Abstract 871: Development of a smartphone-based electrochemiluminescence biosensor for dopamine detection in advanced breast cancer

Introduction: Studies conducted in our laboratory on proteomic profiling of breast cancer serum among women by shotgun LC-MS methodology have identified several biomarkers for early detection of breast cancer. However, not all of the identified biomarkers have been validated due to costs involved with validation tests. The development of a reliable, cost-effective highly sensitive portable system, the Electrochemiluminescence (ECL) biosensor will enable us to validate identified biomarkers that have valuable diagnostic applications.

The purpose of this study was to detect dopamine, which has been identified as a biomarker in advanced breast cancer. Dopamine and its receptors act as novel therapeutic agents in advanced breast cancer. Dopamine significantly enhances the efficacy of commonly used anticancer drugs through its antiangiogenic action.

Methods: In this work, a compact, mobile phone-based ECL sensor apparatus was developed using the phone cameras, screen-printed electrodes (SPE), and mobile app for dopamine detection. Methods of DC voltage application for ECL reaction were comprehensively studied from the mobile phone itself or external power. Under optimized sensing conditions, with disposable carbon SPE and 20 mM coreactant tri-n-propylamine (TPrA), acceptable repeatability and reproducibility were achieved in terms of relative standard deviation (RSD) of intra- and interassays, which were 6.7 and 5.5 %, respectively. The biochemical compound dopamine was measured due to its ECL quenching characteristics and its clinical significance in breast cancer detection and therapeutic properties. The quenching mechanism of Ru(bpy)32+/TPrA by dopamine was investigated based on the estimation of the constants of the Stern-Volmer equations.

Results: The linear range for detectable dopamine concentration was from 1.0 to 50 µM (R2 = 0.982). As the developed mobile phone-based ECL sensor is simple, small and assembled from low-cost components, it offers new opportunities for the development of inexpensive analytical methods and compact sensors.

Conclusion: The ECL sensor demonstrated that a new instrumentation with mobile technology in the point-of-care diagnostics of breast cancer could provide reliability and sensitivity of a high-end equipment. This project is funded by the NSF CBET division.

Citation Format: Hyun J. Kwon, Padma P. Tadi Uppala, Elmer C. Rivera, Mabio R. Neto, Daniel Marsh, Jonathan J. Swerdlow, Rodney L. Summerscales. Development of a smartphone-based electrochemiluminescence biosensor for dopamine detection in advanced breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 871.

Air quality in enclosed railway stations: Quantifying the impact of diesel trains through deployment of multi-site measurement and random forest modelling

Concentrations of the air pollutants (NO₂ and particulate matter) were measured for several months and at multiple locations inside and outside two enclosed railway stations in the United Kingdom - Edinburgh Waverly (EDB) and London King's Cross (KGX) - which, respectively, had at the time 59% and 18% of their train services powered by diesel engines. Average concentrations of NO₂ were above the 40 μg m^-3 annual limit value outside the stations and were further elevated inside, especially at EDB. Concentrations of PM_2.5 inside the stations were 30-40% higher at EDB than outside and up to 20% higher at KGX. Concentrations of both NO₂ and PM_2.5 were highest closer to the platforms, especially those with a higher frequency of diesel services. A random-forest regression model was used to quantify the impact of numbers of different types of diesel trains on measured concentrations allowing prediction of the impact of individual diesel-powered rolling stock.

The Choice and Partnership Approach to community mental health and addictions services: a realist-informed scoping review protocol

INTRODUCTION

Early identification and appropriate treatment of child and adolescent mental health disorders can often be hampered by patchwork services with poorly planned or unclear pathways. The Choice and Partnership Approach (CAPA) is an evidence-based transformational model of community (community-based or outpatient) mental health and addictions services for children and adolescents that aims to better match services to needs and to improve timely access to care. CAPA has been variably implemented across jurisdictions but has not been comprehensively evaluated for its impact on system and client outcomes. Our research question is, 'To what degree does CAPA work, for whom and under what circumstances?'. The purpose of this review is twofold: (1) to gain an understanding of the extent and outcomes of the implementation of CAPA in community mental health and addictions services; and (2) to identify the role of context as it influences the implementation of CAPA and resulting client and system outcomes.

METHODS AND ANALYSIS

We will conduct a realist-informed scoping review of the literature related to CAPA in either child and adolescent or adult community mental health and addictions services. Relevant studies, reports and documentation will be identified by searching the following online databases: MEDLINE, Embase, CINAHL, PsycINFO, Academic Search Premier, ERIC, Web of Science, Cochrane, Dissertations Abstracts, NCBI Bookshelf, PubMed Central and the Canadian Health Research Collection. The search strategy was developed by a health sciences library scientist and informed by a multidisciplinary team comprising methodological and content knowledge experts. The search will gather evidence from multiple online databases of peer-reviewed literature and grey literature repositories. All articles will be independently assessed for inclusion by pairs of reviewers. The key themes derived from a thematic analysis of extracted data will be presented in a narrative overview.

ETHICS AND DISSEMINATION

Research ethics review is not required for this scoping review. The results will be disseminated through meetings with stakeholders (including clients and families, clinicians and decision-makers), conference presentations and peer-reviewed publication. The results of this review will inform an overarching programme of research, policy and quality indicator development to ultimately improve mental health and addictions care and subsequent mental health outcomes for children and adolescents.

A global call to action to improve the care of people with fragility fractures

The ageing of society is driving an enormous increase in fragility fracture incidence and imposing a massive burden on patients, their families, health systems and societies globally. Disrupting the status quo has therefore become an obligation and a necessity. Initiated by the Fragility Fracture Network (FFN) at a "Presidents' Roundtable" during the 5th FFN Global Congress in 2016 several leading organisations agreed that a global multidisciplinary and multiprofessional collaboration, resulting in a Global Call to Action (CtA), would be the right step forward to improve the care of people presenting with fragility fractures. So far global and regional organisations in geriatrics/internal medicine, orthopaedics, osteoporosis/metabolic bone disease, rehabilitation and rheumatology were contacted as well as national organisations in five highly populated countries (Brazil, China, India, Japan and the United States), resulting in 81societies endorsing the CtA. We call for implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay. There is an urgent need to improve: To address this fragility fracture crisis, the undersigned organisations pledge to intensify their efforts to improve the current management of all fragility fractures, prevent subsequent fractures, and strive to restore functional abilities and quality of life.

