Determination of Aconitum Alkaloids in Dietary Supplements and Raw Botanical Materials by Liquid Chromatography/UV Detection with Confirmation by Liquid Chromatography/Tandem Mass Spectrometry: Collaborative Study

An interlaboratory study was conducted to evaluate a method for the determination of 3 Aconitum alkaloids, viz., aconitine, mesaconitine, and hypaconitine, in raw botanical material and dietary supplements. The alkaloids were extracted with diethyl ether in the presence of ammonia. After cleanup by solid-phase extraction to remove matrix interferences, the alkaloids were determined by reversed-phase liquid chromatography (LC)/UV detection at 235 nm with confirmation by LC/tandem mass spectrometry (MS/MS). A total of 14 blind duplicates were successfully analyzed by 12 collaborators. For repeatability, the relative standard deviation (RSDr) values ranged from 1.9 to 16.7, and for reproducibility, the RSDR values ranged from 6.5 to 33. The HorRat values were all <2 with only one exception at 2.3. All collaborating laboratories had calibration curves with correlation coefficients of >0.998. In addition, 6 collaborators performed the confirmation and were able to verify the identities of the alkaloids by using LC/MS/MS.

Local infiltration analgesia in primary total knee arthroplasty

INTRODUCTION

Postoperative pain in total knee arthroplasty (TKA) can hinder rehabilitation and cause morbidity. Local infiltration analgesia (LIA), comprising an anaesthetic drug, non-steroidal anti-inflammatory drug, and adrenaline, has been introduced to reduce pain and systemic side-effects. This study evaluated the efficacy of LIA in TKA with respect to morphine consumption and postoperative pain score.

METHODS

This single-centre retrospective cohort study recruited patients with knee osteoarthritis who were scheduled for primary TKA during the period from January 2017 to December 2017. Patients with chronic inflammatory joint disease, contra-indications for LIA, or dementia were excluded. Patients in the LIA group were administered single-dose LIA intra-operatively, while those in the control group were not. Primary outcomes were postoperative pain score, morphine demand, and morphine consumption; secondary outcomes were range of motion, quadriceps power, and postoperative length of stay.

RESULTS

In total, 136 patients were recruited (68 per group). Total postoperative morphine demand and consumption, as well as pain scores from postoperative day (POD) 1 to POD 4, were lower in the LIA group than in the control group. The range of motion from POD 1 to POD 4 and quadriceps power on POD 1 were higher in the LIA group than in the control group. Quadriceps power from POD 2 to POD 4 and postoperative length of stay were not significantly different between groups.

CONCLUSIONS

Intra-operative single-dose LIA can effectively reduce postoperative pain, morphine demand, and morphine consumption. Therefore, the use of LIA is recommended during TKA.

Predictive factors for length of hospital stay following primary total knee replacement in a total joint replacement centre in Hong Kong

INTRODUCTION

The demand for total knee replacement in Hong Kong places tremendous economic burden on our health care system. Shortening hospital stay reduces the associated cost. The aim of this study was to identify perioperative predictors of length of hospital stay following primary total knee replacement performed at a high-volume centre in Hong Kong.

METHODS

We retrospectively reviewed all primary total knee replacements performed at Yan Chai Hospital Total Joint Replacement Centre from October 2011 to October 2015. Perioperative factors that might influence length of stay were recorded.

RESULTS

A total of 1622 patients were identified. The mean length of hospital stay was 6.8 days. Predictors of prolonged hospital stay following primary total knee replacement were advanced age; American Society of Anesthesiologists physical status class 3; bilateral total knee replacement; in-patient complications; and the need for blood transfusion, postoperative intensive care unit admission, and urinary catheterisation.

CONCLUSIONS

Evaluating factors that can predict length of hospital stay is the starting point to improve our current practice in joint replacement surgery. Prediction of high-risk patients who will require a longer hospitalisation enables proactive discharge planning.

Mortality following primary total knee replacement in public hospitals in Hong Kong

INTRODUCTION

More than 2000 total knee replacements are performed each year in Hong Kong and more than 10 000 patients are on the waiting list. How safe is total knee replacement, however? The aims of the study were to review the mortality of primary total knee replacement in public hospitals in Hong Kong and to identify risk factors for mortality in a high-volume hospital.

METHODS

All primary total knee replacements performed in Hospital Authority hospitals and Yan Chai Hospital from October 2011 to September 2014 were reviewed. Case-control analysis was performed for risk factors of total all-cause mortality in total knee replacement at Yan Chai Hospital.

