The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur.

INTRODUCTION: Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes. METHODS: All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours. RESULTS: Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health. CONCLUSIONS: Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.

Escalating-dose HLA-mismatched DLI is safe for the treatment of leukaemia relapse following alemtuzumab-based myeloablative allo-SCT.

Although the feasibility of using HLA-mismatched unrelated donors as an alternate graft source for haematopoietic SCT (HSCT) has been shown, little is known about the safety of HLA-mismatched DLI for the treatment of relapse. We examined the outcome of 58 consecutive leukaemia patients who received escalating-dose DLI for treatment of relapse after alemtuzumab-conditioned myeloablative unrelated donor HSCT at our institution. High-resolution HLA typing on stored DNA samples revealed mismatches in 28/58 patients who were considered HLA-matched at the time of transplantation. Following DLI from HLA-matched (10/10) (n=30) or -mismatched (7-9/10) (n=28) unrelated donors, we found no significant difference in the incidence of acute GVHD (17.2% versus 23.1%, P=0.59), probability of remission at 3 years (62.1% versus 63.9%, P=0.89) or 5-year OS (89.8% versus 77.7%, P=0.22). We conclude that escalating-dose DLI can be safely given to HLA-mismatched recipients following T-depleted myeloablative HSCT.

Treatment of late-onset tibia vara using afghan percutaneous osteotomy and orthofix external fixation.

The Afghan osteotomy was combined with external fixation on 19 patients (23 extremities) with late-onset tibia vara. The average weight was 258 lb and all patients weighed >95th percentile. The average preoperative deformity was 28.2 degrees. The average intraoperative correction was 27.6 degrees. Average healing time was 141 days. The mean follow-up was 2.7 years. Based on radiographic correction, at long-term follow-up, there were 15 excellent, two fair, and six poor results. The quality of the initial correction was the only significant variable, and it was borderline (p = 0.0587). Complications included loss of alignment, peroneal nerve palsy, superficial pin tract infection, deep infection, and fracture. This method offers a technically simple procedure with a relatively low complication rate. It allows early mobilization and provides the ability to manipulate the correction postoperatively. An excellent long-term outcome is predicated on achieving an acceptable initial correction as determined by intraoperative mechanical axis radiographs.

Recent advances in the treatment and outcome of locally advanced rectal cancer.

OBJECTIVE: To compare the outcomes of treatment of locally advanced rectal cancer of the early era (1975-1990) with those of the late era (1991-1997). BACKGROUND: Preoperative therapy has been used in locally advanced rectal cancer to preserve sphincter function, decrease local recurrence, and improve survival. At the University of Florida, preoperative radiation has been used since 1975, and it was combined with chemotherapy beginning in 1991. METHODS: The records of 328 patients who underwent preoperative radiation or chemoradiation followed by complete resection for locally advanced rectal cancer defined as tethered, annular, or fixed tumors were reviewed. The clinicopathologic characteristics, adjuvant treatment administered, surgical procedures performed, and local recurrence-free and overall survival rates were analyzed. RESULTS: There were 219 patients in the early era and 109 in the late era. No significant differences were seen in patients (age, gender, race) or tumor characteristics (mean distance from the anal verge, annularity, fixation). Preoperative radiation regimens were radiobiologically comparable. No patient in the early era received preoperative chemotherapy, compared with 64 in the late era. Of those receiving any pre- or postoperative chemotherapy, three patients received chemotherapy in the early era, compared with 76 in the late era. Sphincter-preserving procedures increased from 13% in the early era to 52% in the late era. Pathologic downstaging for depth of invasion increased from 42% to 58%, but lymph node negativity remained similar. The 1-, 3-, and 5-year local recurrence-free survival rates were comparable. However, in the late era, 1-, 3-, and 5-year overall survival rates improved significantly compared with those of the early era, and also compared with each of the preceding 5-year intervals. CONCLUSION: The addition of a chemotherapy regimen to preoperative radiation therapy improves survival over radiation therapy alone. Likewise, an improvement in downstaging is associated with an increase in sphincter-preserving procedures.

Surgical management of ankle valgus in children: use of a transphyseal medial malleolar screw.

Valgus deformity of the ankle in children is associated with a wide variety of clinical conditions. A retrospective review was performed of 17 children (29 involved extremities) with ankle valgus deformity who had been managed by use of a percutaneously placed, transphyseal medial malleolar screw. Median age at the time of surgery was 11 years, 2 months. Median postoperative follow-up was 2 years, 2 months. Tibiotalar axis and ankle mechanical axis were the best radiographic indicators of ankle valgus deformity. Fibular station and epiphyseal wedging were poor predictors of ankle alignment. Significant improvement in the tibiotalar axis (median, 12 degrees) was noted at follow-up, and the median rate of correction was 0.59 degree/month. Resumption of physeal growth and recurrence of deformity (rate of 0.60 degree/month) was seen when the screws were removed before skeletal maturity. The transphyseal medial malleolar screw is a minimally invasive, minimally morbid, technically simple method of reversible partial epiphysiodesis at the ankle and is an effective technique for the correction of ankle valgus deformity associated with a wide variety of clinical conditions in children.