Relationships between Neighborhood Walkability and Objectively Measured Physical Activity Levels in Hemodialysis Patients

BACKGROUND/AIMS

Neighborhood walkability is associated with indicators of health in the general population. We explored the association between neighborhood walkability and daily steps in hemodialysis (HD) patients.

METHODS

We measured daily steps over 5 weeks using Fitbit Flex (Fitbit, San Francisco, CA, USA) and retrieved Walk Score® (WS) data by patient's home ZIP code (www.walkscore.com; 0 = poorest walkability; 100 = greatest walkability).

RESULTS

HD patients took a mean of 6,393 ± 3,550 steps/day (n = 46). Median WS of the neighborhood where they resided was 28. Patients in an above-median WS (n = 27) neighborhood took significantly more daily steps compared to those (n = 19) in a below-median WS neighborhood (7,514 ± 3,900 vs. 4,800 ± 2,228 steps/day; p < 0.001, t test). Daily steps and WS were directly correlated (R = 0.425; p = 0.0032, parametric test; R = 0.359, p = 0.0143, non-parametric test).

CONCLUSION

This is the first study conducted among HD patients to indicate a direct relationship between neighborhood walkability and the actual steps taken. These results should be considered when designing initiatives to increase and improvise exercise routines in HD populations.

Measuring Patient-Reported Outcomes in Rhinoplasty Using the FACE-Q: A Single Site Study

Rhinoplasty is one of the most popular surgical cosmetic treatments. Measuring the appearance of the nose has typically involved the use of observer- or surgeon-reported outcome measures (e.g., photographs). While objective outcomes are important, facial appearance is subjective, and therefore outcome assessment should incorporate the patient perspective through the use of patient-reported outcome measures. This study aims to explore relationships between FACE-Q scales scores and measuring adverse effects and change 4 months after surgery in a United Kingdom sample. A questionnaire booklet was completed by patients seeking rhinoplasty between March 2014 and March 2015. The study was conducted at a facial plastic surgery clinic office in London, United Kingdom. Pre- and postoperative rhinoplasty patients aged 19 years and older participated in the study. FACE-Q scales/checklist was utilized for the study. A total of 54 preoperative patients completed seven FACE-Q scales. Before surgery, characteristics of the nose that our sample at least satisfied (i.e., at the harder end of the clinical hierarchy) included the tip of the nose, and how the nose looked in photos and from different angles. In preoperative participants, lower scores for satisfaction with nose and/or nostrils correlated with lower satisfaction with facial appearance and appearance-related psychosocial distress. Participants (N = 13) who had surgery reported significant improvement in satisfaction with the nose, nostrils, and facial appearance overall, and improved psychological and social function. Standardized response means ranged from 0.65 (social function) to 1.55 (facial appearance). The FACE-Q rhinoplasty module can be used in clinical practice, research, and quality improvement to incorporate the patient perspective of appearance in outcome assessments. The level of evidence is defined as level III (diagnostic).

Low-intensity pulsed ultrasound does not influence bone healing by distraction osteogenesis: a multicentre double-blind randomised control trial

AIMS

The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis.

PATIENTS AND METHODS

A total of 62 adult patients undergoing limb lengthening or bone transport by distraction osteogenesis were randomised to treatment with either an active (n = 32) or a placebo (n = 30) ultrasound device. A standardised corticotomy was performed in the proximal tibial metaphysis and a circular Ilizarov frame was used in all patients. The rate of distraction was also standardised. The primary outcome measure was the time to removal of the frame after adjusting for the length of distraction in days/cm for both the per protocol (PP) and the intention-to-treat (ITT) groups. The assessor was blinded to the form of treatment. A secondary outcome was to identify covariates affecting the time to removal of the frame.

RESULTS

There was no difference in the time to removal of the frame between the PP (difference in favour of the control group was 10.1 days/cm, 95% confidence interval (CI) -3.2 to 23.4, p = 0.054) or ITT (difference 5.0 days/cm, 95% CI -8.2 to 18.21, p = 0.226) groups. The smoking status was the only covariate which increased the time to removal of the frame (hazard ratio 0.47, 95% CI 0.22 to 0.97, p = 0.042).

CONCLUSION

LIPUS does not influence the rate of bone healing in patients who undergo distraction osteogenesis. Smoking may influence bone healing. Cite this article: Bone Joint J 2017;99-B:494-502.

Physical Activity and Sleep Patterns in Hemodialysis Patients in a Suburban Environment

Background/Aims: Hemodialysis (HD) patients are less active than their healthy counterparts. They are often plagued with sleep disorders that affect the quality of their sleep. Our aim was to objectively quantify activity and sleep quality among HD patients in a suburban HD population. Methods: Activity and sleep parameters were measured using a commercially available activity tracker in 29 HD patients from Baton Rouge, LA, USA. Patients in the feedback group received their activity and sleep data at each dialysis treatment. In addition, questionnaires were administered at the beginning and end of the study period. Patients were stratified based on activity levels and sleep quality. Results: Patients walked an average of 5,281 steps/day and slept 370.5 min/night. Informing patients about their daily number of steps taken, did not increase activity. Only 3% of the population followed were active, defined as walking more than 10,000 steps per day. Patients walked significantly less on dialysis days compared to the other days of the week. Many of the patients experienced poor sleep quality, with patients in the first shift experiencing the greatest disturbance to their sleep/wake cycle. Conclusion: Patients in a suburban environment walked much less than those in a previously studied urban population. They rarely met the recommended goal of 10,000 steps/day, even on non-dialysis days. Interventions to increase physical activity may target any day of the week, particularly HD days. Prospective, long-term studies are needed to evaluate the use of activity trackers in dialysis patients and their impact on physical activity.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Singular Aspects of General Planar Motions with Two Degrees of Freedom

General planar motions with two degrees of freedom differ funda mentally from those with one degree of freedom, in that they may exhibit "cross-caps" singularities. At such singularities the trajec tories fail to exhibit four of the generic singularity types normally associated with such motions, namely, lips, beaks, and two of their degenerations. Provided cross-caps are avoided, the union of the bifurcation curves associated with the lips and beaks types are char acterized kinematically as envelopes of a two-parameter family of instantaneous singular lines. In the special class of composite planar motions, these lines are described in terms of the classical instanta neous centers of the constituent motions with 1 DOF, and it is shown that not all generic singularity types can appear on the trajectories. Computer-generated pictures illustrate the theory for examples of rational motions.

