Urokinase-plasminogen activator, a marker for aggressive breast carcinomas. Preliminary report

Plasminogen activator is a serine protease which exists in two forms, known as tissue-type plasminogen activator and urokinase-type plasminogen activator. Here, we show that urokinase-type plasminogen activator activity in primary breast carcinomas correlates with both size of tumor and number of axillary nodes with metastases. Patients with primary carcinomas containing high levels of urokinase-type plasminogen activator activity had a significantly shorter disease-free interval than patients with low levels of activity. It is concluded that urokinase-plasminogen activator may be a new prognostic marker in breast cancer.

The laminin-nidogen complex is a ligand for a specific splice isoform of the transmembrane protein tyrosine phosphatase LAR

Leukocyte antigen-related protein (LAR) is a prototype for a family of transmembrane protein tyrosine phosphatases whose extracellular domain is composed of three Ig and several fibronectin type III (FnIII) domains. Complex alternative splicing of the LAR-FnIII domains 4-8 has been observed. The extracellular matrix laminin-nidogen complex was identified as a ligand for the LAR-FnIII domain 5 (Fn5) using a series of GST-LAR-FnIII domain fusion proteins and testing them in in vitro ligand-binding assays. LAR- laminin-nidogen binding was regulated by alternative splicing of a small exon within the LAR-Fn5 so that inclusion of this exon sequence resulted in disruption of the laminin-nidogen-binding activity. Long cellular processes were observed when HeLa cells were plated on laminin-nidogen, but not when plated on a fibronectin surface. Indirect immunofluorescent antibody staining revealed high expression of LAR in a punctate pattern, throughout the length of these cellular processes observed on laminin-nidogen. Antibody-induced cross-linking of LAR inhibited formation of these cellular processes, and inhibition was correlated with changes in cellular actin cytoskeletal structure. Thus, LAR-laminin-nidogen binding may play a role in regulating cell signaling induced by laminin-nidogen, resulting in cell morphological changes.

Accumulation of lovastatin, but not pravastatin, in the blood of cyclosporine-treated kidney graft patients after multiple doses

OBJECTIVES

To study pravastatin and lovastatin pharmacokinetic and pharmacodynamic effects and their interactions with cydosporine (INN, ciclosporin) in kidney transplant patients after single and multiple doses.

SUBJECTS AND METHODS

The pharmacokinetic and pharmacodynamic effects of administration of 20 mg/day oral pravastatin and lovastatin for 28 days and their interactions with cyclosporine (2 to 6 mg/kg/day) were studied in a double-blind, double-dummy, randomized, parallel-group multicenter trial in 44 stable kidney graft recipients.

RESULTS

The median area under the curve [AUC(0-24)] of pravastatin was 249 microg x hr/L (range, 104 to 1026 microg x hr/L) after a single dose (day 1) and 241 microg x hr/L (114 to 969 microg x hr/L) after multiple doses (day 28) and was fivefold higher than values reported in the absence of cyclosporine. The median AUC(0-24) of lovastatin was 243 microg x hr/L (105 to 858 microg x hr/L) on day 1 and 459 microg x hr/L (140 to 1508 microg x hr/L) on day 28. Besides a significant accumulation during the study period (p < 0.001), the lovastatin AUC(0-24) values were twentyfold higher than values reported without cyclosporine. Coadministration of pravastatin or lovastatin did not alter cyclosporine pharmacokinetics. In this study, 20 mg/day doses of both drugs resulted in a significant improvement of the lipid profile and were well tolerated.

CONCLUSIONS

In contrast to lovastatin, pravastatin did not accumulate over the study period, which is probably one of the reasons rhabdomyolysis has been reported in lovastatin-treated but not pravastatin-treated transplant patients receiving cyclosporine immunosuppression.

The influence of preclinical anaemia on outcome following total hip replacement

INTRODUCTION

Preoperative anaemia confers a higher intraoperative and postoperative risk of complications on a patient. Preclinical anaemia is defined as a patient with laboratory indices of anaemia but without any of the symptoms. The patient population who undergo total hip replacement (THR) are elderly and are more likely to fall into this category. Our aim was to assess the effect of preclinical anaemia on a patient's postoperative course.