RESULTS

There were 6588 patients in Hospital Authority hospitals and 1184 in Yan Chai Hospital (1095 unilateral and 89 bilateral total knee replacement). The mean follow-up time of patients in Yan Chai Hospital was 12.8 months. The mortality at 30 days, 90 days and 1 year was 0%, 0.08%, 0.34% for Yan Chai Hospital; and 0.1%, 0.2%, 0.7% for Hospital Authority hospitals, respectively. For Yan Chai Hospital, the mean operation-to-death interval was 21 months (range, 1-35 months). The mean age at death was 78 years and main causes were malignancy (50%) and pneumonia (21%). Predictors of mortality included age at surgery, American Society of Anesthesiologists class 3, and preoperative range of motion. Hospital surgery volume, preoperative co-morbidities, and postoperative deep vein thrombosis were not significant factors.

CONCLUSIONS

Mortality after primary total knee replacement was low in public hospitals in Hong Kong. Patients of older age or poorer general well-being in terms of poor range of motion or American Society of Anesthesiologists class 3 should be in optimal health before surgery and counselled about the higher mortality rate. A citywide joint replacement registry may help monitor and analyse postoperative total knee replacement mortality specific to our locality.

Angiographic factors associated with haemorrhagic presentation of brain arteriovenous malformation in a Chinese paediatric population

OBJECTIVE

To identify specific angiographic factors associated with haemorrhagic presentation of brain arteriovenous malformation in Chinese paediatric patients.

DESIGN

Retrospective cross-sectional observational study.

SETTING

Four locoregional tertiary neurosurgical centres in Hong Kong: Queen Elizabeth Hospital, Tuen Mun Hospital, Kwong Wah Hospital, and Pamela Youde Nethersole Eastern Hospital.

PATIENTS

Patients aged 18 years or younger who underwent pretreatment digital subtraction angiography for brain arteriovenous malformation between 1 January 2005 and 31 July 2013 were included. Patients were divided into haemorrhagic and non-haemorrhagic groups based on the initial presentation. Pretreatment digital subtraction angiographies were independently reviewed by two experienced neuroradiologists.

MAIN OUTCOME MEASURES

The following parameters were evaluated for their association with haemorrhagic presentation by univariate and multivariate analyses: nidus location, nidus size, nidus morphology (diffuse or compact); origin and number of arterial feeders; venous drainage; number of draining veins; presence of aneurysms, venous varices, and venous stenosis.

RESULTS

A total of 67 children and adolescents (28 male, 39 female) with a mean age of 12 years were included. Of them, 52 (78%) presented with haemorrhage. Arteriovenous malformation size (P=0.004) and morphology (P=0.05) were found to be associated with haemorrhagic presentation by univariate analysis. Small arteriovenous malformation nidus size and diffuse nidal morphology were identified as independent risk factors for haemorrhage by multivariate analysis.

CONCLUSION

Smaller arteriovenous malformation size and diffuse nidal morphology are angiographic factors independently associated with haemorrhagic presentation. Bleeding risk is important in determining the therapeutic approach (aggressive vs conservative) and timeframe, particularly in paediatric patients.

Predictive factors for early failure of transarterial embolization in blunt hepatic injury patients

AIM

To evaluate the early success of transarterial embolization (TAE) in patients with traumatic liver haemorrhage and to determine independent factors for its failure.

MATERIALS AND METHODS

From January 2009 to December 2012, TAE was performed in 48 patients for traumatic liver haemorrhage. Their medical charts were reviewed for demographic information, pre-TAE vital signs and laboratory data, injury grade, type of contrast medium extravasation (CME) at CT, angiography findings, and early failure. "Early failure" was defined as the need for repeated TAE or a laparotomy for hepatic haemorrhage within 4 days after TAE. Variables were compared between the early success and early failure groups. Variables with univariate significance were also analysed using multivariate logistic regression for predictors of early failure.

RESULTS

Among 48 liver TAE cases, nine (18.8%) were early failures due to liver haemorrhage. Early failure was associated with injury grade (p = 0.039), major liver injury (grades 4 and 5; p = 0.007), multiple CMEs at angiography (p = 0.031), incomplete TAE (p = 0.002), and elevated heart rate (p = 0.026). Incomplete embolization (OR = 8; p = 0.042), and heart rate >110 beats/min (bpm; OR = 8; p = 0.05) were independent factors for early failure of TAE in the group with major liver injuries.

CONCLUSION

Major hepatic injury is an important factor in early failure. Patients with a heart rate >110 bpm and incomplete embolization in the major injury group have an increased rate of early failure. The success rate of proximal TAE was comparable to that of the more time-consuming, superselective, distal TAE.

