Effect of bimatoprost sustained-release intracameral implant on intraocular pressure and medication burden in patients with prior glaucoma surgery

The present retrospective study evaluated intraocular pressure (IOP) and medication burden after bimatoprost sustained-release (bimatoprost SR, Durysta, Allergan) implantation in patients with glaucoma. A secondary objective was to examine an effect of bimatoprost SR in a subset of patients with prior minimally invasive and incisional glaucoma surgery. A retrospective chart review of 122 eyes that received bimatoprost SR by 6 glaucoma specialists at Wills Eye Hospital between March 2020 and September 2021 was performed. One hundred and eighteen eyes from 84 patients had a reduction in IOP (18.5±5.7mmHg vs. 16.0±5.4mmHg, P<0.01) and required fewer glaucoma medications (2.1±1.4 vs. 1.2±1.2, P<0.01) after bimatoprost SR implantation. In 41 eyes from 31 patients who previously underwent glaucoma surgery (including iStent, goniotomy, trabeculectomy, Xen Gel Stent, or tube shunt surgery), medication burden was decreased after bimatoprost SR implantation (1.9±1.3 vs. 1.0±1.0, P<0.001). These data suggest that bimatoprost SR is an efficacious treatment modality for glaucoma, even in post-surgical patients.

Strengthening the WHO Regional Office for Africa (WHO AFRO) COVID-19 vaccination information system

This manuscript describes the process and impact of strengthening the WHO Regional Office for Africa (WHO AFRO)'s COVID-19 vaccination information system. This system plays a critical role in tracking vaccination coverage, guiding resource allocation and supporting vaccination campaign roll-out for countries in the African region. Recognising existing data management issues, including complex reporting prone to human error, compromised data quality and underutilisation of collected data, WHO AFRO introduced significant system improvements during the COVID-19 pandemic. These improvements include shifting from an Excel-based to an online Azure-based data collection system, automating data processing and validation, and expansion of collected data. These changes have led to improvements in data quality and quantity including a decrease in data non-validity, missingness, and record duplication, and expansion of data collection forms to include a greater number of data fields, offering a more comprehensive understanding of vaccination efforts. Finally, the creation of accessible information products-including an interactive public dashboard, a weekly data pack and a public monthly bulletin-has improved data use and reach to relevant partners. These resources provide crucial insights into the region's vaccination progress at national and subnational levels, thereby enabling data-driven decision-making to improve programme performance. Overall, the strengthening of the WHO AFRO COVID-19 vaccination information system can serve as a model for similar efforts in other WHO regions and contexts. The impact of system strengthening on data quality demonstrated here underscores the vital role of robust data collection, capacity building and management systems in achieving high-quality data on vaccine distribution and coverage. Continued investment in information systems is essential for effective and equitable public health efforts.

Adjuvant Radiation Therapy Improves Local Control in the Treatment of Adnexal Carcinoma

PURPOSE/OBJECTIVE(S)

Adnexal carcinoma (AC) is a rare subset of cutaneous malignancies derived from skin adnexa. There are limited data on the role of adjuvant radiation therapy (RT). This study investigates outcomes associated with adjuvant RT at our high-volume referral center.

MATERIALS/METHODS

Using an institutional pathology database we identified 45 patients with locoregionally-confined AC treated between 2001-2020 with curative intent surgery and RT at initial diagnosis or at the time of locoregionally-confined recurrence. Clinicopathologic variables were described and time to relapse events were assessed by the Kaplan-Meier method.

RESULTS

Median age was 64 yrs (IQR 57-71). Primary tumors were in the head and neck (H&N, n = 36, 80%), trunk/extremities (n = 8, 18%) or unknown (n = 1). The most common histologic subtypes were: sebaceous-14 (31%), microcystic adnexal carcinoma-9 (20%), eccrine-6 (13%), and trichilemmal-5 (11%). Twenty-two (50% of known primaries) had PNI. All patients had primary tumor excision. Six had clinically evident lymphadenopathy (13%), all of whom had lymph node dissection (LND). Five patients without evidence of nodal disease (13%) had sentinel lymph node biopsy (SLNB) with one having SLN+ disease. Thirty patients (67%) received adjuvant locoregional RT at initial diagnosis with the following targets: 21 (30%) primary only, 4 (13%) nodal only, and 5 (17%) both. Of those receiving nodal RT, 7 (78%) had LN+ LND with 2 of those receiving concurrent platinum-based chemoradiation. Sixteen were treated at recurrence with the following targets: 4 (25%) primary only (1 having had prior adjuvant nodal RT), 4 (25%) nodal only, and 8 (50%) both. Across the full cohort, median RT dose was 60 Gy in 30 fractions. Median follow-up from initial surgical resection was 60 months (IQR 30-160). 5-year LC, NC, DFS and DSS were 71%, 86%, 66%, and 91% respectively. The only evaluated factor associated with better outcome was adjuvant primary site RT (5-yr LC 83% vs. 56%, p = 0.01 and 5-yr DFS 83% vs. 46%, p = 0.0003). All 15 patients with local recurrence (LR) had salvage surgery with median subsequent follow-up of 75 months (IQR 2-94). Overall, 5 patients receiving adjuvant primary site RT at any time (initial or salvage) developed subsequent local recurrence (13%). Of the 8 patients who developed nodal recurrence (NR) during follow-up, 1 received adjuvant nodal RT at initial diagnosis. Six of 7 who did not receive prior RT then received adjuvant nodal RT after LND and only 1 developed subsequent NR.

CONCLUSION

AC is a rare skin cancer with a primarily locoregional recurrence pattern. In our experience, adjuvant RT was associated with improved LC which, depending on the tumor location, may help prevent morbid or cosmetically-impactful salvage surgery. Patients with AC would benefit from radiation oncology referral to discuss adjuvant treatment.

First-in-class Microbial Ecosystem Therapeutic 4 (MET4) in combination with immune checkpoint inhibitors in patients with advanced solid tumors (MET4-IO trial)

BACKGROUND

The intestinal microbiome has been associated with response to immune checkpoint inhibitors (ICIs) in humans and causally implicated in ICI responsiveness in animal models. Two recent human trials demonstrated that fecal microbiota transplant (FMT) from ICI responders can rescue ICI responses in refractory melanoma, but FMT has specific limitations to scaled use.

PATIENTS AND METHODS

We conducted an early-phase clinical trial of a cultivated, orally delivered 30-species microbial consortium (Microbial Ecosystem Therapeutic 4, MET4) designed for co-administration with ICIs as an alternative to FMT and assessed safety, tolerability and ecological responses in patients with advanced solid tumors.

RESULTS

The trial achieved its primary safety and tolerability outcomes. There were no statistically significant differences in the primary ecological outcomes; however, differences in MET4 species relative abundance were evident after randomization that varied by patient and species. Increases in the relative abundance of several MET4 taxa, including Enterococcus and Bifidobacterium, taxa previously associated with ICI responsiveness, were observed and MET4 engraftment was associated with decreases in plasma and stool primary bile acids.

CONCLUSIONS

This trial is the first report of the use of a microbial consortium as an alternative to FMT in advanced cancer patients receiving ICI and the results justify the further development of microbial consortia as a therapeutic co-intervention for ICI treatment in cancer.

COVID-19 Mortality and Progress Toward Vaccinating Older Adults - World Health Organization, Worldwide, 2020-2022

After the emergence of SARS-CoV-2 in late 2019, transmission expanded globally, and on January 30, 2020, COVID-19 was declared a public health emergency of international concern.* Analysis of the early Wuhan, China outbreak (1), subsequently confirmed by multiple other studies (2,3), found that 80% of deaths occurred among persons aged ≥60 years. In anticipation of the time needed for the global vaccine supply to meet all needs, the World Health Organization (WHO) published the Strategic Advisory Group of Experts on Immunization (SAGE) Values Framework and a roadmap for prioritizing use of COVID-19 vaccines in late 2020 (4,5), followed by a strategy brief to outline urgent actions in October 2021.^† WHO described the general principles, objectives, and priorities needed to support country planning of vaccine rollout to minimize severe disease and death. A July 2022 update to the strategy brief^§ prioritized vaccination of populations at increased risk, including older adults,^¶ with the goal of 100% coverage with a complete COVID-19 vaccination series** for at-risk populations. Using available public data on COVID-19 mortality (reported deaths and model estimates) for 2020 and 2021 and the most recent reported COVID-19 vaccination coverage data from WHO, investigators performed descriptive analyses to examine age-specific mortality and global vaccination rollout among older adults (as defined by each country), stratified by country World Bank income status. Data quality and COVID-19 death reporting frequency varied by data source; however, persons aged ≥60 years accounted for >80% of the overall COVID-19 mortality across all income groups, with upper- and lower-middle-income countries accounting for 80% of the overall estimated excess mortality. Effective COVID-19 vaccines were authorized for use in December 2020, with global supply scaled up sufficiently to meet country needs by late 2021 (6). COVID-19 vaccines are safe and highly effective in reducing severe COVID-19, hospitalizations, and mortality (7,8); nevertheless, country-reported median completed primary series coverage among adults aged ≥60 years only reached 76% by the end of 2022, substantially below the WHO goal, especially in middle- and low-income countries. Increased efforts are needed to increase primary series and booster dose coverage among all older adults as recommended by WHO and national health authorities.