Organ-Specific and Environmentally Regulated Expression of Two Abscisic Acid-Induced Genes of Tomato : Nucleotide Sequence and Analysis of the Corresponding cDNAs.

The cDNAs, pLE4 and pLE25, represent mRNAs that accumulate in response to water deficit and elevated levels of endogenous abscisic acid in detached leaves of drought-stressed tomato (Lycopersicon esculentum Mill., cv Ailsa Craig) (A Cohen, EA Bray [1990] Planta 182: 27-33). DNA sequence analysis of pLE4 and pLE25 showed that the deduced polypeptides were 13.9 and 9.3 kilodaltons, respectively. Each polypeptide was hydrophilic, cysteine- and tryptophan-free, and found to be similar to previously identified proteins that accumulate during the late stages of embryogenesis. pLE4 and pLE25 mRNA accumulated in a similar organ-specific pattern in response to specific abiotic stresses. Yet, expression patterns of the corresponding genes in response to developmental cues were not similar. pLE25 mRNA accumulated to much higher levels in developing seeds than in drought-stressed vegetative organs. pLE4 mRNA accumulated predominantly in drought-stressed leaves. The similarities and differences in the accumulation characteristics of these two mRNAs indicates that more than one mechanism exists for the regulation of their corresponding genes.

Nucleotide sequence and spatial expression pattern of a drought- and abscisic Acid-induced gene of tomato.

The nucleotide sequence of le16, a tomato (Lycopersicon esculentum Mill.) gene induced by drought stress and regulated by abscisic acid specifically in aerial vegetative tissue, is presented. The single open reading frame contained within the gene has the capacity to encode a polypeptide of 12.7 kilodaltons and is interrupted by a small intron. The predicted polypeptide is rich in leucine, glycine, and alanine and has an isoelectric point of 8.7. The amino terminus is hydrophobic and characteristic of signal sequences that target polypeptides for export from the cytoplasm. There is homology (47.2% identity) between the amino terminus of the LE 16 polypeptide and the corresponding amino terminal domain of the maize phospholipid transfer protein. le16 was expressed in drought-stressed leaf, petiole, and stem tissue and to a much lower extent in the pericarp of mature green tomato fruit and developing seeds. No expression was detected in the pericarp of red fruit or in drought-stressed roots. Expression of le16 was also induced in leaf tissue by a variety of other abiotic stresses including polyethylene glycol-mediated water deficit, salinity, cold stress, and heat stress. None of these stresses or direct applications of abscisic acid induced the expression of le16 in the roots of the same plants. The unique expression characteristics of this gene indicates that novel regulatory mechanisms, in addition to endogenous abscisic acid, are involved in controlling gene expression.

Drought- and ABA-Induced Changes in Polypeptide and mRNA Accumulation in Tomato Leaves.

Drought stress triggers abscisic acid (ABA) biosynthesis resulting in ABA accumulation. The ABA-deficient tomato mutant, flacca (Lycopersicon esculentum Mill. cv Ailsa Craig), does not synthesize ABA in response to drought stress. This mutant has been used to distinguish polypeptides and in vitro translation products that are synthesized during drought stress in response to elevated ABA levels from those that are induced directly by altered water relations. A set of polypeptides and in vitro translation products was synthesized during drought stress in the wild type. These polypeptides and in vitro translation products were synthesized to a lesser extent in the drought-stressed ABA-deficient mutant. Treatment of flacca with ABA resulted in the synthesis of the drought-stress-induced polypeptides and in vitro translation products. These results support the hypothesis that many of the polypeptides that are synthesized during drought are regulated by alterations in ABA concentration. Similarly, the mRNA population was altered by ABA during drought stress.

Multiple osteotomies with Zickel nail fixation for polyostotic fibrous dysplasia involving the proximal part of the femur.

Involvement of the proximal part of the femur by polyostotic fibrous dysplasia is a progressive and disabling condition that leads to deformity. Morbidity is high in terms of recurrent fracture and deformity. Conventional methods of treatment have been ineffective in controlling these problems. The cases of four patients were reviewed to determine the natural history of polyostotic fibrous dysplasia involving the proximal part of the femur. In six femora, multiple osteotomies with fixation using a Zickel nail was utilized to provide definitive control of deformity and recurrent fracture and to allow the patients to return to normal activities.

Isolation and characterization of a genomic clone encoding the ß-subunit of ß-conglycinin.

