Programmed death receptor 1 (PD-1) ligand Fc fusion proteins reduce T-cell proliferation in vitro independently of PD-1

Programmed death receptor 1 (PD-1) is an inhibitory receptor on T cells shown to restrain T-cell proliferation. PD-1 immune checkpoint blockade has emerged as a highly promising approach in cancer treatment. Much of our understanding of the function of PD-1 is derived from in vitro T-cell activation assays. Here we set out to further investigate how T cells integrate inhibitory signals such as PD-1 in vitro using the PD-1 agonist, PD-1 ligand 1 (PD-L1) fusion protein (PD-L1.Fc), coimmobilized alongside anti-CD3 agonist monoclonal antibody (mAb) on plates to deliver PD-1 signals to wild-type and PD-1-/- CD8+ T cells. Surprisingly, we found that the PD-L1.Fc fusion protein inhibited T-cell proliferation independently of PD-1. This PD-L1.Fc inhibition was observed in the presence and absence of CD28 and interleukin-2 signaling. Binding of PD-L1.Fc was restricted to PD-1-expressing T cells and thus inhibition was not mediated by the interaction of PD-L1.Fc with CD80 or other yet unknown binding partners. Furthermore, a similar PD-1-independent reduction of T-cell proliferation was observed with plate-bound PD-L2.Fc. Hence, our results suggest that the coimmobilization of PD-1 ligand fusion proteins with anti-CD3 mAb leads to a reduction of T-cell engagement with plate-bound anti-CD3 mAb. This study demonstrates a nonspecific mechanism of T-cell inhibition when PD-L1.Fc or PD-L2.Fc fusion proteins are delivered in a plate-bound coimmobilization assay and highlights the importance of careful optimization of assay systems and reagents when interpreting their influence on T-cell proliferation.

Abstract PD7-07: Synergistic targeting of CDK4/6 and BCL-2 pathways in estrogen receptor positive breast cancer

Background: Despite incremental advances in chemotherapy and endocrine therapy, survival outcomes for patients with ER-positive (ER+) metastatic breast cancer (MBC) remain poor. The majority of relapsing tumors exhibit deregulation of the cyclin-dependent kinase 4 and 6 (CDK4/6)/cyclin D1 (CCND1)/Rb signaling pathway. CDK4/6 inhibitors (such as palbociclib) in combination with endocrine therapy have been shown to significantly improve progression free survival in patients who are in 1st or 2nd line relapse, although overall survival benefit has yet to be demonstrated. This may reflect their largely cytostatic mechanism of action, with minimal induction of tumor cell death. Thus, combinatorial strategies that also induce apoptosis could be beneficial. Notably, the pro-survival protein BCL-2 is overexpressed in the majority of ER+ tumors and the potent and specific BCL-2 inhibitor venetoclax (ABT-199) has been found to synergize with endocrine therapy in patient derived xenograft (PDX) models. Promising activity has also been observed in an early phase clinical trial. We therefore investigated dual targeting of the CDK4/6 and BCL-2 pathways in pre-clinical models of ER+ and BCL-2+ breast cancer.

Results: We first examined endocrine sensitive or resistant cell-lines and found that pro-survival BCL-2 proteins were upregulated in resistant cells. BCL-2 family protein levels were also found to be elevated in palbociclib resistant cells, suggesting that BCL-2 could represent a therapeutic target. We next determined whether venetoclax improved response to dual therapy comprising the selective estrogen receptor degrader fulvestrant and palbociclib. In clonogenic assays of endocrine sensitive breast cancer cell lines, triple therapy containing venetoclax significantly reduced the number and size of colonies, when compared to double therapy. The addition of venetoclax to fulvestrant/palbociclib also augmented cell death in tumor organoid models derived from either ER+ BCL-2+ primary tumors or PDX models. Moreover, triple therapy improved tumor response and overall survival in mice bearing ER+ BCL-2+ PDX tumors. Mechanistically, this was accompanied by increased apoptosis and reduced cellular proliferation (as determined by cleaved caspase-3 and Ki67 levels, respectively). As CDK4/6 inhibitors have recently been shown to promote anti-tumor immunity, we evaluated immune modulation using the ER+ 67NR cell line in a syngeneic (BALB/c) mouse mammary tumor model. Similar to the PDX models, triple therapy comprising fulvestrant, palbociclib and venetoclax was more effective than double therapy comprising either fulvestrant/palbociclib or fulvestrant/venetoclax. Flow cytometric analysis of tumors revealed that this was accompanied by a reduced intratumoral FOXP3+:cytotoxic CD8 T-cell ratio.

Conclusions: The addition of the BCL-2 inhibitor venetoclax to conventional therapy comprising endocrine therapy and a CDK4/6 inhibitor augments tumor response and elicits a favorable intratumoral immune profile. Collectively, these findings support investigation of combination therapy in the clinic for patients with ER+ BCL-2+ MBC.

