Treatment for unstable intertrochanteric fractures in elderly patients: internal fixation versus cone hemiarthroplasty

PURPOSE. To evaluate the effectiveness of internal fixation versus cone hemiarthroplasty for the treatment of unstable intertrochanteric fractures in elderly patients. METHODS. The choice of treatment was based on the year of admission: between 2001 and 2003, 42 patients (mean age, 73 years) underwent cone hemiarthroplasty using a cementless press fit through a posterior approach, whereas between 1999 and 2001, 45 patients (mean age, 75 years) underwent internal fixation using a dynamic hip screw through a lateral approach in a supine position. Patients with stable fractures with intact lesser trochanter, immobility before injury, age younger than 60 years, or with associated injuries (such as another fracture) were excluded. Patients were encouraged active rehabilitation in bed. Bony union was determined by clinical and radiological examinations. Patients were followed up at 6-week intervals in the first sixth months and every 3 months thereafter until bony union was achieved. In the final follow-up, 32 cone hemiarthroplasty patients and 38 internal fixation patients were available for evaluation according to Merle d'Aubigne and Postel criteria. RESULTS. There were no significant differences between the 2 groups in terms of sex, age, fracture type, Singh index, follow-up period, hospital stay, operating time, and receipt of blood transfusions. Clinical results of both groups were similar. Hemiarthroplasty patients were allowed full weight bearing significantly earlier than the internal fixation patients. CONCLUSION. Cone hemiarthroplasty can be an alternative treatment for unstable intertrochanteric fractures in elderly patients so as to achieve earlier mobilisation.     

An analysis for a cross-over cohort study with an application to the study of triggers of Menière's disease

When studying the effect of a transient exposure on the risk of a rare illness, for time and cost effectiveness it is desirable to follow a cohort of individuals who are 'prone' to the illness over an observation period. In this paper, we present a method of analysis for data arising from such a study. The proposed method can be used to estimate the relative risk of an exposure triggering the illness and the distribution of the time delay from exposure to the onset of illness. The model is extended to include covariate effects and to the situation where there are two types of exposure. For the two types of exposures situation, a model to handle a possible synergism of the exposures is proposed. Finally, the method is applied to study the potential triggers of attacks of Menière's disease.     

Alcohol, Signaling, and ECM Turnover

Alcohol is recognized as a direct hepatotoxin, but the precise molecular pathways that are important for the initiation and progression of alcohol-induced tissue injury are not completely understood. The current understanding of alcohol toxicity to organs suggests that alcohol initiates injury by generation of oxidative and nonoxidative ethanol metabolites and via translocation of gut-derived endotoxin. These processes lead to cellular injury and stimulation of the inflammatory responses mediated through a variety of molecules. With continuing alcohol abuse, the injury progresses through impairment of tissue regeneration and extracellular matrix (ECM) turnover, leading to fibrogenesis and cirrhosis. Several cell types are involved in this process, the predominant being stellate cells, macrophages, and parenchymal cells. In response to alcohol, growth factors and cytokines activate many signaling cascades that regulate fibrogenesis. This mini-review brings together research focusing on the underlying mechanisms of alcohol-mediated injury in a number of organs. It highlights the various processes and molecules that are likely involved in inflammation, immune modulation, susceptibility to infection, ECM turnover and fibrogenesis in the liver, pancreas, and lung triggered by alcohol abuse.     

Differential pattern of DNA-aneuploidy in human malignancies

The differential pattern of DNA-aneuploidy, detected by flow cytometry (FCM) regarding its frequency, grade and multiclonality, was investigated and correlated to tumor type, malignancy grade, tumor stage and prognosis in a multi-institutional study at the University of Münster. High resolution measurements using admixed normal blood reference cells were undertaken in 2413 cases of 13 different malignant diseases and in 776 benign lesions or samples. The incidence of DNA-aneuploidy was highest in melanomas, carcinomas, testicular tumors, sarcomas (75%-95%) and myelomas (65%). Acute leukemias showed an intermediate DNA-aneuploidy rate of 40% with special subgroups represented by common ALL (44%), p less than 0.05) and myelomonocytic/monocytic AML (47%, p less than 0.01). The lowest DNA-aneuploidy-rate was found in basal cell skin carcinomas (19%) and congenital melanocytic nevi (9%). No case of DNA-aneuploidy was observed in the 776 benign lesions or samples.--DNA-indices giving the grade of DNA-aneuploidy with 1.0 for normal diploid G1/0 cells were found distributed predominantly between 1.0 and 2.0 in the solid tumors, except testicular tumors, clustering around a triploid maximum at 1.5. DNA-indices of myelomas and acute leukemias generally ranged below 1.25 with lower DNA-aneuploidy grades in AML than in ALL (p less than 0.01).--In melanomas the aneuploidy rate was higher (86%) in metastases than in the primary tumors (54%, p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Some hematological problems in Indonesia

