Systemic biomarkers currently implicated in the formation of abdominal wall hernia: A systematic review of the literature.

BACKGROUND: Surgery to the abdominal wall is ubiquitous worldwide and hernia treatment is challenging and expensive, posing a critical need to tailor treatment to individual patient risk-factors. In this systematic review, we consider specific systemic factors with potential as biomarkers of hernia formation. METHODS: A healthcare database-assisted search, following PRISMA guidelines, identified journal articles for inclusion and analysis. RESULTS: 14 biomarker studies were selected, comparing hernia patients and hernia-free controls, focusing on markers of extracellular matrix (ECM) remodelling and collagen turnover. Matrix metalloproteinase-2 was increased in patients with inguinal hernia. Markers of type IV collagen synthesis were increased in patients with abdominal wall hernia; while markers of fibrillar collagen synthesis were reduced. Additional other ECM signalling proteins differ significantly within published studies. CONCLUSION: We identify a lack of high-quality evidence of systemic biomarkers in tailoring treatment strategies relative to patient-specific risks, but recognise the potential held within biomarker-based diagnostic studies to improve management of hernia pathogeneses.

Non-random inactivation of large common fragile site genes in different cancers.

The common fragile sites are regions of profound genomic instability found in all individuals. The full size of each region of instability ranges from under one megabase (Mb) to greater than 10 Mbs. At least half of the CFS regions have been found to span extremely large genes that spanned from 600 kb to greater than 2.0 Mbs. The large CFS genes are also very interesting from a cancer perspective as several of them, including FHIT and WWOX, have already demonstrated the capacity to function as tumor suppressor genes, both in vitro and in vivo. We estimate that there may be 40-50 large genes localized in CFS regions. The expression of a number of the large CFS genes has been previously shown to be lost in many different cancers and this is frequently associated with a worse clinical outcome for patients. To determine if there was selection for the inactivation of different large CFS genes in different cancers, we examined the expression of 13 of the 20 known large CFS genes: FHIT, WWOX, PARK2, GRID2, NBEA, DLG2, RORA isoforms 1 and 4, DAB1, CNTNAP2, DMD, IL1RAPL1, IMMP2L and LARGE in breast, ovarian, endometrial and brain cancers using real-time RT-PCR analysis. Each cancer had a distinct profile of different large CFS genes that were inactivated. Interestingly, in breast, ovarian and endometrial cancers there were some cancers that had inactivation of expression of none or only one of the tested genes, while in other specimens there was inactivation of multiple tested genes. Brain cancers had inactivation of many of the tested genes, a number of which function in normal neurological development. We find that there is no relationship between the frequency that any specific CFS is expressed and the frequency that the gene from that region is inactivated in different cancers. Instead, it appears that different cancers select for the inactivation of different large CFS genes.

Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: A randomized, multicenter, double-blind trial.

PURPOSE: To determine whether an antibiotic flush solution containing vancomycin, heparin, and ciprofloxacin (VHC) can prevent the majority of line infections. PATIENTS AND METHODS: A prospective double-blind study was performed comparing VHC to vancomycin and heparin (VH) to heparin alone in 126 pediatric oncology patients. RESULTS: The 153 assessable lines resulted in 36,944 line days studied. There were 58 blood stream infections (43 gram-positive, 14 gram-negative, and one fungal). Forty were defined as line infections (31 heparin, three VH, six VHC). The time to develop a line infection was significantly increased using either antibiotic flush (VH, P =.011; VHC, P =.036). The rate of total line infections (VH, P =.004; VHC, P =.005), gram-positive line infections (VH, P =. 028; VHC, P =.022), and gram-negative line infections (VH, P =.006; VHC, P =.003) was significantly reduced by either VH or VHC. Sixty-two (41%) of the lines developed 119 occlusion episodes (heparin, 3.99 per 1,000 line days; VHC, 1.75 per 1,000 line days; P =.0005). Neither antibiotic could be detected after flushing, and no adverse events were detected, including increased incidence of vancomycin-resistant Enterococcus colonization or disease. CONCLUSION: The use of either VH or VHC flush solution significantly decreased the complications associated with the use of tunneled central venous lines in immunocompromised children and would save significant health care resources.

