Detecting and Locating the Site of Local Relapse Using 18F-PSMA-1007 Imaging After Primary Treatment of 135 Prostate Cancer Patients-Potential Impact on PSMA-Guided Radiation Therapy

PURPOSE

Due to limited imaging options, the visualization of a local relapse of prostate cancer used to pose a considerable challenge. However, since the integration of ¹⁸F-PSMA-1007-PET/CT into the clinic, a relapsed tumor can now easily be detected by hybrid imaging. The present study aimed to evaluate and map the allocate relapse in a large cohort of prostate cancer patients focusing on individual patient management conclusions for radiation therapy.

PROCEDURES

The current study included 135 men with prostate cancer after primary treatment who underwent ¹⁸F-PSMA-1007-PET/CT due to biochemical relapse detecting a local relapse. Imaging data were reassessed and analyzed with regard to relapse locations. For the correlation of tumor foci with clinical data, we used binary logistic regression models as well as the Kruskal-Wallis test and Mann-Whitney test.

RESULTS

In total, 69.6% of all patients (mean age: 65 years) underwent prostatectomy while 30.4% underwent radiation therapy. PET imaging detected most frequently a unifocal relapse (72.6%). There was a statistically significantly higher rate of ipsilateral cases among the relapsed tumors. Comparing both treatment approaches, tumors relapsed most commonly within the posterior region after surgery and transition/peripheral zone after radiation therapy, respectively.

CONCLUSIONS

The present study confirms that ¹⁸F-PSMA-1007-PET/CT is highly suitable for the localization and allocation of a local relapse in patients with prostate cancer. The data enable further optimizing dose prescriptions and target volume delineations of radiation therapy in the future.

POS1173 CLINICAL PRESENTATION AND TREATMENT OF STERNOCOSTOCLAVICULAR HYPEROSTOSIS (SCCH): A SYSTEMATIC REVIEW AND META-ANALYSIS OF SCATTERED EVIDENCE

Background

Sternocostoclavicular hyperostosis (SCCH) is an inflammatory bone disorder within the spectrum of chronic non-bacterial osteomyelitis. SCCH can be a manifestation of SAPHO syndrome, standing acronym for synovitis, acne, pustulosis, hyperostosis and osteitis, but also appears as an isolated clinical entity without joint and skin involvement1,2. Consensus on nomenclature, diagnostic classification, and therapy for SCCH is currently lacking3. Literature is diffuse, and spreads over a wide range of medical disciplines, calling for a first systematic overview.

Objectives

We critically appraised literature with the aim to i) gain overview on the clinical presentation of SCCH and features leading to diagnosis and to ii) evaluate different treatment modalities and treatment response. We focused on the clinical entity of SCCH in adults, either isolated or as a part of SAPHO syndrome.

Methods

We conducted a systematic review and meta-analysis according to the PRISMA guidelines on the clinical presentation and therapeutic modalities applied in adult SCCH patients. Studies covering these respective domains were selected. Risk of bias was assessed using validated tools according to study type. Untransformed numerical data and double-arcsine transformed proportional data were analyzed in a random effects model in R-4.0.5; pooled proportions were reported with 95% confidence intervals (95%CI). Treatment response was categorized as good, partial, or none.

Results

28(i) and 12(ii) studies were included, containing heterogeneous data on 1818 patients. A female predisposition (67%, 95%CI 60-73) and major diagnostic delay (5 years 95%CI 3-7) were noted. Clinical presentation was marked by anterior chest pain (89%, 95%CI 79-96), and swelling (79%, 95%CI 62-91). Pustulosis palmoplantaris was present in 53%, 95%CI37-68, whereas acne (8%, 95%CI4-13) and peripheral arthritis (24%, 95%CI 11-39) were less prevalent. Inflammatory markers were inconsistently elevated and autoantibodies and HLA-B27 prevalence normal. Histopathology was unspecific, and cultures almost exclusively negative. Increased isotope uptake (99%, 95%CI96-100) was the most consistent imaging finding. Amongst manifold treatments (see Figure 1), NSAIDs were mainly partially effective. Pamidronate and biologicals (mainly TNF-α inhibitors) yielded good, though heterogeneous, response in 83%, 95%CI 60-98 and 56%, 95%CI 26-85 respectively.

Figure 1.

Treatment modalities applied in SCCH and their effects on bone pain (data from trials and several cohort studies combined)

Conclusion

Literature on SCCH is extremely heterogeneous. Timely diagnosis proves challenging and mainly follows from the increased isotope uptake on nuclear examination. Biopsies, autoantibodies and HLA-status are non-contributory, and inflammatory biochemical profiles only variably detected. Pamidronate and TNF-α inhibitors emerged as promising therapies, but powered, placebo-controlled research with standardized measures of response is warranted. Inherently, international consensus on SCCH’s diagnostic classification and name appears critical to improve scientific collaboration on this rare disease, and to advance the development of clinical guidelines.

References

[1]Saghafi M, Henderson MJ and Buchanan WW. Sternocostoclavicular hyperostosis. YSARH 1993; 22: 215-223. 10.1016/0049-0172(93)80070-v. DOI: papers3://publication/doi/10.1016/0049-0172(93)80070-v.

[2]Carroll MB. Sternocostoclavicular hyperostosis: a review. Therapeutic advances in musculoskeletal disease 2011; 3: 101-110. 10.1177/1759720X11398333. DOI: papers3://publication/doi/10.1177/1759720X11398333

[3] Kalke S, Perera SD, Patel ND, et al. The sternoclavicular syndrome: experience from a district general hospital and results of a national postal survey. Rheumatology 2001; 40: 170-177. 10.1093/rheumatology/40.2.170. DOI: papers3://publication/doi/10.1093/rheumatology/40.2.170

Acknowledgements

The authors would like to thank Drs. J.W. Schoones, information specialist at the Walaeus Library, Leiden University Medical Center, for his contribution to the search strategy and selection of studies.

Disclosure of Interests

None declared

EFFECT OF ELECTR- AND ULTRAPHONOPHORESIS OF THE PHYTOCOMPLEX ON MICROCIRCULATORY AND BIOCHEMICAL PARAMETERS IN PATIENTS WITH KNEE JOINT OSTEOARTHRITIS