Citation Format: Whittle JR, Vaillant F, Policheni AN, Liu K, Pal B, Giner G, Fernandez K, Gray DH, Caldon CE, Smyth GK, Visvader JE, Lindeman GJ. Synergistic targeting of CDK4/6 and BCL-2 pathways in estrogen receptor positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD7-07.

Abstract PD1-06: A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC)

Background: Venetoclax, a potent and selective inhibitor of the survival protein BCL-2 (recently approved in CLL and in development in other hematopoietic malignancies), has yet to be evaluated in pts with solid tumors. BCL-2 is overexpressed in ˜85% of ER+ breast cancer. Pre-clinical findings using patient-derived xenograft breast tumor models suggest that venetoclax synergizes with endocrine therapy by increasing apoptosis. Here we report mBEP, an investigator-initiated phase 1b study of venetoclax with tamoxifen in 33 pts with ER+ (>1%), BCL-2+ (>10%, 2-3+ intensity) and HER2– MBC.

Methods: We conducted a 3+3 dose escalation study comprising cohorts receiving venetoclax 200, 400, 600 or 800 mg/d with tamoxifen 20 mg/d (continued until progression). The primary endpoint was to determine the maximum tolerated dose (MTD), define dose-limiting toxicities (DLTs) and identify the recommended phase 2 dose (RP2D). In a dose expansion phase (at the RP2D), secondary endpoints including safety and tolerability, response at 24 wks (RECIST v1.1), clinical benefit rate (CBR) and progression-free survival (PFS) were studied.

Results: In the escalation phase (n=15 pts), treatment was well tolerated with no DLTs or high-grade (Gd 3/4) adverse events observed, apart from asymptomatic on-target lymphopenia (Gd 3, 2/15 pts). MTD was not reached. The 800 mg/d dose was selected as the RP2D and the cohort expanded to include 24 pts with ≥24 wks follow up (range 24-105 wks). Fifteen pts had received prior regimens for MBC (median 3, range 1-9) that included tamoxifen in 5/15.

For the RP2D cohort (n=24), overall responses (OR) included 1 CR (4%) and 12 PR (50%), with 5 SD (21%), corresponding to a CBR of 75%. The 9 pts treated in the first line setting experienced a 78% OR (7/9 pts) and 11% SD (1/9 pts), equating to an 89% CBR. The data are immature for determining median PFS for the RP2D cohort (currently 40+ wks).

Treatment responses were pre-empted by metabolic responses (FDG-PET) at 4 wks (seen in 13/16 (81%) pts studied), and correlated with serial changes in circulating tumor DNA (ctDNA). Intriguingly, responses and clinical benefit were observed in pts with plasma-detected ESR1 mutations (4/10 and 7/10, respectively).

The most common treatment-related AEs (CTCAE v4.0) for all pts were lymphopenia in 29/33 (88%; 57% Gd 1-2, 30% Gd 3-4), neutropenia in 24/33 (73%; 67% Gd 1-2, 6% Gd 3), nausea in 22/33 (67%; all ≤Gd 2), anemia in 13/33 (39%; 33% Gd 1-2, 6% G3), thrombocytopenia in 11/33 (33%; all ≤Gd 2), vomiting in 11/33 (33%, all ≤Gd 2), diarrhea in 10/33 (30%; 24% Gd 1-2, 6% Gd 3), infection in 9/33 (27%; 18% Gd 2, 9% Gd 3) and fatigue in 7/33 (21%; all ≤Gd 2). There was one possible treatment-related SAE (infection).

Conclusions: In the first clinical study to evaluate venetoclax in a solid tumor, we demonstrate that combining venetoclax with endocrine therapy has a tolerable safety profile and elicits remarkable activity in ER+ and BCL-2+ MBC. These findings support further investigation of combination therapy for patients with BCL-2-positive breast cancer.

Sponsor: The Royal Melbourne Hospital (ACTRN12615000702516)

Citation Format: Lindeman GJ, Lok SW, Whittle JR, Siow ZR, Bergin AR, Dawson S-J, Desai J, Gray DH, Liew D, Mann GB, Murugasu A, Roberts AW, Rosenthal MA, Shackleton K, Sherman P, Silva MJ, Teh C, Travers A, Vaillant F, Visvader JE. A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-06.

Review of total hip replacement. The Middlemore Hospital experience, 1980-1991

AIM

To determine the outcome of 1951 total hip arthroplasties performed between 1980 and 1991 at Middlemore Hospital.

METHODS

An independent retrospective review was carried out between 1993 to 1995 giving a minimum follow-up of two years. Useable data were obtained for 96.8% of cases.