Indonesia consist of many island inhabited by many ethnic groups with different social economic condition. As in other parts of the world, anemia is still one of the major health problem in Indonesia. The reported anemia prevalence differs in each area and age groups, ranging from 5.4% in well nourished preschool children to 56.3% in primary school children; and 19% to 62.5% in pregnant women. The causes of anemia mostly reported were nutritional like iron deficiency, abnormal hemoglobin besides other conditions. In Cipto Mangunkusumo Hospital as the national referral hospital in Indonesia, in the adults groups, the cause of anemia reported were 14% with iron deficiency, 54% aplastic, 16% hemolytic and 16% other causes. Whereas in the child health department the cause were 29% nutritional deficiency, 31% thalassemia, 10% aplastic, 4% hemolytic and 26% other causes. Thalassemia is quite often reported in Indonesia. In 1955 Lie-Injo first reported the HbE as the most frequently found abnormality among many ethnic groups in Indonesia, ranging from 2.5% to 13.2%. In later studies the prevalence reported varies very much. It was reported as 9.5% in newborns, 22% in pregnant women, and 15.95% to 60% in athletes. The carrier frequency in some areas was between 6-10%, while the pattern of mutation varied widely within each region. Hemophilia cases in Indonesia is still not diagnosed adequately, only 530 cases were reported. The problems were lack of diagnostic laboratories and awareness. As many as 56.9% of the hemophilia patients who received cryoprecipitate were reported positive with HCV antibody. Hematological malignancy is now also became an increasing problem in Indonesia, in child health department the prevalence of leukemia was 57%, and lymphoma 13% among other malignancies. In National Cancer hospital, the prevalence leukemia as diagnosed using morphology and flowcytometry, were 51.4% AML, 19.7% B-ALL, 14.6% T-ALL, 4.5% preB-ALL, with 9.8% cases with co expression, and 30% other malignancies. Due to geographical situation, economic condition and lack of diagnostic laboratory facility many abnormalities were unable to be diagnosed properly.     

Human resources for health in southeast Asia: shortages, distributional challenges, and international trade in health services

In this paper, we address the issues of shortage and maldistribution of health personnel in southeast Asia in the context of the international trade in health services. Although there is no shortage of health workers in the region overall, when analysed separately, five low-income countries have some deficit. All countries in southeast Asia face problems of maldistribution of health workers, and rural areas are often understaffed. Despite a high capacity for medical and nursing training in both public and private facilities, there is weak coordination between production of health workers and capacity for employment. Regional experiences and policy responses to address these challenges can be used to inform future policy in the region and elsewhere. A distinctive feature of southeast Asia is its engagement in international trade in health services. Singapore and Malaysia import health workers to meet domestic demand and to provide services to international patients. Thailand attracts many foreign patients for health services. This situation has resulted in the so-called brain drain of highly specialised staff from public medical schools to the private hospitals. The Philippines and Indonesia are the main exporters of doctors and nurses in the region. Agreements about mutual recognition of professional qualifications for three groups of health workers under the Association of Southeast Asian Nations Framework Agreement on Services could result in increased movement within the region in the future. To ensure that vital human resources for health are available to meet the needs of the populations that they serve, migration management and retention strategies need to be integrated into ongoing efforts to strengthen health systems in southeast Asia. There is also a need for improved dialogue between the health and trade sectors on how to balance economic opportunities associated with trade in health services with domestic health needs and equity issues.     