Intrahippocampal injection of pertussis toxin blocks adenosine suppression of synaptic responses.

Adenosine exerts prominent inhibitory effects on synaptic transmission via a presynaptic action. Using the hippocampal slice preparation, we have found in electrophysiological experiments that this action of adenosine is blocked by intrahippocampal injections of pertussis toxin. In biochemical studies, we have confirmed that this treatment affects the GTP-binding proteins, Gi and Go, in this preparation. These results indicate that both pre- and postsynaptic actions of adenosine involve pertussis toxin-sensitive GTP-binding proteins.

Characterization of [3H] corticosterone binding activity in adrenal incubation media.

Glucocorticoid-binding activity in adrenal incubation media was investigated with regard to characterization of a protein-like ligand. Scatchard analysis of corticosterone binding activity indicated the presence of a single non-interacting protein with a dissociation constant (Kd) of 8.81 X 10(-10) M (0 degrees C), a value which is different from that of plasma and cytoplasmic glucocorticoid binding proteins. In addition, an observed lack of affinity of the protein for dexamethasone distinguishes the protein from Type II cytoplasmic receptor proteins. Thus our data suggest a glucocorticoid-binding protein which is distinct from the two known groups of glucocorticoid-binding proteins, corticosteroid-binding globulin (CBG) and cytoplasmic receptors.

Growth and predictions of growth in the upper extremity.

Teleroentgenograms of the upper extremity in 244 children (123 boys and 121 girls) were made at six-month intervals from the age of seven to the time of skeletal maturity. Lengths were measured to determine the growth remaining at both growth plates of the humerus, radius, and ulna. The subjects were healthy, well nourished, middle-class Americans, mostly of northwest European descent. After the age of seven, the proportion between the upper and lower arms does not change appreciably. The humerus is 18 per cent of standing height in girls at the age of seven and 19 per cent at the age of fifteen. In boys, the humerus is 18 per cent of standing height at the age of seven and 20 per cent at the age of seventeen. The length of the radius is 13 per cent of standing height in girls at the age of seven, increasing to 14 per cent by skeletal maturity. In boys, the length of the radius increases from 14 per cent of standing height at the age of seven to 15 per cent at skeletal maturity. From the age of seven to skeletal maturity, the humerus grows approximately 1.2 centimeters in girls and 1.3 centimeters in boys each year. In girls, the ulna grows approximately 1.0 centimeter and the radius, 0.9 centimeter each year after the age of seven. In boys, the ulna grows approximately 1.1 centimeters and the radius, approximately 1.0 centimeter each year from the age of seven to skeletal maturity. Based on these data, accurate predictions of growth and of growth discrepancy in the upper extremity can be made, and the time at which to perform equalization procedures can be determined more precisely.

A statistical study of Knee injuries due to football in high-school athletes.

I analyzed insurance claims for injuries sustained in high-school football over a three-year period in six western states. Nineteen and one-half per cent of the players sustained at least one injury per season, of which 12.7 per cent were knee injuries. Follow-up questionnaires completed by 529 (81 per cent) of the injured players showed that 394 had been diagnosed as having ligament injuries; eighty-eight, internal derangement of the knee; and forty-seven, patellar injuries. Twenty-six per cent of the patients with ligament injuries had further injury to the involved knee. Fifty-nine per cent of the patients with internal derangement of the knee had subsequent injury to the same knee. Eighty-seven per cent of the patients with patellar injuries had a subsequent injury to the involved knee and an increased incidence (34 per cent) of injury to the contralateral knee.

The incidence of fabellae in osteoarthrosis of the knee.

I examined radiographs of the knees of 600 men to determine the incidence of fabellae in radiographically normal knees as compared with knees with primary osteoarthrosis. At least a unilateral fabella was present in 106 (35 per cent) of 300 patients with primary osteoarthrosis of the knee. In an age-matched group of 300 patients with radiographically normal knees, only forty-four (15 per cent) had a fabella. The presence of a fabella may represent an atavistic pattern, and the fact that knees with primary osteoarthrosis are more likely to contain a fabella raises the question of whether an atavistic pattern predisposes a knee to osteoarthrosis.