RESULTS

The overall wound infection rate was 3.4% (n=65), and of these seven (10.8%) required revision. The revision rate for infection for all patients was 1.16% (n=22). The in-hospital dislocation rate was 2.6% (n=49), and of these five (9.8%) required revision. Patient pain, activity and satisfaction were acceptable. Revision was required for 163 patients (8.7%), mainly for loosening. A survival analysis of the commonly used implants at seven years matched results from other studies. (Stem survival: Spectron 99.5%, Charnley 95.6%. Cup survival: Spectron 97.9%, Charnley 98.1%). Analysis of outcome predictors showed that youth and weight both influence the rate of revision.

CONCLUSIONS

Results in terms of patient satisfaction and revision rates were comparable with other published series. The wound infection rate was higher than desirable, but not unexpected in view of the number of surgeons involved (73) and the lack of special theatre facilities.

Heterogeneous Catalysis with Cross-Linked Lyotropic Liquid Crystal Assemblies: Organic Analogues to Zeolites and Mesoporous Sieves

Organic, nanoporous heterogeneous catalysts based on a carboxylate-containing, amphiphilic mesogen catalyze the Knoevenagel condensation (see schematic representation). These networks maintain their order in solution and can be recycled. Enhanced basicity, excellent site accessibility, and substrate size exclusion are features of these nanostructured systems.

Posterior surgical treatment for the rheumatoid cervical spine

Twenty-six patients with rheumatoid disease affecting the cervical spine underwent surgical treatment for neck pain, neurological deficit, or both. Atlantoaxial subluxation (n=13), subaxial subluxation (n=7) and vertical migration of the odontoid (n=6) were treated. Arthrodesis with autologous bone was augmented with wire, Ransford loop, Hartshill rectangle or Magerl technique. Pain relief occurred in 92% of patients. Neurological deficit improved in 89% and was unchanged in the remainder. Radiographic stability was achieved in all but one patient. Posterior surgery effectively relieved pain and neurological deficit, and the complications encountered did not jeopardize the outcome.

Reamed versus unreamed femoral nails. A randomised, prospective trial

We performed a randomised, prospective trial to evaluate the use of unreamed titanium nails for femoral fractures. Of 48 patients with 50 femoral fractures 45 were followed to union; 23 with an unreamed and 22 with a reamed nail. The study was stopped early because of a high rate of implant failure. The fractures in the unreamed group were slower to unite (39.4 weeks) than those in the reamed group (28.5 weeks; p = 0.007). The time to union was over nine months in 57% of the unreamed group and in 18% of the reamed group. In the unreamed group 14 secondary procedures were required in ten patients to enhance healing compared with three in three patients in the reamed group. Six implants (13%) failed, three in each group. Four of these six fractures showed evidence of delayed union. To achieve quicker union and fewer implant failures we recommend the use of reamed nails of at least 12 mm in diameter for female patients and 13 mm in males.

Matchett Brown hemiarthroplasty for displaced subcapital fractures of the hip

BACKGROUND

Matchett Brown hemiarthroplasty has been routinely performed at Middlemore Hospital in elderly patients following subcapital fracture of the hip. The outcome of patients undergoing Matchett Brown hemiarthroplasty was evaluated.

METHODS

Matchett Brown hemiarthroplasties performed at Middlemore Hospital during 1987 were retrospectively reviewed. Medical records were reviewed and where possible patients were interviewed, examined and radiographs of their hip taken.

RESULTS

The overall survival at follow up was 34%, with the greatest predictor of survival being whether the patient had been living alone prior to the accident. The majority of patients who survived the 4 year follow up had excellent mobility at the time of fracture. At follow up most patients had little or no pain from their hip, but three complained of constant pain.

CONCLUSIONS

Hemiarthroplasty proved to be a satisfactory form of replacement in this group. If one were to select a patient for total hip replacement, rather than hemiarthroplasty, then age alone is not as important as other factors such as degree of mobility and independence of living.

Adjuvant chemotherapy for non-metastatic osteosarcoma of the extremities in two New Zealand cancer centres

BACKGROUND

Adjuvant chemotherapy significantly improves survival of patients with non-metastatic osteosarcoma but most of the data come from trials conducted in major international cancer centres.

AIM

To review the efficacy and toxicity of an adjuvant chemotherapy regimen used in two regional cancer centres in New Zealand.

METHODS

Retrospective review of patients treated for non-metastatic high-grade osteosarcoma of the extremities. The regimen (POMA) consists of high-dose-methotrexate 8 g/m2 and vincristine 1.5 mg/m2 (maximum 2 mg) on days 1 and 8 followed by folinic acid then doxorubicin 50 mg/m2 and cisplatin 100 mg/m2 on day 15. This cycle was repeated every 35 days. Following amputation patients received six cycles while in selected patients two cycles were planned prior to limb salvage surgery followed by a further four cycles. Actuarial survival was calculated using the Kaplan-Meier method.