Predicting 1-year risk for relapse in patients who have discontinued or continued quetiapine after remission from first-episode psychosis

OBJECTIVE

Relapse is common among patients with psychotic disorders. Identification of relapse predictors is important for decision regarding maintenance medication. Naturalistic studies often identify medication non-adherence as a dominant predictor. There are relatively few studies for predictors where adherence is already known. It is this situation i.e., discontinuation of medication that predictors will be most useful. We identify predictors for relapse in situations of (i) discontinuation and (ii) continuation of maintenance medication.

METHOD

Analysis of relapse predictors is based on a randomized controlled study (n=178) comparing relapse rates between patients who discontinued or continued medication for at least 1 year following first-episode psychosis. Demographic, clinical and neurocognitive variables were assessed at baseline as predictors of relapse within 1 year.

RESULTS

Risk of relapse was 79% in the discontinuation group and 41% in the maintenance group. Predictors in the discontinuation group were diagnosis of schizophrenia, poorer semantic fluency performance, and higher blink rate. Predictors in the continuation group were disinhibition soft signs and more general psychopathology symptoms.

CONCLUSION

Different predictors of relapse were identified for first episode psychosis patients who discontinued and continued maintenance medication. Neurocognitive dysfunctions are important predictors for both groups. While signs of frontal dysfunction and dopamine hyperactivity predict relapse in the discontinuation group, sign of cognitive disinhibition predicts relapse in the continuation group.

Elective unilateral total knee replacement using continuous femoral nerve blockade versus conventional patient-controlled analgesia: perioperative patient management based on a multidisciplinary pathway

OBJECTIVES. To evaluate the effectiveness of our new multidisciplinary pathway for total knee replacement patients and compare outcomes after continuous femoral nerve blockade versus conventional patient-controlled analgesia for postoperative pain. DESIGN. Randomised controlled trial in a routine clinical setting. SETTING. Acute orthopaedic wards and operating theatres, Yan Chai Hospital, Hong Kong. PATIENTS. Sixty patients underwent elective unilateral total knee replacement under spinal anaesthesia from May 2009 to September 2011 and were randomly assigned to continuous femoral nerve blockade or conventional patient-controlled analgesia (30 patients in each group). MAIN OUTCOME MEASURES. Quality of pain control was evaluated by pain scores at rest and during mobilisation, opioid consumption, frequency of side-effects, and patient satisfaction score. Rehabilitation progress was assessed according to the day of first starting weight-bearing exercise, day of independent walking in the ward with aid, Timed Up and Go test, and time elapsing till discharge. Surgical outcome was assessed by the Knee Society score 6 months after discharge, re-admissions, and occurrence of complications. RESULTS. Patients having continuous femoral nerve blockade tended to have less pain on movement and achieved earlier mobilisation than those having patient-controlled analgesia. The former group consumed less opioids, had fewer side-effects, and were more satisfied with their postoperative analgesia. Both groups showed an equally high degree of satisfaction with the new management pathway. Hospital stays, surgical outcomes, and frequency of complications were similar in the two groups. CONCLUSION. Continuous femoral nerve blockade proved to be a feasible and better alternative mode of postoperative analgesia than our conventional patient-controlled analgesia. Our new multidisciplinary management pathway and multimodal analgesic regimen featuring the continuous femoral nerve blockade appeared beneficial to patients and effective in our clinical setting.

Angioplasty and stenting for intracranial atherosclerotic stenosis: position statement of the Hong Kong Society of Interventional and Therapeutic Neuroradiology

As a means of preventing secondary ischaemic stroke, angioplasty and stenting are considered potentially beneficial for patients with severe intracranial atherosclerotic stenosis. However, the role of stenting has been challenged since the publication of the first randomised controlled trial on Stenting versus Aggressive Medical Management for Preventing Recurrent stroke in Intracranial arterial Stenosis (SAMMPRIS). This indicated that aggressive medical management was superior to stenting using Wingspan to prevent recurrent stroke, because stenting has a high peri-procedural stroke and death rate. In this paper, we review the management of intracranial atherosclerosis, revisit the skepticism on stenting, and state our position on the topic in the form of recommendations. These are based on the prevalence of the disease in Hong Kong, the high risk of recurrent stroke despite medical therapy in the presence of haemodynamic intracranial stenosis without sufficient collaterals, an analysis of the weak points of SAMMPRIS, and results of clinical studies in Hong Kong.

Maintenance treatment with quetiapine versus discontinuation after one year of treatment in patients with remitted first episode psychosis: randomised controlled trial

OBJECTIVE

To study rates of relapse in remitted patients with first episode psychosis who either continued or discontinued antipsychotic drugs after at least one year of maintenance treatment.