ß-Conglycinin, and abundant storage protein in soybean (Glycine max (L.) Merr.) seeds, is a trimeric protein consisting of various isomers containing the three subunits, α', α and ß. Accumulation of the ß-subunit is unique because it appears to be regulated by a variety of developmental and environmental signals. In this paper we describe the isolation and characterization of a genomic clone encoding the ß-subunit of ß-conglycinin. The genomic clone was characterized by restriction-enzyme mapping and partial DNA sequence analysis, by immunoprecipitation of a hybrid-selected invitro translation product, and by RNA blot hybridization reactions. An mRNA of approx. 1700 nucleotides hybridized to an internal 2-kilobase (kb) region of this 4.4-kb cloned DNA restriction fragment and was translated to yield a polypeptide with an approximate molecular weight of 48 kilodalton. This polypeptide is immunoprecipitable by antibody against ß-conglycinin and is of appropriate size to represent the precursor polypeptide of the ß-subunit. When this sequence was used as a probe in RNA blot hybridization experiments, the ß-gene transcript was first detected by stage K and accumulated through stage O during soybean seed development, coincident with appearance of the ß-subunit. Partial DNA sequence analysis of the 5' end of the gene confirmed that the isolated gene encoded a ß-subunit, based upon the previously reported amino terminal sequence for this protein. Genomic DNA blot hybridization analyses indicate that multiple DNA restriction fragments are highly homologous to this cloned ß-gene sequence.

Expression of the ß-subunit of ß-conglycinin in seeds of transgenic plants.

Soybean (Glycine max (L.) Merr.) seeds contain the storage protein ß-conglycinin, encoded by a multigene family. ß-Conglycinin consists of three subunits; α', α, and ß. A genomic clone for a ß-subunit of ß-conglycinin has been characterized by restriction-enzyme mapping and hybrid selected in-vitro translation followed by immunoprecipitation. In order to determine the developmental regulation of this ß-subunit gene, its expression was studied in seeds of transgenic petunia (Petunia hybrida) and tobacco (Nicotiana tabacum L.) plants. The ß-subunit expressed in seeds of petunia and tobacco was recognized by anti-ß-conglycinin serum at a relative molecular mass of 53 000, equivalent to that of the native protein. Separation of the petunia-seed proteins by isoelectric focusing followed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblot analysis showed that multiple isoelectric forms of the ß-subunit were produced. There was approximately a twofold variation in the accumulation of the ß-subunit protein in the mature seeds of transgenic petunia plants, each containing a single ß-subunit gene. However, the level of protein accumulation in mature seeds and the amount of ß-subunit mRNA in developing seeds was not correlated. Accumulation of the ß-subunit protein in transgenic seeds was less than the α'-subunit protein that accumulated in transgenic petunia seeds containing a single α'-subunit gene and less than the amount of the ß-subunit in mature soybean seeds which contain 8-13 ß-subunit genes. In transgenic tobacco plants, the accumulation of the ß-subunit protein in seeds was generally well correlated with the number of genes that were incorporated in the different transformants.

Regulation by ABA of beta-Conglycinin Expression in Cultured Developing Soybean Cotyledons.

The regulation of cotyledon-specific gene expression by exogenously applied abscisic acid (ABA) was studied in developing cultured cotyledons of soybean (Glycine max L. Merr. cv Provar). When immature cotyledons were cultured in modified Thompson's medium, the addition of ABA resulted in an increased concentration of the beta-subunit of beta-conglycinin, one of the major storage proteins of soybean seeds. The amount of the alpha'-and alpha-subunits of beta-conglycinin was relatively unaffected by the ABA treatment. When fluridone, an inhibitor of carotenoid biosynthesis that has been shown to decrease ABA levels in plant tissues, was added to the medium the level of ABA and the beta-subunit decreased in the cotyledons. Increasing the concentration of sucrose in the culture medium caused an increase in the concentration of ABA and beta-subunit in the cotyledons. When in vitro translation products from RNA isolated from cotyledons cultured with ABA were immunoprecipitated with antiserum against beta-conglycinin, there was an increased amount of pre-beta-subunit polypetide compared to the translation products from RNA isolated from control cotyledons. The pre-beta-subunit polypeptide was not detected in translation products from RNA isolated from fluridone-treated cotyledons. Nucleic acid hybridization reactions showed that the level of beta-subunit mRNA was higher in ABA-treated cotyledons compared to the control, and was lower in the fluridone-treated cotyledons. We have shown that exogenous ABA is able to modulate the accumulation of the beta-subunit of beta-conglycinin in developing cultured soybean cotyledons.

Pantalar arthrodesis: a long-term follow-up.

Eighty-three pantalar arthrodeses in 69 patients performed at the Shriners Hospital for Crippled Children, Greenville, South Carolina, between 1941 and 1977 were evaluated. Follow-up was from 1 to 33 years. Diagnoses included poliomyelitis, myelodysplasia, arthrogryposis, clubfeet, and extremity or spinal cord trauma. Methods of fusion were one-stage pantalar arthrodesis, two-stage triple ankle fusion, one-stage completion of prior tarsal fusion, and one-stage denudation of the talus. Pantalar arthrodesis is successful in the paralytic sensitive foot with a stable knee and there is no greater incidence of nonunion in the one-stage (Hunt-Thompson) procedure than in the two-stage procedure. Complications and failure of fusion are common in the insensitive foot.