RESULTS

Twenty patients were treated with POMA between 1986 and 1993. Amputation was performed in 16 patients and limb-salvage surgery in four. Sixteen patients (80%) remain alive with no evidence of disease at a median follow-up of 40 months. Thirteen patients (65%) have been continuously disease-free. Actuarial survival at five years is 70%. Seven patients relapsed, six in lungs, of whom four underwent pulmonary metastasectomy; three of these remain free of disease 31, 35 and 40 months later. There was no local relapse. The toxicity of POMA is significant but tolerable.

CONCLUSION

The results obtained at two regional cancer centres in New Zealand using POMA compare favourably to those achieved in clinical trials performed at major international cancer centres.

Serum blocks the osteolytic effect of cortisol in neonatal mouse calvaria

Chronic glucocorticoid excess is associated with the development of osteoporosis and, in human subjects, there is histomorphometric evidence of increased bone resorption. Paradoxically, most in vitro studies have suggested that glucocorticoids inhibit bone resorption but recently two groups have demonstrated increased osteolysis in glucocorticoid-treated bone organ cultures. The present study reexamines the effect of cortisol on basal bone resorption in neonatal mouse calvaria with particular emphasis on the effect of serum supplementation of the media. In the absence of serum, 45Ca release was significantly stimulated by 10(-7) M cortisol (treatment/control 1.37 +/- 0.06, P less than 0.005) and by 10(-6) M cortisol (treatment/control 1.27 +/- 0.08, P less than 0.005). The stimulation of resorption by 10(-7) M hydrocortisone was progressive from 24 to 96 hours of incubation. In contrast, when calvaria were incubated in the presence of 5% serum, bone resorption was not increased by cortisol (10(-8) M-10(-6) M). In the presence of 5% charcoal-stripped, heat-inactivated serum, there was a small stimulation of 45Ca release at 10(-6) M hydrocortisone only (treatment/control 1.19 +/- 0.06, P less than 0.01). Incubation of bones with indomethacin did not modify the effect of cortisol in either the presence or absence of serum. In serum-free conditions, cortisol 10(-8) M significantly inhibited the rate of thymidine incorporation, though at higher concentrations this effect was not seen. Cortisol produced a dose-related inhibition of serum-stimulated thymidine incorporation. It is concluded that the presence of serum substantially modifies the effect of cortisol on basal bone resorption.(ABSTRACT TRUNCATED AT 250 WORDS)

Orthopaedic training in private practice

The background philosophy, structure and training experience offered by a new free-standing clinic set up purely to facilitate orthopaedic post-graduate training is described. Emphasis is placed on the ethical issues involved. The educational programme, which includes involvement in all local and national activities, is summarized. The registrars' operative experience is recorded using log-sheet criteria. This venture has predated the major restructuring of the health care system in Auckland, which is anticipated in the next few years, and will therefore allow the training programme to evolve appropriately, employing the educational opportunities of all sectors of health care.

Adenylate cyclase blockers dissociate PTH-stimulated bone resorption from cAMP production

It is uncertain whether adenosine 3',5'-cyclic monophosphate (cAMP) or the inositol-calcium pathway mediates the stimulation of bone resorption by parathyroid hormone (PTH). Incubation of bone organ cultures with cAMP analogues and forskolin has not resolved this question because of the cellular inhomogeneity of bone and the consequent presence of adenylate cyclase-linked receptors for both PTH and calcitonin, hormones with opposite effects on bone resorption. We have used two new inhibitors of adenylate cyclase, 9-(tetrahydro-2-furyl)adenine (SQ 22536) and 2',5'-dideoxyadenosine (DDA), to directly reassess the role of cAMP in PTH-stimulated osteolysis. SQ 22536 (0.01-1.0 mM) and DDA (0.01-1.0 mM) completely blocked PTH stimulation of cAMP production measured in the absence of a phosphodiesterase blocker. In the presence of 1 mM 3-isobutyl-1-methylxanthine, half-maximal inhibition of PTH-induced cAMP production occurred with 0.2 mM SQ and 0.1 mM DDA, respectively. These concentrations of SQ and DDA had no effect on PTH-stimulated 45Ca release from calvaria, although both agents inhibited bone resorption when present at concentrations of 1-2 mM. At these levels, SQ and DDA caused equivalent inhibition of 45Ca release stimulated by 1,25-dihydroxyvitamin D3 but did not affect basal 45Ca release or [3H]-phenylalanine incorporation. It is concluded that substantial blockade of PTH-induced cAMP production does not affect this hormone's stimulation of bone resorption, which is therefore likely to be mediated by another intracellular messenger system, possibly calcium. In millimolar concentrations, SQ and DDA appear to be nonspecific blockers of osteoclastic bone resorption.

