Patient-reported, clinical and radiological factors associated with the result after non-surgical management of acute AC joint dislocation Rockwood type III and V.

PURPOSE: The treatment of Rockwood type III and V acromioclavicular (AC) joint dislocations is controversial, and an individualized treatment algorithm is yet to be developed. The objective of this study was to investigate the association of demographical, clinical, patient-reported and radiological variables with the Western Ontario Shoulder Instability Index (WOSI) score and risk of surgery. METHODS: Inclusion criteria for this prospective cohort study were patients aged 18-60 with an acute AC joint dislocation with >25% increase in the coracoclavicular distance on bilateral Zanca radiographs. Patients were treated non-surgically with 3 months of home-based training and the option of delayed surgical intervention. The outcomes were the WOSI score and surgery yes/no. Demographical, clinical, patient-reported (WOSI and Shoulder Pain and Disability Index [SPADI]) and radiological variables were collected at baseline and 6 weeks after the injury and investigated for association with the outcomes at 3 months, 6 months and 1 year. RESULTS: Ninety-five patients with Rockwood type III/V AC joint dislocation were included. Pre-injury participation in overhead/collision sports was a risk factor for surgery with an odds ratio of 5 (p = 0.03). Reduced range of motion (ROM) at baseline was associated with reduced WOSI scores and increased risk of surgery. At 6 weeks, reduced ROM, increased SPADI and increased pain during cross-over were associated with the outcomes. Radiological measurements were not correlated with the result. At the 6 weeks follow-up, patients eventually requiring surgery could be detected with a sensitivity of 100% and a specificity of 94% based on a SPADI score of >30 and a ROM ≤ 140° in shoulder flexion or abduction. CONCLUSION: ROM was the only variable consistently associated with both WOSI and risk of surgery. Six weeks after the injury, it was possible to detect patients in need of surgery based on ROM and SPADI with a sensitivity of 100% and a specificity of 94%. LEVEL OF EVIDENCE: Level II.

The ISAKOS subclassification of Rockwood type III AC joint dislocations in a stable type A and an unstable type B is not clinically relevant.

PURPOSE: The treatment of Rockwood type III AC joint dislocations has been debated for decades. In 2014, the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee suggested a subclassification of the injury into type A, considered stable and best treated nonsurgically, and type B, considered unstable and best treated surgically. Type B is defined by the presence of scapular dyskinesis and overriding of the clavicle to the acromion on a modified lateral radiograph. The objective of the study was to investigate if this subclassification is clinically relevant. METHODS: This was a prospective cohort study. Inclusion criteria were patients aged 18-60 years with acute AC joint dislocation and a baseline Zanca radiograph with an increase in the CC distance of >25% compared to the uninjured side. All patients were treated nonsurgically with 3 months of home-based training and with the option of delayed surgical intervention. Patients were assessed at baseline and at follow-ups 6 weeks, 3 months, 6 months and 1 year after the injury. At the 6-week follow-up, patients were graded as stable and unstable according to the ISAKOS criteria. Outcomes were the Western Ontario Shoulder Instability Index (WOSI) and referral for surgery. RESULTS: At 6 weeks of follow-up, 20 patients were classified as stable type A and 69 were classified as unstable type B. The ISAKOS subclassification was not clinically relevant, but patients graded as stable had statistically significantly better WOSI scores at 6 months compared to the unstable group (p = 0.03) but not at 3 months or 1 year. Nine patients (9.5%), all from the unstable group, were referred for surgery. No patients from the stable group underwent surgery (n.s). CONCLUSION: The ISAKOS subclassification of Rockwood type III in a stable type A and an unstable type B is not clinically applicable. LEVEL OF EVIDENCE: Level II.

System for time-discretized vacuum ultraviolet spectroscopy of spark breakdown in air.