Early Clinical Outcomes of Short versus Long Proximal Femoral Nail Anti-rotation (PFNA) in the Treatment of Intertrochanteric Fractures

INTRODUCTION

Both short and long PFNA are employed to treat intertrochanteric fractures. Controversy exists in the choice between the two nails as each implant has specific characteristics and theoretical advantages. This retrospective study seeks to examine the operative complication rates and clinical outcomes of short versus long (Proximal Femoral Nail Antirotation) PFNA in the treatment of intertrochanteric fractures.

MATERIAL AND METHODS

Between July 2011 and February 2015, 155 patients underwent PFNA insertion. The decision on whether to use a short or long PFNA nail, locked or unlocked, was determined by the attending operating surgeon. Visual Analogue Pain Score (VAS) Harris Hip Scores (HHS), Short-form 36 Health Questionnaire (SF-36) and Parker Mobility Scores (PMS) were collected at six weeks, six months and one year post-operatively.

RESULTS

A total of 137 (88.4%) patients were successfully followed-up. Forty-two (30.7%) patients received a short PFNA. The patients were similar in baseline characteristics of age, gender, and comorbidities. Operative time was significantly longer in the short PFNA group (62 ±17 mins) versus the long PFNA group (56±17). While the patients in both groups achieved improvement in all outcome measures, there was no significant difference between the groups in terms of HHS (61.0 ±16.0 vs 63.0 ±16.8, p=0.443), PMS (2.3±1.5 vs 2.7±2.1, p=0.545) and VAS (1.7±2.9 vs 1.8 ±2.2 p=0.454). There were 3 (7.1%) and 7 (7.4%) complications in the short versus long PFNA group, respectively.

CONCLUSION

Both short and long PFNA had similar clinical outcomes and complication rates in the treatment of intertrochanteric fractures in an Asian population.

Revision total knee arthroplasty longer term outcome and comparison between infection and aseptic loosening at mean follow-up of 10 years

Background:

Although the majority of total knee arthroplasty cases have good outcome and survival, some arthroplasty eventually required revision. While early outcomes of revision knee arthroplasty are well reported, there is relatively fewer literatures reporting on the longer term outcome of revision knee arthroplasty. This study aims to review the outcome of revision knee arthroplasty for a longer term, and also make comparison between the two common indications for revision arthroplasty of infection and aseptic loosening.

Methods:

This study reviews all total knee arthroplasty revision performed at a single center over a 11 year period. Of the 48 cases found, 35 cases not lost to follow-up had a mean follow-up duration of 10.6 years (SD 2.9) for aseptic loosening, and 10.1 years (SD 2.6) for infection. Data of initial arthroplasty, revision arthroplasty, demographics, follow-up outcome were obtained, analyzed and compared.

Results:

Revision arthroplasty due to infection had more cases that required use of varus/valgus constraints (p ∼ 0.008) and extensile surgical exposure of quadriceps snip (p ∼ 0.005) compared to aseptic loosening. The survival at 10 years for this study is 91% overall (aseptic loosening 93.3%, infection 89.3%). Infection cases had significant initial improvement for range of motion (p ∼ 0.001) and use of walking aid (p ∼ 0.04) at post-operation 1 year, but no significant differences between the infection and aseptic loosening cases at 5 years and 10 years follow-up. Comparison between the two groups on other factors including initial arthroplasty, operative details, demographics, post-operative details and X-rays showed no statistically significant difference.

Early outcomes of proximal humerus fracture fixation with locking plate and intramedullary fibular strut graft

Proximal humerus fractures are commonly encountered in elderly patients. Surgical treatment demonstrates high complication rates, including varus construct collapse and screw cutout. In this study, the authors evaluate the clinical outcome of locking plate fixation with intramedullary fibular strut graft augmentation as a primary surgical treatment in the prevention of early collapse and screw cutout. A total of 9 patients were evaluated. Surgery was performed for displaced proximal humerus fractures between April and December 2011. Patients were either class 2, 3, or 4, according to Neer classification. Mean patient age was 75.4 years. Preoperative and immediate, 6-week, and 3-month postoperative radiographs were evaluated. Head-shaft angles were measured to assess for varus collapse and displacement. Range of motion, complication rates, and functional recovery were also evaluated. Patients underwent open reduction and internal fixation with placement of an intramedullary fibular strut graft. Fixation was achieved with a Philos plate (Synthes, Oberdorf, Switzerland). Reduction and fixation were evaluated with radiographs. Passive exercises and range of motion were allowed immediately postoperatively, and all patients achieved active abduction and forward flexion 6 weeks postoperatively. Shoulder radiographs taken 12 weeks postoperatively revealed no loss of reduction or screw cutout. The introduction of the locking plate has improved outcomes. The addition of an intramedullary strut graft has shown improved preliminary results. Maintained reduction was observed in all 9 patients in the early postoperative period, and good functional motion was achieved. No incidence of screw cutout was recorded.

FZD7 drives in vitro aggressiveness in Stem-A subtype of ovarian cancer via regulation of non-canonical Wnt/PCP pathway

Ovarian cancer (OC) can be classified into five biologically distinct molecular subgroups: epithelial-A (Epi-A), Epi-B, mesenchymal (Mes), Stem-A and Stem-B. Among them, Stem-A expresses genes relating to stemness and is correlated with poor clinical prognosis. In this study, we show that frizzled family receptor 7 (FZD7), a receptor for Wnt signalling, is overexpressed in the Stem-A subgroup. To elucidate the functional roles of FZD7, we used an RNA interference gene knockdown approach in three Stem-A cell lines: CH1, PA1 and OV-17R. Si-FZD7 OC cells showed reduced cell proliferation with an increase in the G0/G1 sub-population, with no effect on apoptosis. The cells also displayed a distinctive morphologic change by colony compaction to become more epithelial-like and polarised with smaller internuclear distances and increased z-axis height. Immunofluorescence (IF) staining patterns of pan-cadherin and β-catenin suggested an increase in cadherin-based cell–cell adhesion in si-FZD7 cells. We also observed a significant rearrangement in the actin cytoskeleton and an increase in tensile contractility in si-FZD7 OC cells, as evident by the loss of stress fibres and the redistribution of phospho-myosin light chain (pMLC) from the sites of cell–cell contacts to the periphery of cell colonies. Furthermore, there was reciprocal regulation of RhoA (Ras homolog family member A) and Rac1 (Ras-related C3 botulinum toxin substrate 1 (Rho family, small GTP-binding protein Rac1)) activities upon FZD7 knockdown, with a significant reduction in RhoA activity and a concomitant upregulation in Rac1 activity. These changes in pMLC and RhoA, as well as the increased TopFlash reporter activities in si-FZD7 cells, suggested involvement of the non-canonical Wnt/planar cell polarity (PCP) pathway. Selected PCP pathway genes (cadherin EGF LAG seven-pass G-type receptor 3 (CELSR3), prickle homolog 4 (Drosophila) (PRICKLE4), dishevelled-associated activator of morphogenesis 1 (DAAM1), profilin 2 (PFN2), protocadherin 9 (PCDH9), protocadherin α1 (PCDHA1), protocadherin β17 pseudogene (PCDHB17), protocadherin β3 (PCDHB3), sprouty homolog 1 (SPRY1) and protein tyrosine kinase 7 (PTK7)) were found to be more highly expressed in Stem-A than non Stem-A subgroup of OC. Taken together, our results suggest that FZD7 might drive aggressiveness in Stem-A OC by regulating cell proliferation, cell cycle progression, maintenance of the Mes phenotype and cell migration via casein kinase 1ɛ-mediated non-canonical Wnt/PCP pathway.