Modern use of smartphone applications in the perioperative management in microsurgical breast reconstruction

BACKGROUND

Advances in mobile telecommunication, improved mobile internet and affordability have led to a significant increase in smartphone use within medicine. The capability of instant messaging, photography, videography, word processing, drawing and internet access allow significant potential in this small portable device. Smartphone use within medicine has grown tremendously worldwide given its affordability, improved internet and capabilities.

METHODS

We have searched for apps specifically helpful in the perioperative care of microsurgical breast reconstructive patients.

RESULTS

The useful apps have been subdivided: (I) communication apps-multimedia messaging, WhatsApp, PicSafeMedi: allow efficient communication via text, picture and video messages leading to earlier assessment and definitive management of free flaps; (II) storage apps-Notability, Elogbook: electronic storage of patient notes and logbooks of case which can be shared with others if required; (III) educational apps-FlapApp, Touch Surgery, PubMed on tap: step by step guides to surgical procedures to aid learning and medical journal database; (IV) flap monitoring app-SilpaRamanitor: free flap monitoring app based on photographic analysis for earlier detection of compromised flaps.

CONCLUSIONS

There has been remarkable growth in smartphones use among surgeons. Apps are being developed for every conceivable use. The future will be in wearable smart devices that allow continuous monitoring with the potential to instigate change should deviations from the norm occur. The smart watch is the start of this digital revolution.

Assessment of the long-term impacts of PM10 and PM2.5 particles from construction works on surrounding areas

Construction activities are common across cities; however, the studies assessing their contribution to airborne PM10 (≤10 μm) and PM2.5 (≤2.5 μm) particles on the surrounding air quality are limited. Herein, we assessed the impact of PM10 and PM2.5 arising from construction works in and around London. Measurements were carried out at 17 different monitoring stations around three construction sites between January 2002 and December 2013. Tapered element oscillating microbalance (TEOM 1400) and OSIRIS (2315) particle monitors were used to measure the PM10 and PM2.5 fractions in the 0.1-10 μm size range along with the ambient meteorological data. The data was analysed using bivariate concentration polar plots and k-means clustering techniques. Daily mean concentrations of PM10 were found to exceed the European Union target limit value of 50 μg m(-3) at 11 monitoring stations but remained within the allowable 35 exceedences per year, except at two monitoring stations. In general, construction works were found to influence the downwind concentrations of PM10 relatively more than PM2.5. Splitting of the data between working (0800-1800 h; local time) and non-working (1800-0800 h) periods showed about 2.2-fold higher concentrations of PM10 during working hours when compared with non-working hours. However, these observations did not allow to conclude that this increase was from the construction site emissions. Together, the polar concentration plots and the k-means cluster analysis applied to a pair of monitoring stations across the construction sites (i.e. one in upwind and the other in downwind) confirmed the contribution of construction sources on the measured concentrations. Furthermore, pairing the monitoring stations downwind of the construction sites showed a logarithmic decrease (with R(2) about 0.9) in the PM10 and PM2.5 concentration with distance. Our findings clearly indicate an impact of construction activities on the nearby downwind areas and a need for developing mitigation measures to limit their escape from the construction sites.

FRAX-based assessment and intervention thresholds--an exploration of thresholds in women aged 50 years and older in the UK

Under current guidelines, based on prior fracture probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold (a fixed threshold from the age of 70 years) reduces this disparity, increases treatment access and decreases the need for bone densitometry.

INTRODUCTION

Several international guidelines set age-specific intervention thresholds at the 10-year probability of fracture equivalent to a woman of average BMI with a prior fracture. At older ages (≥70 years), women with prior fracture selected for treatment are at lower average absolute risk than those selected for treatment in the absence of prior fracture, prompting consideration of alternative thresholds in this age group.

METHODS

Using a simulated population of 50,633 women aged 50-90 years in the UK, with a distribution of risk factors similar to that in the European FRAX derivation cohorts and a UK-matched age distribution, the current NOGG intervention and assessment thresholds were compared to one where the thresholds remained constant from 70 years upwards.

RESULTS

Under current thresholds, 45.1% of women aged ≥70 years would be eligible for therapy, comprising 37.5% with prior fracture, 2.2% with high risk but no prior fracture and 5.4% selected for treatment after bone mineral density (BMD) measurement. Mean hip fracture probability was 11.3, 23.3 and 17.6%, respectively, in these groups. Under the alternative thresholds, the overall proportion of women treated increased from 45.1 to 52.9%, with 8.4% at high risk but no prior fracture and 7.0% selected for treatment after BMD measurement. In the latter group, the mean probability of hip fracture was identical to that observed in women with prior fracture (11.3%). The alternative threshold also reduced the need for BMD measurement, particularly at older ages (>80 years).

CONCLUSIONS

The alternative thresholds equilibrate fracture risk, particularly hip fracture risk, in those with or without prior fracture selected for treatment and reduce BMD usage at older ages.

Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle

The International Osteoporosis Foundation (IOF) Capture the Fracture Campaign aims to support implementation of Fracture Liaison Services (FLS) throughout the world.

