Preemptive multimodal analgesia and post-operative pain outcomes in total hip and total knee arthroplasty.

BACKGROUND: Use of multimodal analgesia (MMA) prior to orthopedic surgery has been adopted by many practitioners as a strategy to minimize use of opioid medications. The purpose of this investigation was to quantify the effect of a preemptive three-drug regimen (acetaminophen, celecoxib, and gabapentin) in terms of post-operative opioid consumption and pain control in the field of total joint arthroplasty. METHODS: A retrospective chart review was conducted on 1691 patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) and stratified by whether they received a preemptive three medication analgesic therapy (acetaminophen, celecoxib, and gabapentin) within 30 to 60 min prior to entering the operating room. Post-operative opioid consumption as well as subjectively reported patient pain scores were assessed throughout their hospital stay. RESULTS: A total of 1416 eligible patients were identified with 485 undergoing THA and 931 undergoing TKA. Statistically significant reductions in oral morphine equivalents were shown on post-operative day zero and two within the TKA cohort, and non-significant reductions were demonstrated in other intervals for both procedure types. Statistically significant reductions in patient reported pain scores were shown in nearly every time interval in both procedure types. CONCLUSION: The receipt of preemptive acetaminophen, celecoxib, and gabapentin 30-60 min prior to total joint arthroplasty demonstrated modest reductions in opioid requirements post-operatively. Patients receiving preemptive MMA reported lower pain scores throughout nearly every time interval during their admission after surgery. Further investigations are warranted regarding optimal preoperative medication therapies to promote adequate post-operative pain control-and ultimately diminished opioid consumption-in the setting of total joint arthroplasty.

The behavioral characteristics of Sotos syndrome.

In this study we describe the levels of clinically significant behavior in participants with Sotos syndrome relative to three matched contrast groups in which the behavioral phenotype is well documented (Autism Spectrum Disorder, ASD; Prader-Willi, and Down syndromes). Parents and carers of 38 individuals with Sotos syndrome (mean age = 17.3; SD = 9.36), completed questionnaires regarding self-injury, aggression, repetitive behavior, autism spectrum phenomenology, overactivity, impulsivity and mood, interest and pleasure. Individuals with Sotos syndrome showed an increased risk of self-injurious behavior, physical aggression, and destruction of property relative to the Down syndrome group but not a greater risk of stereotyped behavior. Impulsivity and levels of activity were also significantly higher relative to those with Down syndrome and comparable to those with ASD. A large proportion of participants met the cut off score for ASD (70.3%) and Autism (32.4%) on the Social Communication Questionnaire. Social impairments were particularly prominent with repetitive behavior and communication impairments less characteristic of the syndrome. Interestingly, preference for routine and repetitive language were heightened in individuals with Sotos syndrome and the repetitive behavior profile was strikingly similar to that observed in individuals with Prader-Willi syndrome. These findings build upon previous research and provide further evidence of the behavioral phenotype associated with Sotos syndrome.

Agreement, Stability, and Validity of Parent- and Youth-Reported Anxiety Symptoms from Childhood to Adolescence.

The current study examined changes in the agreement, stability, and concurrent and predictive validity of parent- and self-reports on a frequently used measure of youth anxiety symptoms, the Screen for Child Anxiety Related Emotional Disorders (SCARED), from age 9 to 15. A community sample of 531 families (youth, mothers, and fathers) completed the SCARED and a semi-structured diagnostic interview when children were ages 9, 12, and 15. Agreement between youth and each parent on youth anxiety symptoms was weak at age 9 (r = 0.12-0.17), but moderate at age 12 (r = 0.31-0.36) and 15 (r = 0.31-0.46); mother-father (r = 0.50-0.53) agreement was greater than youth-parent agreement at every wave. Stability of youth-reported symptoms was low between age 9 and 12 (r = 0.25), but much higher from age 12 to 15 (r = 0.57); mother- and father-reported youth anxiety symptoms demonstrated high stability (r = 0.53-0.74) at both intervals. Self- and parent-reported youth symptoms were both significantly associated with youth anxiety disorder status, cross-sectionally and prospectively. When considered simultaneously at age 9, only parent-reported anxiety symptoms uniquely predicted concurrent and subsequent youth anxiety diagnoses. However, by age 12, parent- and youth-reported anxiety symptoms were each independently associated with concurrent and subsequent anxiety diagnoses. Agreement, stability, and concurrent and predictive validity of youth self-reported anxiety symptoms are poorer than parent-reports in middle childhood, but comparable by middle adolescence. However, all reporters provide unique information about youth anxiety at each of the developmental periods examined.

High resolution melting for mutation scanning of TP53 exons 5-8.

