirect determination of the Q value for proton emission from 105Sb of 356+/-22 keV, which is approximately of 130 keV more bound than previously reported. This result is relevant for the astrophysical rapid proton-capture process, which would terminate in the 105Sn(p,gamma)106Sb(p,gamma)107Te(alpha decay)103Sn cycle at the densities expected in explosive hydrogen burning scenarios, unless unusually strong pairing effects result in a 103Sn(p,gamma)104Sb(p,gamma)105Te(alpha decay)101Sn) cycle.

A comparison of two different approaches for mapping potential ozone damage to vegetation. A model study

Two very different types of approaches are currently in use today for indicating risk of ozone damage to vegetation in Europe. One approach is the so-called AOTX (accumulated exposure over threshold of Xppb) index, which is based upon ozone concentrations only. The second type of approach entails an estimate of the amount of ozone entering via the stomates of vegetation, the AFstY approach (accumulated stomatal flux over threshold of Y nmol m(-2) s(-1)). The EMEP chemical transport model is used to map these different indicators of ozone damage across Europe, for two illustrative vegetation types, wheat and beech forests. The results show that exceedences of critical levels for either type of indicator are widespread, but that the indicators give very different spatial patterns across Europe. Model simulations for year 2020 scenarios suggest reductions in risks of vegetation damage whichever indicator is used, but suggest that AOT40 is much more sensitive to emission control than AFstY values.

Robustness of modelled ozone exposures and doses

This study evaluates the robustness of the AOTX and AF(st)Y indices for assessing the ozone-induced risk to vegetation. These indices represent the accumulated concentration and stomatal flux, respectively, above a threshold value. The robustness is expressed as the sensitivity to changes in inputs and the uncertainty due to input errors. The input data are taken from a regional-scale chemical transport model. Both indices show increasing sensitivity with increasing threshold values. The sensitivity depends on the threshold and the characteristics of the frequency distribution for concentrations and stomatal fluxes. AF(st)Y appears less sensitive than AOTX for the thresholds adopted for critical levels. The couplings between concentration gradients and deposition algorithms complicate the assessment of the total uncertainty. For AF(st)Y, the uncertainty due to the modelled stomatal conductance may sometimes increase, but sometimes decrease, the overall uncertainty significantly. In particular, the maximum stomatal conductance plays an important role in determining the uncertainty.

Acute sporting injuries to the hand and wrist in the general population

We report the incidence of acute sporting injuries to the hand and wrist in the general population that required management in the Orthopaedic department. During a four month period, we prospectively identified all sports related injuries, which were referred for continued management in the Orthopaedic department. Eight hundred and fifty-one sports injuries were identified. Of them 400 (47%) were to the hand and wrist. There were 304 (76%) males and 96 (24%) females with an average age of 24.6 years and 26.5 years respectively. Injuries comprised of 286 (71%) fractures, 88 (22%) soft tissue injuries, 16 (4%) dislocations and 10 (3%) miscellaneous injuries. Twenty-eight (7%) patients required hospital admission. Thirty-seven different sporting activities were identified, with most injuries occurring in popular, physically demanding sports, such as football and rugby. Approximately half of all sporting injuries sustained by the general population are to the hand or wrist. In the majority of cases outpatient management was sufficient.

Limb alignment in computer-assisted minimally-invasive unicompartmental knee replacement

Twenty patients underwent simultaneous bilateral medial unicompartmental knee arthroplasty. Pre-operative hip-knee-ankle alignment and valgus stress radiographs were used to plan the desired post-operative alignment of the limb in accordance with established principles for unicompartmental arthroplasty. In each patient the planned alignment was the same for both knees. Overall, the mean planned post-operative alignment was to 2.3° of varus (0° to 5°).

The side and starting order of surgery were randomised, using conventional instrumentation for one knee and computer-assisted surgery for the opposite side.