Hyperhomocysteinemia exacerbates the development of intimal hyperplasia in Sprague-Dawley rats: Alleviation by rosiglitazone

The amino acid intermediate homocysteine (Hcy) is formed during the metabolism of methionine to cysteine. Hyperhomocysteinemia (HHcy) is recognized as an independent risk factor for coronary atherosclerosis. The circulating levels of total Hcy (tHcy) can increase due to intake of foods rich in methionine or deficiencies of vitamins such as folate, pyridoxine and cyanocobalamin, which are required for the metabolism of Hcy. In addition, mutations in the genes coding for Hcy metabolizing enzymes can contribute to an increase in tHcy levels. Clinical and epidemiological studies have shown that an elevated level of tHcy measured in serum or plasma is a strong predictor of cardiovascular disease risk, which appears to be greatest in patients who have HHcy following a methionine load. Intimal hyperplasia (IH) (intima/media [I/M] ratio) is the universal response of a vessel to injury and may result in vasoconstriction when left unattended. The effect of dietary HHcy on balloon catheter-injured carotid artery and its modulation (if any) by the peroxisome proliferator-activated receptor agonist gamma rosiglitazone was evaluated in 12-week-old female Sprague-Dawley rats fed either a control diet or a diet containing 1% L-methionine. Once the rats were established on the diet, the group that was fed 1% L-methionine was further subdivided and either given an aqueous preparation of 3 mg/kg/day rosiglitazone or the vehicle via oral gavage for one week. This was followed by surgically injuring the left carotid artery using a Maverick Over-The-Wire catheter (2.0 mm × 20 mm, 3.2F; Boston Scientific, USA). The rats were continued on their respective diets and drug regimen for 21 days postsurgery. On day 22 of the procedure, the rats were sacrificed for collection of blood, the carotid arteries and liver for biochemical and histological evaluation. Compared with controls there was a significant increase in both tHcy levels and I/M ratio in the rats fed 1% L-methionine (5.4±0.28 μM versus 32.8±3.01 μM, P<0.002; and 0.175±0.05 versus 1.05±0.23, P<0.005, respectively). The effect of rosiglitazone in rats fed the control diet was not prominent. On the other hand, administration of rosiglitazone to the rats on the 1% L-methionine diet significantly reduced the levels of serum tHcy (16.6±2.1 μM versus 32.8±3.01 μM, P<0.001); however, the tHcy levels remained significantly elevated compared with animals on the control diet (P<0.002). The group receiving the L-methionine diet plus rosiglitazone had an inhibition in the development of IH compared with those receiving the L-methionine diet alone (I/M of 0.278±0.041 versus 1.05±0.23, P<0.01). Moreover, the development of IH in the group receiving the L-methionine diet plus rosiglitazone treatment was not significantly different from that observed in the group on the control diet without rosiglitazone (0.278±0.041 versus 0.175±0.05, respectively). These findings may have important implications in deciphering the molecular mechanisms involved in the augmentation of IH in HHcy and modulation of this process by rosiglitazone.     

Analysis of optimal conditions for retroviral-mediated transduction of primitive human hematopoietic cells

We sought to define optimal conditions for retroviral-mediated transduction of long-lived human hematopoietic progenitors from bone marrow and peripheral blood. CD34+ cells were transduced by the LN and G2 retroviral vectors in the presence or absence of stromal support and with or without cytokine addition. After transduction, a portion of the cells was plated in methylcellulose colony-forming assay, with or without G418, to assess the extent of gene transfer into committed progenitors. The remaining cells from each experiment were transplanted into immunodeficient mice to allow analysis of transduction of long- lived progenitors. Human colony-forming cells contained within the murine bone marrow were analyzed after engraftment periods of 2 to 11 months. Cells were plated in a human-specific colony-forming assay with and without G418 to assess the extent of transduction of primitive progenitors. Individual human colonies were also analyzed by polymerase chain reaction for the presence of provirus. Bone marrow progenitors were efficiently transduced only when stroma was present, whereas mobilized peripheral blood progenitors were effectively transduced in the presence of either stroma or cytokines. Inclusion of the cytokines interleukin-3, interleukin-6, and stem cell factor did not further augment the extent of gene transfer in the presence of a stromal support layer. Additionally, human CD34+ progenitors from bone marrow or mobilized peripheral blood that had been transduced for 3 days in the absence of stroma failed to produce sustained, long-term engraftment of bnx mice. Mice transplanted with the same pools of human progenitors that had been transduced in the presence of stroma for 3 days had significant levels of human cell engraftment at the same timepoints, 7 to 11 months after transplantation. Our data show loss of long-lived human progenitors during 3-day in vitro transduction periods in the absence of stromal support. Therefore, the presence of bone marrow stroma has dual benefits in that it increases gene transfer efficiency and is essential for survival of long-lived human hematopoietic progenitors.