Comparison of detection of glucose-6-phosphate dehydrogenase deficiency using fluorescent spot test, enzyme assay and molecular method for prediction of severe neonatal hyperbilirubinaemia

INTRODUCTION

This study aimed to compare the detection rates of glucose-6-phosphate dehydrogenase (G6PD) deficiency in neonates by fluorescent spot test (FST), enzyme assay and molecular methods, and to identify which method was a significant predictor of severe hyperbilirubinaemia.

METHODS

74 term infants of Chinese descent admitted with severe hyperbilirubinaemia (total serum bilirubin equal or greater than 300 micromol/L) and 125 healthy term infants born in the hospital without severe hyperbilirubinaemia were recruited into the study. Specimens of blood were collected from each infant for FST, G6PD enzyme assay and TaqMan minor groove binder single nucleotide polymorphism genotyping assay.

RESULTS

26 (13.1 percent) infants were diagnosed to have G6PD deficiency by FST. They had significantly lower median enzyme levels (0.8 IU/g Hb, interquartile range [IQR] 0.4-4.3) than those diagnosed to be normal (12.0 IU/g Hb, IQR 10.3-15.8) (p-value is less than 0.0001). Based on the enzyme assay, 39 (19.6 percent) infants had G6PD deficiency at an enzyme cut-off level of less than 8.5 IU/g Hb. G6PD mutation was detected in 27 (13.6 percent) infants. Logistic regression analysis showed that the only significant predictors of severe hyperbilirubinaemia were G6PD deficiency based on a cut-off level of less than 8.5 IU/g Hb (adjusted odds ratio [OR] 5.3, 95 percent confidence interval [CI] 2.4-11.4; p-value is less than 0.0001) and exclusive breast-feeding (adjusted OR 11.4, 95 percent CI 3.1-42.4; p-value is less than 0.0001). The gender and birth weight of infants, FST results, G6PD mutation and the actual G6PD enzyme levels were not significant predictors.

CONCLUSION

A G6PD enzyme level of less than 8.5 IU/g Hb is a significant predictor of severe hyperbilirubinaemia.

Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution

We carried out a retrospective review over ten months of patients who had presented with a low-energy subtrochanteric fracture. We identified 13 women of whom nine were on long-term alendronate therapy and four were not. The patients treated with alendronate were younger, with a mean age of 66.9 years (55 to 82) vs 80.3 years (64 to 92) and were more socially active. The fractures sustained by the patients in the alendronate group were mainly at the femoral metaphyseal-diaphyseal junction and many had occurred after minimal trauma. Five of these patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur. Our study suggests that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. We believe that this finding is important and indicates the need for caution in the long-term use of alendronate in the treatment of osteoporosis.

Recurrent pneumothorax in pregnancy: what should we do after placing an intercostal drain

Recurrent pneumothorax is rare during pregnancy. We describe a Chinese woman, with a history of spontaneous pneumothorax managed with an intercostal drain, who developed a recurrent pneumothorax during her 32nd week of pregnancy. There is no consensus on management in this situation. We review the literature and discuss different management approaches. Thirty-six cases of antepartum pneumothorax have been reported in 31 case reports. An intercostal drain only (n=11) or surgeries (thoracotomy, n=9; or video-assisted thoracoscopy, n=2) were common treatment options with no surgical complications reported. Twenty-two (61%) patients progressed to a normal vaginal delivery, while the rest required forceps delivery (22%) or Caesarean section (14%). No single treatment option outweighed the others. There were no maternal or foetal complications reported in those who underwent antepartum surgical intervention. Surgical management of recurrent pneumothorax during pregnancy is well tolerated.

The use of computer navigation in performing minimally invasive surgery for intertrochanteric hip fractures--The experience in Singapore

OBJECTIVE

Intertrochanteric hip fractures are very common and early mobilisation correlates with a better outcome. The ideal surgical procedure should protect the soft tissue envelope, thereby preserving blood supply and reducing blood loss. Furthermore, occupational exposure to fluoroscopy that is used in hip fracture fixation remains a concern amongst orthopaedic surgeons. Computer-aided surgery can help to reduce reliance on fluoroscopy. We therefore combined the principles of minimally invasive plate osteosynthesis (MIPO) and computer navigation to describe a new procedure. We also present our results using this technique of minimally invasive computer-navigated dynamic hip screw fixation (navMIS-DHS), and compare it to computer-navigated open DHS fixation (nav-DHS) and to conventional open DHS fixation (conv-DHS).

MATERIALS AND METHODS

This paper has three parts. In the first part, we describe the procedure of navMIS-DHS in detail. In the second part, we present our initial retrospective pilot series of 35 cases. Amongst them we performed 5 navMIS-DHS, 3 nav-DHS and 27 conv-DHS. There were also two cases of conv-DHS deliberately performed with a mini-incision in an attempt to see if we could duplicate the 5 cm incision that we achieved with navMIS-DHS. All patients were followed up for a minimum of 6 months. In the third part, we performed a single surgeon prospective evaluation of navMIS-DHS versus conv-DHS involving 43 fractures in two arms.

RESULTS

We were able to achieve reduction in fluoroscopy time. There was also reduction in opiate requirement post-operatively in the minimally invasive procedure. The incision sizes were also smaller. The prospective study also showed less wound-related complications in navMIS-DHS and a shorter time to ambulation. Implant positions were acceptable but we have also described how it may be improved.

CONCLUSIONS

Navigated MIS-DHS, by virtue of less pain, better healing, earlier rehabilitation and potentially shorter hospital stay, would benefit both the patients and reduce the economic strain on the health care system. It is a safe and reproducible procedure. Technical difficulties are present and these need to be addressed with further modifications of technique, and instrumentation.

Acute adverse reactions to magnetic resonance contrast media--gadolinium chelates

The objective of this study was to evaluate the clinical safety of intravenous gadolinium-based contrast media used in patients who underwent MRI at a single institution. Acute adverse reactions to intravenous gadolinium-based contrast media used for MRI at the Princess Margaret Hospital, Hong Kong, SAR, from January 1999 to November 2004 were recorded in an incidence log book. The medical records of patients' demographics were retrospectively reviewed and the nature, frequency and severity of the adverse reactions were investigated and documented. The incidence of acute adverse reactions to intravenous gadolinium-based contrast media was 0.48% (45 patients with 46 adverse reactions). The severity of these adverse reactions were 96% mild, 2% moderate (one patient developed shortness of breath that required oxygen supplementation and intravenous steroidal management) and 2% severe (one patient developed an anaphylactoid reaction, but successfully recovered through timely resuscitation). No patients were recorded as having contrast extravasation and none died as a result of any adverse reaction. Among the 45 patients who developed adverse reactions, three patients (6.7%) had prior adverse reactions to iodinated contrast media, three (6.7%) had prior reactions to a different gadolinium-based contrast agent, one (2%) had asthma and nine (20%) had a history of drug/food allergy. Overall, 41% of the adverse reactions were not documented in the final MRI report or the clinical medical records. Gadolinium-based contrast media are safe and well tolerated by the vast majority of patients. In our study, the adverse reaction rate (0.48%) and the incidence of severe anaphylactoid reaction (0.01%) concur with those reported in the literature. Although most of the symptoms are mild and transient, these adverse reactions must be accurately documented and managed.

Lymphoepithelioma-like carcinoma of the lung: experience with ten cases

OBJECTIVE

Lymphoepithelioma-like carcinoma of the lung (LELC) is a rare form of non-small cell lung cancer predominantly affecting young non-smoking Asians, and there has been only limited experience in its palliative chemotherapy and radiotherapy. We investigated tumour response, time to progression and survival of LELC patients who received such treatment.

DESIGN

We prospectively recruited patients with confirmed advanced LELC who were treated with chemoradiotherapy in our unit, a regional tertiary referral centre for lung cancer treatment.

RESULTS

There were 10 patients (five males, age 47 +/- 9.8 years, median follow-up 22 months) with advanced LELC (respectively 1, 4, and 5 patients at TNM stage IIIA, IIIB and IV) who received systemic chemotherapy and radiotherapy. The primary chemotherapy regimen consisted of 5-fluorouracil/leucovorin/cisplatin. The response rates to 5-fluorouracil/leucovorin/cisplatin were 60% partial response, 10% stable disease, and 30% progressive disease. Eight patients were also given local radiotherapy. Five patients received salvage chemotherapy when disease progressed after primary chemotherapy. The overall median survival was 23.4 +/- 4.7 months.