DESIGN

12 month randomised, double blind, placebo controlled trial.

SETTING

Early psychosis outpatient clinics in Hong Kong.

PARTICIPANTS

178 patients with first episode psychosis who had received at least one year of antipsychotic drug treatment between September 2003 and July 2006 and had no positive symptoms of psychosis.

INTERVENTIONS

Patients received either maintenance treatment with quetiapine (400 mg/day) or placebo and were followed up for the next 12 months or until a relapse occurred.

MAIN OUTCOME MEASURE

Relapse assessed monthly and defined as re-emergence of psychotic symptoms (delusions, conceptual disorganisation, hallucinations, suspiciousness, and unusual thought content) according to predefined thresholds.

RESULTS

178 patients were randomised (89 to quetiapine and 89 to placebo). The Kaplan-Meier estimate of the risk of relapse at 12 months was 41% (95% confidence interval 29% to 53%) for the quetiapine group and 79% (68% to 90%) for the placebo group (P<0.001). Although quetiapine was generally well tolerated, the rate of discontinuation due to adverse or serious adverse events was greater in the quetiapine group (18%; 16/89) than in the placebo group (8%; 7/89) (relative risk 2.29, 95% confidence interval 0.99 to 5.28; chi(2)=3.20, df=1; P=0.07).

CONCLUSION

In a group of asymptomatic patients with first episode psychosis and at least one year of previous antipsychotic drug treatment, maintenance treatment with quetiapine compared with placebo resulted in a substantially lower rate of relapse during the following year. Trial registration Clinical trials NCT00334035.

Evaluation of testing capabilities for the determination of melamine in milk through an interlaboratory proficiency test programme during the melamine crisis

An interlaboratory proficiency testing programme for melamine in milk was organized for field laboratories in Hong Kong, China, during the melamine crisis in late September 2008. One blank test sample and three homogenous samples prepared by gravimetric spiking of melamine at the concentration range of zero to 4.5 mg kg(-1) were given to participants in this programme. A total of 13 participants returned the results to the organizer and they used either liquid chromatography-tandem mass spectrometry (LC-MS/MS) or gas chromatography-mass spectrometry (GC-MS) for their determinations. The performance of the participants was assessed by determining z-scores, calculated from the bias from the assigned reference values and Horwitz standard deviation. The median values of pooled data were found to be in good agreement with the reference values and the majority of the participants demonstrated their capabilities in the quantitative measurement of melamine in milk samples. However, four participants gave false-positive results for the blank test sample, probably due to cross-contamination from other samples, and they were requested to investigate the actual causes. In summary, eight participants (or 62%) demonstrated their competence for all the four test samples.

In vivo evidence of gamma-tocotrienol as a chemosensitizer in the treatment of hormone-refractory prostate cancer

gamma-Tocotrienol (gammaT3) is known to selectively kill prostate cancer (PCa) cells and to sensitize the cells to docetaxel (DTX)-induced apoptosis. In the present study, the pharmacokinetics of gammaT3 and the in vivo cytotoxic response of androgen-independent prostate cancer (AIPCa) tumor following gammaT3 treatment were investigated. Here, we investigated these antitumor effects for PCa tumors in vivo. The pharmacokinetic and tissue distribution of gammaT3 after exogenous gammaT3 supplementation were examined. Meanwhile, the response of the tumor to gammaT3 alone or in combination with DTX were studied by real-time in vivo bioluminescent imaging and by examination of biomarkers associated with cell proliferation and apoptosis. After intraperitoneal injection, gammaT3 rapidly disappeared from the serum and was selectively deposited in the AIPCa tumor cells. Administration of gammaT3 alone for 2 weeks resulted in a significant shrinkage of the AIPCa tumors. Meanwhile, further inhibition of the AIPCa tumor growth was achieved by combined treatment of gammaT3 and DTX (p < 0.002). The in vivo cytotoxic antitumor effects induced by gammaT3 seem to be associated with a decrease in expression of cell proliferation markers (proliferating cell nuclear antigen, Ki-67 and Id1) and an increase in the rate of cancer cell apoptosis [cleaved caspase 3 and poly(ADP-ribose) polymerase]. Additionally, the combined agents may be more effective at suppressing the invasiveness of AIPCa. Overall, our results indicate that gammaT3, either alone or in combination with DTX, may provide a treatment strategy that can improve therapeutic efficacy against AIPCa while reducing the toxicity often seen in patients treated with DTX.