MATERIALS AND METHODS

A prospective analysis of elective THRs performed over a 10-month period was carried out. Preoperative haematological indices were recorded and correlated with postoperative complication rates.

RESULTS

A total of 225 elective THRs were included in the study. Patients with preclinical anaemia on admission had a higher incidence of postoperative infection and transfusion (p<0.001) and a longer postoperative inpatient stay. Preoperative iron supplementation in patients with preclinical iron deficiency anaemia resulted in a reduction in transfusion requirements (p=0.00125).

CONCLUSIONS

Identification and treatment of patients with preclinical anaemia preoperatively may reduce postoperative infection and transfusion needs and result in a shorter inpatient stay.

Flow cytometric analysis of kappa and lambda light chain expression in evaluation of specimens for B-cell neoplasia

Analysis of light chain expression is one of the most important determinations in flow cytometric immunophenotyping of patient specimens. Numerous technical factors, such as antibody choice and cytophilic antibody artifact, impact a laboratory's ability to perform this test. There have been conflicting reports concerning the efficacy of polyclonal versus monoclonal antibodies, as well as methods of circumventing cytophilic antibodies, indicating that a consensus has not been reached on optimal methods for light chain determination. The authors have investigated methods for light chain analysis in 104 normal donors and 366 patient specimens, comparing different anti-light chain antibodies as well as strategies for analysis of specimens with low numbers of monoclonal B cells, admixed polyclonal B cells, or cytophilic antibodies. The patient specimens were either part of the initial diagnostic evaluation of patients with suspected lymphoma, or were performed for staging or assessment of treatment of patients with known B-cell neoplasia. No monoclonality was detected in control specimens, and there was no significant difference in staining with monoclonal verses polyclonal anti-light chain antibodies. In addition, cytophilic antibody did not obscure results in normal controls. Monoclonality was detected in 106 patient specimens, with 89 showing gross involvement with a predominant monoclonal B-cell process. However, in 43% of the grossly monoclonal specimens, there was failure to detect monoclonality with at least one light chain antibody set, with 8% of these cases showing failure with two anti-light chain sets. This indicates the importance of antibody choice in light chain analysis. Cytophilic antibody artifact in monoclonal specimens was easily overcome by appropriate antibody combinations, obviating the need for cytophilic antibody-shedding by incubation at 37 degrees C in fetal calf serum. In 27 patient specimens with low numbers of B cells or admixed polyclonal B cells, a clonal search based on FSC and CD19 or CD20 expression was performed. In 17 of the 27 cases (63%), a small monoclonal population was detected among admixed polyclonal B cells. The authors conclude that multiple strategies are necessary in flow cytometric analysis for B-cell monoclonality.

Plasminogen activator and cancer

Plasminogen activator is a protease which catalyses the conversion of the inactive plasminogen to the active plasmin. Most transformed cell lines and solid tumors produce elevated levels of plasminogen activator compared with nontransformed counterparts. This increased synthesis of plasminogen activator may play a role in tumorigenesis, cancer invasion and metastasis. Measurement of plasminogen activator in tumor extracts and body fluids may provide diagnostic and prognostic information. Finally, since plasminogen activator is an estradiol-inducible enzyme, its measurement in breast carcinomas might be a marker for a functional estrogen receptor.

Pelvic pseudotumor: an unusual presentation of an extra-articular granuloma in a well-fixed total hip arthroplasty

A 76-year-old woman developed a pelvic mass and abdominal pain 12 years after cementless total hip arthroplasty. The mass was a cystic granuloma that communicated with the hip joint via a soft tissue herniation under the inguinal ligament. There was no acetabular lysis or defects. The shell and femoral component were well fixed, the polyethylene was worn, and a liner exchange was undertaken. The cyst was debrided, and follow-up computed tomography demonstrated resolution of the granuloma and no recurrence of the cyst. Removal of the source of the particle wear debris via liner exchange or revision surgery combined with cyst debridement via a single incision is recommended.

A long-term evaluation of the mandibular Schwarz appliance and the acrylic splint expander in early mixed dentition patients

INTRODUCTION

The aim of this prospective longitudinal clinical study was to evaluate the short-term and long-term changes in dental-arch dimensions in patients treated with either an acrylic splint rapid maxillary expander alone (RME-only) or a rapid maxillary expander combined with a mandibular removable Schwarz plate (RME-Sz) in the early mixed dentition, followed later by fixed appliances in the permanent dentition.

