Shoulder injuries in the athlete

Shoulder injuries are common in the athletic population. Injuries can be a result of repetitive overhead use or from direct trauma. Common injury sites include the rotator cuff, glenohumeral joint, acromioclavicular joint, biceps tendon, scapulothoracic articulation, and sternoclavicular joint. The identification, physical exam, and treatment options of these conditions will be discussed.     

Feasibility and Timing of Prehospital Administration of Reteplase in Patients with Acute Myocardial Infarction

Background: In myocardial infarction patients undergoing thrombolysis, treatment delays negatively impact outcomes. This pilot study was conducted to determine the feasibility and timing of field administration of intravenous double bolus reteplase in patients with ST-elevation myocardial infarction. Methods: Sixty three patients with symptoms and EKG changes consistent with acute myocardial infarction of less than six hours duration received the first bolus of reteplase before arriving at the emergency department. A second bolus of reteplase was given in the emergency department. Subsequent resolution of ST-segment elevation was measured. Mean time from symptom onset to paramedic dispatch, and paramedic arrivals to first bolus of reteplase were measured. The mean time from the first bolus of reteplase to heparin bolus in an emergency department was also measured. All patients with evidence of ST-elevation and suspected acute myocardial infarction gave consent for the thrombolytic therapy. There were no refusals of therapy among those candidates eligible for thrombolysis. Results: The mean times from the first bolus of reteplase to heparin bolus in the emergency department was substantially longer than the in-field times. Resolution of ST-segment elevation was recorded in 52 of the 63 patients and the times of resolution ranged from five minutes after the first bolus dose to 190 minutes after the second bolus of reteplase. Resolution of ST-segment elevation and relief of pain occurred almost simultaneously. Conclusions: These results demonstrated that in-field administration of thrombolytic therapy is a viable option to reduce the delay from symptom onset to initiation of thrombolysis. They demonstrated that satisfactory resolution of ST-segment elevation can be recorded in the field. The reduction in mortality observed in this study is comparable to previously published studies on inpatients. Abbreviated Abstract. This open-label pilot study was conducted to determine the feasibility and timing of field administration of intravenous double-bolus reteplase and to measure subsequent resolution of ST elevation in 63 patients with symptoms and ECG changes consistent with acute myocardial infarction for less than 6 hours. These results demonstrated that in-field administration of thrombolytic therapy is a viable option to reduce the delay from symptom onset to initiation of thrombolytic therapy.     

Inhibition of malignant transformation in vitro by inhibitors of poly(ADP-ribose) synthesis.

Malignant transformation in vitro of hamster embryo cells and mouse C3H 10T 1/2 cells by x-rays, ultraviolet light, and chemical carcinogens was inhibited by benzamide and by 3-aminobenzamide at concentrations that are specific for inhibition of poly(ADP-ribose) formation. These compounds slow the ligation stage of repair of x-ray and alkylation damage but not of ultraviolet light damage. At high concentrations they also inhibited de novo synthesis of DNA purines and DNA methylation by S-adenosylmethionine. The suppression of transformation by the benzamides is in striking contrast to their reported effectiveness in enhancing sister chromatid exchange, mutagenesis, and killing in cells exposed to alkylating agents. Our results suggest that mechanisms regulating malignant transformation are different from those regulating DNA repair, sister chromatid exchange, and mutagenesis and may be associated with changes in gene regulation and expression caused by alterations in poly(ADP-ribosyl)ation.     

Is the Durie and Salmon diagnostic classification system for plasma cell dyscrasias still the best choice?

Summary There are a number of systems for diagnosing multiple myeloma, myeloma variants and monoclonal gammopathy of undetermined significance. We compared three systems, those according to Durie and Salmon, to Kyle and Greipp, and to the British Columbia Cancer Agency, using material from a populationbased registry of 847 patients with a paraproteinemia or multiple myeloma. Of these, 157 underwent both bone marrow and X-ray examinations and were subsequently included in our analysis. The differences between the systems were small, even though in only 64% of the cases the diagnosis according to all three systems was identical. The system used by the British Columbia Cancer Agency turned out to be the shortest and easiest system reviewed here. We propose a more frequent application of this system instead of the more commonly used Durie and Salmon and Kyle and Greipp criteria.     

Tumor trapping of 5-fluorouracil: in vivo 19F NMR spectroscopic pharmacokinetics in tumor-bearing humans and rabbits.

The pharmacokinetics of 5-fluorouracil (5FU) were studied in vivo in patients with discrete tumors and in rabbits bearing VX2 tumors by using 19F NMR spectroscopy. The human studies were conducted in a 1.5-T Magnetom magnetic resonance imager (Siemens), and the rabbit studies were conducted in a 4.7-T GE/Nicolet 33-cm bore magnet. Free 5FU was detected in the tumors of four of the six patients and in all VX2 tumors but not in normal rabbit tissues. No other metabolites were seen in these tumors, contrary to the extensive catabolism we had previously documented using 19F NMR spectroscopy in both human and animal livers. The tumor pool of free 5FU in those human tumors that trapped 5FU was determined to have a half-life of 0.4-2.1 hr, much longer than expected and significantly longer than the half-life of 5FU in blood (5-15 min), whereas the half-life of trapped 5FU in the VX2 tumors ranged from 1.05 to 1.22 hr. In this initial experience, patient response to chemotherapy may correlate with extent of trapping free 5FU in the human tumors. These studies document that NMR spectroscopy is clinically feasible in vivo, allows noninvasive pharmacokinetic analyses at a drug-target tissue in real time, and may produce therapeutically important information at the time of drug administration. Demonstration of the trapping of 5FU in tumors provides both a model for studying metabolic modulation in experimental tumors (in animals) and a method for testing modulation strategies clinically (in patients).     