CONCLUSION

The encouraging response to combination chemotherapy with 5-fluorouracil/leucovorin/ cisplatin, although empirical, supports its use with radiotherapy in unresectable lymphoepithelioma-like carcinoma of the lung.

Heart rate responses and oxygen consumption during Tai Chi Chuan practice

Tai Chi Chuan (TCC) is a popular Chinese conditioning exercise, however, its exercise intensity remains controversial. The objective of this study was to determine the exercise intensity of Yang TCC by measuring heart rate (HR) responses and oxygen consumption (VO2) during practice. Fifteen men aged 39.9 +/- 9.5 yrs (range 26-56 yrs) participated in this study. Subjects had practiced classical Yang TCC for 5.8 +/- 2.4 years. HR responses and VO2 were measured during practice of TCC by using a K4 telemetry system. Blood lactate was measured before and immediately after TCC practice. Additionally, breath-by-breath measurement of cardiorespiratory function and sequential determination of blood lactate were performed during the incremental exercise of leg cycling. Measurements obtained during the TCC practice and exercise testing were compared to determine the exercise intensity of TCC. While performing TCC, the mean HR of subjects was 140 +/- 10 bpm, and the mean VO2 was 21.4 +/- 1.5 mL x kg(-1) min(-1). Compared with the data of the exercise test, the HR during practice was 58% of the heart rate range. Meanwhile, the VO2 during TCC practice was 55% of the VO2peak. Additionally, the level of blood lactate immediately after TCC practice was 3.8 mM, which reflected the level of lactate during TCC, approximated the onset of blood lactate accumulation (OBLA). The results demonstrate that TCC is an exercise with moderate intensity, and is aerobic in nature.

Osteoporotic hip fractures in Singapore--costs and patient's outcome

INTRODUCTION

Little data are available on costs and outcome associated with osteoporotic hip fractures in Singapore.

MATERIALS AND METHODS

A retrospective study was carried out on 280 consecutive hip fractures in patients older than 60 years admitted over a 3-year period.

RESULTS

The mean age of patients was 80 years. Sixty-eight per cent were female and 58% were intertrochanteric fractures. Two hundred and sixty-four patients (95%) were operated upon. The mean total hospitalisation period was 17 days. Seventy-six per cent were staying in their own homes prior to the hip fracture while 22% were admitted from nursing homes. After surgery, 63% of patients returned to their homes while 26% needed nursing home care. The index admission mortality rate was 5.7%. Mortality was 26% at 1 year. Of those alive at 1 year, ambulatory status was: 28% were walking without aids, 39% were walking with aids, 24% were wheelchair bound and 9% were bedridden. Poor ambulatory function at discharge was related to increased mortality at 1 year. The average cost incurred was S$7367. The average government subsidy amounted to 82%. Ninety-one per cent of patients were warded in subsidized beds. Breakdown of cost was as follows: hospital stay, 42.6%; surgery, 36.5%; ward treatment, fee 9%; laboratory and X-ray investigations, 4.4%; implant costs, 3.5%; drugs, 1.6% and rehabilitation, 1.1%. Multivariate analysis showed that the cost is significantly related to days spent awaiting surgery, preoperative sepsis, operative complications and cerebrovascular accidents. Young age, good American Society of Anesthetists (ASA) status and endoprosthesis replacement were factors that allowed for early ambulation and lower costs.

CONCLUSION

The mortality rates and functional outcome are not very different from published studies in the West. More of our patients returned to their own homes after hospitalisation. Early surgery, close involvement of the medical social worker and intensive physiotherapy or provision of outpatient therapy facilities may help cut cost of treatment.

Laribacter hongkongensis gen. nov., sp. nov., a novel gram-negative bacterium isolated from a cirrhotic patient with bacteremia and empyema

A bacterium was isolated from the blood and empyema of a cirrhotic patient. The cells were facultatively anaerobic, nonsporulating, gram-negative, seagull shaped or spiral rods. The bacterium grows on sheep blood agar as nonhemolytic, gray colonies 1 mm in diameter after 24 h of incubation at 37 degrees C in ambient air. Growth also occurs on MacConkey agar and at 25 and 42 degrees C but not at 4, 44, and 50 degrees C. The bacterium can grow in 1 or 2% but not 3, 4, or 5% NaCl. No enhancement of growth is observed with 5% CO(2). The organism is aflagellated and nonmotile at both 25 and 37 degrees C. It is oxidase, catalase, urease, and arginine dihydrolase positive, and it reduces nitrate. It does not ferment, oxidize, or assimilate any sugar tested. 16S rRNA gene sequencing showed that there are 91 base differences (6.2%), 112 base differences (7.7%), and 116 base differences (8.2%) between the bacterium and Microvirgula aerodenitrificans, Vogesella indigofera, and Chromobacterium species, respectively. The G+C content (mean and standard deviation) is 68.0% +/- 2.43%, and the genomic size is about 3 Mb. Based on phylogenetic affiliation, the bacterium belongs to the Neisseriaceae family of the beta-subclass of Proteobacteria. For these reasons, a new genus and species, Laribacter hongkongensis gen. nov., sp. nov., is proposed, for which HKU1 is the type strain. Further studies should be performed to ascertain the potential of this bacterium to become an emerging pathogen.

Presence of macrolide resistance in respiratory flora of HIV-Infected patients receiving either clarithromycin or azithromycin for Mycobacterium avium complex prophylaxis

Clarithromycin 500 mg po bid or azithromycin 1200 mg po weekly is recommended as first line prophylaxis for Mycobacterium avium complex (MAC) in patients with HIV infection whose CD4 counts are <50 cells/microL. HIV-infected patients with CD4+ T-cell counts <200 cells/microL were randomized to receive either clarithromycin 500 mg po bid or azithromycin 1200 mg po weekly for 12 weeks. Nasopharyngeal swabs for Streptococcus pneumoniae and Haemophilus influenzae plus an anterior nare culture for Staphylococcus aureus were obtained at pretreatment, at 6 weeks, and at 12 weeks. A throat culture for oral flora was obtained for susceptibility testing against erythromycin. Minimum inhibitory concentrations (MICs) for clarithromycin and azithromycin were performed on all S. pneumoniae, H. influenzae, and S. aureus isolates. The study was terminated after respiratory flora, from all participants, revealed macrolide resistance. Because results of recent randomized trials indicate minimal efficacy of continuing MAC prophylaxis in patients who respond to potent combination antiretroviral therapy, the observed high incidence of macrolide-resistant bacterial colonization of the respiratory tract in this trial supports the discontinuation of macrolide prophylaxis in all AIDS patients whose CD4 counts have risen above 100 cells/microL.

Plasminogen activator inhibitor-1 regulates tumor growth and angiogenesis

Elevated expression of plasminogen activator inhibitor-1 (PAI-1) in tumors is associated with a poor prognosis in many cancers. Reduced tumor growth and angiogenesis have also been reported in mice deficient in PAI-1. These results suggest that PAI-1 may be required for efficient angiogenesis and tumor growth. In the present study, we demonstrate that PAI-1 can both enhance and inhibit the growth of M21 human melanoma tumors in nude mice and that this appears to be due to PAI-1 regulation of angiogenesis. Quantitative analysis of angiogenesis in a Matrigel implant assay indicated that in PAI-1 null mice angiogenesis was reduced approximately 60% compared with wild-type mice, while in mice overexpressing PAI-1, angiogenesis was increased nearly 3-fold. Furthermore, addition of PAI-1 to implants in wild-type mice enhanced angiogenesis up to 3-fold at low concentrations but inhibited angiogenesis nearly completely at high concentrations. Together, these data demonstrate that PAI-1 is a potent regulator of angiogenesis and hence of tumor growth and suggest that understanding the mechanism of this activity may lead to the development of important new therapeutic agents for controlling pathologic angiogenesis.

Tai Chi Chuan training to enhance microcirculatory function in healthy elderly men

OBJECTIVE

To evaluate cutaneous microcirculatory function in geriatric Tai Chi Chuan (TCC) practitioners.

DESIGN

Case-control study.

SETTING

Community setting.

PARTICIPANTS

Ten elderly male TCC practitioners (mean age, 69.9 +/- 1.5 yr) and 10 sedentary men with matched age and body size (mean age, 67.0 +/- 1.0 yr).

INTERVENTION

The TCC group had practiced TCC for 11.2 +/- 3.4 years (mean +/- standard error of the mean), with an exercise frequency of 5.1 +/- 1.8 times weekly. Each session included 20 minutes of warm-up, 24 minutes of TCC practice, and 10 minutes of cool down.