METHODS

The dental casts of 27 RME-only patients were compared with those of 23 RME-Sz patients and 16 untreated controls (CTRL) with constricted maxillary arches at 4 times: pretreatment (T1), after expansion but before fixed appliance therapy (T2), after fixed appliance therapy (T3), and at long-term observation (T4). The mean ages for the treated groups were approximately 9 years at T1, 12 years at T2, 14 years at T3, and 20 years at T4. Arch width, arch depth, arch perimeter, and molar angulation were assessed in all subjects at all observation times. T1-T2, T2-T3, T3-T4, and T1-T4 changes were compared statistically in the treated groups with respect to the CTRL.

RESULTS

Treatment with an RME-only or an RME-Sz followed by fixed appliances produced significant short-term and long-term increases in maxillary arch widths compared with the CTRL. The RME-Sz led to significantly more favorable results than the RME-only protocol: (1) significantly greater increases in the transverse width of the mandibular arch and mandibular arch perimeter in the long term, and (2) uprighting of the mandibular posterior teeth buccally, thus allowing for an amount of maxillary expansion that was clinically effective for the correction of moderate tooth size-arch size discrepancies. In the overall observation interval, the significant increases in maxillary and mandibular arch perimeters in the RME-Sz group were 3.8 and 3.7 mm, respectively, when compared with the CTRL. The RME-only protocol produced modest long-term increases in maxillary arch perimeter (2.6 mm); the average long-term increase in mandibular arch perimeter (2.0 mm) in the RME-only group was not statistically significant.

CONCLUSIONS

The RME-Sz led to significantly more favorable results than the RME-only protocol.

Comparison of the pharmacokinetics of fosinoprilat with enalaprilat and lisinopril in patients with congestive heart failure and chronic renal insufficiency

AIMS

To compare the serum pharmacokinetics of fosinoprilat with enalaprilat and lisinopril after 1 and 10 days of dosing with fosinopril, enalapril and lisinopril.

METHODS

Patients with congestive heart failure (CHF, NYHA Class II-IV) and chronic renal insufficiency (creatinine clearance </=30 ml min-1 ) were randomized to receive fosinopril, enalapril or lisinopril in two parallel-group studies. In the first study 24 patients were treated with 10 mg fosinopril (n=12 patients) or 2.5 mg enalapril (n=12) every morning for 10 consecutive days. In the second study 31 patients were treated with 10 mg fosinopril (n=16 patients) or 5 mg lisinopril (n=15) every morning for 10 consecutive days. Samples of blood were collected for determination of pharmacokinetic parameters. The area under the curve (AUC) between the first and last days of treatment and the accumulation index (AI) were the primary outcome measures.

RESULTS

All three angiotensin converting enzyme (ACE) inhibitors exhibited a significant increase in AUC between the first and last days of treatment in both studies. The difference between the AI for fosinoprilat (1.41) and enalaprilat (1.96) was statistically significant (95% CI: 1.05, 1.84). Similarly, the difference between the AI for fosinoprilat (1.21) and lisinopril (2.76) was statistically significant (95% CI: 1.85, 2.69). All three ACE inhibitors completely inhibited serum ACE for 24 h. All treatments were well tolerated.

CONCLUSIONS

Fosinoprilat exhibits significantly less accumulation than enalaprilat or lisinopril in patients with CHF and renal insufficiency, most probably because fosinoprilat is eliminated by both the kidney and liver, and increased hepatic elimination can compensate for reduced renal clearance in patients with kidney dysfunction.

Expression of a new type high molecular weight receptor (type V receptor) of transforming growth factor beta in normal and transformed cells

A new type high molecular weight receptor (type V receptor) of transforming growth factor beta (TGF-beta) was recently purified from bovine liver plasma membranes and appears not to be related to receptors previously described for TGF-beta (Pauline O'Grady, Ming-Der Kuo, Joseph J. Baldassare, Shuan Shian Huang and Jung San Huang [1991] J. Biol. Chem. 266:8583-8589). This type V receptor may be important in the regulation of cell growth by TGF-beta. We examined its distribution in a wide range of normal and transformed cells. The type V receptor was found to be expressed in many normal cells including cells of epithelial, endothelial, fibroblastic and chondrocytic origins. However, a number of human epithelial tumor cells (5 out of 6 examined) did not express detectable levels of the type V TGF-beta receptor. These results suggest that loss of the type V receptor may potentially contribute to the transformed state of certain epithelial tumor cells.

