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Recombinant adeno-associated viral (rAAV) vector-mediated gene therapy is being developed to treat X-linked retinitis pigmentosa (XLRP) in patients with mutations in the retinitis pigmentosa GTPase regulator ( RPGR ) gene. In preparation for a clinical gene therapy trial, we conducted dose range finding (DRF) studies with an AAV2 capsid with three surface tyrosine residues changed to phenylalanine (AAV2tYF) vector administered by subretinal injection in a naturally occurring RPGR -mutant canine model (XLPRA2) to compare two different human RPGR ( hRPGR ) transgenes and to establish a reasonable starting dose for a clinical trial. Different dose levels of two candidate vectors (0.15 mL at 1.2 × 10 10 -3.0 × 10 12 vg/mL of rAAV2tYF-GRK1- hRPGRco or 4 × 10 10 -3.0 × 10 12 vg/mL of rAAV2tYF-GRK1- hRPGRstb ), 6.0 × 10 11 vg/mL rAAV5-GRK1- hRPGRco reference vector or Vehicle were subretinally administered, and the dogs were followed for 8 weeks postdose. Ophthalmic examinations, analyses of retinal structure by in vivo imaging using confocal scanning laser ophthalmoscopy (cSLO)/optical coherence tomography (OCT) in the Lower (4.0 × 10 10 vg/mL) and Lowest (1.2 × 10 10 vg/mL) Doses, immunological responses by cell based assays or enzyme-linked immunosorbent assay, RPGR transgene expression, and reversal of opsin mislocalization by immunohistochemistry were performed. No sustained signs of ocular discomfort or ophthalmic complications were noted in any of the injected eyes except some in the High Dose group (3.0 × 10 12 vg/mL), which showed signs of retinal detachment and inflammation. A change in fundus reflectivity suggestive of a rescue effect was seen in the High, Mid (6.0 × 10 11 vg/mL), and Low (1.2 × 10 11 vg/mL) Dose groups. cSLO/OCT demonstrated qualitative and quantitative evidence of rescue effect in eyes treated with the Lower Dose. Anti-hRPGR antibodies were absent, but neutralizing antibody titers against AAV2 were detected in all animals dosed with rAAV2tYF in an apparent dose-related pattern. RPGR expression was stronger for rAAV2tYF-GRK1- hRPGRco compared to rAAV2tYF-GRK1- hRPGRstb at all dose levels. Subretinal administration of rAAV2tYF-GRK1- hRPGRco and rAAV2tYF-GRK1- hRPGRstb both corrected rod and cone opsin mislocalization, two early markers of disease in the XLPRA2 canine model of RPGR -XLRP. These results support the selection and use of rAAV2tYF-GRK1- hRPGRco (AGTC-501) and guided the initial doses in clinical studies in patients with XLRP caused by RPGR mutations.

Introduction: The Western Desert Kidney Health Project (WDKHP) aimed to determine the prevalence of type 2 diabetes (T2DM), kidney disease and associated risk factors in Aboriginal and non-Aboriginal people in a remote area of Western Australia., Methods: The project, featuring whole-of-community cross-sectional surveys and health assessments using point-of-care testing, was conducted in five small towns and six remote Aboriginal communities in the Goldfields of Western Australia between 2010 and 2014. Initial health assessments were completed by 597 adults (424 Aboriginal) and 502 children (393 Aboriginal). This included almost 80% of the Aboriginal population. All non-Aboriginal people residing in the six remote Aboriginal communities participated., Results: Risk factors for renal disease and T2DM were present in participants of all ages, including children as young as 2 years. There was no significant difference between Aboriginal and non-Aboriginal children. Aboriginal and non-Aboriginal adult participants had twice the burden of T2DM than the standard Australian population. More than 12% of all children had elevated albumin-creatinine ratio (ACR). Adults had markers of kidney disease at higher rates than expected: 51% of Aboriginal adults and 27% of non-Aboriginal adults had at least one marker of kidney disease (haematuria, proteinuria or elevated ACR). Aboriginal women were the highest risk group (32% T2DM, 40% elevated ACR). Haematuria and low urine pH were common findings, 21% of people had haematuria (greater than trace) and 71% had urine pH of 6 or less; there was no difference in this finding between Aboriginal and non-Aboriginal people., Conclusion: The WDKHP found higher than expected rates of risk factors for T2DM and renal disease compared with Australian Bureau of Statistics rates for Australian Aboriginal and non-Aboriginal adults and children, with Aboriginal women the highest risk group. The rates for non-Aboriginal participants were higher than expected, suggesting exposures in common might be more important than ethnicity.The high prevalence of aciduria and haematuria found in both Aboriginal and non-Aboriginal participants in this study suggests that factors contributing to a chronic metabolic acidosis and inflammation or irritation of the urinary tract need to be explored. Drinking water quality in this remote area is known to be poor and may be an important contributing factor. Many of the contributing factors are potentially modifiable - such as water quality, food supply, exercise opportunities and living conditions - offering scope for interventions to reduce the risk and burden of these diseases.

Applied Genetic Technologies Corporation (AGTC) is developing a recombinant adeno-associated virus (rAAV) vector AGTC-501, also designated rAAV2tYF-GRK1- hRPGRco , to treat X-linked retinitis pigmentosa (XLRP) in patients with mutations in the retinitis pigmentosa GTPase regulator ( RPGR ) gene. The vector contains a codon-optimized human RPGR cDNA ( hRPGRco ) driven by a photoreceptor-specific promoter (G protein-coupled receptor kinase 1 [GRK1]), and is packaged in an AAV2 capsid variant with three surface tyrosine residues changed to phenylalanine (AAV2tYF). We conducted a toxicity and efficacy study of this vector administered by subretinal injection in the naturally occurring RPGR mutant (X-linked progressive retinal atrophy 2 [XLPRA2]) dog model. Sixteen RPGR mutant dogs divided into four groups of three to five animals each received either a subretinal injection of 0.07 mL of AGTC-501 at low (1.2 × 10 11 vector genome [vg]/mL), mid (6 × 10 11 vg/mL), or high dose (3 × 10 12 vg/mL), or of vehicle control in the right eye at early-stage disease. The left eye remained untreated. Subretinal injections were well tolerated and were not associated with systemic toxicity. Electroretinography, in vivo retinal imaging, and histological analysis showed rescue of photoreceptor function and structure in the absence of ocular toxicity in the low- and mid-dose treatment groups when compared with the vehicle-treated group. The high-dose group showed evidence of both photoreceptor rescue and posterior segment toxicity. These results support the use of AGTC-501 in clinical studies with patients affected with XLRP caused by RPGR mutations and define the no-observed-adverse-effect level at 6 × 10 11 vg/mL.