A system for time-discretized spectroscopic measurements of the vacuum ultraviolet (VUV) emission from spark discharges in the 60-160 nm range has been developed for the study of early plasma-forming phenomena. The system induces a spark discharge in an environment close to atmospheric conditions created using a high speed puff value, but is otherwise kept at high vacuum to allow for the propagation of VUV light. Using a vertical slit placed 1.5 mm from the discharge the emission from a small cross section of the discharge is allowed to pass into the selection chamber consisting of a spherical grating, with 1200 grooves/mm, and an exit slit set to 100 µm. Following the exit slit is a photomultiplier tube with a sodium salicylate scintillator that is used for the time discretized measurement of the VUV signal with a temporal resolution limit of 10 ns. Results from discharges studied in dry air, Nitrogen, SF6, and Argon indicate the emission of light with wavelengths shorter than 120 nm where the photon energy begins to approach the regime of direct photoionization.

Mutability of p53 hotspot codons to benzo(a)pyrene diol epoxide (BPDE) and the frequency of p53 mutations in nontumorous human lung.

p53 mutations are common in lung cancer. In smoking-associated lung cancer,the occurrence of G:C to T:A transversions at hotspot codons, e.g., 157, 248, 249,and 273, has been linked to the presence of carcinogenic chemicalsin tobacco smoke including polycyclic aromatic hydrocarbons suchas benzo(a)pyrene (BP). In the present study, we have used a highly sensitive mutation assay to determine the p53 mutation load in nontumorous human lung and to study the mutability of p53 codons 157, 248, 249, and 250 to benzo(a)pyrene-diol-epoxide (BPDE), an active metabolite of BP in human bronchial epithelial BEAS-2B cells. We determined the p53 mutational load at codons 157, 248, 249, and 250 in nontumorous peripheral lung tissue either from lung cancer cases among smokers or noncancer controls among smokers and nonsmokers. A 5-25-fold higher frequency of GTC(val) to TTC(phe) transversions at codon 157 was found in nontumorous samples (57%) from cancer cases (n = 14) when compared with noncancer controls (n = 8; P < 0.01). Fifty percent (7/14) of the nontumorous samples from lung cancer cases showed a high frequency of codon 249 AGG(arg) to AGT(ser) mutations (P < 0.02). Four of these seven samples with AGT(ser) mutations also showed a high frequency of codon 249 AGG(arg) to ATG(met) mutations, whereas only one sample showed a codon 250 CCC to ACC transversion. Tumor tissue from these lung cancer cases (38%) contained p53 mutations but were different from the above mutations found in the nontumorous pair. Noncancer control samples from smokers or nonsmokers did not contain any detectable mutations at codons 248, 249, or 250. BEAS-2B bronchial epithelial cells exposed to doses of 0.125, 0.5, and 1.0 microM BPDE, showed G:C to T:A transversions at codon 157 at a frequency of 3.5 x 10(-7), 4.4 x 10(-7), and 8.9 x 10(-7), respectively. No mutations at codon 157 were found in the DMSO-treated controls. These doses of BPDE induced higher frequencies, ranging from 4-12-fold, of G:C to T:A transversions at codon 248, G:C to T:A transversions and G:C to A:T transitions at codon 249, and C:G to T:A transitions at codon 250 when compared with the DMSO-treated controls. These data are consistent with the hypothesis that chemical carcinogens such as BP in cigarette smoke cause G:C to T:A transversions at p53 codons 157, 248, and 249 and that nontumorous lung tissues from smokers with lung cancer carry a high p53 mutational load at these codons.

Loss of heterozygosity is related to p53 mutations and smoking in lung cancer.

Carcinogenesis results from an accumulation of several genetic alterations. Mutations in the p53 gene are frequent and occur at an early stage of lung carcinogenesis. Loss of multiple chromosomal regions is another genetic alteration frequently found in lung tumours. We have examined the association between p53 mutations, loss of heterozygosity (LOH) at frequently deleted loci in lung cancer, and tobacco exposure in 165 tumours from non-small cell lung cancer (NSCLC) patients. A highly significant association between p53 mutations and deletions on 3p, 5q, 9p, 11p and 17p was found. There was also a significant correlation between deletions at these loci. 86% of the tumours with concordant deletion in the 4 most involved loci (3p21, 5q11-13, 9p21 and 17p13) had p53 mutations as compared to only 8% of the tumours without deletions at the corresponding loci (P< 0.0001). Data were also examined in relation to smoking status of the patients and histology of the tumours. The frequency of deletions was significantly higher among smokers as compared to non-smokers. This difference was significant for the 3p21.3 (hMLH1 locus), 3p14.2 (FHIT locus), 5q11-13 (hMSH3 locus) and 9p21 (D9S157 locus). Tumours with deletions at the hMLH1 locus had higher levels of hydrophobic DNA adducts. Deletions were more common in squamous cell carcinomas than in adenocarcinomas. Covariate analysis revealed that histological type and p53 mutations were significant and independent parameters for predicting LOH status at several loci. In the pathogenesis of NSCLC exposure to tobacco carcinogens in addition to clonal selection may be the driving force in these alterations.