The goal was to study the effect of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex on disruptions in the microcirculation system in the affected joint area and on changes in connective tissue metabolism parameters, metabolic processes, and electrolyte metabolism in patients with knee joint osteoarthritis. Seventy-two patients were randomly assigned to five groups. Patients of the first group were prescribed modulated sinusoidal currents electrophoresis of the phytocomplex. The second group was prescribed ultraphonophoresis of the phytocomplex, the third group was prescribed amplipulse therapy (modulated sinusoidal currents), the fourth group was prescribed ultrasound therapy, and the fifth group was prescribed basic drug therapy. Drug therapy of patients of the fifth group was comparable to the drug treatment of patients of the first four groups. The concentration of the phytocomplex in the working composition was 10%. Electrotherapy was carried out in the full-wave modulated sinusoidal currents mode with I and IV types of operation while ultrasound therapy was carried out in continuous mode with an ultrasound intensity of 0.6 W/cm2. To assess the state of microcirculation, the laser Doppler flowmetry method was used. The pronounced anti-dystrophic effect after the use of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex in patients with knee joint osteoarthritis was based on the correction of microcirculatory disruptions: an increase in the capillary blood flow, an increase in the blood perfusion in tissues, and a decrease in congestion effects in the venular microcirculation. The use of modulated sinusoidal currents electrophoresis of the phytocomplex (ultraphonophoresis of the phytocomplex had an even greater effect) improved the connective tissue metabolism and the content of seromucoid, fibrinogen, and mucoproteins. The use of the studied treatment methods improved magnesium and phosphorus parameters of the electrolyte metabolism. Modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex contributed to the elimination of the metabolic imbalance of acid phosphatase. Ultraphonophoresis of the phytocomplex also contributed to balancing of the alanine aminotransferase and alkaline phosphatase content. As a result of the study, the effect of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex on disruptions in the microcirculation system in the affected joint area and on changes in connective tissue metabolism parameters, metabolic processes, and electrolyte metabolism in patients with knee joint osteoarthritis was established. The obtained results provide the basis for further studies to assess the overall effectiveness of the use of modulated sinusoidal currents electrophoresis and ultraphonophoresis of the phytocomplex in patients with knee joint osteoarthritis.

Loi de santé 2015 : une nécessaire résistance ?

La loi de santé 2015 introduit le principe du tiers payant généralisé (TPG), qui a déjà généralisé l’opposition de la quasi-totalité des médecins libéraux. Au-delà des aspects symboliques du circuit de l’argent, objets de réflexions psychanalytiques plus ou moins légitimes, il s’agit aussi d’un processus macroéconomique qui permet aux assureurs privés d’avoir leur mot à dire sur ce qui est remboursé ou pas. Or les intérêts de la Sécurité sociale sont-ils tout à fait les mêmes que ceux des assureurs privés ? Les déclarations des dirigeants des groupes mutualistes sont tout à fait éclairantes sur le sujet… notamment leur regret de ne pas constituer eux-mêmes la plateforme de paiement qui reste aux mains de la Sécurité sociale. Tous les outils se mettent néanmoins progressivement en place pour passer du « remboursement selon les besoins, basé sur une cotisation selon les moyens », au principe assurantiel du « remboursement selon le niveau de cotisation et de risque ». Où est donc l’amélioration de l’accès, et pour quels soins ? Dans le même temps, les « mutuelles » deviennent obligatoires pour tous les salariés, ce qui accroît considérablement le nombre de cotisants, et « responsables » ce qui limite les remboursements notamment des dépassements d’honoraires. S’il s’agissait initialement de répondre au problème hautement médiatisé du renoncement aux soins, la loi de santé bénéficiera-t-elle bien aux patients ? Pendant ce temps, rien n’est fait sur les questions de démographie médicale, et de répartition géographique des praticiens libéraux, soumis aussi aux technocratiques nouvelles normes d’accessibilité aux personnes handicapées. L’unité créée chez les médecins libéraux contre cette loi permettra-t-elle de trouver des issues honorables ? Le pire pourrait être que les médecins libéraux se retrouvent mieux rémunérés grâce aux mutuelles, sur le modèle des rémunérations sur objectifs de santé publique (ROSP)…

Micro-CT analyses of historical bone samples presenting with osteomyelitis

OBJECTIVE

Osteomyelitis is an inflammation of the bone marrow mainly caused by bacteria such as Staphylococcus aureus. It typically affects long bones, e.g. femora, tibiae and humeri. Recently micro-computed tomography (μCT) techniques offer the opportunity to investigate bone micro-architecture in great detail. Since there is no information on long bone microstructure in osteomyelitis, we studied historic bone samples with osteomyelitis by μCT.

MATERIALS AND METHODS

We investigated 23 femora of 22 individuals suffering from osteomyelitis provided by the Collection of Anatomical Pathology, Museum of Natural History, Vienna (average age 44 ±19 years); 9 femora from body donors made available by the Department of Applied Anatomy, Medical University of Vienna (age range, 56-102 years) were studied as controls. Bone microstructure was assessed by μCT VISCOM X 8060 II with a minimal resolution of 18 μm.

RESULTS

In the osteomyelitic femora, most prominent alterations were seen in the cortical compartment. In 71.4% of the individuals with osteomyelitis, cortical porosity occurred. 57.1% of the individuals showed cortical thinning. In 42.9% trabecularisation of cortical bone was observed.

CONCLUSION

Osteomyelitis is associated with severe alterations of cortical bone structure otherwise typically observed at old age such as cortical porosity and cortical thinning.

A spectroelectrochemical cell for ultrafast two-dimensional infrared spectroscopy

A spectroelectrochemical cell has been designed to combine electrochemistry and ultrafast two-dimensional infrared (2D-IR) spectroscopy, which is a powerful tool to extract structure and dynamics information on the femtosecond to picosecond time scale. Our design is based on a gold mirror with the dual role of performing electrochemistry and reflecting IR light. To provide the high optical surface quality required for laser spectroscopy, the gold surface is made by electron beam evaporation on a glass substrate. Electrochemical cycling facilitates in situ collection of ultrafast dynamics of redox-active molecules by means of 2D-IR. The IR beams are operated in reflection mode so that they travel twice through the sample, i.e., the signal size is doubled. This methodology is optimal for small sample volumes and successfully tested with the ferricyanide/ferrocyanide redox system of which the corresponding electrochemically induced 2D-IR difference spectrum is reported.

A setup for simultaneous measurement of infrared spectra and light scattering signals: watching amyloid fibrils grow from intact proteins

A setup for the simultaneous measurement of mid-infrared spectra and static light scattering is described that can be used for the analysis of the formation of nanoscale and microscopic aggregates from smaller molecules to biopolymers. It can be easily integrated into sample chambers of infrared spectrometers or combined with laser beams from tunable infrared lasers. Here, its use for the analysis of the formation of amyloid fibrils from intact proteins is demonstrated. The formation of amyloid fibrils or plaques from proteins is a widespread and pathogenetic relevant process, and a number of diseases are caused and correlated with the deposition of amyloid fibrils in cells and tissues. The molecular mechanisms of these transformations, however, are still unclear. We report here the simultaneous measurement of infrared spectra and static light scattering for the analysis of fibril formation from egg-white lysozyme. The transformation of the native form into non-native forms rich in β-sheet structure is measured by analysis of the amide I spectral region in the infrared spectra, which is sensitive for local structures. At the same time, light scattering signals at forward direction as well as the forward/backward ratio, which are sensitive for the number of scattering centers and their approximate sizes, respectively, are collected for the analysis of fibril growth. Thermodynamic and kinetic parameters as well as mechanistic information are deduced from the combination of the two complementary techniques.