Applied Genetic Technologies Corporation (AGTC) is developing a recombinant adeno-associated virus (rAAV) vector AGTC-501, also designated AAV2tYF-GRK1-RPGRco, to treat retinitis pigmentosa (RP) in patients with mutations in the retinitis pigmentosa GTPase regulator (RPGR) gene. The vector contains a codon-optimized human RPGR cDNA (RPGRco) driven by a photoreceptor-specific promoter (G protein-coupled receptor kinase 1, GRK1) and is packaged in an AAV2 capsid with three surface tyrosine residues changed to phenylalanine (AAV2tYF). We conducted a safety and potency study of this vector administered by subretinal a injection in the naturally occurring RPGR-deficient Rd9 mouse model. Sixty Rd9 mice (20 per group) received a subretinal injection in the right eye of vehicle (control) or AAV2tYF-GRK1-RPGRco at one of two dose levels (4 × 10 8 or 4 × 10 9 vg/eye) and were followed for 12 weeks after injection. Vector injections were well tolerated, with no systemic toxicity. There was a trend towards reduced electroretinography b-wave amplitudes in the high vector dose group that was not statistically significant. There were no clinically important changes in hematology or clinical chemistry parameters and no vector-related ocular changes in life or by histological examination. Dose-dependent RPGR protein expression, mainly in the inner segment of photoreceptors and the adjacent connecting cilium region, was observed in all vector-treated eyes examined. Sequence integrity of the codon-optimized RPGR was confirmed by sequencing of PCR-amplified DNA, or cDNA reverse transcribed from total RNA extracted from vector-treated retinal tissues, and by sequencing of RPGR protein obtained from transfected HEK 293 cells. These results support the use of rAAV2tYF-GRK1-RPGRco in clinical studies in patients with XLRP caused by RPGR mutations.

Aims: We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency., Patients and Methods: A prospective cohort study of the first 45 shoulder arthroplasties using the SMR Axioma Trabecular Titanium (TT) metal-backed glenoid with autologous bone graft. Between May 2013 and December 2014, 45 shoulder arthroplasties were carried out in 44 patients with a mean age of 64 years (35 to 89). The indications were 23 complex primary arthroplasties, 12 to revise a hemiarthroplasty or resurfacing, five for aseptic loosening of the glenoid, and five for infection., Results: Of the 45 patients, 16 had anatomical shoulder arthroplasties (ASA) and 29 had reverse shoulder arthroplasties (RSA). Postoperatively, 43/45 patients had a CT scan. In 41 of 43 patients (95%), the glenoid peg achieved > 50% integration. In 40 of 43 cases (93%), the graft was fully or partially integrated. There were seven revisions (16%) but only four (9%) required a change of baseplate. Four (25%) of the 16 ASAs were revised for instability or cuff failure. At two-year radiological follow-up, five of the 41 cases (11%) showed some evidence of lucent lines., Conclusion: The use of a metal baseplate with a trabecular titanium surface in conjunction with autologous bone graft is a reliable method of addressing glenoid bone defects in primary and revision RSA setting in the short term. ASAs have a higher rate of complications with this technique.

Physical activity is a key component in the management of diabetes, but most people do not engage in recommended levels of physical activity. A recent consensus statement on exercise management in type 1 diabetes (T1D) fails to mention behavioral change and the specific determinants impacting on exercise management. The aim of this study is to investigate the needs of adults with T1D around physical activity and the challenges they face. Using a person-centered approach, focus groups and individual semi-structured interviews recorded the perspectives of 67 adults aged ≥18 with diabetes. Four global themes were identified: (i) it's a balancing act, (ii) winging it, (iii) engagement and (iv) encouraging uptake. These findings suggest that adults with T1D find it difficult to manage their diabetes and physical activity and decision-making is based on trial and error with minimal input from healthcare professionals. Participants want more information to enable them to manage their diabetes and physical activity effectively. Adults with T1D face unique challenges in relation to physical activity. Participants reported key determinants for being active. Research is needed to understand how physical activity promotion is best developed for those with T1D and the preparedness of healthcare professionals for delivering guidance to adults with T1D.

Aims: The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification., Patients and Methods: A total of 55 total elbow arthroplasties (TEAs) (52 patients) performed between June 2007 and December 2015 were eligible for inclusion in the study (29 TEAs for primary elective arthroplasty and 26 TEAs for trauma). At review, 15 patients (17 total elbow arthroplasties) had died from unrelated causes. There were 14 men and 38 women with a mean age of 70 years (42 to 90). The median clinical follow-up was 3.6 years (1.2 to 6) and the median radiological follow-up was 3.1 years (0.5 to 7.5)., Results: The overall incidence of HO was 84% (46/55). This was higher in the trauma group (96%, 25/26) compared with the elective arthroplasty group (72%, 21/29) (p = 0.027, Fisher's exact test). Patients in the trauma group had HO of higher Brooker class. The presence of HO did not significantly affect elbow range of movement within the trauma or elective groups (elective arthroplasty, Mann-Whitney U test, p = 0.070; trauma arthroplasty, p = 0.370, Mann-Whitney U test)., Conclusion: HO after total elbow arthroplasty is seen more commonly than previously reported. We have reported a significantly higher rate of HO in TEAs performed for trauma than those performed electively. Cite this article: Bone Joint J 2018;100-B:767-71.