Computed tomography in left-sided and right-sided blunt diaphragmatic rupture: experience with 43 patients

AIM

To investigate differences in the radiographic signs for left and right-sided blunt diaphragmatic rupture (BDR) in order to provide guidance to avoid missing these injuries.

MATERIALS AND METHODS

A retrospective review of the computed tomography (CT) examinations of 43 patients with BDR treated at our hospital between January 1995 and 2007 was undertaken. The presence of diaphragmatic discontinuity, diaphragmatic thickening, herniation of abdominal organs into the thoracic cavity, collar/hump sign, dependent viscera sign, abnormally elevated 4 cm or more above the dome of the other-sided hemi-diaphragm, and of associated injuries was recorded and their relationship to each other and to BDR diagnosis examined. A comparison between the use of axial and sagittal/coronal reconstruction images in diagnosis was also performed in 15 patients.

RESULTS

On axial imaging, left-sided diaphragmatic rupture occurred in 31 patients (72%) and right-sided in 12 (28%). Twenty-nine patients had associated injuries. More than 60% of the patients showed the "dependent viscera" sign, "abdominal organ herniation" sign, diaphragm thickening, or had a more than 4 cm elevation of one side of the diaphragm. "Diaphragmatic discontinuity" and "stomach herniation" were seen almost exclusively in left-sided rupture. Those with BDR and haemothorax had a significantly lower incidence of "diaphragm discontinuity" (p=0.034) than those without haemothorax. Sagittal/coronal reconstruction slightly increased the number of band signs, diaphragmatic discontinuities and diaphragmatic thickenings seen.

CONCLUSIONS

Of the CT signs examined in this study, when herniation of abdominal organs was used as a diagnostic marker, only a very small fraction of trauma patients identifiable by CT would be missed. Further, CT signs differ for left-sided and right-sided BDR, thus the possibility of BDR should be considered when any of the reported CT signs are present.

The effect of extrinsic incubation temperature on development of dengue serotype 2 and 4 viruses in Aedes aegypti (L.)

Dengue 2 and 4 viruses obtained from dengue-infected patients were maintained in a C6/36 Aedes albopictus Skuse cell line and used to infect adult female Aedes aegypti mosquitoes. Each serotype was mixed separately with fresh human erythrocytes and fed to adult female mosquitoes using an artificial membrane feeding technique. Fully engorged mosquitoes were selected and retained at 26 degrees C, 28 degrees C and 30 degrees C to observe dengue virus development in Aedes vectors. Virus detection was carried out by reverse-transcriptase polymerase chain reaction (RT-PCR). The virus was first detected on Day 9 at 26 degrees C and 28 degrees C and on Day 5 at 30 degrees C for both dengue 2 and 4. The study shows the incubation period of the viruses decreased when the extrinsic incubation temperature increases.

Evidence of gamma-tocotrienol as an apoptosis-inducing, invasion-suppressing, and chemotherapy drug-sensitizing agent in human melanoma cells

To date, the most effective cure for metastatic melanoma remains the surgical resection of the primary tumor. Recently, tocotrienol-rich-fraction has shown antiproliferative effect on cancer cells. To elucidate this anticancer property in malignant melanoma, this study aimed, first, to identify the most potent isomer for eliminating melanoma cells and second to decipher the molecular pathway responsible for its activity. Results showed that the inhibitory effect of gamma-tocotrienol was most potent, which resulted in induction of apoptosis as evidenced by activation of procaspases and the accumulation of sub-G1 cell population. Examination of the prosurvival genes revealed that the gamma-tocotrienol-induced cell death was associated with suppression of NF-kappaB, EGF-R, and Id family proteins. Meanwhile, gamma-tocotrienol treatment also resulted in induction of JNK signaling pathway, and inhibition of JNK activity by selective inhibitor was able to partially block the effect of gamma-tocotrienol. Interestingly, gamma-tocotrienol treatment led to suppression of mesenchymal markers and the restoration of E-cadherin and gamma-catenin expression, which was associated with suppression of cell invasion capability. Furthermore, synergistic effect was observed when cells were cotreated with gamma-tocotrienol and chemotherapy drugs. Together, our results demonstrated for the first time the anti-invasion and chemonsensitization effect of gamma-tocotrienol against human malignant melanoma cells.

