Clinical assessment of antero-medial rotational knee laxity: a systematic review

Purpose

To inventory the examination methods available to assess antero-medial rotational laxity (AMRL) of the knee following medial collateral ligament injury.

Methods

Searches were conducted in accordance with the PRISMA guidelines and using four online databases: WEB OF SCIENCE, MEDLINE, EMBASE, and AMED. The Critical Appraisal Skills Programme guidelines for Diagnostic Test Studies were used for the quality assessment of the articles.

Results

A total of 2241 articles were identified from the database searches. From this, four articles were included in the final review. All were case–control studies, considered a combined ACL/MCL injury and had small study populations. Specialised equipment was required in all studies, and one needed additional imaging support before measurements could be taken. Two employed commercially available measuring equipment as part of the assessment process.

Conclusion

Clinical assessment of AMRL in relation to a MCL injury remains challenging. Although methods have been developed to support clinical examination, they are limited by a number of factors, including the need for additional time in the clinical environment when setting up equipment, the need for specific equipment to produce and measure rotational movement and imaging support. In addition, there are patient safety concerns from the repeated imaging. A reliable and valid clinical examination remains to be found to truly assess antero-medial rotational laxity of the knee.

Level of evidence

IV.

     

TCRgamma-chain gene rearrangement by PCR-based GeneScan: diagnostic accuracy improvement and clonal heterogeneity analysis in multiple cutaneous T-cell lymphoma samples

Cutaneous T-cell lymphomas are a heterogeneous group of lymphomas where the tumor population emerges within a multiple subclone pattern ("clonal heterogeneity"). PCR analysis has been shown to be useful in the diagnosis of mycosis fungoides (MF) and Sézary Syndrome (SS). Focusing the attention on clonal heterogeneity, the efficacy of the multiplex/heteroduplex (HD) PCR and the GeneScan (GS) capillary electrophoresis analysis was compared in the early diagnosis of MF/SS, using a multiple sample approach. Indeed, GS demonstrated TCRgamma gene rearrangement (GR) in all the 57 SS (100%) and in 123/146 (84%) of the MF samples, whereas the multiplex/HD PCR was less sensitive. An increase in clonality was observed in connection with both a worsening of the cutaneous disease (79% T1/T2; 100% T3/T4) and an increase in the histopathological score (HS < 5, 76%; HS > or = 5, 94%). Clonal heterogeneity with adjunctive reproducible skin TCRgamma-GRs was also observed. "Clonal instability," with different GRs, was present in a small percentage of patients. Therefore, it can be concluded that GS analysis in TCRgamma-GR is able to improve diagnosis in MF/SS patients and the multiple sample approach is helpful for a correct interpretation of clonal patterns in skin lesions, especially in early-stage MF and in SS skin/blood samples.     

Evaluation of the effects of human leukocyte IFN-alpha on the immune response to the HBV vaccine in healthy unvaccinated individuals

HBV vaccine needs 3 injections over 6 months to induce immunity. Thus, the use of adjuvants capable of inducing earlier immune protection would be highly desirable. Most adjuvants may act by inducing cytokines, and among them, type I interferons (IFNs), deserve a special attention in view of the potent immunomostimulatory activity observed in mouse models and on dendritic cell functions. The aim of the present trial was to evaluate the effects of IFN-alpha administered as an adjuvant of HBV vaccine in healthy unvaccinated individuals. No significant enhancing effect on the antibody response was observed, in spite of an early and transient upregulation of costimulatory molecule expression on peripheral blood mononuclear cells, which may be suggestive of an IFN-mediated activation of antigen presenting cells. We conclude that, under the conditions used in this trial, natural IFN-alpha does not act as an adjuvant of the HBV vaccine in healthy unvaccinated individuals.     

Decreased striatal D1 binding as measured using PET and [11C]SCH 23,390 in patients with major depression with anger attacks

This study assessed striatal dopamine 1 (D1) receptor binding in patients with major depressive disorder and anger attacks (MDD+A) and healthy volunteers. We used positron emission tomography with [(11)C]SCH 23,390 to compare 10 patients with MDD+A to 10 healthy volunteers. [(11)C]SCH 23,390 binding in bilateral striata was significantly lower in the MDD+A group when compared to healthy volunteers. These results implicate striatal D1 receptor dysfunction in MDD+A and further suggest an association between dopaminergic transmission and anger or aggression.     

The combination of duloxetine and bupropion for treatment-resistant major depressive disorder

Our objective was to assess the effectiveness and safety of the combination of duloxetine and bupropion for treatment-resistant major depressive disorder (TRD). A retrospective chart review was conducted to identify patients with major depressive disorder (MDD) who had not experienced full remission of symptoms following an adequate trial of either duloxetine (n = 3) or bupropion (n = 7), and who then received the combination of these two antidepressants for TRD. Ten patients [37.2 +/- 11.3 years of age, five women, baseline Clinical Global Impressions (CGI) scale score 4.4 +/- 1.1], seven of whom had not remitted following treatment with bupropion (330 +/- 67 mg, 20.5 +/- 12.2 weeks), and three of whom had not remitted following treatment with duloxetine (90 +/- 30 mg, 18 +/- 2 weeks) received at least 4 weeks of combination treatment. The CGI was administered when the combination was first prescribed, and following 8.8 +/- 4.0 (range, 4-16) weeks of treatment. There was a significant decrease in CGI-S (Severity) scores (4.4 +/- 1.1 to 2.1+/-0.9, P <.0001) following combination treatment. Three (30%) patients were remitters at follow-up, and six (60%) were responders who did not achieve full symptom remission. The mean maximum adjunctive duloxetine and bupropion doses were 60.0 +/- 17.3 mg and 175.0 +/- 114.5 mg, respectively. Side effects reported during combination treatment were nausea (n = 2), dry mouth (n = 2), jitteriness/agitation (n = 2), fatigue/drowsiness (n = 2), increased blood pressure (n = 1), increased sweating (n = 1), insomnia (n = 1), pruritus (n = 1), headache (n = 1), sexual dysfunction (n = 1), and weight gain (n = 1). Although preliminary, these results suggest a possible role for the combination of duloxetine and bupropion for TRD.     