Background: Acromioclavicular joint instability following distal clavicle resection can result in considerable pain and dysfunction., Method: We present a review of 13 patients who underwent ACJ stabilization following one or more distal clavicle resection procedures., Results: The mean Quick DASH and CM scores were 26(0-57) and 73(46-100) respectively. All but one patient reported an improvement in the pain component of their CM score and in the work component of the Quick DASH score., Discussion: Open ACJ stabilization to treat instability following distal clavicle resection resulted in improved functional scores, pain scores and facilitated return to work in most patients.Level of evidence IV.

Introduction: The use of virtual fracture clinics (VFCs) and home management protocols is increasing. The main aim of this research is to determine whether a paediatric home management programme and VFC can be used safely to manage a range of suitable fractures in children., Materials and Methods: Protocols for the home management of stable paediatric fractures were designed by two consultant paediatric orthopaedic surgeons. These were for children between the ages of 18 months and 15 years 364 days. A new tariff was negotiated with the clinical commissioning groups (CCGs) for a VFC new patient review. A prospective analysis was performed for the first 2 months of the programme. Further review periods were undertaken 6 months later and 12 months after that., Results: Sixty-five patients were reviewed in the first 10 VFCs (mean 6.5 cases per week). After 6 months, 164 patients were reviewed in a 3-month period in the VFC, a mean of 11 cases per week. A year later the number of patients reviewed in the VFC had continued to increase with a total of 253 patients in 3 months, mean 21 cases per week. This gave a saving to the CCG of £45,000 per year and to the hospital of £106,000 per year. There were no serious adverse consequences to any patients from the use of the pathway., Discussion and Conclusion: We have reported on the introduction of a paediatric VFC and a home management programme for stable paediatric fractures. We are not aware of any reports in the orthopaedic literature that have described such a comprehensive and innovative re-organisation of paediatric fracture services. We estimate that the NHS could save approximately £10.1 million if all hospitals in England introduced this., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

The elbow is the second most commonly dislocated major joint in adults. Good long-term outcomes have been reported after non-operative management; however, a small proportion (<10%) of patients have a poor outcome and some do require surgical intervention. A review of the anatomy, pathoanatomy, management and outcomes of simple elbow dislocations is presented. Emphasis is placed on emerging concepts regarding the soft tissue injury, the stabilising structures that are injured, the sequence and mechanism of injury and the relationship to elbow stability. The benefits of nonsurgical and surgical management are discussed and a treatment algorithm based on the pathoanatomy is proposed.

Applied Genetic Technologies Corporation (AGTC) is developing a recombinant adeno-associated virus (rAAV) vector expressing the human CNGA3 gene designated AGTC-402 (rAAV2tYF-PR1.7-hCNGA3) for the treatment of achromatopsia, an inherited retinal disorder characterized by markedly reduced visual acuity, extreme light sensitivity, and absence of color discrimination. The results are herein reported of a study evaluating safety and efficacy of AGTC-402 in CNGA3-deficient sheep. Thirteen day-blind sheep divided into three groups of four or five animals each received a subretinal injection of an AAV vector expressing a CNGA3 gene in a volume of 500 μL in the right eye. Two groups (n = 9) received either a lower or higher dose of the AGTC-402 vector, and one efficacy control group (n = 4) received a vector similar in design to one previously shown to rescue cone photoreceptor responses in the day-blind sheep model (rAAV5-PR2.1-hCNGA3). The left eye of each animal received a subretinal injection of 500 μL of vehicle (n = 4) or was untreated (n = 9). Subretinal injections were generally well tolerated and not associated with systemic toxicity. Most animals had mild to moderate conjunctival hyperemia, chemosis, and subconjunctival hemorrhage immediately after surgery that generally resolved by postoperative day 7. Two animals treated with the higher dose of AGTC-402 and three of the efficacy control group animals had microscopic findings of outer retinal atrophy with or without inflammatory cells in the retina and choroid that were procedural and/or test-article related. All vector-treated eyes showed improved cone-mediated electroretinography responses with no change in rod-mediated electroretinography responses. Behavioral maze testing under photopic conditions showed significantly improved navigation times and reduced numbers of obstacle collisions in all vector-treated eyes compared to their contralateral control eyes or pre-dose results in the treated eyes. These results support the use of AGTC-402 in clinical studies in patients with achromatopsia caused by CNGA3 mutations, with careful evaluation for possible inflammatory and/or toxic effects.

