A Rare Case of an Early Postoperative Obstructive Ileus in a Young Female Patient due to a Residual Trichobezoar Mass.

Trichobezoar is a rare cause of small bowel obstruction, whereby a mass forms most commonly in the stomach and duodenum of young females, from ingestion of hair, a condition known as trichophagia. We present a case of recurrent small bowel obstruction due to a residual hair mass that was removed surgically in a young female patient who had a laparotomy and gastrotomy for removal of a large gastric trichobezoar just two weeks prior to the current admission. This case illustrates the importance of a thorough inspection of the whole bowel to ensure that no residual bezoars remain after surgery.

Freezing-in orientational disorder induces crossover from thermally-activated to temperature-independent transport in organic semiconductors.

The crystalline structure of organic materials dictates their physical properties, but while significant research effort is geared towards understanding structure-property relationships in such materials, the details remain unclear. Many organic crystals exhibit transitions in their electrical properties as a function of temperature. One example is the 1:1 charge-transfer complex trans--stilbene-2,3,5,6-tetrafluoro-7,7,8,8-tetracyanoquinodimethane. Here we show that the mobility and resistivity of this material undergo a transition from being thermally activated at temperatures above 235 K to being temperature independent at low temperatures. On the basis of our experimental and theoretical results, we attribute this behaviour to the presence of a glass-like transition and the accompanied freezing-in of orientational disorder of the stilbene molecule.

Hand and wrist research productivity in journals with high impact factors: a 20 year analysis.

Bibliometric analyses, which study trends in research productivity, have not previously been applied to hand and wrist research. This study analyses temporal and geographic trends in hand and wrist research from 1988 to 2007. Original research articles were collected from seven English language journals selected on the basis of impact factor. Research production and quality (level of evidence) were determined by country and global region. Linear regression analysis was used to investigate trends. No significant increase in research volume was observed, but journal impact factors have risen significantly since 1988. Western Europe contributed significantly more high-quality (Level I and II) studies than the United States. Research contributions show a geographical distribution concentrated in the US and Western Europe, but considerable changes in this distribution have occurred. From 1988 to 2007, there was a relative increase in research production from Europe, Latin America and Asia, and a relative decline from the US.

Carpometacarpal and scaphotrapeziotrapezoid arthritis: arthroscopy, arthroplasty, and arthrodesis.

Osteoarthritis of the first carpometacarpal joint is the second most common site of osteoarthritis in humans. Symptomatic isolated scaphotrapeziotrapezoid joint arthritis, though less common overall, is also frequently observed by the hand surgeon. Investigations on the etiology, pathophysiology, natural history, outcomes of traditional treatments, and new forms of surgical techniques have been attracting more interest in the field of hand surgery. The goal of this article is to sort through the current prevailing ideas using recently available literature and to offer a concise, updated guide to further enhance the understanding of thumb carpometacarpal and scaphotrapeziotrapezoid arthritis.

Comminution of the dorsal metaphysis and its effects on the radiographic outcomes of distal radius fractures.

Comminution of the dorsal metaphysis is a relatively common feature of distal radius fractures. However, its effects on the radiographic outcomes of these fractures are not entirely understood. One hundred and twenty-four conservatively managed distal radius fractures were analysed retrospectively to assess the effect of dorsal metaphyseal comminution on fracture stability, especially with respect to initial displacement (minimally displaced versus displaced) and age group. Seventy-seven fractures (62%) had radiographic evidence of dorsal comminution. The secondary displacement rate of these fractures was 75%, compared to 45% in non-comminuted counterparts (P<0.001). In minimally displaced fractures, the secondary displacement rate was higher in those with dorsal comminution as compared to those without (57% vs. 31%, P=0.086). Dorsal metaphyseal comminution was found in 75% of fractures in patients 65+years old (P=0.05). Among those with dorsal comminution, the secondary displacement rates were similar for both men and women (63% vs. 79%; P=0.20). In conclusion, distal radius fractures with dorsal metaphyseal comminution had significantly higher rates of secondary displacement compared to non-comminuted counterparts, and there exists a correlation with this displacement and increasing patient age but not gender.