BACKGROUND: p53 is commonly inactivated by mutations in the DNA-binding domain in a wide range of cancers. As mutant p53 often influences response to therapy, effective and rapid methods to scan for mutations in TP53 are likely to be of clinical value. We therefore evaluated the use of high resolution melting (HRM) as a rapid mutation scanning tool for TP53 in tumour samples. METHODS: We designed PCR amplicons for HRM mutation scanning of TP53 exons 5 to 8 and tested them with DNA from cell lines hemizygous or homozygous for known mutations. We assessed the sensitivity of each PCR amplicon using dilutions of cell line DNA in normal wild-type DNA. We then performed a blinded assessment on ovarian tumour DNA samples that had been previously sequenced for mutations in TP53 to assess the sensitivity and positive predictive value of the HRM technique. We also performed HRM analysis on breast tumour DNA samples with unknown TP53 mutation status. RESULTS: One cell line mutation was not readily observed when exon 5 was amplified. As exon 5 contained multiple melting domains, we divided the exon into two amplicons for further screening. Sequence changes were also introduced into some of the primers to improve the melting characteristics of the amplicon. Aberrant HRM curves indicative of TP53 mutations were observed for each of the samples in the ovarian tumour DNA panel. Comparison of the HRM results with the sequencing results revealed that each mutation was detected by HRM in the correct exon. For the breast tumour panel, we detected seven aberrant melt profiles by HRM and subsequent sequencing confirmed the presence of these and no other mutations in the predicted exons. CONCLUSION: HRM is an effective technique for simple and rapid scanning of TP53 mutations that can markedly reduce the amount of sequencing required in mutational studies of TP53.

Differential expression of selected histone modifier genes in human solid cancers.

BACKGROUND: Post-translational modification of histones resulting in chromatin remodelling plays a key role in the regulation of gene expression. Here we report characteristic patterns of expression of 12 members of 3 classes of chromatin modifier genes in 6 different cancer types: histone acetyltransferases (HATs)- EP300, CREBBP, and PCAF; histone deacetylases (HDACs)- HDAC1, HDAC2, HDAC4, HDAC5, HDAC7A, and SIRT1; and histone methyltransferases (HMTs)- SUV39H1and SUV39H2. Expression of each gene in 225 samples (135 primary tumours, 47 cancer cell lines, and 43 normal tissues) was analysedby QRT-PCR, normalized with 8 housekeeping genes, and given as a ratio by comparison with a universal reference RNA. RESULTS: This involved a total of 13,000 PCR assays allowing for rigorous analysis by fitting a linear regression model to the data. Mutation analysis of HDAC1, HDAC2, SUV39H1, and SUV39H2 revealed only two out of 181 cancer samples (both cell lines) with significant coding-sequence alterations. Supervised analysis and Independent Component Analysis showed that expression of many of these genes was able to discriminate tumour samples from their normal counterparts. Clustering based on the normalized expression ratios of the 12 genes also showed that most samples were grouped according to tissue type. Using a linear discriminant classifier and internal cross-validation revealed that with as few as 5 of the 12 genes, SIRT1, CREBBP, HDAC7A, HDAC5 and PCAF, most samples were correctly assigned. CONCLUSION: The expression patterns of HATs, HDACs, and HMTs suggest these genes are important in neoplastic transformation and have characteristic patterns of expression depending on tissue of origin, with implications for potential clinical application.

Distinct activities of the anaphase-promoting complex/cyclosome (APC/C) in mouse embryonic cells.

The first differentiation event in mammalian development gives rise to the blastocyst, consisting of two cell lineages that have also segregated in how the cell cycle is structured. Pluripotent cells of the inner cell mass divide mitotically to retain a diploid DNA content, but the outer trophoblast cells can amplify their genomes more than 500-fold by undergoing multiple rounds of DNA replication, completely bypassing mitosis. Central to this striking divergence in cell cycle control is the E3 ubiquitin-ligase activity of the anaphase-promoting complex or cyclosome (APC/C). Extended suppression of APC/C activity during interphase of mouse pluripotent cells promotes rapid cell cycle progression by allowing stabilization of cyclins, whereas unopposed APC/C activity during S phase of mouse trophoblast cells triggers proteasomal-mediated degradation of geminin and giant cell formation. While differential APC/C activity might govern the atypical cell cycles observed in pre-implantation mouse embryos, geminin is a critical APC/C substrate that: (1) escapes degradation in pluripotent cells to maintain expression of Oct4, Sox2 and Nanog; and (2) mediates specification and endoreduplication when targeted for ectopic destruction in trophoblast. Thus, in contrast to trophoblast giant cells that lack geminin, geminin is preserved in both mouse pluripotent cells and non-endoreduplicating human cytotrophoblast cells.

Geminin escapes degradation in G1 of mouse pluripotent cells and mediates the expression of Oct4, Sox2, and Nanog.

Geminin is an essential cell-cycle protein that is only present from S phase to early mitosis in metazoan somatic cells. Genetic ablation of geminin in the mouse results in preimplantation embryonic lethality because pluripotent cells fail to form and all cells differentiate to trophoblast. Here we show that geminin is present in G1 phase of mouse pluripotent cells in contrast to somatic cells, where anaphase-promoting complex/cyclosome (APC/C)-mediated proteasomal destruction removes geminin in G1. Silencing geminin directly or by depleting the APC/C inhibitor Emi1 causes loss of stem cell identity and trophoblast differentiation of mouse embryonal carcinoma and embryonic stem cells. Depletion of cyclins A2 or B1 does not induce this effect, even though both of these APC/C substrates are also present during G1 of pluripotent cells. Crucially, geminin antagonizes the chromatin-remodeling protein Brg1 to maintain expression of Oct4, Sox2, and Nanog. Our results define a pluripotency pathway by which suppressed APC/C activity protects geminin from degradation in G1, allowing sustained expression of core pluripotency factors. Collectively, these findings link the cell cycle to the pluripotent state but also raise an unexplained paradox: How is cell-cycle progression possible in pluripotent cells when oscillations of key regulatory proteins are lost?