Hypothesis and Background: Hydrodilatation and physiotherapy are commonly used treatments for primary frozen shoulder. Little is known about the optimal form of physiotherapy. This study reports a randomized controlled trial comparing 2 forms of physiotherapy after hydrodilatation. The null hypothesis was that there would be no difference between the 2 groups at 1 year as measured by the Oxford Shoulder Score (OSS)., Methods: We randomized 41 patients undergoing hydrodilatation for primary frozen shoulder into 2 treatment groups: group 1 (n = 20) underwent supervised physiotherapy in addition to a home exercise program, and group 2 (n = 21) followed a self-directed home exercise program in isolation. Assessment was carried out by a blinded research nurse at baseline, 4 weeks, 3 months, 6 months, and 1 year. The primary outcome measure was the OSS. Other measures were range of movement, visual analog scale pain score, and EQ-5D index., Results: There was no significant difference between the treatment groups at any time point as measured by the OSS or EQ-5D index. In group 1, the OSS improved significantly from 25.00 (95% confidence interval [CI], 21.92-28.08) at baseline to 38.29 (95% CI, 34.01-42.58; P < .0001) at 4 weeks and 43.71 (95% CI, 41.61-45.80; P < .0001) at 1 year. In group 2, the OSS improved significantly from 26.60 at baseline (95% CI, 22.50-30.70) to 40.07 (95% CI, 36.77-43.36; P < .0001) at 4 weeks and 43.00 (95% CI, 39.69-46.31; P < .0001) at 1 year. All outcome measures improved significantly from baseline to 4 weeks., Conclusion: In this group of patients, after a hydrodilatation procedure for the treatment of primary frozen shoulder, there was no significant difference in clinical outcomes between supervised physiotherapy in addition to a home exercise program and a self-directed home exercise program in isolation., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Background: Boxer's elbow has been described in the literature as an extension and hyperextension injury. However, in our experience, there is a coexisting impingement lesion in the anterior compartment of the elbow that has not previously been described. We report a series of professional boxers with elbow disease treated arthroscopically. The aim of the paper was to accurately describe the pathoanatomy of the condition, the key points in its diagnosis, and the outcomes of surgical treatment., Methods: Seven professional boxers were treated for symptomatic elbow disease. Clinical evaluation included range of motion and Disabilities of the Arm, Shoulder, and Hand score. The arthroscopic findings and procedures were documented., Results: Symptoms were mainly those of anterior and posterior impingement; 6 elbows had an anterior impingement lesion and 6 had a posterior impingement lesion. Postoperatively, the mean Disabilities of the Arm, Shoulder, and Hand score was 2.7 (range, 0-13.3) at a median of 15 (range, 6-36) months postoperatively. All boxers returned to their previous level of competition and 5 won their next bout. All of the boxers used an orthodox stance, and in all but 1 case the left elbow was the pathologic elbow., Conclusion: Boxers are prone to development of anterior and posterior elbow impingement. The side of the pathologic process is related to the boxer's stance, with the lead arm being more vulnerable. Arthroscopic débridement is an effective treatment, enabling return to a high competitive level. Surgeons, sports medicine physicians, and physiotherapists should be aware of the condition., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Patient-reported outcome meaures (PROMs) not only provide valuable insights into subjective indices of joint health, but also may provide limited objective information about range of motion (ROM). We sought to evaluate the accuracy of patient-reported range of elbow motion compared to measured ROM., Methods: Sixty clinic patients were recruited, of whom 26 had elbow pathologies and 34 had pathologies other than at the elbow joint. Each patient independently estimated ROM for extension, flexion, pronation and supination before this was measured by a clinician using a universal goniometer, with the mean being the gold standard., Results: We found that patients' ROM estimates were significantly different from measured ROM (p < 0.00001 at 95% confidence interval). There was no statistically significant difference between elbow pathology and non-elbow pathology patients' estimated ROM., Conclusions: There was great disparity between patient-estimated and measured ROM, although estimates of patients with known elbow pathology did not demonstrate any significant difference from their healthy counterparts. These differences may be too great for patient-estimated range of motion to be used as a reliable tool for assessing outcomes.

Applied Genetic Technologies Corporation (AGTC) is developing rAAV2tYF-PR1.7-hCNGB3, a recombinant adeno-associated virus (rAAV) vector expressing the human CNGB3 gene, for treatment of achromatopsia, an inherited retinal disorder characterized by markedly reduced visual acuity, extreme light sensitivity, and absence of color discrimination. We report here results of a study evaluating safety and biodistribution of rAAV2tYF-PR1.7-hCNGB3 in CNGB3-deficient mice. Three groups of animals (n = 35 males and 35 females per group) received a subretinal injection in one eye of 1 μl containing either vehicle or rAAV2tYF-PR1.7-hCNGB3 at one of two dose concentrations (1 × 10(12) or 4.2 × 10(12) vg/ml) and were euthanized 4 or 13 weeks later. There were no test-article-related changes in clinical observations, body weights, food consumption, ocular examinations, clinical pathology parameters, organ weights, or macroscopic observations at necropsy. Cone-mediated electroretinography (ERG) responses were detected after vector administration in the treated eyes in 90% of animals in the higher dose group and 31% of animals in the lower dose group. Rod-mediated ERG responses were reduced in the treated eye for all groups, with the greatest reduction in males given the higher dose of vector, but returned to normal by the end of the study. Microscopic pathology results demonstrated minimal mononuclear cell infiltrates in the retina and vitreous of some animals at the interim euthanasia and in the vitreous of some animals at the terminal euthanasia. Serum anti-AAV antibodies developed in most vector-injected animals. No animals developed antibodies to hCNGB3. Biodistribution studies demonstrated high levels of vector DNA in vector-injected eyes but little or no vector DNA in nonocular tissue. These results support the use of rAAV2tYF-PR1.7-hCNGB3 in clinical studies in patients with achromatopsia caused by CNGB3 mutations.

Applied Genetic Technologies Corporation (AGTC) is developing rAAV2tYF-PR1.7-hCNGB3, a recombinant adeno-associated viral (rAAV) vector expressing the human CNGB3 gene, for treatment of achromatopsia, an inherited retinal disorder characterized by markedly reduced visual acuity, extreme light sensitivity, and absence of color discrimination. We report here results of a study evaluating the safety and biodistribution of rAAV2tYF-PR1.7-hCNGB3 in cynomolgus macaques. Three groups of animals (n = 2 males and 2 females per group) received a subretinal injection in one eye of 300 μl containing either vehicle or rAAV2tYF-PR1.7-hCNGB3 at one of two concentrations (4 × 10(11) or 4 × 10(12) vector genomes/ml) and were evaluated over a 3-month period before being euthanized. Administration of rAAV2tYF-PR1.7-hCNGB3 was associated with a dose-related anterior and posterior segment inflammatory response that was greater than that observed in eyes injected with the vehicle control. Most manifestations of inflammation improved over time except that vitreous cells persisted in vector-treated eyes until the end of the study. One animal in the lower vector dose group was euthanized on study day 5, based on a clinical diagnosis of endophthalmitis. There were no test article-related effects on intraocular pressure, visual evoked potential responses, hematology or clinical chemistry parameters, or gross necropsy observations. Histopathological examination demonstrated minimal mononuclear infiltrates in all vector-injected eyes. Serum anti-AAV antibodies developed in all vector-injected animals. No animals developed antibodies to CNGB3. Biodistribution studies demonstrated high levels of vector DNA in the injected eye but minimal or no vector DNA in any other tissue. These results support the use of rAAV2tYF-PR1.7-hCNGB3 in clinical studies in patients with achromatopsia caused by CNGB3 mutations.