INTRODUCTION

FLS have been shown to close the ubiquitous secondary fracture prevention care gap, ensuring that fragility fracture sufferers receive appropriate assessment and intervention to reduce future fracture risk.

METHODS

Capture the Fracture has developed internationally endorsed standards for best practice, will facilitate change at the national level to drive adoption of FLS and increase awareness of the challenges and opportunities presented by secondary fracture prevention to key stakeholders. The Best Practice Framework (BPF) sets an international benchmark for FLS, which defines essential and aspirational elements of service delivery.

RESULTS

The BPF has been reviewed by leading experts from many countries and subject to beta-testing to ensure that it is internationally relevant and fit-for-purpose. The BPF will also serve as a measurement tool for IOF to award 'Capture the Fracture Best Practice Recognition' to celebrate successful FLS worldwide and drive service development in areas of unmet need. The Capture the Fracture website will provide a suite of resources related to FLS and secondary fracture prevention, which will be updated as new materials become available. A mentoring programme will enable those in the early stages of development of FLS to learn from colleagues elsewhere that have achieved Best Practice Recognition. A grant programme is in development to aid clinical systems which require financial assistance to establish FLS in their localities.

CONCLUSION

Nearly half a billion people will reach retirement age during the next 20 years. IOF has developed Capture the Fracture because this is the single most important thing that can be done to directly improve patient care, of both women and men, and reduce the spiralling fracture-related care costs worldwide.

Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013

Since the launch in 2008 by the National Osteoporosis Guideline Group (NOGG), of guidance for the diagnosis and management of osteoporosis in postmenopausal women and older men in the UK there have been significant advances in risk assessment and treatment. These have been incorporated into an updated version of the guideline, with an additional focus on the management of glucocorticoid-induced osteoporosis, the role of calcium and vitamin D therapy and the benefits and risks of long-term bisphosphonate therapy. The updated guideline is summarised below. The recommendations in the guideline are intended to aid management decisions but do not replace the need for clinical judgement in the care of individuals in clinical practice.

Balloon kyphoplasty compared to vertebroplasty and nonsurgical management in patients hospitalised with acute osteoporotic vertebral compression fracture: a UK cost-effectiveness analysis

The purpose of the study was to estimate the cost-effectiveness of balloon kyphoplasty compared to nonsurgical management and vertebroplasty for the treatment of hospitalised osteoporotic vertebral compression fractures in the UK. A cost-effectiveness model was constructed and used for analysis. Balloon kyphoplasty may be cost-effective compared to relevant alternatives.

INTRODUCTION

The objective of this study was to estimate the cost-effectiveness of balloon kyphoplasty (BKP) for the treatment of patients hospitalised with acute osteoporotic vertebral compression fracture (OVCF) compared to percutaneous vertebroplasty (PVP) and nonsurgical management (NSM) in the UK.

METHODS

A Markov simulation model was developed to evaluate treatment with BKP, NSM and PVP in patients with symptomatic OVCF. Data on health-related quality of life (HRQoL) with acute OVCF were derived from the FREE and VERTOS II randomised clinical trials (RCTs) and normalised to the NSM arm in the FREE trial. Estimated differences in mortality among the treatments and costs for NSM were obtained from the literature whereas procedure costs for BKP and PVP were obtained from three National Health Service hospitals. It was assumed that BKP and PVP reduced hospital length of stay by 6 days compared to NSM.

RESULTS

The incremental cost-effectiveness ratio was estimated at Great Britain Pound Sterling (GBP) 2,706 per quality-adjusted life year (QALY) and GBP 15,982 per QALY compared to NSM and PVP, respectively. Sensitivity analysis showed that the cost-effectiveness of BKP vs. NSM was robust when mortality and HRQoL benefits with BKP were varied. The cost-effectiveness of BKP compared to PVP was particularly sensitive to changes in the mortality benefit.

CONCLUSION

BKP may be a cost-effective strategy for the treatment of patients hospitalised with acute OVCF in the UK compared to NSM and PVP. Additional RCT data on the benefits of BKP and PVP compared to simulated sham surgery and further data on the mortality benefits with BKP compared to NSM and PVP would reduce uncertainty.

Balloon kyphoplasty and vertebroplasty in the management of vertebral compression fractures

Vertebral compression fractures (VCFs) are the most prevalent fractures in osteoporotic patients. The classical conservative management of these fractures is through rest, pain medication, bracing and muscle relaxants. The aim of this paper is to review prospective controlled studies comparing the efficacy and safety of minimally invasive techniques for vertebral augmentation, vertebroplasty (VP) and balloon kyphoplasty (BKP), versus non-surgical management (NSM). The Fracture Working Group of the International Osteoporosis Foundation conducted a literature search and developed a review paper on VP and BKP. The results presented for the direct management of osteoporotic VCFs focused on clinical outcomes of these three different procedures, including reduction in pain, improvement of function and mobility, vertebral height restoration and decrease in spinal curvature (kyphosis). Overall, VP and BKP are generally safe procedures that provide quicker pain relief, mobility recovery and in some cases vertebral height restoration than conventional conservative medical treatment, at least in the short term. However, the long-term benefits and safety in terms of risk of subsequent vertebral fractures have not been clearly demonstrated and further prospective randomized studies are needed with standards for reporting. Referral physicians should be aware of VP/BKP and their potential to reduce the health impairment of patients with VCFs. However, VP and BKP are not substitutes for appropriate evaluation and treatment of osteoporosis to reduce the risk of future fractures.