Medical preparedness, incidents, and group dynamics during the analog MARS2013 mission

Participants on spaceflights and international scientific analog Mars missions can encounter medical incidents (accidents, illnesses) and psychological issues (e.g., stress, group interaction, sleep disturbance, emotions). The aim of this study was to examine these parameters in a field crew living in a desert environment similar to Mars (Group 1) and in Mission Support Center (MSC) personnel on "Earth" (Group 2) during a 4-week mission. Of the 107 medical interventions in the field, 73 mainly minor incidents together with four near accidents and 29 medical checkup interventions were recorded. Of the 32 medical interventions, medical treatments for 23 incidents of minor severity were necessary in Group 2. Injuries (Group 1: 1.4/100 h, Group 2: 0.1/100 h) were significantly increased in the field, and illnesses (Group 1: 0.3/100 h, Group 2: 3.0/100 h) in the MSC personnel. Causes of accidents and illnesses are described. Psychological results show that emotions and stress remained stable in both groups. Sympathy, social competence, teamwork, and leadership showed high scores. These scores were lower on "Earth" but significantly increased in the last weeks. The Sahara's nighttime coldness was reflected in an increased wake-up frequency, and a longer sleeping time peaked in the third week, probably as a result of overfatigue. MARS2013 was a successful mission with highly motivated participants and minor medical incidents. For future analog missions and possibly long-distance open-space missions, some recommendations in terms of medical and psychological preparedness are made to reduce risks for field crew members and MSC personnel.

EXPLOITING CHEMICAL ECOLOGY FOR LIVELIHOOD IMPROVEMENT OF SMALL HOLDER FARMERS IN KENYA

"Push-Pull" is an inexpensive and eminently practical strategy designed for developing countries in order to exploit sound principles of chemical ecology for agricultural pest management. This strategy is specifically suitable for small holder farmers. Their experience can easily be integrated into existing farming practices in their immediate environment. "Push-pull" within one and a half decades became widely established and meanwhile is greatly beneficial to practitioners in East Africa, mainly Kenya. The classical push-pull approach used for applied plant-insect management was pioneered by Khan and Pickett (2000) and subsequent papers of Pickett (2003) and Khan et al. (2006, 2008). Relevant plant species explored so far were maize or sorghum intercropped with other East African plants (Desmodium spp. resp. Melinis minutiflora) possessing natural chemicals repellent resp. attractive for stem borer moths Chilo partellus (Lepidoptera), whereby Desmodium spp. was grown inside the maize rows while M. minutiflora surrounded it. Both simultaneous actions combined resulted in a significant decrease of stem borers in the area to be protected. A benefit to cost ratio of 2.5 was realized. Within a period of 15 years the number of subscribing farmers substantially increased from a few dozen to more than 80,000 in 2014. Two experiments along the paths of chemical ecology were undertaken between Sept 2012 and Feb 2013: One was designed to investigate if the legume D. intortum known to produce repellent volatiles against stem borer moths induces defence in Zea mays varieties. We looked at two open-pollinated farmers' varieties and two commercial hybrid varieties suspecting the farmers' varieties to be responsive rather than the hybrids. However, no defence induction was detected in this study so far. This could be explained by an insufficient production of defence inducing volatiles in leaves of D. intortum whereas flowers might produce a sufficient response. More detailed study is needed. A second approach made use of species-specific insect monitoring traps baited with highly specific female sex pheromones for attracting and monitoring destructive insect pests. The female sex pheromone (8-methyl-decane-2-ol propanoate) of Diabrotica virgifera virgifera (Coleoptera: Chrysomelidae) (Western Corn Rootworm) is readily available as bait in the "Metcalf sticky cup trap" for trapping males, an extraordinarily sensitive technique for monitoring the presence or absence of male beetles in a given area. Li et al. (2006) had argued for the likelihood of easy immigration of this cosmopolitan maize pest into East Africa. Our results, however, so far indicate the absence of a local population in the area of Mbita, while not excluding its presence at Nairobi or Mombasa. Both investigations contribute to different aspects of Kenyan economic development and may be seen as two independent but complementary contributions towards livelihood improvement of small holder farmers in Kenya.

[Drug therapy of fibromyalgia syndrome. Systematic review, meta-analysis and guideline]

BACKGROUND

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.

MATERIALS AND METHODS

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

RESULTS AND CONCLUSION

Amitriptyline and-in case of comorbid depressive disorder or generalized anxiety disorder-duloxetine are recommended. Off-label use of duloxetine and pregabalin can be considered in case of no comorbid mental disorder. Strong opioids are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Down-regulation of KRAS-interacting miRNA-143 predicts poor prognosis but not response to EGFR-targeted agents in colorectal cancer

BACKGROUND

MicroRNA-143 (miRNA-143) is frequently down-regulated in colorectal cancer (CRC) and may influence CRC cell proliferation, apoptosis and sensitivity to 5-fluorouracil. mRNA encoded by the KRAS oncogene has been identified as a target of miRNA-143. However, the prognostic significance of miRNA-143 expression and the ability to predict patient response to epidermal growth factor receptor (EGFR)-targeted agents have not yet been explored.

METHODS

We examined 77 CRC patients who were identified by pyrosequencing to have wild-type KRAS and were subsequently treated with EGFR-targeted therapy with the monoclonal antibodies cetuximab or panitumumab. MicroRNA-143 expression was measured in CRC tissue and corresponding non-neoplastic colon tissue by RT-PCR and its expression level was correlated with clinico-pathological characteristics. Univariate and multivariate analyses were used to calculate cancer-specific survival (CSS). The progression-free survival (PFS) and objective response rates on EGFR-targeted therapy were also evaluated.

RESULTS

Down-regulation of miRNA-143 was observed in 47 out of 77 (61%) tumours. Multivariate Cox regression analysis identified low levels of miRNA-143 expression as an independent prognostic factor with respect to CSS (hazard ratio=1.92, confidence interval=1.1-3.4, P=0.024). A significant difference was also observed with regard to PFS on EGFR-targeted therapy (P=0.031), but there were no significant differences with regard to the objective response rates.

CONCLUSION

Our data indicate that miRNA-143 expression levels serve as an independent prognostic biomarker for CRC in KRAS wild-type patients. No role for miRNA-143 expression as a predictive biomarker for EGFR-targeted agents could be identified. Given its negative impact on CSS and PFS, miRNA-143 represents a novel prognosticator and a promising drug target for patients with CRC.

[Pharmacological treatment of fibromyalgia syndrome]

BACKGROUND

An interdisciplinary guideline for the treatment of fibromyalgia syndrome (FMS) and chronic widespread pain (CWP) was developed in cooperation with ten German medical and psychological associations and two patients' self-help organizations.

METHODS

Using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/ 2006) a systematic literature search was performed, which included all randomised controlled trials (RCT) evaluating multicomponent therapy in FMS and CWP. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of recommendation was graded according to the German program for disease management guidelines. Consensus was achieved using a multi-step nominal group procedure.

RESULTS

The short-term use of amitriptyline is strongly recommended (grade A) and the short-term use of fluoxetine und duloxetine is recommended (grade B).