Nickel(II) induces microsatellite mutations in human lung cancer cell lines.

Nickel(II) is a human carcinogen causing respiratory cancers. The purpose of this study was to determine whether Ni(II) may induce microsatellite mutations in human cells. We transfected the three human lung tumor cell lines A427, HCC15 and NCI-H2009 with a mammalian expression vector containing a (CA)(13) repeat in the coding sequences of the reporter hygromycin gene (hyg). A total of 33 clones carrying the integrated vector derived from the three cell lines was investigated for spontaneous and Ni(II)-induced hygromycin-resistant (hyg(r)) reversion mutants. Significantly higher frequencies of hyg(r) reversion mutations were observed in Ni(II)-treated cells (NCI-H2009 and HCC-15) than control cells. In the majority of the colonies hyg(r) phenotype was due to mutations within the integrated (CA) repeat sequence. The type of mutations consisted of both contraction and expansion of the (CA) repeat unit. The finding that Ni(II) promotes microsatellite mutations raises the possibility that genetic instability may be a mechanism involved in nickel carcinogenesis.

Induction of microsatellite mutations by oxidative agents in human lung cancer cell lines.

Genomic instability has been associated with cancer development. Oxidative DNA damage seems to contribute to genetic instability observed in cancer. We have used human lung cancer cell lines carrying a plasmid vector containing a (CA)(13) microsatellite sequence to study frameshift mutations mediated by ROS-generating chemicals paraquat and hydrogen peroxide. Exposure of the cells to both paraquat and hydrogen peroxide resulted in significantly higher mutation frequencies compared with untreated control cells. Mutation frequencies up to 27-fold higher than the spontaneous mutation frequencies were obtained. The majority of the reversion mutants contained frameshift mutations within the target sequence. However, the pattern of deletions and additions was significantly different in the two cell lines. These results indicate that oxidative damage may play a role in instability of microsatellite sequences in vivo.

p53 mutations in defined structural and functional domains are related to poor clinical outcome in non-small cell lung cancer patients.

The prognostic value of p53 status in non-small cell lung cancer has been investigated in 148 patients with clinical stage I-IIIB disease. Tumor tissues were examined for mutations in exons 4-9, with emphasis on defined structural and functional domains. Eighty-four mutations were detected in 83 (54%) of the patients. Eighty-eight percent of the mutations were within exons 5-8, and 12% of the mutations were within exons 4 and 9. Missense mutations occurred in 67% of the tumors, and 30% were null mutations (10% stop mutations, 15% frameshift mutations, and 5% splice site mutations). Patients with mutations in p53 had a significantly higher risk for lung cancer-related death and for death from all causes than those with wild-type p53 [hazard ratio (HR) = 2.09 and 95% confidence interval (CI) = 1.20-3.64 and HR = 1.69 and 95% CI = 1.06-2.70, respectively]. Mutations in p53 related to even still poorer lung cancer-related prognosis were found at the following locations: (a) exon 8 (HR = 3.5; 95% CI, 1.59-7.71)]; (b) the structural domains L2 + L3 (HR = 2.36; 95% CI, 1.18-4.74), and (c) codons involved in zinc binding (HR = 11.7; 95% CI, 3.56-38.69). Together, the biologically functional group of severe flexible mutants (codons 172, 173, 175, 176, 179, 181, 238, 245, and 267) and severe contact mutants (248, 282) were significantly related to shorter lung cancer-related survival (HR = 4.16; 95% CI, 1.93-8.97). Squamous cell carcinoma was the dominant histological type in tumors involved in poor prognosis in exon 8 (HR = 3.19; 95% CI, 1.07-9.45). These results indicate that mutations in defined structural and functional domains of p53 may be useful molecular biological markers for prognosis and treatment strategy in non-small cell lung cancer patients.