Straight-line graphs for the prediction of growth of the upper extremities.

A simple graphic method was used for the prediction of growth and the determination of when a corrective procedure should be performed to equalize the lengths of the upper extremities. Straight-line graphs, similar to those described by Moseley for the lower extremities, were constructed for the radius, ulna, and humerus. The data for the current study were derived from a multidisciplinary, longitudinal study of growth in 244 healthy children (123 boys and 121 girls)--from infancy to skeletal maturity--and from previously constructed graphs depicting remaining growth. The use of this method can simplify the planning of an equalization procedure for an upper extremity.

Knee arthrodesis with a tension-band plate.

Twenty-six patients had an arthrodesis of the knee using a single anterior, broad, contoured dynamic-compression plate and screws that were applied as a tension band. Bone grafts were not used. No external immobilization was required, and immediate partial weight-bearing was encouraged. The minimum follow-up period was two years, and solid osseous union occurred in each patient. When last seen, all patients were free of pain and could walk without external support. The desired alignment was achieved in each patient, and no complications that were related to this method occurred. Tension-band plating, in our opinion, represents the best method of arthrodesis of the knee that is currently available.

Degenerative symptomatic lumbar scoliosis.

Scoliosis with progressive deformity can develop late in life. The authors studied 200 patients older than age 50 years with back pain and recent onset of scoliosis. Seventy-one percent of patients were women, and no patient had undergone spinal surgery. The curves involved the area from T12 to L5 with the apex at L2 or L3 and did not exceed 60 degrees. Degenerative facet joint and disc disease always were present, and the curves were associated with a loss of lumbar lordosis. Forty-five patients with severe pain and neurologic deficits were studied using myelography. Indention of the column of contrast medium was seen at several levels but was most severe at the apex of the curve. It was least severe at the lumbosacral joint. The curves progressed an average of 3 degrees per year over a 5-year period in 73% of patients. Grade 3 apical rotation, a Cobb angle of 30 or more, lateral vertebral translation of 6 mm or more, and the prominence of L5 in relation to the intercrest line were important factors in predicting curve progression.

High cost of high school football injuries.

This study examines year-to-year (1965, 1976 to 1977) and state-to-state (six western United States) cost variations in relation to injury site, severity, and repetition of high school football injuries. Data were collected from the files of the largest single insurer of secondary school students in these states. Analysis was made through a specially programmed Qantel 1300 computer. The average claim cost in 1965 was $34.72 in 1976 was $149.93, and, in 1977, it was $177.95. The average cost was lowest in Utah and highest in California. In the 1976 to 1977 season, 3,501 claims from 15,252 players were reported. Over 25% of the claims filed were from players who had more than come claim per season. Relatively minor injuries (sprains, strains, contusions, and abrasions) accounted for 72.3% of all injuries but only 42.4% of medical costs. Lower extremity injuries accounted for one-third of the injuries and one-half of the costs. Knee injuries alone accounted for 12.7% of all injuries and 31.8% of all medical costs paid by the insurance company. It is proposed that trainers and coaches not only know how to care for minor injuries but also that they are more rigid in their criteria for fitness, agility, stamina, and psychologic factors so that players predisposed to injury and repeated injuries will not contribute to the escalating medical costs of high school football injuries.

Cost of high school soccer injuries.

This study examines the cost of high school soccer injuries. Data was collected from the files of the largest single insurer of secondary school students in six western states. Analysis was made through a specially programmed Qantel 1300 computer (Empire Computer Systems, Seattle, Washington). The average claim cost was $127.29 for injuries in 1976 to 1977, ranging from the lowest in Washington to the highest in California. During this period 436 claims from 10,634 players were reported. Relatively minor injuries (sprains, strains, contusions, and abrasions) accounted for 75.9% of all injuries but only 49.4% of all costs; lower extremity injuries accounted for more than one-half of all injuries and costs. Knee injuries alone represented 11.7% of all injuries--28.2% of all medical costs paid by the insurance companies. Injuries occur only one-fifth as frequently in soccer, compared with football. It is anticipated that medical expenses for soccer players will be less than 16% of expenses incurred by an equal number of football players.

