Apolipoprotein E s4 Allele and Outcomes of Traumatic Spinal Cord Injury

Abstract

Background/Objective: To test the hypothesis that apolipoprotein E (APOE) polymorphisms are associated with outcomes after spinal cord injury (SCI).

Methods: Retrospective cohort study, from rehabilitation admission to discharge.

Participants: Convenience sample of 89 persons with cervical SCI (C3-C8) treated from 1995 through 2003. Median age was 30 years (range 14-70); 67 were male (75%) and 83 were white (93%).

Main Outcome Measures: American Spinal Injury Association (ASIA) motor and sensory scores, ASIA Impairment Scale (AIS), time from injury to rehabilitation admission, and length of stay (LOS) in rehabilitation.

Results: Subjects with an APOE s4 allele (n = 15; 17%) had significantly less motor recovery during rehabilitation than did individuals without an s4 allele (median 3.0 vs 5.5; P < 0.05) and a longer rehabilitation LOS (median 106 vs 89 days; P = 0.04), but better sensory-pinprick recovery (median 5.0 vs 2.0; P = 0.03). There were no significant differences by APOE s4 allele status in sensory-light touch recovery, likelihood of improving AIS Grade, or time from injury to rehabilitation admission.

Conclusions: APOE ε4 allele was associated with differences in neurological recovery and longer rehabilitation LOS. Genetic factors may be among the determinants of outcome after SCI and warrant further study.     

Athletic injury to the first metatarsal phalangeal joint

Résumé: La survenue et la fréquence des lésions de l’articulation métatarsophalangienne du gros orteil augmentèrent avec l’introduction du revêtement artificiel sur les terrains de football américains. Les lésions en cause, dénommées ≪ turf toe ≫ par Bowers et Martin en 1976 consistent en un étirement du complexe capsulo–ligamentaire de l’articulation métatarsophalangienne du gros orteil.Les lésions peuvent être une fracture d’un sésamoïde, la migration ou un diastasis d’un sésamoïde bipartite, une avulsion de la capsule avec éventuellement présence de corps étrangers intra–articulaires, signant une fracture de la tête métatarsienne.Clanton a proposé une classification des lésions qui est utilisée dans les indications thérapeutiques.Le traitement est le plus souvent conservateur, la chirurgie peut intervenir en cas d’échec : cheilectomie-synovectomie, réparation de la capsule plantaire, excision sésamoïdienne.L’apparition d’une telle lésion chez un sportif de haut niveau peut avoir des conséquences graves sur la poursuite du sport.     

Mechanical comparison of two types of fixation for proximal first metatarsal crescentic osteotomy

BACKGROUND: The proximal crescentic osteotomy is an effective technique for correcting a widened 1-2 intermetatarsal angle associated with moderate to severe hallux valgus deformities. However, postoperative dorsal malunion at the osteotomy site from loss of fixation has been reported. The purpose of this study was to evaluate the biomechanical characteristics of a new custom-designed plate and compare it to the traditional screw and Kirschner wire construct. METHODS: Twenty identical Sawbone (Pacific Research Laboratories, Vashon, WA) models were used for the study. A proximal crescentic osteotomy was done on each specimen, and 10 were secured with a dorsomedial plate (group I). The remaining 10 models were fixed with a screw and Kirschner wire combination (group II). Physiologic cyclical testing was done using a mechanical testing machine to evaluate dorsal displacement of the metatarsal. Load-to-failure testing was then done on each specimen to evaluate ultimate failure and stiffness of the constructs. Groups I and II were statistically compared using paired t-testing. RESULTS: The mean dorsal displacement of the first metatarsal head after 1000 cycles was 0.19 mm (SD = 0.09 mm) for group I and 0.28 mm (SD = 0.15) for group II, and the difference was not statistically significant (p = 0.08). Group I demonstrated statistically superior ultimate failure strength (95.2 N) and stiffness (26.8 N/mm) compared to group II (73.7 N, 19.4 N/mm). CONCLUSIONS: Based on Sawbone models, dorsal plate fixation of proximal crescentic osteotomy provides a stronger construct than the traditional screw and Kirschner wire construct. The clinical use of the specially-designed plate described in this study may lower the incidence of dorsal malunions that occur postoperatively and may decrease the occurrence of transfer metatarsalgia. Its application may be particularly helpful in patients with poor bone quality.     