Surgical exposure of the radial head, proximal radius, capitellum, and proximal ulna can be achieved through several different approaches. The most commonly used are: the Kocher, Kaplan, and extensor digitorum communis splitting. Each of these approaches has its own limitations and dangers. In this article we describe a modified version of the less commonly used Boyd approach. We have used this approach with a transosseous lateral collateral ligament and annular ligament repair for operative treatment of fractures involving the radial head, proximal radius, proximal ulna including the coronoid, capitellum, and lateral column of the distal humerus. In our experience, the approach results in superior exposure of the lateral elbow while minimizing the risk of injury to the posterior interosseous nerve.

Unlabelled: Connective tissue growth factor (CTGF) is a matricellular protein that mediates cell-matrix interaction through various subtypes of integrin receptors. This study investigated the role of CTGF and integrin αvβ6 in hepatic progenitor/oval cell activation, which often occurs in the form of ductular reactions (DRs) when hepatocyte proliferation is inhibited during severe liver injury. CTGF and integrin αvβ6 proteins were highly expressed in DRs of human cirrhotic livers and cholangiocarcinoma. Confocal microscopy analysis of livers from Ctgf promoter-driven green fluorescent protein reporter mice suggested that oval cells and cholangiocytes were the main sources of CTGF and integrin αvβ6 during liver injury induced by 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC). Deletion of exon 4 of the Ctgf gene using tamoxifen-inducible Cre-loxP system down-regulated integrin αvβ6 in DDC-damaged livers of knockout mice. Ctgf deficiency or inhibition of integrin αvβ6, by administrating the neutralizing antibody, 6.3G9 (10 mg/kg body weight), caused low levels of epithelial cell adhesion molecule and cytokeratin 19 gene messenger RNAs. Also, there were smaller oval cell areas, fewer proliferating ductular epithelial cells, and lower cholestasis serum markers within 2 weeks after DDC treatment. Associated fibrosis was attenuated, as indicated by reduced expression of fibrosis-related genes, smaller areas of alpha-smooth muscle actin staining, and low collagen production based on hydroxyproline content and Sirius Red staining. Finally, integrin αvβ6 could bind to CTGF mediating oval cell adhesion to CTGF and fibronection substrata and promoting transforming growth factor (TGF)-β1 activation in vitro., Conclusions: CTGF and integrin αvβ6 regulate oval cell activation and fibrosis, probably through interacting with their common matrix and signal partners, fibronectin and TGF-β1. CTGF and integrin αvβ6 are potential therapeutic targets to control DRs and fibrosis in related liver disease., (© 2014 by the American Association for the Study of Liver Diseases.)

Purpose: The role of microRNA (miRNA) regulation in corneal wound healing and scar formation has yet to be elucidated. This study analyzed the miRNA expression pattern involved in corneal wound healing and focused on the effect of miR-133b on expression of several profibrotic genes., Methods: Laser-ablated mouse corneas were collected at 0 and 30 minutes and 2 days. Ribonucleic acid was collected from corneas and analyzed using cell differentiation and development miRNA PCR arrays. Luciferase assay was used to determine whether miR-133b targeted the 3' untranslated region (UTR) of transforming growth factor β1 (TGFβ1) and connective tissue growth factor (CTGF) in rabbit corneal fibroblasts (RbCF). Quantitative real-time PCR (qRT-PCR) and Western blots were used to determine the effect of miR-133b on CTGF, smooth muscle actin (SMA), and collagen (COL1A1) in RbCF. Migration assay was used to determine the effect of miR-133b on RbCF migration., Results: At day 2, 37 of 86 miRNAs had substantial expression fold changes. miR-133b had the greatest fold decrease at -14.33. Pre-miR-133b targeted the 3' UTR of CTGF and caused a significant decrease of 38% (P < 0.01). Transforming growth factor β1-treated RbCF had a significant decrease of miR-133b of 49% (P < 0.01), whereas CTGF, SMA, and COL1A1 had significant increases of 20%, 54%, and 37% (P < 0.01), respectively. The RbCF treated with TGFβ1 and pre-miR133b showed significant decreases in expression of CTGF, SMA, and COL1A1 of 30%, 37%, and 28% (P < 0.01), respectively. Finally, there was significant decrease in migration of miR-133b-treated RbCF., Conclusions: Significant changes occur in key miRNAs during early corneal wound healing, suggesting novel miRNA targets to reduce scar formation.

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019). We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

Purpose: Connective tissue growth factor (CTGF) is a fibrogenic cytokine that is up-regulated by TGF-β and mediates most key fibrotic actions of TGF-β, including stimulation of synthesis of extracellular matrix and differentiation of fibroblasts into myofibroblasts. This study addresses the role of proteolytic processing of CTGF in human corneal fibroblasts (HCF) stimulated with TGF-β, normal ocular tissues and wounded corneas., Methods: Proteolytic processing of CTGF in HCF cultures, normal animal eyes, and excimer laser wounded rat corneas were examined by Western blot. The identity of a 21-kDa band was determined by tandem mass spectrometry, and possible alternative splice variants of CTGF were assessed by 5' Rapid Amplification of cDNA Ends (RACE)., Results: HCF stimulated by TGF-β contained full length 38-kDa CTGF and fragments of 25, 21, 18, and 13 kDa, while conditioned medium contained full length 38- and a 21-kDa fragment of CTGF that contained the middle "hinge" region of CTGF. Fragmentation of recombinant CTGF incubated in HCF extracts was blocked by the aspartate protease inhibitor, pepstatin. Normal mouse, rat, and rabbit whole eyes and rabbit ocular tissues contained abundant amounts of C-terminal 25- and 21-kDa fragments and trace amounts of 38-kDa CTGF, although no alternative transcripts were detected. All forms of CTGF (38, 25, and 21 kDa) were detected during healing of excimer ablated rat corneas, peaking on day 11., Conclusions: Proteolytic processing of 38-kDa CTGF occurs during corneal wound healing, which may have important implications in regulation of corneal scar formation.