A statistical study of physician care patterns in high school football injuries.

This study examines the specialty background, relative activity, role, and cost of care among physicians treating high school football injuries in six western states. There were 1,000 injuries (in 1,000 players) in the 1980 football season. Among the players, 30.7 and 17.9% were treated solely by general practitioners and emergency room physicians, respectively. Orthopedic surgeons exclusively managed 17.1% of players, and 6.8% were seen initially by the emergency room physician and referred to an orthopedic surgeon. Osteopaths solely treated 6.4% of players. Chiropractic was the exclusive care for 6.4%. Four and nine-tenths per cent of players were seen initially by general practitioners and referred to an orthopedic surgeon. Emergency room physicians referred 3% of their injured high school football players to general practitioners. The remaining 6.8% of players were cared for by dentists, pediatricians, general surgeons, naturopaths, neurosurgeons, urologists, otolaryngologists, and ophthalmologists. General practitioners referred 14% of their patients, and emergency room physicians referred 73.6% of their patients. The most common referral was to an orthopedic surgeon. Two hundred ninety-eight players ultimately received care from an orthopedist, including 82% of all patients with fractures. For patients with the same diagnosis, costs for care by orthopedic surgeons were 54% higher than the fees charged by a general practitioner.

Substance P level in synovial fluid may predict pain relief after knee replacement.

Substance P is readily detected in the synovial fluid of the knee in which it acts as a powerful inflammatory agent in response to injury and disease. It may be an objective predictor of pain after knee replacement surgery. The level of substance P was measured in the synovial fluid in both knees of 114 patients having unilateral and in 86 patients having bilateral total knee replacement for osteoarthritis. All had severe pain in the knee to be replaced and joint destruction. Substance P was elevated in 73% of replaced knees but not in normal or asymptomatic knees. Good or excellent pain relief was achieved in 97% of patients with an elevated preoperative level of substance P and in 61% of those with a normal preoperative level (p < 0.05 compared with preoperative values).

Delayed union of humeral shaft fractures treated by closed flexible intramedullary nailing.

Ten patients with humeral shaft fractures and no clinical or radiographic signs of healing after at least six weeks' immobilisation were treated by flexible intramedullary nailing using a closed retrograde technique. Bone grafting was not performed, and active movement was encouraged after operation. Nine fractures healed; the mean time to union was 10.5 weeks (range 6 to 22 weeks). One patient needed compression plating and bone grafting at 22 weeks, and another required re-operation for distal migration of the rods. There were no infections, nerve palsies or other complications. Stiffness of the shoulder which had developed during early treatment improved after operation.

Lengthening the ulna in patients with hereditary multiple exostoses.

Deformity of the forearm is common in patients with hereditary multiple exostoses, producing cosmetic and functional impairment in which shortening of the ulna is a significant factor. The results of ulnar lengthening in 10 forearms of eight patients are reported. Lengthening was performed by osteotomy of the shaft followed immediately by a bone graft and internal fixation, or by gradual distraction with an external fixator. In all patients the appearance was improved and the range of radial deviation at the wrist was increased. In most patients forearm movement and radial head stability were improved. Partial recurrence of the deformity was seen during the follow-up of skeletally immature patients, but in general ulnar lengthening was found to be a useful operation.

Patient preferences in knee prostheses.

A total of 344 patients underwent bilateral total knee replacement (TKR) using a different prosthesis on each side. Four knee prostheses were used: anterior and posterior cruciate-retaining (ACL-PCL), posterior cruciate-retaining (PCL), medial or lateral pivot (MLP), and posterior cruciate-substituting (PS). All patients had good or excellent results. The range of movement, relief from pain, alignment, and stability did not vary among any of the prostheses. Forty-one of 46 patients (89%) preferred the ACL-PCL to the PS knee and 27 of 35 patients (77%) the MLP knee to the PS knee. Of the patients with an ACL-PCL knee on one side and a MLP on the other, an equal number preferred each type. The MLP knee was preferred to the PCL by 34 (79%) patients. PS and PCL knees were preferred equally. Patients with bilateral TKRs preferred retention of both their cruciate ligaments or substitution with a medial or lateral pivot prosthesis.