MAIN OUTCOME MEASURES

A graded exercise test with gas analysis was conducted on a bicycle ergometer for each subject. Skin blood flow (SkBF), cutaneous vascular conductance, and skin temperature were measured at rest and during exercise testing. Plasma nitric oxide metabolite was analyzed before and immediately after exercise.

RESULTS

The TCC group had a 34% higher VO(2)peak than the control group; it also had a higher SkBF, cutaneous vascular conductance, and skin temperature than the control group at rest and during exercise; and it also had a higher level of plasma nitric oxide metabolite than the sedentary group at rest and after exercise.

CONCLUSION

Older TCC practitioners had higher cutaneous microcirculatory function during exercise than did their sedentary counterparts. Moreover, this change may be partially mediated by enhancement of nitric oxide release.

Body weight, serum uric acid and lipid profile one year after spinal cord injury

BACKGROUND

Survey of the serum lipoprotein profile, uric acid levels and body weight in Chinese patients with spinal cord injury (SCI) one year after injury, and to report the data of patients with SCI at different levels.

METHODS

Seventy-seven Chinese patients with SCI categorized into cervical SCI, thoracic SCI, and lumbar SCI groups were enrolled in the study. The serum uric acid and lipoprotein profiles of these patients were evaluated one year after injury. All of the data in those different groups of SCI patients were compared with normal levels. Body weight before and after injury were also evaluated.

RESULTS

Serum uric acid was within normal limits in all three SCI groups. A similar lower in serum high density lipoprotein cholesterol (HDL-C) level was observed in all three groups of SCI patients. Higher serum levels were observed in total cholesterol (TC) in the lumbar SCI group, triglyceride and very low density lipoprotein cholesterol in the thoracic and lumbar SCI group, and TC/HDL-C ratio in all three SCI groups. Decrease of body weight were noted in cervical and thoracic SCI patients.

CONCLUSION

Further long-term follow up was necessary to determine the serum lipid and body weight change in patients with SCI at different levels.

Asymmetric epoxidation of olefins catalyzed by chiral iminium salts generated in situ from amines and aldehydes

[reaction: see text] A new approach for catalytic asymmetric epoxidation of olefins was developed that utilized chiral iminium salts, generated in situ from chiral amines and aldehydes, as catalysts. Epoxidation reactions can be conducted with 20 mol % of amines and aldehydes. The enantioselectivity of epoxides can be up to 65%. This modular approach obviates the difficulties inherent in the preparation and isolation of unstable exocyclic iminium salts.

Kinetic resolution of acyclic secondary allylic silyl ethers catalyzed by chiral ketones

Kinetic resolution of acyclic secondary allylic silyl ethers by chiral dioxiranes generated in situ from chiral ketones (R)-1 and (R)-2 and Oxone was investigated. An efficient and catalytic method has been developed for kinetic resolution of those substrates with a CCl(3), tert-butyl, or CF(3) group at the alpha-position. In particular, high selectivities (S up to 100) were observed for kinetic resolutions of racemic alpha-trichloromethyl allylic silyl ethers 7 and 9-15 catalyzed by ketones (R)-2. Both the recovered substrates and the resulting epoxides were obtained in high enantiomeric excess. On the basis of steric and electrostatic interactions between the chiral dioxiranes and the racemic substrates, a model was proposed to rationalize the enantioselectivities and diastereoselectivities in the chiral ketone-catalyzed kinetic resolution process.

Open reduction and temporary rigid internal fixation of Lisfranc fracture-dislocations

AIM

To review the results of open reduction and temporary rigid screw fixation of Lisfranc fracture-dislocations performed in Singapore General Hospital (SGH) from 1996 to 1998.

METHODS

A retrospective review of II cases of Lisfranc injuries treated with temporary rigid internal screw fixation with a minimum follow up of six months was carried out. Radiological assessment was made at follow up to ascertain the anatomical reduction achieved and complications such as post-traumatic arthritis. In addition, the patients were evaluated with a functional assessment with relation to pain, interference to usual activities and the time to resumption of work.

RESULTS

Anatomical reduction was achieved in all cases. None of the cases showed loss of reduction at follow up after the temporary implants were removed. No longitudinal arch collapse or other deformities were seen. All the patients had good or excellent functional outcomes.

CONCLUSIONS

Results of treatment of Lisfranc injuries are related to anatomical correction. Temporary screw fixation allows rigid internal fixation with stability to allow anatomical correction. Screws also maintain their stability longer, allowing ligamentous injuries the longer period necessary for healing. In conclusion, temporary rigid screw fixation of Lisfranc fracture maintains anatomical reduction and gives excellent functional outcomes for the patients.

Inhibition of angiogenesis in vivo by plasminogen activator inhibitor-1

The process of angiogenesis is important in both normal and pathologic physiology. However, the mechanisms whereby factors such as basic fibroblast growth factor promote the formation of new blood vessels are not known. In the present study, we demonstrate that exogenously added plasminogen activator inhibitor-1 (PAI-1) at therapeutic concentrations is a potent inhibitor of basic fibroblast growth factor-induced angiogenesis in the chicken chorioallantoic membrane. By using specific PAI-1 mutants with either their vitronectin binding or proteinase inhibitor activities ablated, we show that the inhibition of angiogenesis appears to occur via two distinct but apparently overlapping pathways. The first is dependent on PAI-1 inhibition of proteinase activity, most likely chicken plasmin, while the second is independent of PAI-1's anti-proteinase activity and instead appears to act through PAI-1 binding to vitronectin. Together, these data suggest that PAI-1 may be an important factor regulating angiogenesis in vivo.

Ultrasound evaluation of plantar fasciitis

OBJECTIVE

To investigate the sonographic features of plantar fasciitis (PF).

METHODS

High-resolution ultrasound was used to measure the thickness and echogenicity of the proximal plantar fascia and associated heel pad thickness for 102 consecutive patients with PF (unilateral: 81, bilateral: 21) and 33 control subjects.

RESULTS

The mean thickness of the plantar fascia was greater on the symptomatic side for patients with bilateral and unilateral PF than on the asymptomatic side for patients with unilateral PF, and also control subjects (5.47+/-1.09, 5.61+/-1.19, 3.83+/-0.72, 3.19+/-0.43 mm, respectively, p<0.001). A substantial difference in thickness between the asymptomatic side of patients with unilateral PF and control subjects was also noted (p=0.001). The heel pad thickness was not show different between control subjects and patients with PF. The incidence of hypoechoic fascia was 68.3% (84/123). Other findings among the patients from our test group included intratendinous calcification (two cases), the presence of perifascial fluid (one case), atrophic heel pads (one case), and the partial rupture of plantar fascia (one case).

CONCLUSION

Increased thickness and hypoechoic plantar fascia are consistent sonographic findings in patients exhibiting PF. These objective measurements can provide sufficient information for the physician to confirm an initial diagnosis of PF and assess individual treatment regimens.

Soluble recombinant endostatin purified from Escherichia coli: antiangiogenic activity and antitumor effect

Endostatin is a potent and specific antiangiogenic protein capable of inhibiting the growth of murine and xenotransplanted human tumors. Thus far, however, recombinant endostatin prepared from Escherichia coli is insoluble after purification and therefore inappropriate for clinical settings. A soluble form of endostatin is available from a yeast system with relatively low yield and high cost, which has made it difficult to produce endostatin in quantities sufficient for extensive clinical evaluation. In this study, we developed a protocol to generate soluble recombinant murine endostatin from E. coli at a yield of 150 mg/liter-culture and 99% purity. The in vivo antiangiogenic and antitumor activities of the soluble recombinant endostatin are equally as potent as those of the previously published insoluble form. A similar protocol may be used to produce soluble human endostatin.

Temporal stride and force analysis of cane-assisted gait in people with hemiplegic stroke

OBJECTIVE

To understand the underlying biomechanics of temporal stride and force in people with hemiplegic stroke during cane-assisted walking.

DESIGN

Three forceplates, 6 cameras, and an instrumented cane were integrated to analyze the cane-assisted gait of people with hemiplegic stroke. Temporal-stride parameters, and peak vertical, anterior (propulsive), posterior (braking), and lateral shear forces, as well as propulsive-breaking impulses were analyzed.

SETTING

Chang Gung Memorial Hospital, Medical Center, Taiwan.

PARTICIPANTS

Twenty people with hemiplegic stroke.

MAIN OUTCOME MEASURES

Temporal-stride and force parameters.