Coordinator-based systems for secondary prevention in fragility fracture patients

The underlying causes of incident fractures--bone fragility and the tendency to fall--remain under-diagnosed and under-treated. This care gap in secondary prevention must be addressed to minimise both the debilitating consequences of subsequent fractures for patients and the associated economic burden to healthcare systems. Clinical systems aimed at ensuring appropriate management of patients following fracture have been developed around the world. A systematic review of the literature showed that 65% of systems reported include a dedicated coordinator who acts as the link between the orthopaedic team, the osteoporosis and falls services, the patient and the primary care physician. Coordinator-based systems facilitate bone mineral density testing, osteoporosis education and care in patients following a fragility fracture and have been shown to be cost-saving. Other success factors included a fracture registry and a database to monitor the care provided to the fracture patient. Implementation of such a system requires an audit of existing arrangements, creation of a network of healthcare professionals with clearly defined roles and the identification of a 'medical champion' to lead the project. A business case is needed to acquire the necessary funding. Incremental, achievable targets should be identified. Clinical pathways should be supported by evidence-based recommendations from national or regional guidelines. Endorsement of the proposed model within national healthcare policies and advocacy programmes can achieve alignment of the objectives of policy makers, professionals and patients. Successful transformation of care relies upon consensus amongst all participants in the multi-disciplinary team that cares for fragility fracture patients.

Stromal features are predictive of disease mortality in oral cancer patients

Worldwide, approximately 405 000 cases of oral cancer (OSCC) are diagnosed each year, with a rising incidence in many countries. Despite advances in surgery and radiotherapy, which remain the standard treatment options, the mortality rate has remained largely unchanged for decades, with a 5-year survival rate of around 50%. OSCC is a heterogeneous disease, staged currently using the TNM classification, supplemented with pathological information from the primary tumour and loco-regional lymph nodes. Although patients with advanced disease show reduced survival, there is no single pathological or molecular feature that identifies aggressive, early-stage tumours. We retrospectively analysed 282 OSCC patients for disease mortality, related to clinical, pathological, and molecular features based on our previous functional studies [EGFR, αvβ6 integrin, smooth muscle actin (SMA), p53, p16, EP4]. We found that the strongest independent risk factor of early OSCC death was a feature of stroma rather than tumour cells. After adjusting for all factors, high stromal SMA expression, indicating myofibroblast transdifferentiation, produced the highest hazard ratio (3.06, 95% CI 1.65-5.66) and likelihood ratio (3.6; detection rate: false positive rate) of any feature examined, and was strongly associated with mortality, regardless of disease stage. Functional assays showed that OSCC cells can modulate myofibroblast transdifferentiation through αvβ6-dependent TGF-β1 activation and that myofibroblasts promote OSCC invasion. Finally, we developed a prognostic model using Cox regression with backward elimination; only SMA expression, metastasis, cohesion, and age were significant. This model was independently validated on a patient subset (detection rate 70%; false positive rate 20%; ROC analysis 77%, p < 0.001). Our study highlights the limited prognostic value of TNM staging and suggests that an SMA-positive, myofibroblastic stroma is the strongest predictor of OSCC mortality. Whether used independently or as part of a prognostic model, SMA identifies a significant group of patients with aggressive tumours, regardless of disease stage.

Betel-derived alkaloid up-regulates keratinocyte alphavbeta6 integrin expression and promotes oral submucous fibrosis

Oral submucous fibrosis (OSF) is a premalignant, fibrosing disorder of the mouth, pharynx, and oesophagus, with a malignant transformation rate of 7-13%. OSF is strongly associated with areca (betel) nut chewing and worldwide, over 5 million people are affected. As αvβ6 integrin is capable of promoting both tissue fibrosis and carcinoma invasion, we examined its expression in fibroepithelial hyperplasia and OSF. αvβ6 was markedly up-regulated in OSF, with high expression detected in 22 of 41 cases (p < 0.001). We investigated the functional role of αvβ6 using oral keratinocyte-derived cells genetically modified to express high αvβ6 (VB6), and also NTERT-immortalized oral keratinocytes, which express low αvβ6 (OKF6/TERT-1). VB6 cells showed significant αvβ6-dependent activation of TGF-β1, which induced transdifferentiation of oral fibroblasts into myofibroblasts and resulted in up-regulation of genes associated with tissue fibrosis. These experimental in vitro findings were confirmed using human clinical samples, where we showed that the stroma of OSF contained myofibroblasts and that TGF-β1-dependent Smad signalling was detectable both in keratinocytes and in myofibroblasts. We also found that arecoline, the major alkaloid of areca nuts, up-regulated keratinocyte αvβ6 expression. This was modulated through the M(4) muscarinic acetylcholine receptor and was suppressed by the M(4) antagonist, tropicamide. Arecoline-dependent αvβ6 up-regulation promoted keratinocyte migration and induced invasion, raising the possibility that this mechanism may support malignant transformation. Over 80% of OSF-related oral cancers examined had moderate/high αvβ6 expression. These data suggest that the pathogenesis of OSF may be epithelial-driven and involve arecoline-dependent up-regulation of αvβ6 integrin.

Cost-effectiveness of balloon kyphoplasty in patients with symptomatic vertebral compression fractures in a UK setting

SUMMARY

Balloon kyphoplasty (BKP) is a procedure used to treat vertebral compression fractures (VCFs). We developed a cost-effectiveness model to evaluate BKP in United Kingsdom patients with hospitalised VCFs and estimated the cost-effectiveness of BKP compared to non-surgical management. The results indicate that BKP provides a cost-effective alternative for treating these patients.

INTRODUCTION

VCFs of osteoporotic patients are associated with chronic pain, a reduction in health-related quality of life (QoL) and high healthcare costs. BKP is a minimally invasive procedure that has resulted in pain relief, vertebral body height-restoration, decreased kyphosis and improved physical functioning in patients with symptomatic VCFs. BKP was shown to improve health-related QoL in a 12-month interim analysis of a randomised phase-III trial.

METHODS

The objectives of this study were to develop a Markov cost-effectiveness model to evaluate BKP in patients with painful hospitalised VCFs and to estimate the cost-effectiveness of BKP compared with non-surgical management in a UK setting. It was assumed that QoL-benefits found at 12 months linearly approached zero during another 2 years, and that patients receiving BKP warranted six fewer hospital bed days compared with patients given non-surgical management.

RESULTS

The procedure was associated with quality-adjusted life-years (QALY)-gains of 0.17 and cost/QALY-gains at 8,800 pound sterling. The results were sensitive to assumptions about avoided length of hospital-stay and persistence of kyphoplasty-related QoL-benefits.