The role of Id-1 in chemosensitivity and epirubicin-induced apoptosis in bladder cancer cells

Recurrence and progression are the major problems in the treatment of bladder cancer. Increased expression of Id-1, a basic helix-loop-helix transcription factor, has recently been shown in several types of advanced cancer. Some studies have provided evidence to suggest that Id-1 can be considered a potential therapeutic target. The objective of this study was to investigate the role of Id-1 in the chemosensitivity of bladder cancer cells, and the effect of Id-1 on chemotherapeutic drug-induced apoptosis in bladder cancer cells. We compared the different sensitivity to epirubicin in RT112 and MGH-U1 cell lines with different Id-1 expression. Then, we transfected different vectors into RT112 and MGH-U1 respectively, and generated the stable Id-1 up-regulation and down-regulation transfectants. The results of cell viability assay showed up-regulation of Id-1 in RT112 leading to increased sensitivity in response to epirubicin, and down-regulation of Id-1 increased cellular sensitivity to epirubicin. Furthermore, the analysis of apoptosis related protein revealed that up-regulation of Id-1 suppressed epirubicin-induced apoptosis and down-regulation of Id-1 leading to increased epirubicin-induced apoptosis. Wound closure assay showed up-regulation of Id-1 leading to improved migration abilities of bladder cancer cells under chemotherapy. Our results suggest that up-regulation of Id-1 in bladder cancer cells lead to increased cell viability in response to epirubicin by its improved anti-apoptotic role, and down-regulation of Id-1 increases cellular sensitivity to epirubicin by increased anticancer drug-induced apoptosis.

Useful prediction of ureteral calculi visibility on abdominal radiographs based on calculi characteristics on unenhanced helical CT and CT scout radiographs

AIMS

To determine whether visibility of ureteral calculi on plain radiographs of the kidney, ureter and bladder (KUB) could be predicted based on characteristics on unenhanced helical computed tomography (UHCT) and CT scout radiographs (CTSR).

METHODS

One hundred and twenty-three patients diagnosed with 140 ureteral calculi on UHCT, had undergone both UHCT and KUB within 24 h and before calculus passage or intervention were included. The visibility of ureteral calculi on KUB and CTSR as well as their sizes, locations and densities on UHCT were recorded. The association of CTSR/UHCT characteristics of ureteral calculi and their visibility on KUB were analysed. Multivariate analyses using logistic regression were computed as predictors for visibility on KUB.

RESULTS

Of the 140 calculi, 56 (40%) and 98 (70%) were visible on CTSR and KUB respectively. All calculi detectable on CTSR were also visible on KUB. Multivariate analyses of the 84 CTSR undetectable calculi revealed that non-middle ureteral location and higher calculi densities on UHCT were significant predictors of visibility on KUB. All non-middle ureteral calculi with density > 800 Hounsfield units (HU) were visible on KUB. Of 23 calculi in the middle ureter or with density < 200 HU, 17 (74%) were invisible on KUB.

CONCLUSIONS

Ureteral calculi characteristics on UHCT and CTSR are useful for predicting their visibility on KUB. Patients with visible calculi on CTSR or non-middle ureteral calculi with density > 800 HU are suitable for KUB to follow-up calculi status.

Radiation-induced peripheral nerve neurofibromata in a patient receiving hypofractionated radiation therapy

Radiation-induced peripheral nerve tumor, in particular a benign entity such as a neurofibroma, is rare, with only a few cases being reported so far. We demonstrate a case of radiation-induced neurofibromata along the left cervical nerve roots in a man with a background of localized targeted hypofractionated radiation therapy as adjuvant treatment for left cervical nodal metastasis complicating nasopharyngeal carcinoma. The toxicity of high-dose radiation in a hypofractionated regime is also stressed.

E-cadherin upregulation as a therapeutic goal in cancer treatment

We review the role of E-cadherin in cancer progression, and its therapeutic restoration as a strategy to suppress metastasis. We subsequently discuss E-cadherin upregulating drugs, proposing a schema for restoring E-cadherin by targeting its epigenetic and transcriptional regulators. These pathways will likely provide significant future treatment breakthroughs against cancer metastasis.

Id-1 promotes chromosomal instability through modification of APC/C activity during mitosis in response to microtubule disruption