Purpose: To investigate signal transduction pathways for connective tissue growth factor (CTGF) in human corneal fibroblasts (HCF)., Methods: Expression of 75 kinases in cultures of serum-starved (HCF) were investigated using protein kinase screens, and changes in levels of phosphorylation of 31 different phosphoproteins were determined at 0, 5, and 15 minutes after treatment with CTGF. Levels of phosphorylation of three signal transducing phosphoproteins (extracellular regulated kinase 1 [ERK1], extracellular regulated kinase 2 [ERK2] [MAPKs], and signal transducer and activator of transcription 3 [STAT3]) were measured at nine time points after exposure to CTGF using Western immunoblots. Inhibition of Ras, MEK1/2 (MAPKK), and ERK1/2, on CTGF-stimulated fibroblast proliferation and collagen gel contraction was assessed using selective inhibitors farnesylthiosalicylic acid, PD-98059, and SB203580, respectively., Results: Thirty two of the 75 kinases (43%) evaluated by the kinase screen were detected in extracts of quiescent HCF, suggesting these kinases are available to respond acutely to CTGF exposure. Addition of CTGF increased levels of phosphorylation of five phosphoproteins (ERK1 and 2, MEK1/2 [MAPKK], STAT3, and SAPK/JNK), and decreased levels of phosphorylation of 14 phosphoproteins (including protein kinases B and C) after 5 and 15 minutes. Further analysis of ERK1 and 2 and STAT3 phosphorylation showed rapid increases within 1 minute of CTGF exposure that peaked between 5 and 10 minutes then returned to pretreatment levels by 30 minutes. Treatment of HCF with selective inhibitors of Ras, MEK 1/2, and ERK1/2 individually blocked both CTGF induced cell proliferation, and collagen gel contraction., Conclusions: Results from protein kinase screens and selective kinase inhibitors demonstrate Ras/MEK/ERK/STAT3 pathway is required for CTGF signaling in HCF.

Patients undergoing primary total hip arthroplasty (THA) have historically been over-transfused. In a district general hospital setting, the authors observed a significant downward trend in blood transfusion requirements in these patients over 6 years after a change in transfusion policy. The purpose of this study was to retrospectively analyze the change in transfusion practice and present the results of the restrictive transfusion policy. All patients undergoing primary THA between January 2003 and December 2008 were identified from hospital records. Pre- and postoperative hemoglobin levels, transfusion trigger hemoglobin, blood transfusion requirements, patient age and sex, 30-day mortality, and length of stay data were analyzed for all patients. A total of 1169 primary THAs were performed. Annual allogeneic blood transfusion requirements reduced progressively from 151 units in 2003 to 90 units in 2008 despite an increase in the number of patients undergoing THA. During this period, the proportion of patients transfused decreased from 35% to 17%. A reduction of mean transfusion trigger hemoglobin from 79 to 73 g/L was observed over the study period. No patient experienced any significant complications as a result of undertransfusion. The authors' institution has steadily restricted the use of blood transfusion in patients undergoing THA to those symptomatic of anemia. Increasing confidence among medical and nursing staff that reduced postoperative hemoglobin levels can be safely tolerated has resulted in a 55% reduction in blood transfusion in patients undergoing THA with no other change of practice., (Copyright 2012, SLACK Incorporated.)

The aim of the present study was to investigate the safety and efficacy of local implantation of BMP-7 for the treatment of resistant non-unions in the upper and lower limb. Fifty-two patients (30 males, mean age 52.8 years; range 20-81) were treated with local BMP-7 implantation in a bovine bone-derived collagen paste with or without revision of fixation. Thirty-six patients had closed injuries, ten had open injuries and six had infected non-unions. Patients had undergone a mean of 2 (1-5) operations prior to implantation of BMP-7. Clinical and radiological union was achieved in 94% at a mean time of 5.6 months (3-19). Two patients with subtrochanteric femoral fractures failed to achieve union secondary to inadequate fracture stabilisation, persistent unfavourable biological environment and systemic co-morbidities. One patient developed synostosis attributed to the BMP-7 application. This study demonstrates BMP-7 implanted in a bovine-derived collagen paste is an effective adjunctive treatment for resistant non-unions in the upper and lower limb., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: There has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures., Patients and Methods: Hip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture., Results: 81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture. Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture., Discussion and Conclusion: Simultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Excessive scarring (fibrosis) is a major cause of pathologies in multiple tissues, including lung, liver, kidney, heart, cornea, and skin. The transforming growth factor-β (TGF-β) system has been shown to play a key role in regulating the formation of scar tissue throughout the body. Furthermore, connective tissue growth factor (CTGF) has been shown to mediate most of the fibrotic actions of TGF-β, including stimulation of synthesis of extracellular matrix and differentiation of fibroblasts into myofibroblasts. Currently, no approved drugs selectively and specifically regulate scar formation. Thus, there is a need for a drug that selectively targets the TGF-β cascade at the molecular level and has minimal off-target side effects. This chapter focuses on the design of hammerhead ribozymes, measurement of kinetic activity, and assessment of knockdown mRNAs of TGF-β and CTGF in cell cultures.

We report the early results of high tibial osteotomy (HTO) in medial compartment osteoarthritis (OA) and varus deformity using the Taylor spatial frame (TSF). Between October 2005 and April 2007, 9 patients with medial compartment OA and varus deformity underwent TSF application and medial opening wedge HTO. Pre- and post-operative Oxford knee scores, SF-12 and visual analogue pain scores were recorded along with radiographic outcomes. Median follow-up was 19 months (range 15-35). Mean age at operation was 49 years (range 37-59). The median time spent in the frame was 18 weeks (range 12-37). The mean preoperative Oxford knee score was 28.7. This improved to a mean of 35.4 post-operatively (P = 0.0142). 6 (67%) patients had a documented pin-site infection. With TKR as an end point, the survival rate of HTOs was 88.9% at a median of 19 months follow-up. This study demonstrates that in selected patients the TSF provides a viable treatment option for performing HTO in medial compartment OA with varus deformity.