CONCLUSION

In conclusion, the results indicate that BKP provides a cost-effective alternative for treating patients with hospitalised VCFs in a UK-setting.

Binary phase diagram of hydrated dimyristoylglycerol-dimyristoylphosphatidylcholine mixtures

The thermotropic phase behavior of binary mixtures of dimyristoylphosphatidylcholine with dimyristoyl glycerol (DMPC-DMG) has been studied in aqueous dispersion by using differential scanning calorimetry and spin label electron spin resonance spectroscopy. Phase identifications have been made by means of (31)P nuclear magnetic resonance spectroscopy and x-ray diffraction. The binary phase diagram of DMPC-DMG mixtures displays three regions corresponding to the existence of compounds (C1 and C2, respectively) with approximately 1:1 and 1:2 mol/mol DMPC:DMG stoichiometries. The first region displays immiscibility between DMPC and C1 in the low temperature lamellar phase and miscibility of the components in the fluid phase that is lamellar. The second region displays immiscibility between C1 and C2 in the low temperature phase that is lamellar, whereas the fluid phase is of the inverted hexagonal type (H(II)). The third region displays immiscibility between C2 and DMG in the low temperature phase that is lamellar, whereas the fluid phase is isotropic. The presence of immiscible DMG in the low temperature phase of the third region is indicated by hysteresis in the temperature scans corresponding to conversion between the stable and metastable crystalline polymorphs. Analysis of the first region of the phase diagram using regular solution theory further demonstrates the existence of a DMPC:DMG complex with approximately 1:1 stoichiometry and provides parameters for the nonideality of mixing in the fluid phase.

Distance measurements using paramagnetic ion-induced relaxation in the saturation transfer electron spin resonance of spin-labeled biomolecules: Application to phospholipid bilayers and interdigitated gel phases

The saturation transfer electron spin resonance (STESR) spectra of spin-labeled phosphatidylcholines in gel phase lipid bilayers are shown to be sensitive to dipolar spin-spin interactions with paramagnetic ions in the aqueous phase. The reciprocal integrated intensity of the STESR spectrum is linearly dependent on aqueous Ni(2+) ion concentration, hence, confirming the expectation that the STESR intensity is directly proportional to the spin-lattice relaxation time of the spin label. The gradient of the relaxation rate with respect to Ni(2+) ion concentration decreases strongly with the position of the nitroxide group down the sn-2 chain of the spin-labeled lipid and is consistent with a 1/R(3) dependence on the distance, R, from the bilayer surface. The values derived for the dimensions of the bilayer and lipid molecules in the case of dipalmitoyl phosphatidylcholine (DPPC) are in good agreement with those available from x-ray diffraction studies. Allowance for the multibilayer nature of the DPPC dispersions gives an estimate of the water layer thickness that is also consistent with results from x-ray diffraction. The profile of the paramagnetic ion-induced relaxation is drastically changed with DPPC dispersions in glycerol for which the lipid chains are known to be interdigitated in the gel phase. The terminal methyl groups of the lipid chains are located approximately in register with the C-3 atoms of the sn-2 chain of the oppositely oriented lipid molecules in the interdigitated phase. The thickness of the lipid layer and the effective thickness of the lipid polar group are reduced by approximately 40% in the interdigitated phase as compared with the bilayer phase. The calibrations of the distance dependence established by use of spin labels at defined chain positions should be applicable to STESR measurements on other biological systems.

Kinetics and dynamics of annealing during sub-gel phase formation in phospholipid bilayers: A saturation transfer electron spin resonance study

The saturation transfer electron spin resonance (STESR) spectra of spin-labeled phosphatidylcholine have been used to follow the kinetics of conversion from the gel phase to the sub-gel phase in aqueous bilayers of dipalmitoyl phosphatidylcholine. This is a simple, well-defined model system for lipid domain formation in membranes. The integrated intensity of the STESR spectrum from the chain-labeled lipid first increases and then decreases with time of incubation in the gel phase at 0 degrees C. The first, more rapid phase of the kinetics is attributed to the conversion of germ nuclei to growth nuclei of the sub-gel phase. The increase in STESR intensity corresponds to the reduction in chain mobility of spin labels located in the gel phase at the boundaries of the growth nuclei and correlates with the increase in the diagnostic STESR line height ratios over this time range. The second, slower phase of the kinetics is attributed to growth of the domains of the sub-gel phase. The decrease in STESR intensity over this time regime corresponds to exclusion of the spin-labeled lipids from the tightly packed sub-gel phase and correlates quantitatively with calibrations of the spin label concentration dependence of the STESR intensity in the gel phase. The kinetics of formation of the sub-gel phase are consistent with the classical model for domain formation and growth. At 0 degrees C, the half-time for conversion of germ nuclei to growth nuclei is approximately 7.7 h and domain growth of the sub-gel phase is characterized by a rate constant of 0.025 h(-1). The temperature dependence of the STESR spectra from samples annealed at 0 degrees C suggests that the subtransition takes place via dissolution of sub-gel phase domains, possibly accompanied by domain fission.

Analysis of the bilayer phase transition temperatures of phosphatidylcholines with mixed chains

The analysis of the chain-length dependence of the chain-melting transition temperatures of bilayers composed of lipids with identical chains (Marsh, D. 1991. Biochim. Biophys. Acta. 1062: 1-6) is extended to include lipids with chains of unequal length. The bilayer transition temperatures of saturated asymmetrical phosphatidylcholines are interpreted by assuming that the transition enthalpy and transition entropy are linearly related to the absolute value of the difference in chain length between the sn-1 and sn-2 chains, with constant end contributions. Such an assumption is supported by calorimetric data on phosphatidylcholines of constant mean chainlength and varying chain asymmetry. In particular, a symmetrical linear dependence is observed on the chain asymmetry, Deltan, which is centered around a value Deltan degrees that corresponds to the conformational inequivalence of the sn-1 and sn-2 chains. The transition temperature then takes the form: T(t) = T(t) (infinity)(n - n(H) - h' Deltan + Deltan degrees )/(n - n(s) - s' Deltan + Deltan degrees ) where n(H), n(s) are the end contributions, and h', s' are fractional deficits in the incremental transition enthalpy and entropy, respectively, arising from the overlapping regions of the longer chains. Optimization on the transition temperature data for the dependence on chain asymmetry of three series of phosphatidylcholines with constant mean chainlength, n, yields parameters that are capable of predicting the dependence of the transition temperatures on chain asymmetry for other mean chainlengths. The dependence of the transition temperature on mean chainlength for phosphatidylcholines in which the chain asymmetry is maintained constant, as well as the dependence on both mean chain length and chain asymmetry for phosphatidylcholines in which one of the two chains is maintained of constant length, are also described with high accuracy by using the same parameters.