CONCLUSIONS

The recommendations regarding pharmacological treatment of FMS are limited by the short duration of the RCT, the lack of follow-ups and absence of cost-effectiveness studies.

Biosynthesis, axonal transport and turnover of neuronal substance P

In dorsal root ganglia substance P is synthesized ribosomally, probably via a precursor. A second peptide, apparently a modified form of substance P (8-11), is cosynthesized with substance P and transported with it down both dorsal roots and peripheral branches. Four times as much substance P-like immunoreactivity is transported peripherally as centrally. Only 30% of axonal substance P-like immunoreactivity is available for rapid axonal transport and this is transported at a rate of 4.9 mm h-1. Axonal transport is not necessary for substance P synthesis. Doses of anisomycin which inhibit CNS protein synthesis by more than 95% do not cause any fall in substance P levels over an eight-hour period in ganglia, spinal cord or brain, suggesting that turnover is slower than that of conventional transmitters. However, stimulation of the hindlimbs of these animals reduces substance P levels in the dorsal horn. The turnover rate of spinal cord substance P, estimated either by relating the amount transported down dorsal roots to that in terminals or by measuring the decline of substance P levels after intrathecal colchicine, is four to five days. The functional organization of the substance P neuron is discussed with particular reference to the maintenance of peptide levels in terminals.

Regulation of insulin-like growth factor binding protein-5, four and a half lim-2, and a disintegrin and metalloprotease-9 expression in osteoblasts

The roles of insulin-like growth factors (IGFs) in regulating growth and their modulation by six IGF binding proteins (IGFBP) are well established. IGFBP-5, the most abundant IGFBP stored in bone, is an important regulator of bone formation via IGF-dependent and -independent mechanisms. Two new proteins, four and a half lim (FHL)-2, a transcription modulator that interacts with IGFBP-5, and a disintegrin and metalloprotease (ADAM)-9, an IGFBP-5 protease, have been identified as potential regulators of IGFBP-5 action in bone. We tested the hypothesis that agents which modulate bone formation by regulating IGFBP-5 expression would also regulate FHL-2 and ADAM-9 expression in a coordinated manner. We evaluated the expression of IGFBP-5, FHL-2, and ADAM-9 by real-time reverse transcriptase (RT)-PCR during differentiation of mouse bone marrow stromal cells into osteoblasts and in response to treatment with bone formation modulators in the LSaOS human osteosarcoma cell line. IGFBP-5 and FHL-2 increased 4.3- and 3.0-fold (P < or = 0.01), respectively, during osteoblast differentiation. Dexamethasone (Dex), an inhibitor of bone formation, decreased IGFBP-5 and FHL-2 and increased ADAM-9 in LSaOS cells (P < or = 0.05). Bone morphogenic protein (BMP)-7, a stimulator of bone formation, increased IGFBP-5 and decreased ADAM-9 (P<0.01). To determine if BMP-7 would eliminate Dex inhibition of IGFBP-5, cells were treated with Dex+BMP-7. The BMP-7-induced increase in IGFBP-5 was reduced, but not eliminated, in the presence of Dex (P < or = 0.01), indicating that BMP-7 and Dex may regulate IGFBP-5 via different mechanisms. Transforming growth factor (TGF)-beta, a stimulator of bone formation, increased IGFBP-5 and FHL-2 expression (P < or = 0.01). IGF-I and TNF-alpha decreased expression of ADAM-9 (P<0.05). In conclusion, our findings are consistent with the hypothesis that FHL-2 and ADAM-9 are important modulators of IGFBP-5 actions and are, in part, regulated in a coordinated manner in bone.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Personality pathology and outcome in recurrently depressed women over 2 years of maintenance interpersonal psychotherapy

BACKGROUND

Empirical data on the impact of personality pathology on acute treatment outcome for depression are mixed, in part because of challenges posed by assessing trait-like personality patterns while patients are in an active mood episode. To our knowledge, no previous study has examined the effect of personality pathology on maintenance treatment outcome. By maintenance treatment we refer to long-term treatment provided to prevent depression recurrence among remitted patients.

METHOD

Structured Clinical Interviews for the DSM-III-R Personality Disorders (SCID-II) were obtained on a sample of 125 recurrently depressed women following sustained remission of the acute mood episode and prior to entering maintenance treatment. SCID-II interviews were then repeated following 1 and 2 years of maintenance interpersonal psychotherapy.

RESULTS

At the pre-maintenance assessment, 21.6% of the sample met SCID-II personality disorder criteria. Co-morbid personality pathology was related to an earlier age of onset, more previous depressive episodes, and a greater need for adjunctive pharmacotherapy to achieve remission of the acute mood episode. Co-morbid personality pathology predicted both higher rates of depression recurrence and a shorter time to recurrence over the 2-year course of maintenance treatment. Notably, among those patients who remained depression-free, continuous levels of personality pathology steadily declined over the 2-year course of maintenance therapy.

CONCLUSIONS

Results highlight the need for early and effective intervention of both episodic mood disorder and inter-episode interpersonal dysfunction inherent to the personality disorders. Future maintenance treatment trials are needed to clarify the relationship between episodic mood disorder and personality function over time.

[Treatment of pain in cancer patients]

Patients experiencing constant pain continue to receive less than optimal treatment. In the case of cancer pain in particular, adequate therapy is a must. On the basis of the WHO analgesic ladder, nonopioids and opioids of varying potency must be applied as required, together with antiemetics, laxatives, gastric-protective preparations and bisphosphonates to ameliorate side effects. A particular problem in the treatment of cancer pain is the suddenly occurring stress and perforation pain. This can be reduced with fast-acting opioids such as the fentanyl stick. If the patient does not respond adequately to any of the noninvasive methods, local anesthetics and opiates applied via an i.v. pump system that permits bolus application and spinal and epidural methods have proven useful.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

[Distinctive features of the os naviculare pseudarthrosis vs the os naviculare accessorius]

We report on two cases in which the differential diagnosis between an os tibiale externum (os naviculare accessorius) and a post-traumatic pseudarthrosis of the os naviculare was subject to discussion.Both patients had suffered an acute trauma in the region of the middle foot and showed identical clinical symptoms. Conventional X-ray did not allow a definite classification of the diagnosis either.However, this was possible in both cases by virtue of typical signs evidenced by computed tomography and magnetic resonance imaging.

[Cemented versus uncemented hip replacement--rational decision making using the BiCONTACT total hip system]

The BiCONTACT femoral stem has been developed as a modular system which is suitable for both cemented and uncemented implantation. A highly standardized procedure using an identical set of instruments for both modes of fixation ensures bone preservation. Primary stability is achieved by special design parameters. The cementless implants are coated proximally, thus facilitating osteointegration and proximal load transfer. Cemented stems provide an identical design but a smooth surface and are anchored by a homogenous cement mantle. The BiCONTACT stem is in use in the BG Trauma Center Tuebingen since 14 years and a consecutive series of 250 cases (series A) with uncemented implantation and of 250 cases (series B) with cemented implantation has been analyzed in two different prospective follow-up studies. Long-term survival after 11 years was 97.1 % (95 % confidence limits: 93.8 %-98.7 %) for series A, the follow-up rate was 99.2 %. For series B, the follow up-rate was also 99.2 %, survival estimate after 11 years was 97.5 % (95 % CI: 94.2 %-99.0 %).