Operative repair of fourth and fifth toe corns

METHODS: We report a retrospective review of 57 consecutive patients (72 feet) over a period of 20 years who had been treated operatively for either a lateral fifth toe corn or an interdigital corn of the fourth interdigital space more than two years previously. Of these, 51 patients (62 feet) returned for a follow-up evaluation at a minimum of two years (average of over seven years) which included a review of the interval history since the surgery, a physical examination, a radiographic evaluation, and assessment of the patient's satisfaction with the alignment and results of surgery. Treatment of 31 lateral fifth toe corns involved either a lateral condylectomy and flexor tenotomy or a complete condylectomy. Treatment of 31 interdigital corns comprised either a single condylectomy, double condylectomy of adjacent corns, or a complete condylectomy (hammertoe repair) of a symptomatic corn. Treatment in each case was dependent upon the severity of the deformity. RESULTS: There was found to be no significant difference in comparison of the two major groups (interdigital corns and lateral fifth toe corns) with the measurement of the relative length of the fourth and fifth metatarsals, toe malalignment, angulation of the fourth and fifth toes (MTP-4, MTP-5 angles), and the phalangeal-5 angle. Pain was relieved in 58 of 62 feet (93%) and subjective acceptable alignment was achieved in 54 of 62 feet (87%). At final follow-up 53 feet were rated by patients as excellent, seven as good, one as fair, and one as poor. Complications included numbness of the involved digit (six feet). There were two superficial infections. There were two cases of joint instability due to excessive bone resection. Joint stiffness was commonly observed (34/62 feet, 55%), but was not associated with diminished satisfaction at final follow-up. Mild asymptomatic recurrence of a callosity was noted in 10 feet and moderate or severe recurrence was noted in two feet. Dissatisfaction was associated with moderate or severe recurrence. CONCLUSION: In this retrospective study at an average of more than seven years, we achieved a high level of patient satisfaction treating both lateral fifth toe corns and interdigital corns with a partial and/or complete condylectomy, the choice depending upon the magnitude of the deformity and the callus, and the fixed nature of the lesser toe deformity.     

Effects of inhibition of myocardial extracellular-responsive kinase and P38 mitogen-activated protein kinase on mechanical function of rat hearts after prolonged hypothermic ischemia

BACKGROUND: Mitogen-activated protein kinases (MAPKs), including extracellular-responsive kinase (ERK) and p38 MAPK, are activated by stresses associated with hypothermia-rewarming and ischemia-reperfusion. Their activation in heart is associated with beneficial (preconditioning) and adverse effects (apoptosis and impaired contractility). This study determined whether ERK and p38 MAPK activities are altered by hypothermic ischemia and normothermic reperfusion and the consequences of their inhibition on recovery of myocardial function. METHODS: Left ventricular work (L x min(-1) x mm Hg) was assessed during normothermic perfusion (30 min) of isolated rat hearts that were either freshly excised or previously subjected to hypothermic storage (8 hr, 3 degrees C) and rewarming (10 min, 37 degrees C) before normothermic reperfusion (30 min). Phospho-specific immunoblot analysis of p38 MAPK was performed in hearts and various cultured cells. RESULTS: Compared with fresh hearts, hearts subjected to hypothermia and rewarming demonstrated impaired left ventricular work (1.96+/-0.53, n=12 vs. 8.37+/-0.46, n=4, <0.05) during reperfusion. The ERK inhibitor, PD98059 (20 microM), present during storage and rewarming, caused modest improvement (3.66+/-0.75, n=9, <0.05). The p38 MAPK inhibitor, SB202190 (10 microM), when present during reperfusion, improved recovery (to 6.12+/-0.75, n=6, <0.05); it was ineffective if present only during rewarming (1.52+/-0.88, n=4). In rat2 fibroblasts, hypothermia and rewarming activated p38 MAPK and its downstream kinase MAPK-activated protein kinase 2, but not c-Jun N-terminal kinase/stress-activated protein kinase. CONCLUSIONS: Myocardial p38 MAPK and MAPK-activated protein kinase 2 are stimulated by hypothermia, ischemia, and rewarming and are detrimental to recovery of mechanical function of hearts subjected to prolonged hypothermic storage. Inhibition of p38 MAPK may be useful in protocols to improve the recovery of mechanical function of cold-stored hearts.     