Association of a polymorphism in the lipin 1 gene with systolic blood pressure in men

BACKGROUND: Lipin 1 plays a role in abdominal obesity, insulin resistance, and hypertriglyceridemia. The gene is located at 2p25.1, a susceptibility locus for hypertension. We studied the association of tagging single-nucleotide polymorphisms (SNPs) in the lipin 1 (LPIN1) gene with hypertension and blood pressure. METHODS: Twelve tagging SNPs from the HapMap database were genotyped using Sequenom MassArray in 268 hypertensive subjects and 407 normotensive controls, of whom 268 matched the cases in age and sex. RESULTS: None of the tagging SNPs were found to be associated with hypertension after correcting for multiple testing, although carriers of the minor allele of rs10520097 had nominally lower odds for hypertension (P = 0.014). After excluding subjects who were on antihypertensive medications, the minor allele of rs10495584 was nominally associated with lower mean systolic and diastolic blood pressures in men (121.1 +/- 14.2 and 76.3 +/- 10.2 mm Hg vs. 127.4 +/- 15.2 and 80.1 +/- 10.5 mm Hg, P = 0.002 and 0.007, respectively), but not in women (P > 0.05). The association of rs10495584 with systolic blood pressure in men remained significant after correcting for multiple testing and adjustment for age, waist circumference, insulin resistance, triglyceride, and high-density lipoprotein (HDL) cholesterol (beta = -0.158, P = 0.005). An analysis of statistically similar SNPs (ssSNPs) in the regions surrounding rs10495584 suggested that its effect may be caused by its high linkage disequilibrium (LD) with the SNP, rs11524, in which the major allele forms an exonic splicing silencer sequence. CONCLUSION: Our study provides further evidence that lipin 1 may play a role in blood pressure regulation, especially in men.     

Early and 8 year results of aortic valve replacement: a clinical study of 232 patients

The study concerns early and late results of aortic valve replacement (AVR) in 232 patients with aortic valve disease, using the Bj?rk-Shiley tilting-disc prosthesis. Of the 232, 27 patients had some evidence of mitral valve disease with valvulotomy having been undertaken in 7 previously, and in 12 at the time of the aortic valve replacement. Patients who underwent simultaneous mitral valve replacement and/or aorta coronary artery bypass grafting are not included in this analysis. To establish predictions of early death and late survival the patients were divided into two groups (A and B), taking 6 pre-operative risk factors into consideration: systolic pressure gradient greater than or equal to 100 mmHg; NYHA class IV; depressed left ventricular function (heart failure); previous valvulotomy of the aortic valve; advanced age (greater than or equal to 70 years) and surgery during the acute stage of bacterial endocarditis. In group A, consisting of 132 patients with no preoperative risk factors, early mortality was 1.5% (2/132). In group B, with 1 or more risk factors, early mortality amounted to 15% (15/100), (P less than 0.01). Subdividing group B into patients with one of the first three risk factors and patients with two or three of these risk factors, mortality was 12% (9/73) and 27% (6/22), respectively. Actuarially determined survival curves showed an 8-year survival rate of 84.2% for patients in group A and 59.6% for patients belonging to group B. Corrected for early mortality, however, the difference in late mortality is not significant. Analysis showed that early mortality was related to myocardial preservation: results for coronary perfusion and cardioplegic arrest were similar, but results were far less good when hypothermic ischaemic arrest was applied. Late results were less favourable in patients who had prior mitral valve disease not requiring mitral valve replacement at the time of AVR, or in those who developed mitral valve disease. The results allow the authors to conclude that AVR is a relatively safe procedure with a low operative mortality and few postoperative complications in patients with no 'risk factors'.     

Diagnosis of inferior wall myocardial infarction during right ventricular apical pacing.

The diagnosis of inferior wall myocardial infarction is often masked during ventricular pacing. We observed paced ventricular beats with a qR pattern in leads 2,3, and aVF in a patient with acute inferior wall myocardial infarction and a temporary pacemaker at the apex of the right ventricle. Such a pattern might be specific for the diagnosis of inferior wall myocardial infarction, because it is never seen during uncomplicated pacing from anywhere within the right ventricular cavity.     

Presenting signs and symptoms in multiple myeloma: High percentages of stage III among patients without apparent myeloma-associated symptoms

We studied the medical histories of 127 patients diagnosed with multiple myeloma included in a population-based registry of 945 patients with a paraprotein or multiple myeloma in the region of the Comprehensive Cancer Center West (CCCW). We defined patients not immediately diagnosed or delayed diagnosis as those patients in whom myeloma was not included in the initial differential diagnosis. We found that 37% belonged to this category. These patients more often had symptoms not associated with multiple myeloma. Since a surprising 51% of patients with delayed diagnosis turned out to have stage-Ill myeloma, the physician should be alert to the presence of this disease, despite the fact that co-morbidity may mask its presence.