Stimulation of the synthesis of collagenase activator protein in cartilage by a factor present in synovial-conditioned medium

We have purified a low molecular weight protein from medium conditioned by calf synovium with physical and biological properties similar to the leukocyte cytokine interleukin 1 (IL-1). The factor is active in stimulating the synthesis (three- to fivefold) of collagenase activator protein (CAP) by the surface (1-2 mm) of articular cartilage while CAP synthesis in the deeper zones of articular cartilage is not affected. Recombinant mouse IL-1 and commercially available purified human IL-1 are also capable of stimulating cartilage to synthesize and secrete CAP. The synthesis of other proteins, including collagenase, appeared to be unaffected by either the synovial factors or the human and mouse IL-1.

The in vitro effect of gold complexes on bone resorption

Mouse calvaria were maintained in organ culture without serum additives. The effects of three gold complexes--aurothioglucose, aurothiomalate, and auranofin--on active bone resorption (45Ca release) and hydroxyproline synthesis were determined. The influence of these compounds on DNA and protein synthesis and lysosomal enzyme release from calvaria was also assessed. All gold complexes reduced bone resorption to some extent, with auranofin being the most potent within a narrow concentration range (10(-6) M). This concentration of auranofin also significantly inhibited collagen synthesis, although DNA and protein synthesis were unaffected. None of the compounds tested appeared to mediate their action via significant inhibition of lysosomal enzyme release.

The effects of hydrocortisone, parathyroid hormone and the bisphosphonate, APD, on bone resorption in neonatal mouse calvaria

The effects of hydrocortisone and parathyroid hormone (PTH) upon bone resorption rates in neonatal mouse calvaria have been studied. Bone resorption (measured as 45Ca release) was significantly increased by hydrocortisone (10(-7) M and 10(-6) M) and there was a dose-dependent rise with PTH (0.3-0.9 micrograms/liter). When both PTH 0.3 micrograms/liter and hydrocortisone 10(-8) M were present in the incubating medium, bone resorption did not differ from control, but increasing the hydrocortisone concentration to 10(-7) M augmented 45Ca release by 25% (P less than 0.02) and doubling of the PTH level was associated with a 10% increase (nonsignificant). When both PTH and hydrocortisone were present in the higher concentrations (0.6 micrograms/liter and 10(-7) M, respectively) 45Ca release increased by 39% (P less than 0.005) above that resulting from the lower levels of both hormones (0.3 micrograms/l and 10(-8) M, respectively). (3-Amino-1-hydroxypropylidene)-1,1-bisphosphonate (APD) in concentrations of 3 X 10(-5) M and 10(-4) M, produced inhibition of basal and hydrocortisone/PTH-stimulated bone resorption without evidence of toxicity. These results indicate that hydrocortisone stimulates bone resorption in neonatal mouse calvaria in vitro, in contrast to the results found in fetal rat bone culture systems. PTH has a similar effect, which is additive to that of hydrocortisone and the combined stimulation can be overcome by APD. The possible relevance of these results to the development and prevention of glucocorticoid-induced osteoporosis is discussed.

Inhibition of prostaglandin action and bone resorption by copper

Mouse calvaria were maintained in organ culture without serum additives. The effects of Cu2+ on bone resorption and on the synthesis and action of prostaglandins were studied. Non-toxic concentrations of copper sulphate (5 microM) were found to decrease active resorption, measured by 45Ca release, to 54% control values (p less than 0.001), while prostaglandin F (PGF), prostaglandin E2 (PGE2), and 6-keto-prostaglandin F1 alpha, (6-keto-PGF1 alpha), determined by radioimmunoassay, were increased above controls (p less than 0.05). These effects of Cu2+ on prostaglandin synthesis were confirmed by the isolation and quantitation of [3H]-labelled metabolites released from calvaria which had been pre-labelled with [3H]-arachidonic acid. PGE2, PGF2 alpha, 6-keto-PGF1 alpha, and thromboxane B2 (TxB2) were all higher in copper-exposed calvaria, but their relative amounts remained unchanged. There was no evidence that Cu2+ influenced the mobilisation of [3H]-arachidonic acid from prelabelled calvaria. The stimulation of bone resorption by exogenous prostaglandins was decreased in the presence of Cu2+ (p less than 0.005), while parathormone-mediated bone resorption was virtually unaffected. Cu2+ also increased the inhibition of bone resorption seen with indomethacin (p less than 0.05). In addition to the effects of the metal on prostaglandin action Cu2+ also decreased beta-glucuronidase activity in the media to 86% of the control values (p less than 0.001). The action of Cu2+ in inhibiting bone resorption in vitro appears complex but does not involve inhibition of prostaglandin synthesis. It is likely that Cu2+ has more than one inhibitory locus.