Pharmacokinetics of single-dose oral stavudine in subjects with renal impairment and in subjects requiring hemodialysis

Two open-label studies assessed the pharmacokinetics of single orally administered doses of 40 mg of stavudine in subjects with renal impairment. In one study (study I), 15 subjects with selected degrees of renal impairment, but not requiring hemodialysis, were stratified into three groups of five subjects each according to creatinine clearance (CL(CR)) normalized by body surface area (ml/min/1.73 m(2)): mild (CL(CR), 60 to 80), moderate (30 to 50), and severe (/= 90) were also enrolled. The stavudine area under the curve from 0 h to infinity (AUC(0-infinity)) increased nonlinearly with declining renal function: 1,864, 2,215, 3,609, and 5,928 ng. h/ml for normal renal function and for mild, moderate, and severe renal impairment, respectively (P = 0.0001 between renal impairment groups). The following stavudine dosage recommendations for renal impairment were proposed for subjects weighing >/=60 kg: CL(CR) of >50 ml/min/1.73 m(2), 40 mg every 12 h; CL(CR) of 21 to 50 ml/min/1. 73 m(2), 20 mg every 12 h; and CL(CR) of 10 to 20 ml/min/1.73 m(2), 20 mg every 24 h. For subjects weighing <60 kg, the proposed doses were 30, 15, and 15 mg, respectively, with the same dosing intervals specified above. In a second study (study II), 12 subjects with end-stage renal disease requiring hemodialysis three times a week were enrolled in a randomized, open-label crossover study (dialysis 2 h after dosing and lasting 4 h or dosing without dialysis). There were no statistically significant differences for AUC(0-infinity), AUC(2-6), time to maximum concentration of drug in serum, half-life, or apparent oral clearance when the two treatment dosage regimens were compared. As a result of study II, the recommended dosing rate for subjects requiring hemodialysis was the same as that proposed for those with severe renal impairment not requiring hemodialysis; however, dosing was recommended to follow hemodialysis and to occur at the same time each day.

Tissue-type plasminogen activator in breast cancer: relationship with estradiol and progesterone receptors

Plasminogen activator (PA) is an estradiol-inducible enzyme and therefore a potential marker for a functional estradiol receptor (ER) in human breast carcinomas. In this investigation tissue-type PA (t-PA) correlated significantly with both ER and progesterone receptors (PR) in human breast carcinomas. In contrast, neither total PA activity nor urokinase-like PA showed any significant correlation with either ER or PR. Other proteases such as a trypsin-like protease, a chymotrypsin-like protease, and cathepsin B also showed no correlation with ER and PR. It was concluded that the t-PA form of PA may be a marker for a functional ER in breast carcinoma and thus be of value in predicting hormone-dependent breast cancers.

Testing transposable elements as genetic drive mechanisms using Drosophila P element constructs as a model system

The use of transposable elements (TEs) as genetic drive mechanisms was explored using Drosophila melanogaster as a model system. Alternative strategies, employing autonomous and nonautonomous P element constructs were compared for their efficiency in driving the ry+ allele into populations homozygous for a ry- allele at the genomic rosy locus. Transformed flies were introduced at 1%, 5%, and 10% starting frequencies to establish a series of populations that were monitored over the course of 40 generations, using both phenotypic and molecular assays. The transposon-borne ry+ marker allele spread rapidly in almost all populations when introduced at 5% and 10% seed frequencies, but 1% introductions frequently failed to become established. A similar initial rapid increase in frequency of the ry+ transposon occurred in several control populations lacking a source of transposase. Constructs carrying ry+ markers also increased to moderate frequencies in the absence of selection on the marker. The results of Southern and in situ hybridization studies indicated a strong inverse relationship between the degree of conservation of construct integrity and transposition frequency. These finding have relevance to possible future applications of transposons as genetic drive mechanisms.