RESULTS

All patients walked at a relatively slow speed, ranging from 4.2 to 35.8cm/s. The triple and double support occupied most of the gait cycle (GC), whereas the single support occupied only 10% of GC. The applied vertical, propulsive, braking, and lateral shear forces on either foot and the cane were 89.7% to 97.6%, 2.2% to 4.8%, 2.9% to 3.9%, and 5.5% to 6.7% body weight (BW), respectively. Patients applied less than 25% BW of peak vertical forces on the cane. They applied greater peak propulsive forces and impulses on the sound foot, while applying greater peak braking forces and impulses on the affected foot and cane.

CONCLUSIONS

The cane provided support and a braking function for people with hemiplegic stroke. People with stroke walking with cane assistance rely mostly on the sound limb for propulsion, while using the affected limb and cane for braking. Data provided could be useful in assessing the nature of cane assistance and in planning therapeutic strategies for people with stroke.

Effects of task goal and personal preference on seated reaching kinematics after stroke

BACKGROUND AND PURPOSE

Current theories of motor control in rehabilitation focus on how the nervous system responds to many types of external and internal constraints to execute motor behavior to accomplish a task. However, the dynamic interplay between these 2 constraints remains unclear. This study examined the impact of some aspects of internal and external constraints on motor performance in persons with stroke.

METHODS

Twenty-seven persons with stroke used the uninvolved arms to perform an upper-extremity reaching task under 4 experimental conditions, formed by the crossing of functional goals and personal preferences. For the higher level of a functional goal, subjects took a drink from a can of beverage. For the lower level of a functional goal, subjects brought the can to the mouth without drinking. The level of personal preferences was determined, by interview, by the degree of predilection for particular beverages.

RESULTS

Significant and large effects of functional goals and personal preference were found in the variables of movement time and reaction time. However, the data trend of the 4 testing conditions varied according to presence of visuospatial neglect and side of lesion.

CONCLUSIONS

Offering choices for the treatment activities and incorporating functional goals to therapeutic tasks might enhance response rate or movement efficiency, depending on the side of the lesion and presence of visuospatial neglect. The findings suggest that the consideration of the neglect phenomenon is a necessity when rehabilitative treatment planning incorporates constraint factors.

A novel approach for the identification of unique tumor vasculature binding peptides using an E. coli peptide display library

BACKGROUND

Tumor neovascularization is necessary for continued tumor growth and metastasis. During the process of endothelial cell (EC) recruitment and tumor infiltration, specific molecular markers unique for this interaction are expressed on the EC surface. Targeting these molecular markers would, in effect, allow for specific tumor targeting. Tripeptide sequence motifs have previously been reported that will bind to angiogenic tumor ECs. These sequences were identified from in vivo phage peptide display libraries. The purpose of this study was to use a more simplified bacterial peptide display library in an in vitro system to seek out peptide motifs with unique binding to tumor microvasculature.

METHODS

FliTrx is a bacterial peptide display library containing the entire repertoire of possible random dodecapeptides expressed on the flagella tip of E. coli. Two EC populations were used for the screening process, Matrigel invading cells (MAGIC) and tumor-derived endothelial cells (TDEC). MAGIC are obtained from ECs that infiltrate a subcutaneous fibroblast growth factor-containing Matrigel deposit, and TDEC are ECs selectively obtained from tumor vasculature. FliTrx cells were incubated with MAGIC at 4 degrees C to remove any potential clones displaying peptides that will bind to nonspecific EC surface targets. The non-binding cells were then incubated with TDEC, allowing for clones displaying potential binding peptides to bind tumor specific targets on TDECs. The bacterial population was then expanded and this "panning" process was carried out a total of five times. Peptide insert sequences from 100 bacterial colonies were analyzed for potential repetitive peptide motifs.

RESULTS

Recurring peptide sequences were detected that were 3-mers (13 sequences) and 4-mers (4 sequences). Of the 3-mers, four repeated 3 times, whereas none of the 4-mers repeated more than twice. All of the repeated sequences were basic in charge, and arginine was the most commonly seen amino acid. A tripeptide basic-basic-nonpolar amino acid arrangement was the most prevalent charge sequence in all repetitive motifs (17 repeat sequences). Two test peptides showed TDEC binding specificity, and both conformed to the basic-basic-nonpolar motif.

CONCLUSIONS

We report peptide sequences derived from panning an in vitro system designed to detect tumor-EC specific markers. These putative motifs may serve as molecular determinants for a novel therapeutic modality aimed at specifically targeting tumors through tumor angiogenic vessels.

Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection

OBJECTIVE

To investigate the efficacy of ultrasound-guided steroid injection for the treatment of proximal plantar fasciitis and to evaluate mechanical properties of the heel pad after steroid injection.

DESIGN

Proximal plantar fascia and heel pad were assessed with a 10-MHz linear array ultrasound transducer. Pain intensity was quantified with a tenderness threshold (TT) and visual analog scale (VAS). The transducer was incorporated into a specially designed device to measure mechanical properties of the heel pad. Evaluations were performed before injection and at 2 weeks and 3 months after injection.

SETTING

An outpatient clinic of a tertiary care center.

PATIENTS

Fourteen consecutive patients with unilateral proximal plantar fasciitis.

INTERVENTION

Ultrasound-guided injection of 7 mg betamethasone and 0.5 mL of 1% lidocaine into the inflamed proximal plantar fascia.

MAIN OUTCOME MEASURES

VAS, TT, heel pad and plantar fascia thickness, and echogenicity of the proximal plantar fascia on sonogram were assessed. Mechanical properties included unloaded heel pad thickness, compressibility index, and energy dissipation ratio.

RESULTS

Both VAS score +/- standard deviation (SD; 5.43 +/- 2.03, 1.39 +/- 2.19, 0.57 +/- 1.40 at the 3 measurements, respectively) and TT +/- SD (5.05 +/- 1.42, 9.34 +/- 1.84, 9.93 +/- 1.98 kg/cm2 at the 3 measurements, respectively) improved significantly (p < .001) after steroid injection. The mean thickness of the plantar fascia was greater in the symptomatic side than in the asymptomatic side before treatment (0.58 +/- 0.13 cm vs 0.40 +/- 0.11 cm, p < .001). The thickness had decreased significantly 3 months after injection (0.46 +/- 0.12 cm at 2 weeks, 0.42 +/- 0.10 cm at 3 months, p < .001). The hypoechogenicity at the proximal plantar fascia disappeared after steroid injection (p < .001). Mechanical properties of the heel pad did not change 3 months after steroid injection (p > .05).

CONCLUSION

Ultrasound offers an objective measurement of the therapeutic effect on proximal plantar fasciitis. Accurate steroid injection under ultrasound guidance can effectively treat proximal plantar fasciitis without significant deterioration of the mechanical properties of the heel pads.

Tumor biology: use of tiled images in conjunction with measurements of cellular proliferation and death in response to drug treatments

Tumor growth is dependent on the balance between cell proliferation and cell death, and these events occur heterogenously within an individual tumor. We present a methodology that provides integrative information about cell kinetics, cell death, and cell growth within individual tumors in animals treated with cytotoxic chemotherapeutic agents. Using HCT-116 and NCI-H460 cells, human colonic adenocarcinoma and non-small cell lung cells, respectively, traditional xenograft studies were performed. The tumor-bearing animals were treated with cyclophosphamide (Cytoxan), gemcitabine (Gemzar), or mitomycin C, and extensive analysis of the tumors was studied. Cell kinetics were evaluated by measuring the apoptotic and proliferation indices. The ability to image an entire tumor section using "tiling" by creating a large montage from many high-resolution images makes it possible to identify regional differences within areas of tumor and to demonstrate differences in these tumor regions after treatment with selected chemotherapeutic agents. Two specific areas within tumors have been identified: (a) areas of viable cells within the cell cycle, determined by bromodeoxyuridine and/or morphological characteristics determined by hematoxylin staining; and (b) areas of necrosis determined by the absence of bromodeoxyuridine and proliferating cell nuclear antigen-labeled cells coupled with morphological changes. By standardizing the tumor size to 100 mm2, different patterns of tumor responses to chemotherapeutic agents were determined. By creating such tiled images and by quantitating cell cycle kinetics, it is possible to gain a more complete understanding of tumor growth and response to treatment, leading to the development of more reliable methods for assessing the clinical behavior of anticancer drugs.