The mean variation between the pre-operative plan and the achieved correction in the navigated and the non-navigated limb was 0.9° (sd 1.1; 0° to 4°) and 2.8° (sd 1.4; 1° to 7°), respectively. Using the Wilcoxon signed rank test, we found the difference in variation statistically significant (p < 0.001).

Assessment of lower limb alignment in the non-navigated group revealed that 12 (60%) were within ± 2° of the pre-operative plan, compared to 17 (87%) of the navigated cases.

Computer-assisted surgery significantly improves the post-operative alignment of medial unicompartmental knee arthroplasty compared to conventional techniques in patients undergoing bilateral simultaneous arthroplasty. Improved alignment after arthroplasty is associated with better function and increased longevity.

Blood loss after total knee replacement: effects of computer-assisted surgery

We carried out a prospective randomised study to evaluate the blood loss in 60 patients having a total knee arthroplasty and divided randomly into two equal groups, one having a computer-assisted procedure and the other a standard operation. The surgery was carried out by a single surgeon at one institution using a uniform approach. The only variable in the groups was the use of intramedullary femoral and tibial alignment jigs in the standard group and single tracker pins of the imageless navigation system in the tibia and femur in the navigated group. The mean drainage of blood was 1351 ml (715 to 2890; 95% confidence interval (CI) 1183 to 1518) in the computer-aided group and 1747 ml (1100 to 3030; CI 1581 to 1912) in the conventional group. This difference was statistically significant (p = 0.001). The mean calculated loss of haemoglobin was 36 g/dl in the navigated group versus 53 g/dl in the conventional group; this was significant at p < 0.00001. There was a highly significant reduction in blood drainage and the calculated Hb loss between the computer-assisted and the conventional techniques. This allows the ordering of less blood before the operation, reduces risks at transfusion and gives financial saving. Computer-assisted surgery may also be useful for patients in whom blood products are not acceptable.

Pharmacokinetic and maximum tolerated dose study of micafungin in combination with fluconazole versus fluconazole alone for prophylaxis of fungal infections in adult patients undergoing a bone marrow or peripheral stem cell transplant

In this dose escalation study, 74 adult cancer patients undergoing bone marrow or peripheral blood stem cell transplantation received fluconazole (400 mg/day) and either normal saline (control) (12 subjects) or micafungin (12.5 to 200 mg/day) (62 subjects) for up to 4 weeks. The maximum tolerated dose (MTD) of micafungin was not reached, based on the development of Southwest Oncology Group criteria for grade 3 toxicity; drug-related toxicities were rare. Commonly occurring adverse events considered related to micafungin were headache (6.8%), arthralgia (6.8%), hypophosphatemia (4.1%), insomnia (4.1%), maculopapular rash (4.1%), and rash (4.1%). Pharmacokinetic profiles for micafungin on days 1 and 7 were similar. The mean half-life was approximately 13 h, with little variance after repeated or increasing doses. Mean maximum concentrations of the drug in serum and areas under the concentration-time curve from 0 to 24 h were approximately proportional to dose. There was no clinical or kinetic evidence of interaction between micafungin and fluconazole. Five of 12 patients (42%) in the control group and 14 of 62 (23%) in the micafungin-plus-fluconazole groups had a suspected fungal infection during treatment which resulted in empirical treatment with amphotericin B. The combination of micafungin and fluconazole was found to be safe in this high-risk patient population. The MTD of micafungin was not reached even at doses up to 200 mg/day for 4 weeks. The pharmacokinetic profile of micafungin in adult cancer patients with blood or marrow transplants is consistent with the profile in healthy volunteers, and the area under the curve is proportional to dose.

Quantifying the passive extensibility of the flexor pollicis longus muscle in people with tetraplegia

STUDY DESIGN

Repeat measures design.

OBJECTIVE

The purpose of this study was firstly, to describe a simple clinical tool that can be used to measure the extensibility of the flexor pollicis longus (FPL) muscle; secondly, to test its reliability; and thirdly, to attain some 'normative' data of the extensibility of the FPL muscle in a representative sample of people with tetraplegia.