The in vitro effect of indomethacin on basal bone resorption, on prostaglandin production and on the response to added prostaglandins

Mouse calvaria were maintained in organ culture without serum additives. Basal active resorption, as measured by 45Ca and hydroxy-proline release, was significantly inhibited to 74% control levels by indomethacin (1.4 X 10(-7) M). Prostaglandin F and prostaglandin E2 production, determined by radioimmunoassay, were both significantly lowered by this concentration of indomethacin. DNA, protein and hydroxyproline synthesis, as indices of cell toxicity, were unaffected by low concentrations of indomethacin, while concentrations of 1.4 X 10(-6) M inhibited protein synthesis (p less than 0.005). In the presence of indomethacin (1.4 X 10(-7) M) both PGE2 and PGF2 alpha stimulated resorption in a dose-dependent manner, with PGE2 being the more potent. Neither prostaglandin affected hydroxyproline synthesis at low concentrations, but PGE2 had a marked inhibitory action at a higher concentration (10(-6) M). In combination, the effects of PGE2 and PGF2 alpha showed no evidence of synergism or any antagonistic action. The study shows that in vitro calcium and hydroxyproline resorption in the unstimulated mouse calvaria are inhibited by indomethacin at concentrations measured in serum during human therapy. The decreased PGF and PGE2 production associated with this decreased bone resorption in the presence of non-toxic concentrations of indomethacin would suggest a role for these prostaglandins in maintaining the basal resorption of cultured bone.

The effect of blood transfusion on the incidence of deep vein thrombosis

The incidence of postoperative deep vein thrombosis in 120 patients undergoing elective total hip replacement was determined venographically. Significantly more blood was administered to those developing thrombosis, particularly in the subgroups given general anaesthesia (P less than 0.05). There were no differences in the postoperative haemoglobin values in any of these groups. The distribution of other risk factors identified, namely previous thrombo-embolism, malignancy and previous vein surgery or injections did not influence this finding. The use of TED stockings (Kendall) was effective. It is suggested that greater emphasis should be placed on techniques that reduce blood loss such as regional anaesthesia and the posterior approach to the hip. Further research into the fluids used for blood volume maintenance will be beneficial.

The detection of deep venous thrombosis by impedance plethysmography in hip surgery patients

Cuff impedance plethysmography has been performed on 120 patients undergoing total hip replacement surgery, all of whom have had venography. The low incidence of thrombosis (17.5%) precluded any accurate data on sensitivity, but specificity was 85%, positive accuracy 48%, negative accuracy 92% and validity 82%. There was a high false positive rate in the first postoperative week (40% of 25 negative venograms). The technique is of value for the exclusion of thrombi in such patients after the eighth postoperative day. Venography will still be required for the positive identification of thrombi in any research protocol.

Orthopaedic training in New Zealand

This paper illustrates some of the problems associated with a nationally organised training programme. The limit on entry numbers is on the 'best guess' for manpower requirements and not on the number of training posts available and hence a challenge can always be made on the grounds that a 'closed shop' is being operated. Experience has shown that to date this is not a valid criticism. However, there is little room for expanding the number of training posts available so that the annual intake cannot be expanded significantly beyond present levels. The selection criteria and methodology are discussed in detail, representing our current practice without any claim to have established an ideal technique. Finally, when a trainee is seconded from an overseas programme and the question of approval of his time in this country is raised, it is most important that the host institution have data relevant to both the local and the national scene.

Bone resorption and prostaglandin production by mouse calvaria in vitro: response to exogenous prostaglandins and their precursor fatty acids

Mouse calvaria were maintained in organ culture for 96 h and endogenous prostaglandin production and active bone resorption (45Ca release) measured. After a lag phase of 12 h, active resorption increased over the 96 h period. The amounts of prostaglandins released into the culture medium (measured by radioimmunoassay) were highest in the first 24 h of culture. Unless these were removed by preculturing for 24 h, or suppressed by indomethacin, no response to exogenous PGE2, or prostaglandin precursors could be demonstrated. Bone resorption was stimulated after preculture by both PGE2 and PGF2 alpha in a dose-dependent manner (10-8M-10-5M), with PGE2 being the more potent. Collagen synthesis was unaffected by PGF2 alpha, whereas PGE2 (10-5M) had an inhibitory effect. Eicosatrienoic acid did not stimulate bone resorption at lower concentrations (10-7M-1-5M), but was inhibitory at 10-4M. Arachidonic acid also inhibited resorption at 10-4m, but at lower concentrations (10-7M-10-5M) increased active resorption. This was concomitant with a rise in PGE2 and PGF2 alpha levels, PGE2 production being significantly higher than PGF2 alpha. The effects of PGE2 (10-8M) and PGF2 alpha (10-8M) appeared additive; there was no evidence of synergistic or antagonistic effects when varying ratios of PGE2: PGF2 alpha were employed.