The addition of an upper-extremity curriculum in medical school education and its assessment.

This study assessed the impact of changes made to address the inadequate upper-extremity education through preclinical medical school curriculum reform. After the administration of a new upper-extremity curriculum, which also increased the time devoted to three preclinical medical school courses from 7.25 to 21.25 hours, second-year medical students were evaluated for mastery of these concepts through a national validated objective examination, and attitude and skill through clinical confidence and subjective surveys. After implementation of the new upper-extremity curriculum, students had significantly greater confidence in their ability to perform a physical examination but not in identifying differential diagnoses of the upper-extremity. Students were more satisfied with the amount of time spent on the musculoskeletal system but their performance in the national examination did not change.

Validation of a modern activity hand survey with respect to reliability, construct and criterion validity.

This study validates a novel, modern wrist and hand functional assessment: the Modern Activity Subjective Survey of 2007 (MASS07). In total, 326 patients visiting an academic tertiary-care orthopaedic hand clinic (April 2006-April 2007) were recruited to complete the MASS07 questionnaire, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and Patient-Rated Wrist Evaluation (PRWE) to assess construct validity, criterion validity and test-retest reliability of the MASS07. MASS07 correlated strongly with both PRWE (0.81) and DASH (0.85) even when adjusted for age, sex and history of hand problems (P<0.001). MASS07 scores compared for 42 patients with repeated visits indicated no statistically significant difference between MASS07 scores at the patients' first and second clinic visit. We conclude that the newly constructed MASS07 instrument is valid and reliable with respect to the outpatient population with a wide spectrum of hand and wrist pathologies for fast and effective assessment of patient-reported hand function during modern daily activities.

Design, synthesis, and biological activity of a novel non-cisplatin-type platinum-acridine pharmacophore.

Platinum-acridine conjugates were prepared from [PtCl2(ethane-1,2-diamine)] and the novel acridinylthioureas MeHNC(S)NMeAcr (6) and MeHNC(S)NMe(CH2CH2)NHAcr (15) by replacing one chloro leaving group in the cisplatin analogue with thiourea sulfur. In HL-60 leukemia cells, IC(50) values for 7 (Pt-tethered 6) and 16 (Pt-tethered 15) were 75 and 0.13 microM, respectively. In the ovarian cell lines 2008 and C13, 16 was active at micromolar concentrations and showed only partial cross-resistance with clinical cisplatin. Possible structure-activity relationships are discussed.

A new quasi-one-dimensional niobium oxychloride cluster compound Cs2Ti4Nb6Cl18O6: structural effects of ligand combination.

The new niobium oxychloride cluster compound, Cs2Ti4Nb6Cl18O6, was obtained by solid-state synthesis techniques in the course of our systematic investigation of metal oxychloride systems aimed at the preparation of low-dimensional cluster compounds. Cs2Ti4Nb6Cl18O6 crystallizes in the trigonal system, with unit cell parameters a= 11.1903(7), c = 15.600(2) A, space group P3bar1c, Z = 2. Its crystal structure was determined by single-crystal X-ray diffraction techniques. The full-matrix least-squares refinement against F(2) converged to R(1) = 0.048 (F(o) > 4sigma(F(o))), wR(2) = 0.069 (all data). The structure is based on an octahedral cluster unit (Nb6Cl(i)6O(i)6)Cl(a)6 in which the six edge-bridging oxide ligands are arranged in two sets of three on opposite sides of the Nb6 octahedron. Ti(3+) ions link the clusters through O(i) and Cl(a) ligands to form linear chains running along the c axis. The location of titanium ions correlates with the arrangement of oxide ligands around the Nb6 metal core. The chains interact with each other through additional Ti(3+) and Cs(+) ions. Interchain interactions are significantly weaker than intrachain interactions, resulting in a quasi-one-dimensional character of the overall structure.