Evidence for anti-osteoporosis therapy in acute fracture situations--recommendations of a multidisciplinary workshop of the International Society for Fracture Repair

The International Society for Fracture Repair convened a multidisciplinary workshop to assess the current evidence around the interaction between anti-osteoporosis drugs and the healing of incident fractures, with a view to making recommendations for clinical practice. The consensus was that there is no evidence-based reason to withhold anti-resorptive therapy while a fracture heals, whether or not the patient was taking such therapy when the fracture occurred. The workshop also considered existing models of service provision for secondary prevention and concluded that the essential ingredient for reliable delivery is the inclusion of a dedicated coordinator role. Several unresolved issues were defined as subjects for further research, including the question of whether continuous long-term administration of anti-resorptives may impair bone quality. The rapidly changing area requires re-assessment of drugs and their interaction with fracture healing in the near future.

Cervical range of movement in relation to neck dimension

The authors investigated the effect of neck dimension upon cervical range of motion. Data relating to 100 healthy subjects, aged between 20 and 40 years, were recorded with respect to age, gender and range of motion in three planes. Additionally, two widely used methods of measuring neck motion, chin-sternal distance and uniplanar goniometer, were assessed against a validated measurement tool, the 'CROM goniometer'. Using multiple linear regression analysis it was determined that sagittal flexion (P = 0.002) and lateral rotation (P < 0.0001) were most closely related to neck circumference alone whereas lateral flexion (P < 0.0001) was most closely related to a ratio of circumference and length of neck. Hence, assessing cervical range of motion as outcome variable or as a measure at posttreatment follow-up, neck circumference was shown to be one of the factors influencing total neck motion, particularly sagittal flexion and lateral tilt. Comparison of cervical range of motion assessed with a validated measurement tool, the CROM goniometer, with results of both frequently applied clinician's instruments, the uniplanar goniometer and measurement of chin-sternal distance, showed low reliability with the latter techniques, and motion values measured with these techniques should be interpreted with caution if using them for comparison of cervical range of motion of alike groups. We demonstrated that neck dimension should be incorporated into cervical functional outcome assessment and one should be wary about recorded values for neck motion from non-validated measurement tools.

Intramembrane water associated with TOAC spin-labeled alamethicin: electron spin-echo envelope modulation by D2O

Alamethicin is a 20-residue, hydrophobic, helical peptide, which forms voltage-sensitive ion channels in lipid membranes. The helicogenic, nitroxyl amino acid TOAC was substituted isosterically for Aib at residue positions 1, 8, or 16 in a F50/5 alamethicin analog to enable EPR studies. Electron spin-echo envelope modulation (ESEEM) spectroscopy was used to investigate the water exposure of TOAC-alamethicin introduced into membranes of saturated or unsaturated diacyl phosphatidylcholines that were dispersed in D2O. Echo-detected EPR spectra were used to assess the degree of assembly of the peptide in the membrane, via the instantaneous diffusion from intermolecular spin-spin interactions. The profile of residue exposure to water differs between membranes of saturated and unsaturated lipids. In monounsaturated dioleoyl phosphatidylcholine, D2O-ESEEM intensities decrease from TOAC(1) to TOAC(8) and TOAC(16) but not uniformly. This is consistent with a transmembrane orientation for the protoassembled state, in which TOAC(16) is located in the bilayer leaflet opposite to that of TOAC(1) and TOAC(8). Relative to the monomer in fluid bilayers, assembled alamethicin is disposed asymmetrically about the bilayer midplane. In saturated dimyristoyl phosphatidylcholine, the D2O-ESEEM intensity is greatest for TOAC(8), indicating a more superficial location for alamethicin, which correlates with the difference in orientation between gel- and fluid-phase membranes found by conventional EPR of TOAC-alamethicin in aligned phosphatidylcholine bilayers. Increasing alamethicin/lipid ratio in saturated phosphatidylcholine shifts the profile of water exposure toward that with unsaturated lipid, consistent with proposals of a critical concentration for switching between the two different membrane-associated states.

The morbidity of the button-over-nail technique for zone 1 flexor tendon repairs. Should we still be using this technique?

The button-over-nail technique is commonly used to fix the core suture to the distal phalanx for flexor digitorum profundus repairs in zone 1. We report a retrospective study of 23 consecutive patients who had a repair of the flexor digitorum profundus tendon in zone 1 using the button-over-nail technique. Fifteen patients experienced a complication, of which ten were directly related to the button-over-nail technique. Complications included nail deformities, fixed flexion deformities of the distal interphalangeal joint, infections and prolonged hypersensitivity. Two patients required amputation of the fingertip. We recommend that the button-over-nail technique should be avoided or used only with caution and with close attention to the details of the technique.