Hallux valgus in men. Part II: First ray mobility after bunionectomy and factors associated with hallux valgus deformity

PURPOSE: To determine the 1st ray mobility following a distal soft-tissue procedure with proximal osteotomy (DSTP-PMO) and any associated factors. METHODS: A retrospective study of 30 men (35 feet) was performed. First ray mobility, ankle dorsiflexion, pes planus, and metatarsus adductus were evaluated at the final follow-up. All internal fixation was routinely removed at six to eight weeks postoperatively. Standard radiographs were evaluated and angular measurements were calculated on all feet. RESULTS: The mean follow-up was 78 months. No cases of degenerative arthritis of the 1st MTC joint were noted on follow-up radiographs. DSTP-PMO resulted in a mean postoperative 1st ray mobility of 4.9 mm (range, 2.5 to 8). In those feet evaluated following bunion correction, there was no correlation with pes planus, limited ankle dorsiflexion or metatarsus adductus. The preoperative hallux valgus angle and 1-2 intermetatarsal angle correlated with toe pronation and a positive family history. Twenty-two patients had an AOFAS score of 90-100, seven of 80-89 and one less than 69. CONCLUSION: Hallux valgus in this group of male patients was not associated with limited ankle dorsiflexion or pes planus. Men with toe pronation and a positive family history had a greater hallux valgus deformity than those without after a distal soft tissue repair with proximal first metatarsal osteotomy. There was no evidence of first ray hypermobility after a DSTP-PMO.     

Alterations in intervertebral disc composition,matrix homeostasis and biomechanical behavior in the UCD‐T2DM rat model of type 2 diabetes

Type 2 diabetes (T2D) adversely affects many tissues, and the greater incidence of discogenic low back pain among diabetic patients suggests that the intervertebral disc is affected too. Using a rat model of polygenic obese T2D, we demonstrate that diabetes compromises several aspects of disc composition, matrix homeostasis, and biomechanical behavior. Coccygeal motion segments were harvested from 6‐month‐old lean Sprague‐Dawley rats, obese Sprague‐Dawley rats, and diabetic obese UCD‐T2DM rats (diabetic for 69 ± 7 days). Findings indicated that diabetes but not obesity reduced disc glycosaminoglycan and water contents, and these degenerative changes correlated with increased vertebral endplate thickness and decreased endplate porosity, and with higher levels of the advanced glycation end‐product (AGE) pentosidine. Consistent with their diminished glycosaminoglycan and water contents and their higher AGE levels, discs from diabetic rats were stiffer and exhibited less creep when compressed. At the matrix level, elevated expression of hypoxia‐inducible genes and catabolic markers in the discs from diabetic rats coincided with increased oxidative stress and greater interactions between AGEs and one of their receptors (RAGE). Taken together, these findings indicate that endplate sclerosis, increased oxidative stress, and AGE/RAGE‐mediated interactions could be important factors for explaining the greater incidence of disc pathology in T2D. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:738–746, 2015.     

Diagnosing appendicitis with CT and ultrasound using prospective patient stratification by body mass index

Purpose: To determine the accuracy of CT and ultrasonography (US) in diagnosing appendicitis in adults stratified to either modality on the basis of body mass index (BMI), a measure of body habitus. Methods: Seventy-two adults with suspected appendicitis and demonstrating atypical clinical features were prospectively stratified to either appendiceal CT or US based on BMI. Patients with BMI < 30 underwent US and with BMI ≥ 30 underwent CT. Outcomes were determined by surgery, the medical record, and clinical follow-up after 3 months. Results: Of the 72 patients enrolled, 30 (24 women and 6 men) underwent CT and 42 (35 women and 7 men) underwent US. The average BMI was 34 ± 4 among patients who had CT and 24 ± 3 among patients who had US. Of the patients who had CT scans, 4 had positive scans for appendicitis and all of these were proven at surgery to have appendicitis. The remaining 26 patients had negative CT scans for appendicitis. Twenty-two of these were subsequently proven either by surgery or clinical follow-up not to have appendicitis, while 4 were lost to follow-up. This corresponds to a sensitivity, specificity, positive predictive value, and negative predictive value of 100 %. Twelve ultrasound examinations were positive for appendicitis. Nine of these patients had appendicitis proven at surgery, 1 had a perforated Meckel's diverticulum, and 2 did not have appendicitis after clinical follow-up. Twenty-seven patients had negative ultrasound exams for appendicitis. However, 6 of these had appendicitis proven at surgery, 17 did not have appendicitis, and 4 were lost to follow-up. Three patients had ultrasound exams that were equivocal for appendicitis; of these, 1 had appendicitis and 2 did not. For US, this corresponds to a sensitivity of 60 %, specificity of 85 %, PPV of 75 %, and NPV of 74 %. Conclusion: This study suggests that CT is an accurate method of evaluating adults with suspected appendicitis who have BMI ≥ 30. Stratifying patients with BMI < 30 to US did not reproduce the results already reported in the literature.