Growth factor may decrease muscle atrophy secondary to denervation.

Despite modern microsurgical techniques, functional outcomes following brachial-plexus reconstruction and peripheral-nerve repair are usually unsatisfactory, because irreversible muscle atrophy develops before reinnervation occurs. Insulin growth factor-1 (IGF-1) has been shown to improve muscle regeneration after injury, and may have a role in muscle preservation following denervation. This study evaluated the histologic, immunohistochemical, and electrophysiologic differences between normal and denervated muscle over an 8-week time period, and also evaluated the effects of injecting IGF-1 into denervated muscle. Denervated mice gastrocnemius muscles demonstrated a decrease in muscle diameter, a decrease in muscle weight, early nuclear proliferation, and a decrease in fast twitch and maximum tetanic strength, compared to normal gastrocnemius muscle up to 8 weeks following denervation. Four weeks after denervated muscle was injected with IGF-1 at time zero, however, relative preservation of muscle diameter and weight, and maintenance of electrophysiologic contractile properties were observed. These preliminary data suggest that IGF-1 may prevent muscle atrophy secondary to denervation.

The efficiency of muscle-derived cell-mediated bone formation.

The development of new clinically applicable methods for the delivery of bone morphogenic protein (BMP) is an area of intensive research. Cell-mediated gene therapy approaches are being explored as a potential delivery vehicle. Primary muscle-derived cells isolated from an adult mouse were transduced with an adenoviral-BMP-2 construct. These cells were injected into the triceps surae of severe combined immune deficient (SCID) mice where they induced heterotopic bone formation. BMP-2 expression by these muscle-derived cell constructs was measured in vitro to estimate in vivo BMP-2 delivery. In vitro expression of BMP-2 by 3 x l0(5) muscle-derived cells was 87.89 ng/72 h. These results suggest that the efficiency of muscle cell-based gene delivery of BMP-2 exceeds the direct delivery of recombinant BMP-2 protein.

Transsacral versus modified pelvic landmarks for percutaneous iliosacral screw placement--a computed tomographic analysis and cadaveric study.

The alar roots of the first sacral body are the usual confines for iliosacral screw (IS) placement when stabilizing a sacroiliac joint injury or sacral fracture. The traditional transsacral method of IS placement aligns the screw horizontally through the sacral ala on both the inlet and outlet views of the sacrum. A modified oblique method of IS placement aligns the screw in an oblique fashion, directed inferiorly to superiorly and posteriorly to anteriorly. The purpose of this investigation was to first define the S-1 segment boundaries for both methods of placement by analyzing the 3-dimensional (3-D) composites of 40 pelvic computed tomography (CT) scans, and then to evaluate the actual placement of ISs under fluoroscopy in 10 cadaveric pelves comparing the transsacral with the modified oblique techniques. Critical dimensions of 7.3 mm and 14.6 mm were considered as the diameter sizes of one and two cannulated screws, respectively. From the 3-D CT composites, the mean anterior/posterior (A/P) measurements were 10.9 mm and 18.0 mm, comparing transsacral with modified oblique methods, respectively. Moreover, 9/40 (22.5%) of the transsacral A/P measurements were <7.3 mm, while all of the modified oblique A/P measurements were >7.3 mm. The mean superior/inferior (S/I) measurements were 18.0 mm for transsacral and 26.2 mm for modified oblique placement. Out of 40 transsacral S/I measurements, 4 (10%) were <14.6 mm, while all the modified oblique S/I measurements were >14.6 mm. In the second part of this study, 10 uninjured cadaveric pelves had unilateral percutaneous IS placed under fluoroscopic guidance (inlet, outlet, and lateral projections) by one orthopedic traumatologist. The final position of all 10 screws was confirmed on fluoroscopy by two independent orthopedic trauma surgeons. The first 5 screws were placed by using transsacral pelvic landmarks. Modified landmarks guided the other 5 screws. The accuracy of final screw position was determined by "postoperative" CT scans interpreted by a blinded musculoskeletal radiologist. The screws inserted using transsacral pelvic landmarks were errant in 3 of the 5 cases. Neurovascular complications could be expected from the extraosseous position of all 3 screws. All 5 screws were located within the confines of the S-1 segment by means of the modified oblique technique. Thus, the modified oblique placement technique allowed greater accuracy and reliability over transsacral landmarks in placing percutaneous ISs. The use of the modified oblique pelvic landmarks is warranted during percutaneous iliosacral screw stabilization of the posterior pelvis.