Introduction: The aim of this study was to characterise current rotator cuff repair activity in the UK with emphasis on the management of rotator cuff tears in the elderly population (over 70s)., Methods: A one-page web-based survey was created. All British Elbow and Shoulder Society (BESS) members and surgeons who listed the shoulder as an area of specialist interest on the website http://www.specialistInfo.com/ were invited to complete this., Results: A total of 103 surgeons completed the survey; most (n =89, 86%) were BESS members. They had spent a median of 10 years (range: 9 months - 30 years) in consultant practice and performed an annual median of 200 (range: 0-1,000) arthroscopic shoulder procedures. For rotator cuff repair the favoured method was arthroscopic for 47 consultants (46.5%), open or mini-open for 41 (40.6%) and both for 13 (12.9%). The annual median number of arthroscopic and open cuff repairs was 20 (range: 0-250) and 12 (range: 0-100) respectively. The longer the time in practice, the fewer the reported number of arthroscopic cuff repairs (r(s)=-0.22, p=0.027) and the greater the number of open and mini-open cuff repairs (r(s)=0.33, p=0.001). In the management of a full-thickness rotator cuff tear in a patient over 70 years of age, 27 (26.7%) would perform an open or mini-open repair, 43 (42.6%) an arthroscopic repair and 22 (21.8%) would not attempt a repair., Conclusions: Surgeons performing a higher volume of arthroscopic cuff repairs annually were more likely to repair cuff tears and they predicted significantly better outcomes of cuff repair for both pain and shoulder movement. Our results reflect the existing conflicting evidence regarding the indications for and methods of treatment of rotator cuff disease.

The Artelon carpometacarpal joint implant is a degradable interposition arthroplasty spacer intended for use in thumb carpometacarpal joint osteoarthritis. Recently there have been reported cases of foreign body reaction attributed to the Artelon implant, which raise concerns about the use of this implant. The implant's manufacturers claim excellent biocompatibility. We report 3 cases of persistent pain after thumb carpometacarpal joint arthroplasty performed using Artelon implants. In all 3 cases that required removal of the Artelon implant and trapeziectomy to achieve subsequent symptom relief, foreign body-type reaction associated with the Artelon was seen histologically., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Procedures performed at the incorrect anatomical site are commonly perceived as being relatively rare. However, they can be a devastating event for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong-site, wrong-procedure and wrong-patient events occur more commonly than we think. Furthermore, their incidence may be increasing as NHS Trusts increase the volume and complexity of procedures undertaken in order to cope with increasing demands on the system. In previous studies from North America orthopaedic surgery has been found to be the worst-offending specialty. In this paper we review the existing literature on wrong-site surgery and analyse data from the National Patient Safety Agency and NHS Litigation Authority on 292 cases of wrong-site surgery in England and Wales. Orthopaedic surgery accounted for 87 (29.8%) of these cases. In the year 2006 to 2007, the rate of wrong-site surgery in England and Wales was highest in orthopaedic surgery, in which the estimated rate was 1:105,712 cases.

The Thomas splint is a common piece of equipment in emergency departments and orthopaedic units in hospitals worldwide. Its basic design has changed little since its first description by Hugh Owen Thomas was published in 1875. We have reviewed the origins of the Thomas splint as a means of correction of deformities of the lower limb and its evolution through both World Wars into an essential item for the management of trauma of the lower limb.

Background: Surgical research articles utilise a variety of descriptive and inferential methods to present and analyse data. The aim of this study was to determine the appropriateness of descriptive methods (e.g. mean, median, SD, range) and survey the use of inferential methods (statistical tests) in key general surgical journals., Methods: Articles were retrieved from the first three issues of four general surgical journals (Annals of Surgery, British Journal of Surgery, The Surgeon and the Annals of the Royal College of Surgeons of England) in the year 2005. Only original articles were included. Study characteristics, use and appropriateness of descriptive statistics and the number and types of statistical methods employed were evaluated., Results: Of the 144 articles analysed, 119 made use of continuous data. Of these, the use of descriptive methods was inadequate or inappropriate in 50%. The use of '+/-' to describe data dispersion without further explanation occurred in 6.7% and standard error of mean (SEM) was inappropriately used in a further 9.2% of the articles. No statistical methods were described in 23% of the articles. The six most common tests used (Pearson's chi-square, Fisher's exact test, unpaired t test, Mann-Whitney test, log rank and the Cox proportional hazards) accounted for the majority (69%) of the statistical methods employed., Conclusion: These results highlight the need for training surgical researchers in 'data description and reporting' and for improved screening by journal reviewers/editors. Critical appraisal of surgical research can be undertaken with a comprehensive understanding of only a limited number of statistical methods.

We present results on the effects of various hydrophobic drugs and additives on the micellar structure of Pluronic F127 solutions. Small-angle neutron scattering experiments on 5wt% F127 solutions were used to measure micelle core size (R(1)), micelle corona size (R(2)), intermicellar interaction distance (R(int)), polydispersity (sigma), and aggregation number (N(agg)); dynamic light scattering was used to measure critical micelle concentration (CMC); and ultraviolet spectroscopy was used to measure drug solubility and apparent micelle-water partition coefficient (K(mw)). The core and corona size were found to generally increase in the presence of the drugs, as did R(int). Both sigma and N(agg) were found to decrease in the presence of most of the drugs, and the CMC was found to vary considerably with no clear correlation. A design of experiments (DOE) approach was used to analyze the results and build empirical correlations. All of the parameters from the SANS experiments were found to depend strongly on drug solubility, with a weak dependence on K(mw) in most cases. The aggregation number, however, was found to depend strongly on both K(mw) and solubility. The correlations can be used to roughly predict the structural parameters of F127 micelles for other hydrophobic drugs.