Id-1 (Inhibitor of DNA binding/differential-1) plays a positive role in tumorigenesis through regulation of multiple signaling pathways. Recently, it is suggested that upregulation of Id-1 in cancer cells promotes chromosomal instability. However, the underlying molecular mechanism is not known. In this study, we report a novel function of Id-1 in regulation of mitosis through physical interaction with Cdc20 (cell division cycle protein 20) and Cdh1 (Cdc20 homolog 1). During early mitosis, Id-1 interacts with Cdc20 and RASSF1A (Ras association domain family 1A), leading to enhanced APC(Cdc20) activity, which in turn promotes cyclin B1/securin degradation and premature mitosis. During late mitosis, Id-1 binds to Cdh1 and disrupts the interaction between Cdh1 and APC, resulting in suppression of APC(Cdh1) activity. On the other hand, overexpression of Cdh1 leads to Id-1 protein degradation, suggesting that Id-1 may also act as a substrate of APC(Cdh1). The negative effect of Id-1 on APC(Cdh1) results in suppression of APC(Cdh1)-induced Aurora A and Cdc20 degradation, leading to failure in cytokinesis. As a result, overexpression of Id-1 in human prostate epithelial cells leads to polyploidy in response to microtubule disruption, and this effect is abolished when Id-1 expression is suppressed using antisense technology. These results demonstrate a novel function of Id-1 in promoting chromosomal instability through modification of APC/C activity during mitosis and provide a novel molecular mechanism accounted for the function of Id-1 as an oncogene.

Extracellular matrix-dependent regulation of angiogenin expression in human placenta

Knowledge of the rapidly developing hierarchy of controls affecting vascular development in placenta is required to understand how the growth factors and their receptor-mediated signals actually produce vessels. At the cell biological level, these events clearly require stable interactions between the cells, and cells with the surrounding ECM. The objective of the study was to understand the role of integrins and ECM on the expression and secretion of angiogenin in placentas and from trophoblasts in culture. Functionally active term placental explant culture and trophoblast cultures were used to demonstrate the differential secretion profile of angiogenin and real-time quantitative RT-PCR to demonstrate the mRNA expression in the presence or absence of ECM proteins. In this study, a significant increase in expression and secretion of angiogenin occurred in the presence of vitronectin (VN) and fibronectin (FN). Using antibody-blocking experiments it was also demonstrated that the angiogenin secretion is mediated by placental integrins, alpha(V)beta3 and alpha5beta1. In addition, exposure to hypoxic conditions resulted in diminished angiogenin secretion in the presence of both ECMs suggesting that angiogenin expression in the presence of ECM is modulated by local O2 concentration. In conclusion, this study provides evidence for the regulatory role of ECM and integrins on the mRNA expression and secretion of angiogenin in human placenta. ECMs may have a pivotal role in enhancing secretion of this peptide necessary for placental angiogenesis and provides the impetus as additional targets for the control of angiogenesis in pathological pregnancy.

Knee flexion after total knee arthroplasty

PURPOSE

To identify factors related to knee flexion after total knee arthroplasty in a Chinese population.

METHODS

Records of 242 total knee arthroplasties were retrospectively reviewed. The parameters evaluated were age, gender, diagnosis, preoperative knee flexion and extension, preoperative flexion arc, tibiofemoral angle, Knee Society knee score and functional score, and implant design.

RESULTS

Advanced age, female gender, and good preoperative flexion and flexion arc were related to better postoperative flexion. Postoperative flexion tended to migrate to the middle range despite different ranges of preoperative flexion. Preoperative tibiofemoral malalignment had no significant effect on postoperative flexion.

CONCLUSION

Contemporary designs of posterior stabilised prostheses with right and left femoral components were superior to older designs.

MAD2ΔC induces aneuploidy and promotes anchorage-independent growth in human prostate epithelial cells

The mitotic arrest deficient 2 (MAD2) is suggested to play a key role in a functional mitotic checkpoint because of its inhibitory effect on anaphase-promoting complex/cyclosome (APC/C) during mitosis. The binding of MAD2 to mitotic checkpoint regulators MAD1 and Cdc20 is thought to be crucial for its function and loss of which leads to functional inactivation of the MAD2 protein. However, little is known about the biological significance of this MAD2 mutant in human cells. In this study, we stably transfected a C-terminal-deleted MAD2 gene (MAD2DeltaC) into a human prostate epithelial cell line, Hpr-1 and studied its effect on chromosomal instability, cell proliferation, mitotic checkpoint control and soft agar colony-forming ability. We found that MAD2DeltaC was able to induce aneuploidy through promoting chromosomal duplication, which was a result of an impaired mitotic checkpoint and cytokinesis, suggesting a crucial role of MAD2-mediated mitotic checkpoint in chromosome stability in human cells. In addition, the MAD2DeltaC-transfected cells displayed anchorage-independent growth in soft agar after challenged by 7,12-dimethylbenz[A]anthracene (DMBA), demonstrating a cancer-promoting effect of a defective mitotic checkpoint in human cells. Furthermore, the DMBA-induced transformation was accompanied by a complete loss of DNA damage-induced p53 response and activation of the MAPK pathway in MAD2DeltaC cells. These results indicate that a defective mitotic checkpoint alone is not a direct cause of tumorigenesis, but it may predispose human cells to carcinogen-induced malignant transformation. The evidence presented here provides a link between MAD2 inactivation and malignant transformation of epithelial cells.