Early clinical trial of MDL 73.147 EF: a new 5-HT3-receptors antagonist for the prevention of chemotherapy-induced nausea and vomiting

BACKGROUND

Like MDL 72.222, one of the first selective 5-hydroxytryptamine3 (5-HT3) receptors antagonist discovered, MDL 73.147 EF has been shown to possess antiemetic properties in the ferret model. We conducted a phase I study with MDL 73.147 EF in 31 patients, treated with emetogenic drugs over one to five days (cisplatin, cyclophosphamide, doxorubicin, dacarbazine).

PATIENTS AND METHODS

5 groups of at least 5 patients received rising unit doses of MDL 73.147 EF (10 to 50 mg) intravenously before chemotherapy, with two more doses per day if needed. Nausea was assessed by a patient-completed visual analogue scale and episodes of vomiting recorded by an independent observer.

RESULTS

51.6% of the patients were complete responders on day one and 40% on days two to five. One patient was given other rescue antiemetic therapy. Adverse events included constipation (25.8%), mildly elevated blood pressure (12.9%) and other minor events. No extrapyramidal effects have been reported. There was no suggestion of dose-dependent efficacy at the dose levels studied in this limited set of patients.

CONCLUSIONS

We conclude that MDL 73.147 EF is a well tolerated and possibly effective antiemetic.

Evidence for conformational changes in Escherichia coli porphobilinogen deaminase during stepwise pyrrole chain elongation monitored by increased reactivity of cysteine-134 to alkylation by N-ethylmaleimide

Porphobilinogen deaminase from Escherichia coli becomes progressively more susceptible to inactivation by the thiophilic reagent N-ethylmaleimide (NEM) as the catalytic cycle proceeds through the enzyme-intermediate complexes ES, ES2, ES3, and ES4. Site-directed mutagenesis of potentially reactive cysteines has been used to identify cysteine-134 as the key residue that becomes modified by the reagent and leads to inactivation. Since cysteine-134 is buried at the interface between domains 2 and 3 of the E. coli deaminase molecule, the observations suggest that a stepwise conformational change occurs between these domains during each stage of tetrapyrrole assembly. Interestingly, mutation of the invariant active-site cysteine-242 to serine leads to an enzyme with up to a third of the catalytic activity found in the wild-type enzyme. Electrospray mass spectrometry indicates that serine can substitute for cysteine as the dipyrromethane cofactor attachment site.

Hurling-related hand injuries

Hurling is a contact sport, associated with significant morbidity. We have identified specific hand injuries sustained by participants and quantified the functional and financial implications of these injuries. Over a 3-month period, all hand injuries seen in the fracture clinic of our regional trauma unit were studied prospectively. Of the 123 consecutive injuries, 41 (33%) were sustained during hurling matches. Metacarpal (47%) and proximal phalangeal (37%) fractures were the most frequent. Eight hurlers (20%) required surgical intervention. Only four (10%) of the injured players were wearing hand protection. The mean cost of injury to the player was pound 615. We suggest the introduction of the mandatory use of hand protection for hurling.

Fosinopril/hydrochlorothiazide: single dose and steady-state pharmacokinetics and pharmacodynamics

AIMS

Fosinoprilat, the active product of fosinopril, is eliminated by an hepatic pathway in addition to the renal pathway shared by other angiotensin converting enzyme inhibitors (ACEIs). This study aimed to determine whether impaired renal function affects the pharmacokinetics and pharmacodynamics of a combination of fosinopril and hydrochlorothiazide (HCTZ).

METHODS

The study had a parallel-group design comparing patients with renal impairment and body-mass-index-matched normal controls. The study was done in a University clinic in 13 patients with renal impairment (mean creatinine clearance 55.7+/-15.6 ml min-1 1.73 m-2 ) and 13 age-, sex-, and body-mass-index-matched normal controls (mean creatinine clearance 102.4+/-8.9 ml min-1 1.73 m-2 ). All patients and normal controls received fosinopril sodium 20 mg and HCTZ 12.5 mg as a daily oral administration on days 1-5. Non-compartmental pharmacokinetic parameters of fosinoprilat and HCTZ were determined from blood and urine samples obtained over 48 h starting on Day 1 (single dose) and Day 5 (steady state): maximum serum concentration (Cmax ), time to maximum serum concentration (tmax ), area under the serum concentration-time curve during the dosing interval (AUC), cumulative urinary excretion (CUE) and the accumulation index (AI; ratio of AUC-day 5/AUC-day 1). Pharmacodynamic parameters were also measured over 24 h on day 1 and over 48 h on day 5: serum ACE activity and arterial blood pressure.