Long-term results with the BiCONTACT system--aspects to investigate and to learn from

The BiCONTACT femoral stem for cementless fixation is being used without any technical modification after 15 years. The long-term results should be evaluated in this study. A consecutive series was continuously monitored in a prospective follow-up study. A survival analysis was performed, clinical results were rated according to the Harris score. There were 236 patients with 250 total hip replacements (THR); mean age at time of implantation was 58.2 years. Indications for THR included osteoarthritis (62.4%), dysplasia (16.8%), trauma (8.4%) and femoral-head necrosis (16.8%). Average time of follow-up evaluation was 8.9 years (range 7.4-10.7 years). At follow-up, 27 patients had died and two could not be located. Seven patients were revised--two for infection, one for recurrent dislocation, two for component undersizing with rapid subsidence, and one for aseptic loosening of a varus-malaligned stem; one radiologically well-fixed stem had been revised during acetabular revision. Survival estimate showed an overall survival rate of 97.1% after 11 years (confidence limits: 98.7% upper and 93.6% lower). Radiologically, tiny reactive lines (< 2 mm) were present in the distal zones of the femoral shaft, but no radiolucencies could be found in the proximal anchoring zone. Migration analysis with Ein-Bild-Röntgen-analyse/femoral component analysis (EBRA/FCA) demonstrated a very small amount of migration: in 31.0%, the overall migration was between 0.5 and 1 mm after 120 months; 8.5% had an absolute amount of subsidence exceeding 2 mm after 120 months (one case more than 3 mm). Mean subsidence was 0.2 mm after 3 months and 6 months, 0.3 mm after 12 months, and reached 0.5 mm after 10 years. An initial small amount of subsidence could be detected in 45.1%, and 15.5% had a late onset of subsidence. Continuous sinking could be found in 12.7%, while 26.8% had irregular patterns of migration. Clinical results were somewhat compromised by a higher-than-average rate of cup loosening (uncoated threaded cup). The average Harris hip score at follow-up was 84.3 points. Interestingly, no femoral osteolysis could be detected, even in cases with severe acetabular osteolyses, indicating sealing of the stem interface by tight osseointegration of the proximally-coated stem.

The risks of reuse: legal implications for hospitals of reusing single-use medical devices

There is no doubt that the practice of reuse in hospitals is a reaction to the budgetary constraints under which hospitals are operating. However, the costs of appropriately monitoring and sterilizing reused equipment as well as the significant risk of patient harm and potential liability raise the unavoidable question of whether this practice is an advisable one. These costs and risk should be carefully examined before a decision about whether to reuse single-use devices is made.

Testicular germ cell cancer despite previous local radiotherapy to the testis

BACKGROUND

Testicular intraepithelial neoplasia (TIN, also carcinoma in situ of the testis) is the uniform precursor of testicular germ cell cancer. Local radiotherapy to the testis with dosages of 18-20 Gy has been found to safely eradicate TIN and germ cells, too. Thus, the general assumption is that the development of invasive germ cell tumours can be prevented by this radiotherapy.

PATIENTS AND METHODS

Herein, we report two patients with one-sided testicular tumour and biopsy-proven contralateral TIN. Both of them developed germ cell neoplasms in the remaining testis although local radiotherapy with 20 Gy had been applied to the testis.

RESULTS

One patient developed pure seminoma 7 years after completion of radiotherapy, the other developed a combined tumour consisting of embryonal carcinoma and seminoma after 5 years. Treatment consisted of orchiectomy in each of the cases. Histologically, both had TIN in the testicular tissue surrounding the new growths.

CONCLUSIONS

Pathogenetically, a small fraction of radioresistent TIN cells overcoming irradiation and progressing to full-blown germ cell cancer in the later course may be the histogenetic clue to explain these unexpected events. Other explanations, though less probable, could be technical radiotherapeutic failure due to targeting problems and a pre-existing radioresistent germ cell tumour in the irradiated testicle.

Novel chemokine functions in lymphocyte migration through vascular endothelium under shear flow

The recruitment of circulating leukocytes at vascular sites in target tissue has been linked to activation of Gi-protein signaling in leukocytes by endothelial chemokines. The mechanisms by which apical and subendothelial chemokines regulate leukocyte adhesion to and migration across endothelial barriers have been elusive. We recently found that endothelial chemokines not only stimulate integrin-mediated arrest on vascular endothelial ligands but also trigger earlier very late antigen (VLA)-4 integrin-mediated capture (tethering) of lymphocytes to vascular cell adhesion molecule 1 (VCAM-1)-bearing surfaces by extremely rapid modulation of integrin clustering at adhesive contact zones. This rapid modulation of integrin avidity requires chemokine immobilization in juxtaposition with the VLA-4 ligand VCAM-1. We also observed that endothelial-bound chemokines promote massive lymphocyte transendothelial migration (TEM). It is interesting that chemokine-promoted lymphocyte TEM requires continuous exposure of lymphocytes but not of the endothelial barrier to fluid shear. It is noteworthy that lymphocyte stimulation by soluble chemokines did not promote lymphocyte TEM. Our results suggest new roles for apical endothelial chemokines both in triggering lymphocyte capture to the endothelial surface and in driving post-arrest events that promote lymphocyte transmigration across endothelial barriers under shear flow.

Allogeneic cancellous bone graft and a Burch-Schneider ring for acetabular reconstruction in revision hip arthroplasty

BACKGROUND

There is an ever-increasing number of failed hip arthroplasties associated with massive deficiency of acetabular bone stock consisting of a segmental or cavitary defect. This study was undertaken to evaluate the long-term results after use of morselized cryopreserved allogeneic bone graft and an antiprotrusio cage to treat such a deficiency.

METHODS

From January 1, 1988, to January 1, 1994, forty-one patients (forty-one hips) with an acetabular defect classified as type IIl or IV according to the American Academy of Orthopaedic Surgeons system were operated on with use of a Burch-Schneider ring and morselized cryopreserved allogeneic cancellous bone graft. Thirty-eight patients (thirty-eight hips) were available for clinical and radiographic follow-up examinations at an average of 7.3 years (range, 4.2 to 9.4 years) after surgery.

RESULTS

All measured clinical parameters had improved significantly by the time of the follow-up examination (p < 0.0001). Radiographs confirmed that none of the thirty-eight hips had any measurable migration or displacement of the acetabular component and that osseous consolidation occurred only within the grafted area in all patients.

CONCLUSION

Acetabular reconstruction with use of morselized cryopreserved allogeneic cancellous bone graft and the Burch-Schneider ring can be highly successful in managing massive acetabular deficiencies in revision hip arthroplasty.