Gene-environment interactions in human lung cancer.

Gene-environment interactions are thought to be critical for several diseases such as cancer, diabetes, heart disease and asthma. Cancer is a result of multiple gene-environment interactions occurring over several decades. During tumor development the cell accumulates multiple genetic changes, which generate the transformed phenotype, i.e. a cell with increased genetic instability. Lung cancer is a useful model for the study of the interplay between genetic factors and environmental exposure since the primary etiology is well established. Several polymorphic enzymes that may be important determinants of susceptibility have been demonstrated. Data also provide evidence for sex differences in lung cancer susceptibility. Furthermore, certain chemical carcinogens may contribute to the carcinogenic process in the lung epithelial cells by inducing genomic instability either directly or indirectly through inflammatory processes.

GSTM1 and NAT2 polymorphisms in operable and non-operable lung cancer patients.

We have genotyped 657 Norwegian men, including 282 lung cancer patients (147 non-operable and 135 operable) and 375 healthy referents (210 smokers and 165 non-smokers), to study the possibility that glutathione S-transferase M1 (GSTM1)-null and/or N-acetyl transferase 2 (NAT2)-slow genotypes confer susceptibility towards lung cancer in smokers. Compared with smoking referents, there was a significant over-representation of the GSTM1-null genotype among patients with squamous cell carcinoma (SQ) [odds ratio (OR) = 1.7, 95% confidence interval (95%CI) = 1.1-2.7], and the NAT2-slow genotype among patients with large cell carcinoma or mixed histological diagnosis (LM) (OR = 2.5, 95%CI = 1.0-6.1). In contrast to operable patients, non-operable patients showed a clear over-representation of slow genotypes if they were younger (

DNA mismatch binding in human lung tumor cell lines.

Defects in mismatch repair (MMR) genes have been involved in several types of sporadic and hereditary cancers. In order to elucidate the role of MMR in human lung carcinogenesis we examined DNA mismatch binding in cell-free extracts of seven lung tumor cell lines and five corresponding lymphoblastoid cell lines from lung cancer patients. Using the technique of bandshift assay we have demonstrated that 2/7 of the tumor cell lines are aberrant in binding to specific DNA mismatches while all lymphoblastoid cell lines were proficient in binding to all tested mismatches. Both extracts were aberrant in binding to G/T mismatch whereas one of the cell lines showed deficiency in binding to the C:A mismatches as well. Immunoblotting analysis showed that all known DNA mismatch repair (MMR) proteins were present in these extracts. The cell line deficient in binding to both G:T and C:A mismatches showed microsatellite instability (MSI) in tumor DNA and higher resistance to the alkylating agent N-methyl-N'-nitro-N-nitrosoguanidine (MNNG). This report indicates that DNA mismatch binding deficiencies may be implicated in at least a subgroup of human lung cancer.

Sex differences in lung CYP1A1 expression and DNA adduct levels among lung cancer patients.

Several epidemiological studies have indicated that female tobacco smokers may be at higher risk of lung cancer than males. In a study of lung cancer cases, we have found that female smokers had a significantly higher level of aromatic/hydrophobic DNA adducts in their nontumor lung tissue (15.39+/-9.47 adducts/10(8) nucleotides, n = 29) than male smokers (12.08+/-8.14, a = 93; P = 0.047). Females had significantly higher levels of adducts/pack-year (females 0.95+/-0.82 adducts/pack-year and males 0.46+/-0.46; P = 0.0004) and adducts/cigaret/day (females 1.48+/-1.29 and males 0.89+/-0.74, P = 0.015). By quantitative reverse transcription-PCR, it was found that female smokers exhibited a significantly higher expression level of lung CYP1A1 (494+/-334 CYP1A1 mRNA/10(6) glyceraldehyde-3-phophate dehydrogenase mRNA, n = 15) compared with males (210+/-208, n = 12; P = 0.016). Furthermore, for both sexes combined a significant correlation between CYP1A1 expression and DNA adduct level was found (r = 0.50, P = 0.009). In conclusion, the observed sex difference in aromatic/hydrophobic DNA adduct levels may at least in part be explained by different levels of CYP1A1 expression.