Neuroserpin reduces cerebral infarct volume and protects neurons from ischemia-induced apoptosis

Neuroserpin, a recently identified inhibitor of tissue-type plasminogen activator (tPA), is primarily localized to neurons within the central nervous system, where it is thought to regulate tPA activity. In the present study neuroserpin expression and its potential therapeutic benefits were examined in a rat model of stroke. Neuroserpin expression increased in neurons surrounding the ischemic core (ischemic penumbra) within 6 hours of occlusion of the middle cerebral artery and remained elevated during the first week after the ischemic insult. Injection of neuroserpin directly into the brain immediately after infarct reduced stroke volume by 64% at 72 hours compared with control animals. In untreated animals both tPA and urokinase-type plasminogen activator (uPA) activity was significantly increased within the region of infarct by 6 hours after reperfusion. Activity of tPA then decreased to control levels by 72 hours, whereas uPA activity continued to rise and was dramatically increased by 72 hours. Both tPA and uPA activity were significantly reduced in neuroserpin-treated animals. Immunohistochemical staining of basement membrane laminin with a monoclonal antibody directed toward a cryptic epitope suggested that proteolysis of the basement membrane occurred as early as 10 minutes after reperfusion and that intracerebral administration of neuroserpin significantly reduced this proteolysis. Neuroserpin also decreased apoptotic cell counts in the ischemic penumbra by more than 50%. Thus, neuroserpin may be a naturally occurring neuroprotective proteinase inhibitor, whose therapeutic administration decreases stroke volume most likely by inhibiting proteinase activity and subsequent apoptosis associated with focal cerebral ischemia/reperfusion. (Blood. 2000;96:569-576)

Correlation of polyelectromyographic patterns and clinical upper motor neuron syndrome in hemiplegic stroke patients

OBJECTIVE

To investigate the correlation between movement patterns, measured by polyelectromyography (PEMG), and clinical upper motor neuron (UMN) syndrome in stroke patients.

DESIGN

PEMG patterns, recorded from pairs of flexor-extensor muscles during voluntary maneuvers, and motor outcomes were assessed approximately 1 month after stroke (early stage). Motor outcomes were reassessed 6 months later (late stage).

PARTICIPANTS

Thirty-nine hemiplegic stroke patients and 18 healthy control subjects.

MAIN OUTCOME MEASURES

Passive stretch reflexes (PSRs), Brunnstrom's stages, and walking ability.

RESULTS

Six PEMG patterns, varying from complete reciprocal to complete synchrony, were identified. Higher PEMG pattern scores were associated with better Brunnstrom's stages (r > .80), walking ability (r > .39), and some PSRs (r < -.37). PEMG patterns could separate patterns 1 and 2 from patterns 3 and 4 for patients with early Brunnstrom's stages 1 and 2. Patterns 1 and 2 (reduced agonist electromyographic activities) indicated weakness and resulted in the worst motor outcomes. Patterns 3 and 4 (cocontraction and coactivation) indicated spasticity and associated synergistic movements. Patients with patterns of 5 and 6 (reciprocal electromyographic activities) had more selective motor control.

CONCLUSIONS

PEMG patterns correlate with clinical UMN syndromes and may allow treatment strategy planning on the basis of underlying motor control, as well as the prediction of final motor outcomes soon after stroke, even in patients who cannot move their legs initially.

Effect of strenuous arm exercise on oxidized-LDL-potentiated platelet activation in individuals with spinal cord injury

This study investigates how strenuous arm exercise affects oxidized-low density lipoprotein (O(X)-LDL) mediated-platelet activation in patients with SCI. Ten patients with SCI and ten age- and sex-matched healthy subjects exercised strenuously using an arm crank ergometer. The following measurements were taken both when the subjects were at rest, and immediately after exercise: plasma lipid profile, O(X)-LDL mediated platelet aggregability and [Ca(2+)]i, urinary 11-dehydro-thromboxane B2 (11-dehydro-TXB2) and 8-iso-prostaglandin F(2alpha), (8-iso-PG F(2alpha)) contents, and plasma NO metabolite (nitrite plus nitrate) level. Based on these measurements, the major findings of this study can be summarized as follows: 1) the SCI group had higher urinary 8-iso-PGF(2alpha) and 11-dehydro-TXB2 contents, but a lower plasma nitrite plus nitrate level than the control group; 2) at rest, the SCI group had a higher platelet aggregability and [Ca(2+)]i, and O(X)-LDL-potentiated platelet activation than the control group; 3) O(X)-LDL-potentiated platelet aggregation was enhanced by strenuous arm exercise in both groups, but the effect of exercise was more pronounced in the SCI group than in the control group; 4) treating the platelet with L-arginine inhibited O(X)-LDL-potentiated platelet activation in both groups. The study concludes that individuals with SCI had more extensive resting and exercise-enhanced O(X)-LDL-potentiated platelet activation and greater amounts of preformed lipid peroxides than those without SCI. Therefore, supplementation therapy with antioxidants may be needed for patients with SCI, especially in a strenuous arm exercise period.

Resistive inspiratory muscle training: its effectiveness in patients with acute complete cervical cord injury

OBJECTIVE

To evaluate if resistive inspiratory muscle training (RIMT) can improve lung function in patients with complete tetraplegia within half a year after trauma.

DESIGN

A prospective study. The experimental patients received training with a Diemolding Healthcare Division inspiratory muscle trainer for 15 to 20 minutes per session, twice per day, 7 days a week for 6 weeks.

SETTING

Hospital-based rehabilitation units.

PATIENTS

Twenty patients who were in their first 6 months of complete cervical cord injury were randomly enrolled into RIMT (10 patients) and control (10 patients) groups.

MAIN OUTCOME MEASURE

Spirometry, lung volume test, maximal inspiratory pressure, maximal expiratory pressure, and modified Borg scale measurements at rest were performed before training and at the end of 6 weeks of training.

RESULTS

Most of the pulmonary parameters showed statistically significant improvements within the RIMT and control groups, but the improvements were greater in the RIMT group. In addition, the improvements in total lung capacity, total lung capacity predicted percentage, vital capacity, minute ventilation, forced expiratory volume in 1 second predicted percentage, and the resting Borg scale in the RIMT group showed significantly greater improvement.

CONCLUSION

RIMT can improve ventilatory function, respiratory endurance, and the perceived difficulty of breathing in patients with complete cervical spinal cord injury within half a year after trauma.

Balance evaluation in hemiplegic stroke patients

BACKGROUND

Decreased equilibrium in standing and walking is a common problem associated with hemiplegic stroke patients. Stroke patients with balance problems are prone to falls. In addition to spatial recognition, the appropriate pattern of muscle activity to preserve balance depends on sensory and motor processes. Previous reports have mentioned that the right posterior parietal cortex seems to be predominantly involved in spatial integration. We therefore wanted to conduct a study to quantify and compare the balance control between right hemispheric stroke and left hemispheric stroke patients.

METHODS

Thirty hemiplegic stroke patients (14 right, 16 left) and 15 age-matched healthy subjects were included in this study. The objective measurement of the basic components of balance control was performed using the SMART Balance Master. The motor status of the hemiplegic limbs was evaluated by Brunnstrom staging. The functional outcome of the stroke patients was evaluated by the functional independence measure (FIM).

RESULTS

The balance function of stroke patients was significantly worse as compared to that of the healthy subjects especially in dynamic stability. However, different from the other reports, our right hemispheric stroke patients had better balance function than our left hemispheric patients. The locomotion and mobility scores of the FIM were also better in the right hemispheric stroke patients.

CONCLUSION

This result suggested that the motor function of the healthy limbs of stroke patients may play an important role in their balance function. The results of this study may provide a guide for prescribing a more efficient rehabilitation program for stroke patients.

Tai Chi Chuan to improve muscular strength and endurance in elderly individuals: a pilot study

OBJECTIVE

To evaluate the training effect of a Tai Chi Chuan (TCC) program on knee extensor muscular strength and endurance in elderly individuals.

DESIGN

Before-after trial.

SETTING

Community setting.

PARTICIPANTS

Forty-one community dwelling subjects aged 61.1 +/- 9.8 years undertook a TCC program. Nine dropped out during the study. Pretraining and posttraining measurements were obtained from 15 men and 17 women.

INTERVENTION

Subjects participated in a 6-month TCC program. Each session consisted of 20 minutes of warm-up, 24 minutes of structured TCC training, and 10 minutes of cool-down exercises.

MAIN OUTCOME MEASURES

Peak torque of dominant and nondominant knee extensors was tested at speeds of 60 degrees , 180 degrees , and 240 degrees/sec concentrically and eccentrically. Muscular endurance of the knee extensor was tested at the speed of 180 degrees /sec.