The Src kinase p56(lck) up-regulates VLA-4 integrin affinity. Implications for rapid spontaneous and chemokine-triggered T cell adhesion to VCAM-1 and fibronectin

In circulating lymphocytes, the VLA-4 integrin preexists in multiple affinity states that mediate spontaneous tethering, rolling, and arrest on its endothelial ligand, vascular cell adhesion molecule-1 (VCAM-1). The regulation and function of VLA-4 affinity in lymphocytes has never been elucidated. We show here that p56(lck), the major Src kinase in T cells, is a key regulator of high affinity VLA-4. This high affinity is essential for the rapid development of firm adhesion of resting T cells to VCAM-1 and to their extracellular matrix ligand, fibronectin. Lck-regulated VLA-4 function does not require intact TCR nor several key components of the TCR signaling pathway, including ZAP-70 and SLP-76. Furthermore, stimulation of p56(lck) by the phosphatase inhibitor, pervanadate, triggers firm VLA-4-dependent adhesion to VCAM-1. Although Lck is not required for chemokine receptor signaling to mitogen-activated protein kinase, the presence of Lck-regulated high affinity VLA-4 also facilitates firm adhesion triggered by the chemokine, SDF-1, at short-lived contacts. Surprisingly, bond formation rates, ability to tether cells to VLA-4 ligand, and VLA-4 tether bond stability under shear flow are not affected by VLA-4 affinity or Lck activity. Thus, the ability of high affinity VLA-4 to arrest cells on VCAM-1 under flow arises from instantaneous post-ligand strengthening rather than from increased kinetic stability of individual VLA-4 bonds. These results suggest that p56(lck) maintains high affinity VLA-4 on circulating lymphocytes, which determines their ability to strengthen VLA-4 adhesion and rapidly respond to proadhesive chemokine signals at endothelial sites.

Results of a cemented titanium alloy straight femoral shaft prosthesis after 10 years of follow-up

Two-hundred fifty implantations of a cemented femoral stem made of titanium alloy in 239 patients were followed for 9.7 years (range 8.7-10.3 years). Eighty-nine patients with 93 hips have died and two could not be located. Five hips have been revised, two for infection, one for aseptic loosening and two during revision of the cup. Three stems showed radiological loosening but have not been revised. The average hip score was 85. The results are encouraging and comparable to other cemented femoral stems.

Arabidopsis eIF3e (INT-6) associates with both eIF3c and the COP9 signalosome subunit CSN7

The Arabidopsis COP9 signalosome is a multisubunit repressor of photomorphogenesis that is conserved among eukaryotes. This complex may have a general role in development. As a step in dissecting the biochemical mode of action of the COP9 signalosome, we determined the sequence of proteins that copurify with this complex. Here we describe the association between components of the COP9 signalosome (CSN1, CSN7, and CSN8) and two subunits of eukaryotic translation initiation factor 3 (eIF3), eIF3e (p48, known also as INT-6) and eIF3c (p105). To obtain a biochemical marker for Arabidopsis eIF3, we cloned the Arabidopsis ortholog of the eIF3 subunit eIF3b (PRT1). eIF3e coimmunoprecipitated with CSN7, and eIF3c coimmunoprecipitated with eIF3e, eIF3b, CSN8, and CSN1. eIF3e directly interacted with CSN7 and eIF3c. However, eIF3e and eIF3b cofractionated by gel filtration chromatography in a complex that was larger than the COP9 signalosome. Whereas eIF3, as detected through eIF3b, localized solely to the cytoplasm, eIF3e, like CSN7, was also found in the nucleus. This suggests that eIF3e and eIF3c are probably components of multiple complexes and that eIF3e and eIF3c associate with subunits of the COP9 signalosome, even though they are not components of the COP9 signalosome core complex. This interaction may allow for translational control by the COP9 signalosome.

The pachytene checkpoint in Saccharomyces cerevisiae requires the Sum1 transcriptional repressor

Saccharomyces cerevisiae mutants that fail to complete meiotic recombination are blocked by the RAD17/RAD24/MEC1 checkpoint signaling pathway in pachytene when early sporulation genes are expressed. Middle genes are not activated in checkpoint-arrested cells because the Ndt80 transcription factor is inhibited. We find that the pachytene checkpoint requires Sum1, a transcriptional repressor that recognizes a subset of Ndt80-binding sites. Mutants lacking Sum1 or Rad17 partially bypass the block to the nuclear divisions but do not form spores, while mutants lacking both Sum1 and Rad17 completely bypass the block and form morphologically normal spores. The level of Sum1 protein decreases as middle genes are expressed, and this decrease is blocked in checkpoint-arrested cells. These data suggest that Sum1 levels are regulated by the checkpoint and that progression of the meiotic divisions and spore differentiation can be differentially controlled by competition of the Sum1 repressor and Ndt80 activator for occupancy at key middle promoters.

Dependency of the [18F]fluoromisonidazole uptake on oxygen delivery and tissue oxygenation in the porcine liver

We have previously shown that the accumulation of fluorine-18-labeled fluoromisonidazole ([(18)F]FMISO) is inversely correlated to tissue oxygenation, allowing the quantification of porcine liver tissue hypoxia in vivo. We determined the activity from administered [(18)F]FMISO in relation to the hepatic oxygen availability and the partial pressure of oxygen in tissue (tPO(2)) to define a critical oxygen delivery on a regional basis. [(18)F]FMISO was injected 2 h after onset of regional liver hypoxia due to arterial occlusion of branches of the hepatic artery in 10 domestic pigs. During the experimental procedure the fractional concentration of inspired oxygen (FiO(2)) was set to 0.67 in group A ( N=5) and to 0.21 in group B ( N=5) animals. Immediately before sacrifice, the tPO(2) was determined in normal flow and flow-impaired liver segments. The standardized uptake values (SUV) for [(18)F]FMISO was calculated from 659 single tissue samples obtained 3 h after injection of approximately 10 MBq/kg body weight [(18)F]FMISO and was compared with the regional total hepatic oxygen delivery (DO(2)) calculated from the regional arterial and portal venous flow (based on (141)Ce- and (99m)Tc-microspheres measurements) and the oxygen content of the arterial and portal venous blood. In 121 tPO(2)-measured liver tissue samples, the mean DO(2) was significantly decreased in occluded liver tissue samples [group A: 0.063 (0.044-0.089); group B: 0.046 (0.032-0.066)] compared to normal flow segments [group A: 0.177 (0.124-0.252); group B: 0.179 (0.128-0.25) mL x min(-1) x g(-1); geometric mean (95% confidence limits); p < 0.01 in group A and p < 0.001 in group B]. The tPO(2) of occluded segments [group A: 5.1 (3.2-8.1); group B: 3.9 (2.4-6.2) mm Hg] was significantly decreased compared to normal flow segments [group A: 20.2 (12.6-32.5); group B: 22.4 (14.3-35.2) mm Hg; p < 0.01 in group A and p < 0.001 in group B]. Three hours after [(18)F]FMISO administration, the mean [(18)F]FMISO SUV determined in tPO(2)-measured occluded segments was significantly higher [group A: 4.08 (3.12-5.34), group B: 5.43 (4.14-7.13)] compared to normal liver tissue [group A: 1.57 (1.2-2.06), group B: 1.5 (1.16-1.93); p < 0.001 for both groups]. The [(18)F]FMISO SUV allowed prediction of the tPO(2) with satisfying accuracy in hypoxic regions using the exponential regression curve [[(18)F]FMISO=1.05+6.7((-0.117 tPO(2))); r(2)=0.75; p < 0.001]. In addition, regardless of ventilation conditions, a significant exponential relationship between the DO(2) and the [(18)F]FMISO SUV was found ( r(2)=0.39, p < 0.001). Our results suggest that the reduction of the oxygen delivery below the critical range of 0.1-0.11 mL x min(-1) x g(-1) regularly causes liver tissue hypoxia. The severity of hypoxia is reflected by the [(18)F]FMISO accumulation and allows the in vivo estimation of the tPO(2) in hypoxic regions.