SETTING

A spinal cord injury unit in Sydney.

SUBJECTS

A total of 37 people (62 hands) with C4-C7 tetraplegia.

MAIN OUTCOME MEASURES

Angle of the carpometacarpal (CMC) joint of the thumb was measured in all subjects with the application of a series of thumb extensor torques. A device specifically designed for this purpose was used to standardize the torque and objectively quantify the CMC joint angle. In addition, repeat measurements were taken 3-5 days later in one subgroup of 13 subjects (one hand per subject) and 3 months later in another subgroup of 13 subjects (one hand per subject).

ANALYSIS

Intraclass correlation coefficients and percent close agreement scores were derived to quantify the 3-5 days and 3-month reliability between repeat measurements.

RESULTS

The median CMC angle of the thumb with the application of a 0.044 Nm torque was 63 degrees (range, 20-93 degrees). The intraclass correlation coefficients with the application of a 0.044 Nm torque were 0.88 (95% CI, 0.65-0.96) for measurements taken 3-5 days apart, and 0.90 (95% CI, 0.67-0.97) for measurements taken 3 months apart.

CONCLUSION

This study describes a simple and reliable way of measuring the extensibility of the FPL muscle in people with tetraplegia. This assessment tool and the 'normative' data provided in this study can be used to further investigate the contribution of the passive mechanical properties of the FPL muscle to hand function of people with C6 and C7 tetraplegia.

Treatment of AIDS-associated myelopathy with L-methionine: A placebo-controlled study

BACKGROUND

The histopathology of AIDS-associated myelopathy (AM) closely resembles that of myelopathies due to cobalamin or folate deficiency, with white matter vacuolization in the spinal cord. The pathogenesis of AM appears unrelated to direct HIV infection of the spinal cord. There is abnormal trans-methylation metabolism in AM, with decreased availability of the methyl group donor S-adenosyl-methionine (SAM). The authors hypothesized that treatment with l-methionine, the direct metabolic precursor of SAM, might improve AM.

OBJECTIVE

To determine the safety and efficacy of l-methionine treatment in AM.

METHODS

Fifty-six patients with clinical diagnosis of AM were randomized to a Phase II, double-blind, placebo-controlled study comparing the effect of l-methionine 6 g/day in two divided doses with that of placebo. Study duration was 12 weeks. All patients had somatosensory evoked potentials with prolonged central conduction time (CCT) at entry. Change in CCT was the primary endpoint of the study. Frequency of adverse events (AEs) was used to assess safety. Secondary endpoints were strength, spasticity, and urinary function. Biochemical measurements included serum methionine and homocysteine and CSF SAM.

RESULTS

There were no significant differences in AEs between the two groups. Serum homocysteine increased in l-methionine-treated patients from 7.2 (+/-5.2 SD) to 12.6 (+/-6.15 SD) micromol/L. The mean CCT at baseline was 25.9 milliseconds (+/-7.3 SD) for the treatment group and 24.1 milliseconds (+/-7.0 SD) for the placebo group. At completion, it was 3.0 milliseconds (+/-6.1 SD) for the treatment group and 23.6 milliseconds (+/-5.5 SD) for the placebo group (p = 0.17). In a subset of 15 patients with CSF studies, SAM levels increased in the l-methionine but not in the placebo group (p = 0.07). There was no significant effect of treatment on strength, spasticity, or urinary function.

CONCLUSIONS

l-methionine was safe and well tolerated although in some patients induced an increase of serum homocysteine. There was a nonsignificant improvement in CCT in treated patients but no benefit in any of the clinical measures.

Outcome of tibial plateau fractures managed with calcium phosphate cement

OBJECTIVES

To compare the use of an injectable calcium phosphate cement (Skeletal Repair System (SRS), Norian corporation, Cupertino, CA) and minimal internal fixation with buttress plating and bone grafting for lateral tibial plateau fractures.