Growth factors improve muscle healing in vivo.

Injury to muscles is very common. We have previously observed that basic fibroblast growth factor (b-FGF), insulin growth factor type 1 (IGF-1) and nerve growth factor (NGF) are potent stimulators of the proliferation and fusion of myoblasts in vitro. We therefore injected these growth factors into mice with lacerations of the gastrocnemius muscle. The muscle regeneration was evaluated at one week by histological staining and quantitative histology. Muscle healing was assessed histologically and the contractile properties were measured one month after injury. Our findings showed that b-FGF, IGF and to a less extent NGF enhanced muscle regeneration in vivo compared with control muscle. At one month, muscles treated with IGF-1 and b-FGF showed improved healing and significantly increased fast-twitch and tetanus strengths. Our results suggest that b-FGF and IGF-1 stimulated muscle healing and may have a considerable effect on the treatment of muscle injuries.

Direct-, fibroblast- and myoblast-mediated gene transfer to the anterior cruciate ligament.

The anterior cruciate ligament (ACL) has poor capabilities of healing. Maturation or "ligamentization" of the ACL following autograft or allograft reconstruction has been found slow and remains under investigation. In vitro and in vivo studies have shown that platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-beta), and epidermal growth factor (EGF) have the potential to improve ligament healing. Gene therapy approaches may represent a new alternative in delivering these specific growth factors to the ACL. The aim of this study was to investigate the feasibility of three different gene therapy approaches (direct-, fibroblast-, and myoblast-mediated gene transfer) to the ACL. Rabbit myoblasts and ACL-fibroblasts were transduced with 5 x 10(7) recombinant adenoviral particles carrying the LacZ reporter gene (MOI = 50). Myoblasts and fibroblasts (1 x 10(6)) were each injected into the right ACL of 10 adult rabbits; direct injection of 5 x 10(7) adenoviral particles was performed in 10 other rabbits. The left side was used as sham. The beta-galactosidase production was revealed using the LacZ histochemical technique. The transduced fibroblasts and myoblasts were found in the ligament tissue and in the synovial tissue surrounding the ACL at 4, 7, 14, and 21 days postinjection. The myoblasts fused and formed myotubes in the ligament. The direct approach also allowed the transfer of the marker gene in the ligament at 4, 7, 21, and 42 days postinjection. X-gal staining revealed no expression of beta-galactosidase in the sham ligament. The presence of cells expressing the marker gene in the ACL opens up the possibility of delivering proteins (i.e., PDGF, TGF-beta, and EGF) capable of improving ACL healing and graft maturation. Furthermore, engineered myoblasts may mediate and accelerate the intraligament neovascularization. This new technology based on gene therapy and tissue engineering may allow a persistent expression of selected growth factors to enhance ACL healing following injury.

Use of muscle cells to mediate gene transfer to the bone defect.

Segmental bone defects and nonunions are relatively common problems facing all orthopaedic surgeons. Osteogenic proteins, i.e., BMP-2, can promote bone healing in segmental bone defects. However, a large quantity of the human recombinant protein is needed to enhance the bone healing potential. Cell mediated gene therapy in the bone defect can allow a sustained expression of the osteogenic proteins and further enhance bone healing. Muscle cells can be easily isolated and cultivated, and they are known to be an efficient gene delivery vehicle to muscle and nonmuscle tissues. Furthermore, they are capable of transforming into osteoblasts when stimulated by BMP-2. Thus, the utilization of muscle cells as the gene delivery vehicle to a bone defect would be an important step in establishing a less invasive treatment for non-unions and segmental bone defects. Muscle cells were transduced when the adenoviral-lacZ vector and injected into the bone defect and the muscles surrounding the defect. Expression of the marker gene was visualized 7 days after the injection, both macroscopically and microscopically, using lacZ histochemistry. The lacZ expressing cells in the defect tissue were also stained for desmin, a muscle specific marker, indicating the presence of muscle cells that have fused into myofibers in this nonmuscle bone defect area. With successful myoblast mediated gene delivery into the segmental bone defect, future experiments would focus on delivering viral vectors expressing osteogenic proteins to eventually improve bone healing postinjury.