Prognostic significance of Id-1 and its association with EGFR in renal cell cancer

AIMS

Epidermal growth factor receptor (EGFR) is suggested as one of the positive regulators in the invasive progression of renal cell cancer (RCC). Recently, Id-1 (inhibitor of differentiation or DNA binding), a helix-loop-helix transcription factor, has been identified as one of the key factors in the EGFR signalling pathway. The aim of this study was to investigate the significance of Id-1 expression in renal cell cancer and to study its relationship with EGFR.

METHODS AND RESULTS

Id-1 and EGFR expression was examined in tissue microarray (TMA) samples of 107 RCC and 32 normal kidney specimens by immunohistochemistry. Relative Id-1 and EGFR protein expression was quantified by estimating the staining intensity on a four-grade scale. We found that while negative to weak expression of Id-1 and EGFR was observed in non-malignant kidney tissues, most RCCs showed significant positive Id-1 and EGFR expression in tumour cells. In addition, Id-1 immunostaining intensity was positively associated with increased tumour staging, grading and EGFR expression.

CONCLUSION

Overexpression of Id-1 is a novel marker for advanced RCC which is positively correlated with EGFR expression. Our results suggest that Id-1 may play an important role in the development of RCC and indicate that Id-1 is a potential marker of patients with a poor prognosis.

Significance of TWIST and E-cadherin expression in the metastatic progression of prostatic cancer

AIM

Development of metastasis is one of the main causes of prostatic cancer-related death. We have previously found that up-regulation of TWIST, a highly conserved basic helix-loop-helix transcription factor, in prostatic cancer cells can promote epithelial to mesenchymal transition through down-regulation of E-cadherin. The present study aimed to investigate the prognostic significance of TWIST and to correlate TWIST and E-cadherin expression in prostatic cancer specimens.

METHODS AND RESULTS

TWIST and E-cadherin expression was studied in 115 prostatic cancer specimens, eight cases of prostatic intraepithelial neoplasia and 37 cases of benign prostatic hyperplasia by immunohistochemistry. Increased cytoplasmic expression of TWIST was associated with malignant transformation of prostatic epithelium and histological progression of prostatic cancer, while nuclear TWIST expression was significant in predicting the metastatic potential of the primary prostatic cancer. In addition, high levels of TWIST expression were also significantly associated with aberrant E-cadherin expression.

CONCLUSIONS

These results suggest that TWIST may serve as a prognostic marker for high-grade prostatic cancer. In addition, up-regulation of TWIST in combination with aberrant E-cadherin expression in primary prostatic cancer specimens may predict development of distal metastatic disease.

Blunt pancreatic trauma and pseudocyst: management of major pancreatic duct injury

When there is no major pancreatic duct injury or the injury involves only the distal duct, percutaneous drainage should be considered the primary therapeutic procedure for traumatic pancreatic pseudocyst. If the pseudocyst does not then resolve, endoscopic retrograde pancreatography should be performed to prove proximal duct injury. When the major pancreatic duct is disrupted but not obstructed, pancreatic duct stenting may avert surgical resection. If the major duct is obstructed, surgical resection is required.

Intraspinal and intracranial hemorrhage after lumbar puncture

Two cases of spinal epidural hematoma and two cases of intracranial subdural hematoma after lumbar puncture (LP) are reported in children receiving chemotherapy for acute lymphoblastic leukemia and non-Hodgkin lymphoma. The bleeding was asymptomatic but interfered with treatment in one case, and caused either severe backache or headache but no neurological deficit in the other three patients. The platelet counts were 8 and 46 x 10(9)/L in two patients and were normal in the other patients at the time of LP. All recovered without surgical treatment. There is an inherent, albeit uncommon, risk of bleeding into the central nervous system associated with LP in children with cancer and should be distinguished from postdural puncture headache (PDPH). Thrombocytopenia is not always an accompanying factor.

Inflammatory myofibroblastic tumor of the nasal cavity

Inflammatory myofibroblastic tumor (IMT) is a rare tumor with a variable natural history and biologic behavior, ranging from completely benign to malignant with fatal outcome. We report a case of benign IMT in the left nasal cavity with radiologic features mimicking angiofibroma. We also demonstrate the hypervascular nature of this disease on angiography and the contribution of preoperative embolization in assisting surgical excision and minimizing the potential uncontrolled intraoperative bleeding.