STUDY DESIGN

Retrospective analysis with 13 age, sex and fracture matched pairs of tibial plateau fractures.

METHODS

Thirteen patients with lateral tibial plateau fractures treated with buttress plating and bone grafting were matched with 13 patients treated using minimal internal fixation and an injectable calcium phosphate cement (SRS). All patients were followed for a minimum of one year. The operative time, quality of reduction, maintenance of reduction and development of post-traumatic osteoarthritis was compared in both groups.

RESULTS

The mean duration of surgery was 101 min in patients treated with buttress plating and bone grafting and 55 min in patients treated with SRS (P < 0.0001). Nine patients in the internal fixation and bone graft group had excellent anatomical reductions as judged on post-operative radiographs but some loss of reduction was observed in 8 of the 13 (61%) cases. All 13 patients from the SRS group had an excellent reduction on post-operative radiographs but 3 (23%) demonstrated some loss of reduction of the plateau. The mean residual plateau depression at one year was 4mm in the buttress plate group and 0.7 mm in the SRS group (P < 0.005). Two patients (15%) in the buttress plate group developed post-traumatic osteoarthritis and required knee arthroplasty.

CONCLUSIONS

The use of SRS was associated with more favourable anatomical results than conventional treatment with buttress plating and bone grafting for lateral tibial plateau fractures.

Re-evaluating selection criteria for local anaesthesia in day surgery

Day surgery is an increasing element of surgical practice, particularly in plastic surgery. A large proportion of work is undertaken using local anaesthesia in the elderly who have associated co-morbidity. At present no national guidelines exist for the use of local anaesthesia in day surgery. This study aimed to examine the relationship between patient selection and complications, in order to identify those who should be excluded from local anaesthetic day surgery treatment. A retrospective analysis of patients undergoing local anaesthetic plastic surgical procedures over a 10-month period identified 328 operative episodes. There were 37 complications, two of which required admission 5 days post surgery for treatment of wound infection. The remaining complications were treated on an outpatient basis. An increased level of complication was seen in males with elevated systolic blood pressure and with the use of full thickness skin grafts in reconstruction. Age, smoking, ASA grade, and medication that altered coagulation (aspirin, warfarin and steroids) were not associated with increased complication levels. We conclude that local anaesthetic plastic surgical procedures are associated with a very low level of risk, and are suitable for those patients traditionally regarded as unsuitable for general anaesthetic day surgery.

Gynaecologic cancer incidence, Kingston and St Andrew, Jamaica, 1973-1997, and gynaecologic cancer mortality, Jamaica, 1999

The incidence of gynaecologic cancers in women from Kingston and St Andrew for the period 1973-1997 were reviewed by analyzing data previously published by the Jamaica Cancer Registry. Gynaecologic cancer-related mortality statistics for the entire island for 1999 were compiled from data obtained from the Registrar General's Department (RGD) and the Statistical Institute of Jamaica (STATIN). Data were compared to gynaecologic cancer statistics for women from the United States of America for 1973-1997. A total of 2862 gynaecologic cancers were registered for the years 1973-1997, which represents 26.8% of all female cancers from Kingston and St Andrew. Cervical cancer accounted for 62% of these gynaecologic cancers. The 268 cancer-related deaths (168 due to cervical cancer) registered in Jamaican women for 1999 represent approximately 15% of all female cancer-related deaths. The present incidence (27.9 per 100,000) and mortality rate (15.8 per 100,000) of cervical cancer are much higher than that documented for American women--both African Americans and Caucasians--and signify the limited success, to date, of efforts to decrease the incidence and mortality of cervical cancer by the implementation of cervical cancer screening programmes. For the time period reviewed, an increase was noted in the incidence of cancer of the corpus uteri while decreases were recorded for the incidence of choriocarcinoma, ovarian cancer and cancers arising from the vulva, vagina and fallopian tube.