Ex vivo gene transfer using adenovirus-mediated full-length dystrophin delivery to dystrophic muscles.

Duchenne muscular dystrophy (DMD) is an X-linked recessive muscle disease characterized by a lack of dystrophin expression. Myoblast transplantation and gene therapy have the potential of restoring dystrophin, thus decreasing the muscle weakness associated with this disease. In this study we present data on the myoblast mediated ex vivo gene transfer of full-length dystrophin to mdx (dystrophin deficient) mouse muscle as a model for autologous myoblast transfer. Both isogenic primary mdx myoblasts and an immortalized mdx cell line were transduced with an adenoviral vector that has all viral coding sequences deleted and encodes beta-galactosidase and full-length dystrophin. Subsequently, these transduced myoblasts were injected into dystrophic mdx muscle, where the injected cells restored dystrophin, as well as dystrophin-associated proteins. A greater amount of dystrophin replacement occurred in mdx muscle following transplantation of mdx myoblasts isolated from a transgenic mouse overexpressing dystrophin suggesting that engineering autologous myoblasts to express high amounts of dystrophin might be beneficial. The ex vivo approach possesses attributes that make it useful for gene transfer to skeletal muscle including: (1) creating a reservoir of myoblasts capable of regenerating and restoring dystrophin to dystrophic muscle; and (2) achieving a higher level of gene transfer to dystrophic muscle compared with adenovirus-mediated direct gene delivery. However, as observed in direct gene transfer studies, the ex vivo approach also triggers a cellular immune response which limits the duration of trans-gene expression.

Gene transfer to muscle using herpes simplex virus-based vectors.

The main goal of gene therapy for Duchenne muscular dystrophy (DMD) is to restore dystrophin into as many muscle cells as necessary to be therapeutic. Herpes simplex virus type 1 (HSV-1) represents a promising new viral vector capable of efficient transduction of myofibers in vivo. The viral genome is large and can accommodate multiple or large non-viral genes including the full-length dystrophin. Here we report on the use of a replication defective HSV-1 mutant vector (DZ) deleted for the essential immediate early (IE) gene ICP4 for studies of reporter gene transfer and expression following direct inoculation of mouse skeletal muscle. Our initial experiments showed that HSV-1 can efficiently infect and express a foreign reporter gene in myoblasts and myotubes in vitro. Furthermore, the intramuscular inoculation of HSV-1 resulted in transduction of a significant number of muscle fibers in newborn mice and some muscle fibers in adult animals. We have attempted to exploit these features to develop new HSV mutant vectors for dystrophin gene delivery to DMD muscle, however two impediments to using this virus for muscle gene delivery have to be overcome: namely viral cytotoxicity and the differential transducibility with HSV-1 throughout the development of muscle fibers. To solve the first problem, virus mutants deleted for the immediate early (IE) genes (ICP4, ICP22, ICP27 and UL41) were constructed and the multiple deleted virus was greatly reduced in cytotoxicity relative to our first generation HSV vector strains. Current work is aimed at incorporating full-length dystrophin under muscle specific promoter (muscle creatine kinase MCK) into these new viral vectors. To address the second problem we have analysed by immunohistochemistry the spreading of the HSV-1 in newborn versus adult muscles to determine whether mature basal lamina which surrounds the adult muscle fibers blocks the HSV-1 entry into the mature muscle fibers.