Hras1 VNTR alleles as susceptibility markers for lung cancer: relationship to microsatellite instability in tumors.

PURPOSE: To further evaluate lung cancer risk associated with rare Hras1 VNTR alleles and possible biological mechanisms. MATERIALS AND METHODS: The Hras1 VNTR was genotyped in 295 lung cancer patients and 500 healthy controls by PCR and high resolution electrophoresis. Microsatellite alterations were examined in 168 tumors by PCR and capillary electrophoresis. RESULTS: 35 Hras1 VNTR alleles were found, of which 24 were defined as rare. A relative risk of 3.3 (95% CI; 1.9-6.0) associated with rare alleles was obtained using the total groups. Increased risk was significant both for males and females. When a matched control group was used, a relative risk of 12.7 (95% CI; 1.7-93.9) was calculated for individuals with rare alleles at the Hras1 VNTR locus. A low frequency of microsatellite alterations was observed (4.7%) in lung tumors. The frequency of altered microsatellite loci was higher among patients with rare Hras1 VNTR alleles than among patients with common alleles. CONCLUSION: Rare Hras1 VNTR alleles are associated with lung cancer risk, and a genetic mechanism which increases allelic diversity may be involved.

Glutathione S-transferase M1 and P1 genotypes and urinary excretion of 1-hydroxypyrene in coke oven workers.

The objective of this study was to analyze the effect of the GSTM1 and GSTP1 genotypes on urinary 1-hydroxypyrene, a biomarker for exposure to polycyclic aromatic hydrocarbon. Urine samples were collected from coke oven workers at two time points (from 66 and 46 workers, respectively) and 1-hydroxypyrene was quantitated by HPLC chromatography. The genotype of GSTM1 and GSTP1 was determined by a PCR methods discriminating between GSTM1 present or absent and three different alleles for GSTP1. The mean value of urinary 1-hydroxypyrene was higher at both time points in coke oven workers with GSTM1 gene present compared to workers having the GSTM1 null genotype, but this difference was not statistically significant. The GSTM1 and GSTP1 genotypes were not significant parameters in a multiple regression analysis with urinary 1-hydroxypyrene as the dependent variable and with GSTM1, GSTP1, exposure group and smoking habit as explanatory variables. The biomarker 1-hydroxypyrene is not or only marginally influenced by the GSTM1 genotype. No systematic influence of the GSTP1 genotypes was found.

Supporting CPR development with the commercial off-the-shelf systems evaluation technique: defining requirements, setting priorities, and evaluating choices.

This article describes the circumstances that led the Department of Defense (DoD) to adopt a standard streamlined business process to support its computer-based patient record (CPR) system. The DoD used the commercial off-the-shelf systems evaluation technique (COSSET) to accomplish this goal.

Genotypes of glutathione transferase M1 and P1 and their significance for lung DNA adduct levels and cancer risk.

The A-G polymorphism at codon 104 in the glutathione S-transferase P1 (GSTP1) gene was examined in 138 male lung cancer patients and 297 healthy controls. The patients had significantly higher frequency of the GG genotype (15.9%) and a lower frequency of AA (38.4%) than the controls (9.1% and 51.5%, respectively). The level of hydrophobic DNA-adducts were determined in lung tissue from 70 current smokers. Patients with the GG genotype had a significantly higher adduct level than patients with AA (15.5 +/- 10.2 vs 7.9 +/- 5.1 per 10(8) nucleotides, P = 0.006). We also analyzed the deletion polymorphism in the GSTM1 gene in 135 male patients and 342 controls. The patients were stratified according to histology, smoking dose, age, adduct level and mutational types found in the tumors (Ki-ras and p53 genes). The results consistently indicated that the GSTM1 null genotype was associated with a slightly increased lung cancer risk. When the combined GST M1 and P1 genotypes were examined, patients with the combination null and AG or GG had significantly higher adduct levels than all other genotype combinations (P = 0.011). The distribution of combined genotypes was also significantly different in cases and controls, mainly due to increased frequency of the combination GSTM1 null and GSTP1 AG or GG among patients.