RESULTS

Fosinoprilat pharmacokinetic parameters on day 1 in renally impaired vs normal patients: Cmax=387+/-0.19 vs 324+/-0.25 ng ml-1 (P=0.07); tmax=3.5 vs 3.0 h (P=0.58); AUC=3510+/-0.29 vs 2701+/-0.35 ng ml-1 h (P=0. 072); CUE=5.08+/-2.70 vs 7.40+/-2.56% (P=0.009). Fosinoprilat parameters on day 5: Cmax=517+/-0.40 vs 357+/-0.19 ng ml-1 (P=0. 007); tmax=3.0 vs 3.0 h (P >0.99); AUC=4098+/-0.43 vs 2872+/-0.30 ng ml-1 h (P=0.027); CUE=6.81+/-3.53 vs 8.10+/-2.80% (P=0.068). AI=1. 17+/-0.33 vs 1.06+/-0.23 (P=0.29). In both groups ACE inhibition and blood pressure response were similar over 24 h and slightly greater 48 h after last dosing.

CONCLUSIONS

In renally impaired subjects fosinopril and HCTZ can be coadministered without undue increases in fosinoprilat concentrations or any clinically significant pharmacodynamic effects. This is probably due to the dual excretory pathways for fosinoprilat.

Influence of level of concentrate feeding on milk production and pasture utilization by Friesian cows grazing tropical grass-legume pasture

Four groups of four Friesian cows grazed green panic (Panicum maximum var. trichog1ume)- glycine (Glycine wightii cv. Tinaroo) pastures at 4 cows ha-1 for 36 weeks from January to October 1975. Cows were individually fed 0, 2, 4 and 6 kg cow-1 day-1 respectively of a maize-soybean meal concentrate. Fat corrected milk (FCM) response to concentrate was linear and was related to the total concentrate intake (X) by the equation, FCM = 1992 + 1.03 X (R.S.D. � 23; P < 0.001) Persistency of lactation decreased with decreasing levels of concentrate feeding (P < 0.01) and lactation length was reduced for cows receiving low levels of concentrates (P < 0.05). Milk fat content was reduced (P < 0.05) and solids-not-fat and casein contents increased by concentrate feeding (P < 0.05). Cows fed 6 kg concentrate cow-1 day-1 were 50 kg cow-1 heavier at drying off than cows fed no concentrate (P < 0.05). Pasture yield on offer to cows was increased linearly with increased concentrate feeding (P < 0.05) and pasture intake by cows was estimated to decrease by 0.9 kg for each kg of concentrate fed (P < 0.05). FCM response to concentrate appeared to increase markedly when pasture on offer fell below 2500 kg DM ha-1. We conclude that FCM response to concentrate will usually be linear for cows grazing tropical pastures, and the size of this response will be strongly influenced by the period of feeding and the yield of pasture on offer to cows.

A phase I antiemetic study of MDL 73,147EF, a novel 5-hydroxytryptamine antagonist in cancer patients receiving emetogenic chemotherapy

BACKGROUND

We conducted a phase I study with MDL 73,147EF, a new 5 hydroxytryptamine 3 (5-HT3) receptor antagonist, in 25 patients requiring emetogenic chemotherapy.

PATIENTS AND METHODS

5 groups of 5 patients received rising unit doses of MDL 73,147EF (10 to 50 mg) intravenously before chemotherapy, with two additional doses per day if needed. Nausea was assessed by a patient-completed visual analogue scale and episodes of vomiting were recorded by an independent observer.

RESULTS

42% of the patients were complete or major responders on day one. Five patients were given other rescue antiemetic therapy. Adverse effects included headache (16%) diarrhea (8%) and other minor events. The best results were obtained with the 30, 40 and 50 mg doses.

CONCLUSIONS

MDL 73,147EF is a well-tolerated and probably effective antiemetic agent which requires further evaluation in randomised controlled clinical studies.