[Functional results after suture repair in ruptures of the long biceps tendon with special consideration of subacromial impingement]

Operative treatment for ruptures of the long biceps tendon still is discussed controversially. In the present literature the keyhole-technique is recommended according to favourable biomechanical conditions. In recent years refixation to the short biceps tendon was preferred. Now it is supposed that this technique may provoke subacromial impingement considering the loss of depression function of the long biceps tendon to the humeral head. Between 1980 to 1991 83 patients with rupture of the long biceps tendon were treated operatively by refixation to the short head. 28 patients were investigated after an average follow-up of 6.5 years. Due to the criteria of the Constant-Score 85% of patients achieved very good, 15% good results. At our patients provocation of a subacromial impingement could not be observed. The subacromial space was not reduced in the postoperative x-ray control. Compared with the non-operated shoulder isokinetic determination of isometric maximal peak torque for elbow-flexion, shoulder-abduction and shoulder-flexion yield to almost identical results for the operated shoulder. Refixation to the short head can be advised for treatment of ruptures of the long biceps tendon due to the certain technique with a low complication rate and very good functional outcome.

[Interdisciplinary consensus on diagnosis and therapy of testicular tumors. Results of an update conference based on evidence-based medicine. German Testicular Cancer study Group (GTCSG)]

BACKGROUND

An "Interdisciplinary Consensus Statement on the Diagnosis and Therapy of Testicular Tumors" was prepared in 1996 by the "Interdisciplinary Testicular Tumor Working Group" (IAH) with input from representatives from diagnostic and therapeutic disciplines of various working groups of the German Cancer Society (Strahlenther Onkol 1997;173:397-406). In 1998 the IAH met again together with the "Testicular Tumor Working Party" of the Urooncology Working Group (AUO) and formed the "German Testicular Cancer Study Group" (GTCSG). Defined and accepted interdisciplinary standards from the initial meeting were revised based on current scientific developments and clinical results. This cooperating effort increased the quality of the initial recommendations and helped to put the recommendations for diagnosing and treating testicular tumor on a broader scientific basis.

METHODS

According to the principles of "evidence-based medicine" (EBM), the Consensus from 1996 was modified, based on the current level of evidence from the published literature. The methodological process and evaluation criteria used were that of the "Cochrane Collaboration".

RESULTS

An "Interdisciplinary Update Consensus Statement" summarizes and defines the diagnostic and therapeutic standards according to the current scientific practices in testicular cancer. For 21 separate areas scientifically based decision criteria are suggested. For treatment areas where more than one option exist without a consensus being reached for a preferred strategy, such as in seminoma in clinical Stage I or in non-seminoma Stages CS I or CS IIA/B, all acceptable alternative strategies with their respective advantages and disadvantages are presented. This "Interdisciplinary Update Consensus" was presented at the 24th National Congress of the German Cancer Society on March 21st and subsequently evaluated and approved by the various German scientific medical societies.

Results of an uncemented straight femoral shaft prosthesis after 9 years of follow-up

The first consecutive 250 implantations of an uncemented, proximally anchored straight femoral shaft prosthesis (BiCONTACT) in 236 patients are included in this prospective follow-up study. Average time of follow-up evaluation was 8.9 years (range, 7.4-10.7 years). At follow-up, 27 patients had died, and 2 could not be located. Seven patients underwent revision-2 for infection, 1 for recurrent dislocation, 2 for component undersizing with rapid subsidence, and 1 for aseptic loosening of a varus-malaligned stem; 1 radiologically well-fixed stem had been revised during acetabular revision. Overall survival was 97.1% after 11 years (confidence limits, 98.7% [upper] and 93.6% [lower]). The average Harris Hip score at time of follow-up was 84.3 points. Radiologically, tiny reactive lines (<2 mm) were present in the distal zones of the femoral shaft, but no radiolucencies could be found in the proximal anchoring zone. The midterm to long-term follow-up results with the evaluated femoral component are encouraging and are comparable to those of modern techniques of cementing in primary total hip arthroplasty.

cDNA cloning and analysis of tissue-specific expression of mouse peroxisomal straight-chain acyl-CoA oxidase

Straight-chain acyl-CoA oxidase is the first and rate limiting enzyme in the peroxisomal beta-oxidation pathway catalysing the desaturation of acyl-CoAs to 2-trans-enoyl-CoAs, thereby producing H2O2. To study peroxisomal beta-oxidation we cloned and characterized the cDNA of mouse peroxisomal acyl-CoA oxidase. It consists of 3778 bp, including a 1983-bp ORF encoding a polypeptide of 661 amino-acid residues. Like the rat and human homologue the C-terminus contains an SKL motif, an import signal present in several peroxisomal matrix proteins. Sequence analysis revealed high amino-acid homology with rat (96%) and human (87%) acyl-CoA oxidase in addition to minor homology ( approximately 40%) with other related proteins, such as rabbit trihydroxy-cholestanoyl-CoA oxidase, human branched chain acyl-CoA oxidase and rat trihydroxycoprostanoyl-CoA oxidase. Acyl-CoA oxidase mRNA and protein expression were most abundant in liver followed by kidney, brain and adipose tissue. During mouse brain development acyl-CoA oxidase mRNA expression was highest during the suckling period indicating that peroxisomal beta-oxidation is most critical during this developmental stage. Comparing tissue mRNA levels of peroxisome proliferator-activated receptor alpha and acyl-CoA oxidase, we noticed a constant relationship in all tissues investigated, except heart and adipose tissue in which much more, and respectively, much less, peroxisome proliferator-activated receptor alpha mRNA in proportion to acyl-CoA oxidase mRNA was found. Our data show that acyl-CoA oxidase is an evolutionary highly conserved enzyme with a distinct pattern of expression and indicate an important role in lipid metabolism.

A Long Straight Stem with Distal Interlocking for Uncemented Stem Revision in THR

Femoral revision in total hip replacement (THR) is often demanding due to severe bone defects of the proximal femur. The surgical technique must provide sufficient stability in the distal femur. However, long-term stability depends on preserving or even rebuilding proximal bone stock.