Protein-lipid interactions with Fusobacterium nucleatum major outer membrane protein FomA: spin-label EPR and polarized infrared spectroscopy

FomA, the major outer membrane protein of Fusobacterium nucleatum, was expressed and purified in Escherichia coli and reconstituted from detergent in bilayer membranes of phosphatidylcholines with chain lengths from C(12:0) to C(17:0). The conformation and orientation of membrane-incorporated FomA were determined from polarized, attenuated total reflection, infrared (IR) spectroscopy, and lipid-protein interactions with FomA were characterized by using electron paramagnetic resonance (EPR) spectroscopy of spin-labeled lipids. Approximately 190 residues of membranous FomA are estimated to be in a beta-sheet configuration from IR band fitting, which is consistent with a 14-strand transmembrane beta-barrel structure. IR dichroism of FomA indicates that the beta-strands are tilted by approximately 45 degrees relative to the sheet/barrel axis and that the order parameter of the latter displays a discontinuity corresponding to hydrophobic matching with fluid C(13:0) lipid chains. The stoichiometry ( N b = 23 lipids/monomer) of lipid-protein interaction from EPR demonstrates that FomA is not trimeric in membranes of diC(14:0) phosphatidylcholine and is consistent with a monomeric beta-barrel of 14-16 strands. The pronounced selectivity of interaction found with anionic spin-labeled lipids places basic residues of the protein in the vicinity of the polar-apolar membrane interfaces, consistent with current topology models. Comparison with similar data from the 8- to 22-stranded E. coli outer membrane proteins, OmpA, OmpG, and FhuA, supports the above conclusions.

alpha vbeta 6 Integrin promotes the invasion of morphoeic basal cell carcinoma through stromal modulation

Basal cell carcinoma (BCC) is the most prevalent cancer in the Western world and its incidence is increasing. The pathogenesis of BCC involves deregulated Sonic hedgehog signaling, leading to activation of the Gli transcription factors. Most BCCs have a nodular growth pattern, and are indolent, slow-growing, and considered "low-risk" lesions. In contrast, the "high-risk" morphoeic variant, which causes significant morbidity, has an infiltrative growth pattern, and is so-called because of its densely fibrous stroma. As alpha v beta 6 is capable of promoting both carcinoma invasion and fibrosis, we examined the expression of this integrin in BCCs and found that the morphoeic type showed significantly higher alpha v beta 6 expression than the nodular type (P = 0.0009). In order to examine the function of alpha v beta 6, we transfected the transcription factors Gli1 or Gli2 into NTERT, human keratinocytes to generate a BCC model. These cells expressed alpha v beta 6 and were invasive, although inhibition of alpha v beta 6 had no direct effect on cell invasion. However, the cells showed alpha v beta 6-dependent activation of transforming growth factor-beta1, which induced transdifferentiation of human fibroblasts into myofibroblasts. Paracrine secretion of hepatocyte growth factor/scatter factor by these myofibroblasts promoted c-Met-dependent tumor invasion in both Transwell and three-dimensional organotypic assays. These experimental in vitro findings were confirmed using human clinical samples in which we showed that the stroma of morphoeic BCC is myofibroblast-rich compared with nodular BCC (P = 0.0036), that myofibroblasts express hepatocyte growth factor/scatter factor, and that morphoeic BCCs are strongly c-Met-positive. These data suggest that alpha v beta 6-dependent transforming growth factor-beta1 activation induces both the infiltrative growth pattern and fibrotic stroma so characteristic of morphoeic BCC.

Incorporation of outer membrane protein OmpG in lipid membranes: protein-lipid interactions and beta-barrel orientation

OmpG is an intermediate size, monomeric, outer membrane protein from Escherichia coli, with n beta = 14 beta-strands. It has a large pore that is amenable to modification by protein engineering. The stoichiometry ( N b = 20) and selectivity ( K r = 0.7-1.2) of lipid-protein interaction with OmpG incorporated in dimyristoyl phosphatidylcholine bilayer membranes was determined with various 14-position spin-labeled lipids by using EPR spectroscopy. The limited selectivity for different lipid species is consistent with the disposition of charged residues in the protein. The conformation and orientation (beta-strand tilt and beta-barrel order parameters) of OmpG in disaturated phosphatidylcholines of odd and even chain lengths from C(12:0) to C(17:0) was determined from polarized infrared spectroscopy of the amide I and amide II bands. A discontinuity in the protein orientation (deduced from the beta-barrel order parameters) is observed at the point of hydrophobic matching of the protein with lipid chain length. Compared with smaller (OmpA; n beta = 8) and larger (FhuA; n beta = 22) monomeric E. coli outer membrane proteins, the stoichiometry of motionally restricted lipids increases linearly with the number of beta-strands, the tilt (beta approximately 44 degrees ) of the beta-strands is comparable for the three proteins, and the order parameter of the beta-barrel increases regularly with n beta. These systematic features of the integration of monomeric beta-barrel proteins in lipid membranes could be useful for characterizing outer membrane proteins of unknown structure.

Microcomputed tomography imaging in a rat model of delayed union/non-union fracture

We aimed to develop a clinically relevant delayed union/non-union fracture model to evaluate a cell therapy intervention repair strategy. Histology, three-dimensional (3D) microcomputed tomography (micro-CT) imaging and mechanical testing were utilized to develop an analytical protocol for qualitative and quantitative assessment of fracture repair. An open femoral diaphyseal osteotomy, combined with periosteal diathermy and endosteal excision, was held in compression by a four pin unilateral external fixator. Three delayed union/non-union fracture groups established at 6 weeks--(a) a control group, (b) a cell therapy group, and (c) a group receiving phosphate-buffered saline (PBS) injection alone--were examined subsequently at 8 and 14 weeks. The histological response was combined fibrous and cartilaginous non-unions in groups A and B with fibrous non-unions in group C. Mineralized callus volume/total volume percentage showed no statistically significant differences between groups. Endosteal calcified tissue volume/endosteal tissue volume, at the center of the fracture site, displayed statistically significant differences between 8 and 14 weeks for cell and PBS intervention groups but not for the control group. The percentage load to failure was significantly lower in the control and cell treatment groups than in the PBS alone group. High-resolution micro-CT imaging provides a powerful tool to augment characterization of repair in delayed union/non-union fractures together with outcomes such as histology and mechanical strength measurement. Accurate, nondestructive, 3D identification of mineralization progression in repairing fractures is enabled in the presence or absence of intervention strategies.