Intra-articular Botulinum Toxin Type A: A new approach to treat arthritis joint pain

There is a growing need for novel treatments of refractory arthritis joint pain as the aging population is expanding with many patients who are unable to undergo joint replacement surgery. We are studying the efficacy and safety of intra-articular injection of Botulinum Toxin Type A (IA-BoNT/A) into joints with arthritis pain. In several small open label studies, initial effects for IA-BoNT/A were encouraging because two thirds of the patients had more than 50% reduction in joint pain severity that was associated with a significant improvement in function. Importantly no serious adverse effects of IA-BoN/A were noted. Based on these initial results, we have completed two pilot randomized controlled trials in painful shoulder joints and painful knee joints. In the shoulder study, IA-BoNT/A produced a significant decrease in shoulder pain severity at one month (6.8-4.4 on VAS, p = .002) that was also significantly better than the non-significant change after IA-Saline placebo (1.6 unit difference favoring IA-BoNT/A, p = .014). In the knee study IA-BoNT/A produced a significant 48% decrease in McGill Total Pain Score at one month (p = .01 1) that was still significant at 3 mo after injection (p = .002). There was a strong placebo response in one third of those but the decrease in pain severity was not significant. We are currently conducting a RCT of IA-BoNT/A for painful prosthetic knee joints. Based on these initial studies of IA-BoNT/A we have gone ‘back to the bench’ to standardize a menu of pain behaviors for mice with acute inflammatory arthritis pain and chronic inflammatory arthritis pain. IA-BoNT/A significantly reduced arthritis joint tenderness (evoked pain score) in acute and chronic inflammatory arthritis and normalized impaired spontaneous wheel running in mice with chronic inflammatory arthritis but not in those with acute inflammatory arthritis. With these models of arthritis and pain behavior methods we will be able to screen potential intra-articular analgesics, define dose response curves and injection schedule, and study the relationships of articular pain and loss of function.     

Cellular fatty acid compositions of an unidentified organism and a bacterium associated with cat scratch disease.

The cellular fatty acid composition of a gram-negative bacterium associated with cat scratch disease was determined by capillary gas chromatography-mass spectrometry (GC-MS). The fatty acid profile of this organism was distinct from those of other bacteria we have tested and was characterized by an unknown acid which was identified as 11-methyloctadec-12-enoic acid. The position of the branched methyl group in this acid was established by GC-MS of the reduced acid, and the location of the double bond was confirmed by GC-MS analysis of dimethyl disulfide derivatives. Another clinical isolate with no known relationship to cat scratch disease but with similar morphological and biochemical features had a similar fatty acid profile, including 11-methyloctadec-12-enoic acid.     

Abdominal aortic aneurysm repair in patients with pelvic kidney. Technical considerations and literature review

Effective methods for performing abdominal aortic aneurysmectomy associated with congenital pelvic kidney are presented. The embryology and surgical anatomy of these lesions are reviewed. Ordinarily, successful aortic reconstruction can be performed with low risk to the pelvic kidney by use of readily available in situ cold perfusion. Two illustrative case reports applying this method are presented. The recently reported technique of double proximal clamping of the aorta was also employed in one case. This technique allows lumbar collaterals within the aneurysm to perfuse the kidney during construction of the proximal aortic anastomosis, thereby minimizing absolute renal ischemic time. Both in situ cold perfusion and double proximal clamping are effective methods for renal preservation that do not rely on complex extraanatomic techniques. A review of the literature with a discussion of the advantages and disadvantages of previously reported methods of renal preservation is presented.     

Entrapment of below-the-knee bypass grafts

A case is presented in which a below-the-knee saphenous vein bypass graft was compressed between the sartorius and the semimembranosis, semitendinosis, and gracilis muscles. Angiography and noninvasive Doppler showed occlusion with leg extension but no obstruction to flow with flexion. Recognition of this entrapment syndrome and its prompt correction can preserve patency of the graft.     

A modified technique for use of the intraluminal valve cutter in in situ saphenous vein grafts

A modified technique for the use of the disposable intraluminal valve cutter in the performance of in situ saphenous vein arterial bypass grafts is presented. The technique results in a more physiologic dilatation of the vein and can be expeditiously performed with minimal intimal trauma to the vein graft. Long incisions necessary to expose the entire vein with the use of other techniques can be avoided, thereby decreasing the potential for wound healing problems commonly associated with vascular reconstruction in ischemic limbs.     

Effectiveness of anidulafungin in eradicating Candida species in invasive candidiasis

In a phase 2 open-label, dose-ranging study in patients with candidemia, anidulafungin was effective in eradicating Candida albicans and other species of Candida. The anidulafungin MIC distribution showed that Candida albicans and C. glabrata were the most susceptible species and C. parapsilosis was the least susceptible species.     

The clinical microbiology laboratory as an aid in infection control. The application of molecular techniques in epidemiologic studies of methicillin-resistant Staphylococcus aureus

A microbiologic surveillance study was performed in order to estimate the point prevalence, source, and nosocomial acquisition of methicillin-resistant Staphylococcus aureus (MRSA) within the Iowa City Veterans Affairs Medical Center (IC VAMC). Immediately following the microbiologic surveillance study, a cluster of nosocomial MRSA infections was detected by routine infection control surveillance. An epidemiologic investigation was conducted and all isolates of MRSA detected during the microbiologic surveillance study and the subsequent cluster of nosocomial infections were characterized by restriction endonuclease analysis of plasmid DNA (REAP). REAP subtyping defined a total of ten distinct subtypes from 24 patients infected or colonized with MRSA. The documentation of a single subtype of MRSA (subtype A2) in nine patients from the surgical service, eight of which were hospitalized in the surgical intensive care unit, provided convincing evidence of a breakdown of infection control practices in that unit. REAP subtyping was a highly discriminating means of identifying different subtypes among the various isolates of MRSA and was useful in directing infection control efforts to specific problem areas within the hospital. Molecular typing methods, such as REAP, when used appropriately in conjunction with careful epidemiologic investigation provide an effective approach to the investigation and control of the spread of MRSA within the hospital.