[Muscle strength after surgical treatment of ruptures of the long biceps tendon by refixation to the short head]

Operative treatment for ruptures of the long biceps tendon still is discussed controversially. In the present literature surgical repair is advised for sporting and high demand patients due to favourable functional results and low loss of strength. Until now only few objective and reproducible results were published. In the present literature the keyhole-technique is recommended due to favourable bio-mechanical conditions. To evaluate postoperative strength 19 patients were investigated after an average follow-up of 6.5 years, by clinical examination and isokinetic measurement. Compared with the non-operated shoulder isokinetic determination of isometric maximal peak torque and strength during concentric stress for elbow-flexion, shoulder-abduction and shoulder-flexion yield to almost identical results for the operated shoulder. According to the criteria of the Constant-Score all patients achieved very good and good results. Refixation to the short head can be advised for treatment of ruptures of the long biceps tendon due to the certain technique with a low complication rate and very good functional outcome.

Sum1 and Hst1 repress middle sporulation-specific gene expression during mitosis in Saccharomyces cerevisiae

Meiotic development in yeast is characterized by the sequential induction of temporally distinct classes of genes. Genes that are induced at the middle stages of the pathway share a promoter element, termed the middle sporulation element (MSE), which interacts with the Ndt80 transcriptional activator. We have found that a subclass of MSEs are strong repressor sites during mitosis. SUM1 and HST1, genes previously associated with transcriptional silencing, are required for MSE-mediated repression. Sum1 binds specifically in vitro to MSEs that function as strong repressor sites in vivo. Repression by Sum1 is gene specific and does not extend to neighboring genes. These results suggest that mechanisms used to silence large regions of chromatin may also be used to regulate the expression of specific genes during development. NDT80 is regulated during mitosis by both the Sum1 and Ume6 repressors. These results suggest that progression through sporulation may be controlled by the regulated competition between the Sum1 repressor and Ndt80 activator at key MSEs.

Allogenic bone graft viability after hip revision arthroplasty assessed by dynamic [18F]fluoride ion positron emission tomography

The biological fate of allogenic bone grafts in the acetabular cavity and their metabolic activity after acetabular augmentation is uncertain but is most important for the stability of hip implants after hip revision arthroplasty. The aim of this study was to quantify regional bone metabolism after hip replacement operations. Dynamic [18F]fluoride ion positron emission tomography (PET) was used to investigate the metabolic activity of acetabular allogenic bone grafts and genuine bone, either 3-6 weeks (short-term group, n = 9) or 5 months to 9 years (long-term group, n = 10) after hip revision arthroplasty. Applying a three-compartment model, the fluoride influx constant was calculated from individually fitted rate constants (Knlf) and by Patlak graphical analysis (Kpat). The results were compared with genuine cancellous and cortical acetabular bone of contralateral hips without surgical trauma (n = 7). In genuine cortical bone, Knlf was significantly increased in short- (+140.9%) and long-term (+100.0%) groups compared with contralateral hips. Allogenic bone grafts were characterised by a significantly increased Knlf in the short-term group (+190.9%) compared with contralateral hips, but decreased almost to the baseline levels of contralateral hips (+45.5%) in the long-term. Values of Knlf cor-related with the rate constant K1 in genuine (r = 0.89, P<0.001) and allogenic bone regions (r = 0.79, P<0.001), indicating a coupling between bone blood flow and bone metabolism in genuine bone as well as allogenic bone grafts. Kpat values were highly correlated with Knlf measurements in all regions. In conclusion, [18F]fluoride ion PET revealed the presence of an increased host bone formation in allogenic bone grafts early after hip revision arthroplasty. In contrast to genuine cortical bone, allogenic bone graft metabolism decreased over time, possibly due to a reduced ability to respond to the same extent as genuine bone to elevated metabolic demands after surgery.

[Structure quality in outpatient care of chronic pain patients]

BACKGROUND

Outcome quality of medical treatment depends on structure quality of the treatment facility. In the present study we tried evaluate structural parameters of outpatient treatment facilities relating to management of headache, low back pain and cancer pain.

METHODS

109 outpatient treatment facilities (104 offices, 3 outpatient departments of hospitals, 2 pain ambulances of hospitals) in middle franconia, one of the larger Bavarian administrative division (population: 1,6 Mio.), have been evaluated by questionnaires. Questions examined certain structural conditions of the treatment facility as compared to german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung").

RESULTS

Only one treatment facility worked within an interdisciplinary setting. Less than 25% (median) of total patients of an outpatient treatment facility suffered from acute or chronic headache, low back pain or cancer pain. 38% of physicians participated regularly on pain conferences. Established methods for diagnosis and documentation of patients suffering from chronic headache, chronic back pain and cancer pain were regularly used by 16%, 12% and 10% of physicians, respectively. Regular interdisciplinary cooperation in the management of patients with chronic headache, chronic back pain and cancer pain was indicated by 28%, 24% and 41% of physicians, respectively. However, personal discussion of patient related problems took place in less than 5% of physicians. Although a considerable number of different therapies (included as standard therapy for outpatient management of chronic pain in the "Schmerztherapievereinbarung") can be applied in each outpatient treatment facility (median:5), psychological therapy for management of chronic headache, chronic back pain and cancer pain was used regularly by 5%, 2% and 7% of physicians, respectively. Scoring of all examined structural parameters provides a measure for the quality of the parameters of a certain outpatient treatment facility as compared to that of an optimal outpatient facility for pain treatment (quality score=100%). However, 75% of examined outpatient treatment facilities reached quality scores only up to 43%.

CONCLUSIONS

There are considerable structural deficits in outpatient treatment facilities involved in management of patients suffering from chronic headache, chronic back pain and cancer pain. Realisation of standards according to the "Schmerztherapievereinbarung" needs organisation of an interdisciplinary network between the different specialties necessary for pain management. Interdisciplinary cooperation should be supported by the official organization of the medical self-government in Germany--the Kassenärztliche Vereinigung--which has to assure optimal conditions for outpatient treatments.

Distinct steps in yeast spore morphogenesis require distinct SMK1 MAP kinase thresholds

The SMK1 mitogen-activated protein kinase is required for spore morphogenesis in Saccharomyces cerevisiae. In contrast to the multiple aberrant spore wall assembly patterns seen even within a single smk1 null ascus, different smk1 missense mutants block in a coordinated fashion at intermediate stages. One smk1 mutant forms asci in which the four spores are surrounded only by prospore wall-like structures, while another smk1 mutant forms asci in which the spores are surrounded by inner but not outer spore wall layers. Stepwise increases in gene dosage of a hypomorphic smk1 allele allow for the completion of progressively later morphological and biochemical events and for the acquisition of distinct spore-resistance phenotypes. Furthermore, smk1 allelic spore phenotypes can be recapitulated by reducing wild-type SMK1 expression. The data demonstrate that SMK1 is required for the execution of multiple steps in spore morphogenesis that require increasing thresholds of SMK1 activity. These results suggest that quantitative changes in mitogen-activated protein kinase signaling play a role in coordinating multiple events of a single cellular differentiation program.