Surfing Behind a Boat: Quality and Reliability of Online Resources on Scaphoid Fractures

BACKGROUND

Patients seeking information and advice on treatment of scaphoid fractures unknowingly confront longstanding medical controversies surrounding the management of this condition. However, there are no studies specifically looking into the quality and reliability of online information on scaphoid fractures.

METHODS

We identified 44 unique websites for evaluation using the term "scaphoid fractures". The websites were categorized by type and assessed using the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria and the Health on the net (HON) code.

RESULTS

The majority of websites were commercial (n = 13) followed by academic (n = 12). Only seven of the websites were HON certified. The mean DISCERN score was 43.8. Only 4 websites scored 63 or above representing excellent quality with minimal shortcomings but 13 websites scored 38 or below representing poor or very poor quality. The mean JAMA benchmark criteria score was 2.2. The Governmental and Non-Profit Organizations category websites had the highest mean JAMA benchmark score. The websites that displayed the HON-code seal had higher mean DISCERN scores and higher mean JAMA benchmark scores compared to websites that did not display the seal.

CONCLUSIONS

Good quality health information is certainly available on the Internet. However, it is not possible to predict with certainty which sites are of higher quality. We suggest clinicians should have a responsibility to educate their patients regarding the unregulated nature of medical information on the internet and proactively provide patients with educational resources and thus help them make smart and informed decisions.

Outcome of open massive rotator cuff repairs with double-row suture knotless anchors: case series

PURPOSE

The aim of the present study was to evaluate functional and quality of life outcomes after transosseous equivalent (TOE) double row suture technique for massive rotator cuff (RTC) tear repair using validated subjective and objective measures. This technique has shown promising preliminary results in RTC repair; however, a paucity of evidence regarding these outcomes in massive RTC (MRTC) tear repair exists.

METHODS

Patients were identified using the Hospital Inpatient Enquiry Scheme. Pre-operative MRI and medical records were reviewed. A massive RTC tear was defined as the detachment of two or more tendons from their point of insertion on the humeral head. The Constant and Oxford Shoulder Scores (OSS) and SF-12 questionnaire were used for evaluation.

RESULTS

Twenty-two patients were studied (72.7 % male; mean age at surgery, 62.6 years). Mean follow up was 14 (range six to 30) months. At six weeks postoperatively, 68 % achieved good or excellent shoulder function as measured by the OSS and Constant score. The cohort's mean SF-12 physical and emotional scores were significantly lower (p = 0.0002 and 0.037) and the vitality and mental health scores were higher (p = 0.005 and 0.006) than the reference norm scores.

CONCLUSIONS

The TOE double row surgical repair for MRTC tears provides good to excellent functional outcomes and is associated with high vitality and mental health scores at a mean of 14 months. Physical and emotional scores were lower than reference norm. These results suggest this repair technique is appropriate for massive rotator cuff tears, and future randomised control studies are warranted.

Unusual osseous metastases from rectal adenocarcinoma: a case report and review of the literature

INTRODUCTION

Rectal adenocarcinoma typically metastasizes to the liver. When osseous spread occurs, it is most commonly detected in the vertebrae and pelvis. Distal osseous spread is unusual and may be the first presentation of the carcinoma. We present a review of the current literature on unusual osseous rectal adenocarcinoma metastases and highlight a case of a scapular lesion as the first presentation of rectal carcinoma from our institution.

MATERIALS AND METHODS

A Pubmed search using keywords 'rectal carcinoma metastases,' 'colorectal cancer metastases' and 'skeletal metastases' was performed.

RESULTS

Twenty-four cases were identified (54 % male, mean age at diagnosis 61 ± 16 years). The most common site was the mandible, followed by the foot. In four cases, the metastasis was the first presentation of the carcinoma. Mean time from resection of the primary tumour to osseous metastases diagnosis of skeletal metastases was 26 ± 17 (SD) months. Mean time from diagnosis of skeletal metastases to death was 3.2 (±2.8) months.

CONCLUSION

Rectal adenocarcinoma osseous metastases located distal to the pelvis and/or vertebrae are rare and associated with a poor prognosis. Unusual bony lesions should raise an index of suspicion for distal carcinoma, including rectal carcinoma.