Use of treatment algorithms for depression

Depression continues to be a treatment challenge for many physicians-psychiatrists and primary care physicians alike-in part because of the nature of the disorder, but also because of the wide variety of medications and other treatments available, each with a distinct efficacy and safety profile. One way of negotiating treatment decisions is to use treatment guidelines and algorithms. This Commentary, which appears in the September 2006 issue of The Journal of Clinical Psychiatry (2006;67:1458-1465), provides the primary care clinician with insight into the pros and cons of using treatment algorithms to guide the treatment of depression. -Larry Culpepper, M.D.     

Multicenter case-control study on restless legs syndrome in multiple sclerosis: the REMS study

Study objectives:

To verify the existence of a symptomatic form of restless legs syndrome (RLS) secondary to multiple sclerosis (MS) and to identify possible associated risk factors.

Design:

Prospective, multicenter, case-control epidemiologic survey.

Settings:

Twenty sleep centers certified by the Italian Association of Sleep Medicine.

Patients:

Eight hundred and sixty-one patients affected by MS and 649 control subjects.

Interventions:

N/A.

Measures and results:

Data regarding demographic and clinical factors, presence and severity of RLS, the results of hematologic tests, and visual analysis of cerebrospinal magnetic resonance imaging studies were collected. The prevalence of RLS was 19% in MS and 4.2% in control subjects, with a risk to be affected by RLS of 5.4 (95%confidence interval: 3.56–8.26) times greater for patients with MS than for control subjects. In patients with MS, the following risk factors for RLS were significant: older age; longer MS duration; the primary progressive MS form; higher global, pyramidal, and sensory disability; and the presence of leg jerks before sleep onset. Patients with MS and RLS more often had sleep complaints and a higher intake of hypnotic medications than patients with MS without RLS. RLS associated with MS was more severe than that of control subjects.

Conclusions:

RLS is significantly associated with MS, especially in patients with severe pyramidal and sensory disability. These results strengthen the idea that the inflammatory damage correlated with MS may induce a secondary form of RLS. As it does in idiopathic cases, RLS has a significant impact on sleep quality in patients with MS; therefore, it should be always searched for, particularly in the presence of insomnia unresponsive to treatment with common hypnotic drugs.

Citation:

Manconi M; Ferini-Strambi L; Filippi M; Bonanni E; Iudice A; Murri L; Gigli GL; Fratticci L; Merlino G; Terzano G; Granella F; Parrino L; Silvestri R; Aricò I; Dattola V; Russo G; Luongo C; Cicolin A; Tribolo A; Cavalla P; Savarese M; Trojano M; Ottaviano S; Cirignotta F; Simioni V; Salvi F; Mondino F; Perla F; Chinaglia G; Zuliani C; Cesnik E; Granieri E; Placidi F; Palmieri MG; Manni R; Terzaghi M; Bergamaschi R; Rocchi R; Ulivelli M; Bartalini S; Ferri R; Lo Fermo S; Ubiali E; Viscardi M; Rottoli M; Nobili L; Protti A; Ferrillo F; Allena M; Mancardi G; Guarnieri B; Londrillo F. Multicenter Case-Control Study on Restless Legs Syndrome in Multiple Sclerosis: the REMS Study. SLEEP 2008;31(7):944-952.     

Cisplatin plus Gemcitabine as Adjuvant Chemotherapy for Radically Resected Non–Small-Cell Lung Cancer: A Pilot Study

BackgroundThe combination cisplatin/gemcitabine is one of the most active and well-tolerated regimens in advanced non–small-cell lung cancer (NSCLC). We undertook this pilot study to evaluate postoperative drug delivery and toxicity of cisplatin plus gemcitabine in patients with radically resected stage IB-III NSCLC.Patients and MethodsTwenty-two consecutive patients were treated with cisplatin 80 mg/m² on day 1 and gemcitabine 1200 mg/m² on days 1 and 8 every 3 weeks for 4 planned courses. Most patients (50%) had pathologic stage IIIA disease; all had an Eastern Cooperative Oncology Group performance status score of 0 or 1. The median age was 63 years (range, 56-73 years). Six out of 22 patients (27.3%) had undergone pneumonectomy.ResultsA total of 85 courses of chemotherapy were administered, and the median number of courses was 4 (range, 1-4 courses); twenty-one out of 22 patients received the planned 4 courses of chemotherapy. Chemotherapy caused grade 3 anemia in 1 patient, grade 3 thrombocytopenia in another patient, and grade 3/4 neutropenia in 4 patients; grade 3 vomiting was observed in 3 patients, and grade 3 anorexia and grade 3 asthenia were both observed in 1 patient. No treatment-related deaths occurred. The median delivered dose intensities of cisplatin and gemcitabine were 24.3 mg/m²/week (97.2%) and 700.9 mg/m² weekly (87.5%), respectively.ConclusionThe combination of cisplatin/gemcitabine is a feasible and well-tolerated regimen in the adjuvant setting. Future trials should better define the best strategy in terms of efficacy, toxicity, and quality of life between this combination and the standard regimen, cisplatin plus vinorelbine.