Absence of mutations in the transforming growth factor-beta type II receptor in sporadic lung cancers with microsatellite instability and rare H-ras1 alleles.

The transforming growth factor-beta type II receptor (RII) is commonly mutated in colon and gastric cancers with microsatellite instability (MI). We utilized our series of lung cancers with MI and rare alleles of the H-ras1 gene to determine the association between MI and RII mutations and searched the entire RII coding region in 33 lung cancers with MI by polymerase chain reaction-single-strand conformation polymorphism analysis. We found no mutations, and these data support other recent evidence that RII mutations rarely occur except in colon and gastric tumors with MI.

Rare alleles at different VNTR loci among lung-cancer patients with microsatellite instability in tumours.

Work in our laboratory has shown a significantly higher frequency of microsatellite mutations in tumours from lung-cancer patients with rare alleles at the HrasI VNTR locus compared with those with common alleles. In 137 lung-cancer patients, the association between microsatellite instability and rare alleles at the HrasI VNTR locus was confirmed with 17 microsatellite markers. We found a significant association between LOH in lung tumours of marker D3s966 with microsatellite instability. In samples with LOH at marker D3s966 (3p21.3) 22% of loci tested showed instability, whereas 8% showed instability without LOH at D3s966. To investigate whether rare alleles at the HrasI locus are linked to rare alleles at other loci, a second minisatellite (D17S4) was genotyped. In a population of 406, 4 individuals with D 17S4 rare alleles were detected of whom 3 also had rare alleles at the HrasI VNTR locus. The probability of this association to occur by chance is low. Thus, rare alleles at the HrasI locus may be associated with rare alleles at other loci, and could be an indication of germline instability. The findings indicate that microsatellite instability in lung tumours is not strictly associated with features in the HrasI proto-oncogene, but may be the result of the same mechanism(s) that generate(s) new alleles at the HrasI and D17S4 loci.

p53 mutations in lung tumours: relationship to gender and lung DNA adduct levels.

Human lung cancer exhibits a high frequency of transversion mutations at G:C base pairs of the p53 gene, possibly the result of DNA damage by cigarette smoke constituents, most notably benzo[a]pyrene. We have investigated gender differences in the p53 mutational spectrum and levels of hydrophobic DNA adducts. Tumour tissue was obtained from 115 non-small cell lung cancer tumours and examined for mutational alterations in the p53 gene (exons 4-9) using PCR and single-strand conformational polymorphism analysis. We have previously examined exons 5-8 in lung cancer. Sequence analysis of exons 4 and 9 revealed that almost 20% of the mutations were located in exons 4 and 9. The levels of hydrophobic DNA adducts in non-tumorous lung tissue of 55 of the patients were analyzed by the 32P-postlabelling assay. There were both a higher frequency of G:C-->T:A mutations and a higher average hydrophobic DNA adduct level in females than in male patients, even though the level of exposure to carcinogens from cigarette smoking was lower among the females than among the males. Frameshift mutations were more common in women than in men (30 versus 15%). These preliminary findings lend support to epidemiological evidence that women may be at greater risk than men of contracting tobacco-induced lung cancer.

A hereditary genetic marker closely associated with microsatellite instability in lung cancer.

Alterations in 5 microsatellite loci were analyzed in tumors from 137 patients with primary non-small cell lung carcinomas that were also genotyped for the Hras1 variable number of tandem repeats (VNTR) locus. Twenty-nine patients (21%) had changes in at least one microsatellite locus. A majority of these cases (24 of 29, 83%) had VNTR alleles classified as rare in the population. The frequency of these rare alleles were significantly higher among lung cancer patients than in healthy controls (P = 0.016 or 1.80; 95% confidence interval = 1.13-2.85). Microsatellite alterations were significantly more frequent among patients with at least one rare Hras1 VNTR allele (24 of 40, 60%) compared to patients with two common alleles (5 of 97, 5%; P < 0.001 or 27.6; 95% confidence interval = 8.18-82.9). Microsatellite alterations were also more frequent among patients below 50 years of age (8 of 21, 38%) than for older patients (21 of 112, 19%).