A histochemical study of muscle in club foot

A histochemical analysis was made of 103 muscle biopsies taken from 62 patients with idiopathic club feet. Any reduction in the diameter of the muscle fibres associated with wasting of the calf muscle was recorded. Histochemical abnormalities existing in these biopsies were revealed by comparison with normal biopsies obtained from the normal legs of 13 children with unilateral deformities. No significant difference was found between the diameter of the muscle fibres taken from normal and affected legs aged under six months. This indicates that wasting of the calf muscle is due to a reduction in the number of fibres rather than their size. The muscle structure was normal excluding denervation and reinnervation. The soleus muscle in patients aged under six months contained 61 per cent Type 1 fibres in the affected legs, compared to 44.3 per cent in normal legs. Similar values were found in the normal and abnormal tibialis posterior muscles, long flexors of the toe and peroneal muscles. The change in composition of the soleus muscle and the reduction in the number of fibres may be caused by a defective neural influence on the development of the limb in club foot.

Inhibition of active bone resorption by copper

An investigation of the role of copper in bone metabolism was undertaken. Explanted calvaria from 6-day-old mice were grown for 48 h in medium with and without the addition of copper sulfate. Active resorption was found to be significantly inhibited in the presence of copper sulfate concentrations of 10(-6)M and above. Copper sulfate concentrations of 10(-5)M and above inhibited hydroxyproline, protein, and DNA synthesis. Lower concentrations wee ineffective. The effect of 5 X 10(-6)M copper sulfate on resorption was reversible. Several other compounds were tested for similar effects and at 5 X 10(-6)M were found to inhibit bone resorption in the order: copper sulfate greater than brown gold chloride greater than sodium aurothiomalate greater than zinc sulfate greater than sodium sulfate. The copper sulfate effect was twice that of sodium aurothiomalate, and sodium sulfate was not significantly inhibitory. The results suggest that the high serum copper levels associated with rheumatoid arthritis may reflect the activity of a hypothetical control mechanism of bone resorption. In the diseased state this would act to restore the normal rate of bone resorption.

The incidence of femoral neck fractures in New Zealand

This study reviews the incidence of femoral neck fractures in New Zealand Maoris and non-Maoris. A comparison made with corresponding overseas studies shows that the New Zealand non-7aori age-sex incidence is one of the highest yet observed. Maori women are shown to have an incidence of hip fracture significantly lower than non-Maori women. These results are discussed in the light of the current debate on the aetiology of femoral neck fractures.

The effect of varying oxygen tensions on hydroxyproline synthesis in mouse calvaria in vitro

Six-day-old mouse calvaria were grown in vitro on a grid culture system in Medium 199 containing titriated proline. Gas atmospheres containing various oxygen concentrations up to 25% were introduced to influence the rate of collagen formation as determined by the synthesis of labelled hydroxyproline in the explants. There was an increase in synthesis in response to 15% oxygen with a possible further small increase in 25% oxygen. Measurement of the release of unlabelled hydroxyproline into the medium as an estimate of collagen breakdown indicates an increase in resorption with increasing oxygen concentrations up to 20%. In this model, therefore, there is increased collagen turnover with increasing oxygen tension in the physiologic range. Although the observations reflect collagen formation and do not necessarily measure bone formation, the results are consistent with data derived from other sources suggesting that bone formation is increased by improved oxygenation.

The control of bone induction in soft tissues

The induction of bone at the boundary of parenchymal organs has been studied using acid demineralized rib implants in rabbits. The induction of bone is usually confined to that portion of an implant protruding from such an organ though both scant cartilage induction and the induction of bone within the territory of parenchymal organs were seen on a few occasions. Neonatal splenectomy does not influence the inductive properties of bone matrix in muscle or other soft tissues. The inclusion of composite autografts of liver and acid demineralized bone in muscle results in a reduction in the induction rate. It is postulated that the parenchymal organs exclude osteoprogenitor cells and possibly blood-bone bone-marrow-derived osteoinductor releasing cells by some mechanism that is diffusable, thus preventing the initial inductive event. Composite grafts of matrix and muscle produce bone in these tissue, demonstrating that once bone cell differentiation by induction is initiated bone tissue develops even in spleen, liver and kidney parenchyma.

Lanthanide markers in a single sample for nutrient studies in humans

Multiple Lanthanide markers were used to develop procedures for determinations of intake and apparent utilization of four nutrients using data from fecal analysis and known concentrations of markers in nutrients. Terbium oxide was given as the intake marker. All foods contained the other non-absorbed markers, each marker in direct proportion to the amount of a specific nutrient in each food. Nutrient markers were oxides of samarium, scandium, ytterbium, and europium. Fecal collection and subsequent analysis of nutrients and markers were completed. Fecal marker concentration stabilized 2 days following initiation of the marker regime. Thus, after 3 days, a single grab sample could be utilized to analyze for nutrient utilization. The ratio of nutrient marker proportional to nutrient and intake to nutrient excretion provides the data for the calculation of apparent utilization for as many nutrients as nutrient markers incorporated into the food. When direct and marker methods of determining nutrient intake and apparent utilization were compared, no significant differences were found for gross energy, fat, protein, and calcium.