RESULTS

In the group of men, concentric knee extensor peak torque increased by 15.1% to 20.0% and eccentric peak torque increased by 15.1% to 23.7%. The group of women also showed increases, ranging from 13.5% to 21.8% in concentric peak torque, and 18.3% to 23.8% in eccentric peak torque. In addition, the knee extensor endurance ratio increased by 9.6% to 18.8% in the men and 10.1% to 14.6% in the women.

CONCLUSION

TCC training may enhance muscular strength and endurance of knee extensors in elderly individuals.

Role of chronic exercise in decreasing oxidized LDL-potentiated platelet activation by enhancing platelet-derived no release and bioactivity in rats

This study investigates how chronic exercise affects Ox-LDL mediated-platelet activation. Five-week-old male Wistar rats were assigned to either control or trained groups. Trained rats were treadmill-trained for 10 weeks after familiarization. The following measurements were taken in both control and trained groups: plasma lipid profile, oxidation of LDL, platelet adhesiveness, aggregability, cGMP contents, plasma and platelet-NO metabolite (nitrite plus nitrate) levels, and urinary 8-iso-prostaglandin F2alpha (8-iso-PG F2alpha) levels. Based on those measurements, major findings in this study can be summarized as follows: 1) the trained group prolonged the lag time of isolated LDL subjected to copper-induced in vitro oxidation significantly longer than the control group; 2) although having higher plasma and platelet derived-NO metabolite levels, the trained group had lower urinary excretion of 8-iso-PGF2alpha than the control group; 3) the trained group had a lower platelet adhesiveness and aggregability and higher platelet derived-NO metabolite and cGMP productions than the control group; 4) the trained group had a lower Ox-LDL-potentiated platelet adhesiveness and aggregability and Ox-LDL-attenuated NO metabolite and cGMP productions in platelet than the control group; and 5) treating the platelet with L-arginine inhibited Ox-LDL-potentiated platelet activation in both control and trained groups. Results in this study demonstrate that amounts of preformed lipid peroxides decrease while NO production (which acts as an antioxidant) is significantly increased after chronic exercise. Moreover, exercise training decreases Ox-LDL-potentiated platelet activation most likely by enhancing platelet-derived NO release and bioactivity.

Brain lesion size and location: effects on motor recovery and functional outcome in stroke patients

OBJECTIVE

To investigate effects of brain lesion profiles that combined sizes and locations on motor recovery and functional outcome after stroke in hemiplegic patients.

DESIGN

Delimiting sizes (a threshold lesion size) of 5 primary locations were identified to establish brain lesion profiles based on magnetic resonance imaging findings 1 month after stroke. Motor and functional outcome were correlated with brain lesion profiles and other brain lesion factors to identify the most dominant factor.

SETTING

Medical center, rehabilitation department.

PARTICIPANTS

Fifty-five hemiplegic patients.

MAIN OUTCOME MEASURES

Brunnström's stages and Functional Independence Measure (FIM) scores were assessed 1 and 6 months after stroke.

RESULTS

With delimiting sizes for the cortical, corona radiata, internal capsule, putaminal, and thalamic regions set at 75, 4, .75, 22, and 12cm3, respectively, brain lesion profiles play a dominant role in determining final Brunnström's stages (Spearman's rho = .861, p < .01) and FIM score (Spearman's rho = .571, p < .01). Brunnström's and FIM scores had no or only weak negative relationship with either absolute or relative lesion size.

CONCLUSIONS

These findings may suggest that motor and functional outcomes after stroke correlate with brain lesion profiles (a combination of delimiting sizes and primary locations) more than with absolute or relative lesion sizes only. Delimiting sizes in determining final outcomes varied markedly according to the primary lesion locations.

Effect of exercise training on oxidized LDL-mediated platelet function in rats

This study investigates how exercise training affects Oxidized LDL (Ox-LDL) mediated-platelet activation. Five-week-old male Wistar rats were assigned to either control or trained groups. Trained rats were treadmill-trained for 10 weeks after familiarization. The following measurements were taken in both control and trained groups: Ox-LDL-mediated platelet aggregability and [Ca2+]i, plasma and platelet-derived nitric oxide (NO) metabolite (nitrite plus nitrate) levels, and antiaggregating activity of NO derived from endothelial cells. Based on those measurements, major findings in this study can be summarized as follows: 1) the trained group had a higher plasma -NO metabolite level than the control group; 2) the trained group had a lower platelet aggregability and [Ca2+]i elevation and a higher platelet derived-NO metabolite level than the control group; 3) the trained group had lower Ox-LDL-potentiated platelet aggregability and [Ca2+]i elevation and Ox-LDL-attenuated NO metabolite in platelet than the control group; 4) treating the platelet with L-arginine inhibited Ox-LDL-potentiated platelet activation in both control and trained groups; 5) Ox-LDL enhances platelet aggregation directly although impairing NO bioactivity but not guanylate cyclase activity in both control and trained groups. Results in this study demonstrate that exercise training decreases Ox-LDL-potentiated platelet activation most likely by enhancing platelet-derived NO release.

A non-transmembrane form of Jagged-1 regulates the formation of matrix-dependent chord-like structures

Jagged-Notch interactions regulate a transmembrane ligand-receptor signaling pathway involved in the regulation of cell fate determination as well as myoblast and endothelial cell differentiation. To further examine the role of the transmembrane ligand, Jagged-1, in the regulation of cell differentiation, we stably transfected NIH 3T3 cells with a truncated form of Jagged(J)-1, which results in the secretion of a soluble(s) form of the protein. Comparison of gene expression by serial analysis demonstrated that among the 227 transcripts differentially regulated in the sJ-1 transfectants, the expression of the pro-alpha-2(I) collagen transcript and pro-alpha-1(I) collagen translation product was predominantly repressed in sJ-1 transfectants. When plated on extracellular matrices, sJ-1 transfectants formed prominent chord-like structures on type I collagen but not on fibrin, fibronectin, or vitronectin. While the sJ-1 transfectants exhibited growth kinetics similar to control cells and were unable to grow in soft agar, the cells were less sensitive to contact inhibition of growth in vitro and sJ-1 allografts formed tissue masses in nude mice after a prolonged latency period and exhibited an abundance of host-derived microvascular endothelial cells. These data suggest that J-1 may be able to modulate, in a matrix-dependent manner, the organization of cell to cell interactions including its ability to promote the development of chord-like structures.

The new design of an infrared-controlled human-computer interface for the disabled

This paper reports on the development of an eyeglass- type infrared (IR)-controlled computer interface for the disabled. This system may serve to assist those who suffer from spinal cord injuries or other handicaps to operate a computer. This system is comprised of three major components: 1) an infrared transmitting module, 2) an infrared receiving/signal-processing module, and 3) a main controller, the Intel-8951 microprocessor. The infrared transmitting module utilizes tongue-touch circuitry which is converted to an infrared beam and a low power laser (<0.1 mW) beam. The infrared receiving/signal-processing module, receives the infrared beam and fine tunes the unstable infrared beam into standard pulses which are used as control signals. The main controller is responsible for detecting the input signals from the infrared receiving/signal-processing module and verifying these signals with the mapping table in its memory. After the signal is verified, it is released to control the keys of the computer keyboard and mouse interface. This design concept was mainly based on the idea that the use of an infrared remote module fastened to the eyeglasses could allow the convenient control of the input motion on the keys of a computer keyboard and mouse which are all modified with infrared receiving/signal-processing modules. The system is designed for individuals with spinal cord injuries and disabled in which the subjects' movement are severely restricted. The infrared transmitting module can be easily mounted on eyeglasses or artificial limbs.

Acetabular revision. The role of rings and cages

This study reports on the successful long-term use of the acetabular roof ring and the antiprotrusio cage in acetabular reconstruction in which the hip center and acetabular biomechanics are normalized and bone stock is restored through the use of morselized allograft. The failure rate of the acetabular roof ring used in 57 patients who were followed up for a mean of 8.3 years was 12.5%. The failure rate of the antiprotrusio cage used in 38 patients who were followed up for a mean of 6.6 years was 5.4%. The higher failure rate of the acetabular roof ring resulted from its inappropriate use in patients with medial wall deficiency and protrusio. The acetabular roof ring is indicated for patients with isolated peripheral segmental or cavitatory defects. The antiprotrusio cage is indicated for patients with extensive combined segmental and cavitatory defects but particularly for those patients with protrusio and medial segmental bone loss. Both methods have given a high degree of success for evaluation of implant specific, patient subjective, and global health status instruments such as the Short Form-36.