The effects of varying oxygen tensions upon bone resorption in vitro

Calvaria from six-day-old infant mice were grown on a grid culture in a chemically defined medium under varying oxygen tensions. Quantitative isotope studies demonstrated a linear association between bone resorption and oxygen tension in the physiological range. This result was supported by histological, histochemical and vital staining experiments. The clinical finding of osteoporosis in areas of hyperaemia could therefore be attributed to a rise in oxygen tension causing increased bone resorption.

The effects of hyperoxia upon bone in organ culture

Hyperoxia has been reported to stimulate both resorption and synthesis of bone in vitro. The effects of increased oxygen tension were re-investigated using calvaria from infant mice maintained in a stationary grid culture system for 48 48 hours with an unsupplemented chemically defined medium. Resting resorption due to osteoclastic activity was demonstrated in the explants in air by Von Kossa staining, histology, and 45 Ca release. Resorption was inhibited by exposure to 95 per cent oxygen or hyperbaric oxygenation at 2 atmospheres pressure. Hyperoxia also depressed new bone formatin by osteoblasts although the production of a new collagen, as measured by the incorporation of 3H-proline, was greater in calvaria cultured in hyperbaric oxygen than in paired explants in 95 per cent oxygen. Thus hyperoxia was toxic for both synthetic and resorptive activity of bone cells; these effects may stem from the loss of vital factors present in natural MEDIA supplements.

Excision arthroplasty of the hip

The results of excision arthroplasty on forty hips in thirty-two patients have been studied by personal review. The mean follow-up was ten years and the results were graded in the Lazansky system. The outcome was fairly predictable, most patients achieving a fair to good result. The patients were satisfied with the operation in unilateral cases as a secondary operation, but it was generally unsatisfactory as a primary procedure or when performed bilaterally. Pain relief was satisfactory, and previously infected hips achieved sound wound and bone healing. Half could walk with no aid or one stick. No correlation could be found between the radiological appearances and the quality of the result.

Studies of nutritional safety of some heavy metals in mice

Heavy metals have been proposed as nutrient markers to allow the accurate determination of the time of passage, nutrient intake, or apparent utilization of multiple nutrients. In order to evaluate possible toxic effects of scandium, chromium, lanthanum, samarium, europium, dysprosium, terbium, thulium, and ytterbium oxides, and barium sulfate upon growth, general development, reproduction, and lactation, mice were fed different levels of these compounds for three generations. The amount of elements fed were 0,110, 100, and 1000 times the use amount. The use amounts were (in ppm2.) : Sc, 0.12; Cr, 0.02; La.0.40;; Sm. 0.80; Eu, 0.036:TB, 1.20; Dy, 1.20; Tm. 0.08; Tb, 0.12; and Ba, 0.008. The use amount was one-fifth of the concentration required for activation analysis. Mortality and morbidity were negligible. No consistent growth rate changes were observed; however, different groups showed different growth rates during different generations. The number of mice born showed no significant differences amoung treatment groups. Survival, growth rate, hematology, morphological development, maturation, reproduction, and lactational performance were comparable in mice fed the different levels of 10 heavy metal oxides to those mice fed the basal diet.

Observations on the induction of bone in soft tissues

Using bone decalcified with 0-6 N hydrochloric acid as an inducing agent, the inductive capacity of different soft tissue sites was investigated. Muscle and fascia regularly permitted the induction of bone, while spleen, liver and kidney suppressed bone induction. Bone formation could be induced in these organs if living autologous fascia was implanted together with the inducing agent; while bone formation was inhibited when living autologous spleen tissue was implanted with the inducing agent to normally favourable sites. The administration of systemic heparin and the diphosphonate ethane-1-hydroxyl, 1-diphosphonic acid (EHDP) suppressed bone induction. It is suggested that for bone induction to occur in soft tissues, three conditions must be present: 1) an inducing agent; 2) an osteogenic precursor cell; and 3) an environment which is permissive to osteogenesis. The presence of osteogenic inhibitors in spleen, liver and kidney is postulated.

Simple Bone Cysts: Results of a Pilot Survey

A study of simple bone cysts is reported, giving the results of a pilot study of all cases traceable over the past 10 years in Auckland. Curettage and grafting arc shown to be of dubious value. The natural history of some examples is described to illustrate principles thought to contradict earlier concepts of the origin of these lesions.