Methanococcus jannaschii accumulates alpha- and beta-glutamate as osmolytes. The effect of these and other solutes on the thermostability of two multisubunit metabolic enzymes from M. jannaschii, aspartate transcarbamoylase catalytic trimer (ATCase C3) and glutamine synthetase (GS), has been measured and compared to solute effects on bacterial mesophilic counterparts in order to explore if osmolytes accumulated by each organism can preferentially stabilize the proteins to thermal unfolding. For both ATCase enzymes and for the B. subtilis GS, the solutes normally accumulated by the organism were very effective in protecting the enzyme from losing activity at high temperatures, although solute effects on loss of secondary structure did not necessarily correlate with this thermoprotection of activity. The recombinant M. jannaschii GS exhibited quite different behavior. The pure enzyme had a thermal unfolding transition with a midpoint temperature (Tm) less than 60 degrees C, well under the growth temperature of the organism (85 degrees C). None of the small molecule solutes tested (including the K+-glutamate isomers accumulated by M. jannaschii) significantly stabilized the protein to incubation at 85 degrees C. Instead, protein-protein interactions, as illustrated by E. coli GroEL or ribosomal protein L2 stabilization of GS, appeared to be the dominant factor in stabilizing this archaeal enzyme at the growth temperature.

Despite improving childhood coverage of the measles-mumps-rubella vaccine (MMR) in Victoria during the 1990s, mumps and rubella notifications in age groups eligible for vaccination persisted. This study reviewed the mumps and rubella surveillance data from 1993 to 2000 with a specific focus on method of diagnosis. There were 474 notifications of mumps over the seven-year period (annual median 61, range 40 to 77) and 3,544 notifications of rubella (annual median 297, range 66 to 1,165). The highest notifications rates for mumps were consistently among the 1-4 and 5-9 year age groups, whereas there was a marked change in the age distribution of rubella notifications during this interval. A large rubella outbreak occurred in 1995 with 1,165 notifications; the highest notification rates were males aged 15-24 years, infants under one year of age (males and females), and those aged 5-14 years (males and females), respectively. The susceptibility of 5-24 year olds reflects historical changes to the Australian Standard Vaccination Schedule. Rubella notifications returned to baseline levels in 1998 with the highest notification rates in infants aged under one year, and children aged 1-4 years. For both mumps and rubella, the majority of notifications for all age groups were clinically diagnosed, and were most common in children.

In the years 1999-2000, there was an increase in the incidence of meningococcal disease in Victoria, largely caused by Neisseria meningitidis serogroup C. This change was associated with a shift in age distribution of cases, with relatively more disease appearing in the 15-29 year age group, and with 40/58 serogroup C isolates in 2000 exhibiting a new macrorestriction pattern (pattern A). Thirty-four of 52 pattern A isolates tested displayed the novel phenotype C:2a:P1.4, and were consistently porA VR type P1.7-2,4 by DNA sequencing. Nine of 10 representative pattern A isolates analysed displayed a housekeeping gene allele profile (ST-11) that is characteristic of the electrophoretic type (ET)-15 variant that has caused outbreaks in Canada, the Czech Republic and Greece. Meningococci belonging to the ST-11 complex that were isolated in Victoria prior to 1999 did not display either restriction pattern A or PorA VR type P1.7-2,4.

Methanococcus thermolithotrophicus, a thermophilic methanogenic archaeon, produces and accumulates beta-glutamate and L-alpha-glutamate as osmolytes when grown in media with <1 M NaCl. When the organism is adapted to grow in >1 M NaCl, a new zwitterionic solute, N(epsilon)-acetyl-beta-lysine, is synthesized and becomes the dominant osmolyte. Several techniques, including in vivo and in vitro NMR spectroscopy, HPLC analyses of ethanol extracts, and potassium atomic absorption, have been used to monitor the immediate response of M. thermolithotrophicus to osmotic stress. There is a temporal hierarchy in the response of intracellular osmolytes. Changes in intracellular K(+) occur within the first few minutes of altering the external NaCl. Upon hypoosmotic shock, K(+) is released from the cell; relatively small changes occur in the organic osmolyte pool on a longer time scale. Upon hyperosmotic shock, M. thermolithotrophicus immediately internalizes K(+), far more than would be needed stoichiometrically to balance the new salt concentration. This is followed by a decrease to a new K(+) concentration (over 10-15 min), at which point synthesis and accumulation of primarily L-alpha-glutamate occur. Once growth of the M. thermolithotrophicus culture begins, typically 30-100 min after the hyperosmotic shock, the intracellular levels of organic anions decrease and the zwitterion (N(epsilon)-acetyl-beta-lysine) begins to represent a larger fraction of the intracellular pool. The observation that N(epsilon)-acetyl-beta-lysine accumulation occurs in osmoadapted cells but not immediately after osmotic shock is consistent with the hypothesis that lysine 2,3-aminomutase, an enzyme involved in N(epsilon)-acetyl-beta-lysine synthesis, is either not present at high levels or has low activity in cells grown and adapted to lower NaCl. That lysine aminomutase specific activity is 8-fold lower in protein extracts from cells adapted to low NaCl compared to those adapted to 1.4 M NaCl supports this hypothesis.

The structure of the crown ether 1,8-(3,6,9-trioxaundecane-1,11-diyldioxy)-9,10-dihydro-10,10-dimethylanthracene-9-ol, C(24)H(30)O(6).H(2)O (1), code name P326, the parent compound for a series of derivatives, has been determined by both X-ray diffraction at room temperature and neutron diffraction at very low temperature. The unit cells are very similar at both temperatures and in both cases the crystals exhibit P2(1) symmetry with Z = 4 (two molecules, A and B, respectively, per asymmetric unit) and pseudosymmetry P2(1)/c. The higher symmetry is broken mainly by the two independent water molecules in the unit cell, some reflections which would be absent in P2(1)/c having strong intensities in both the X-ray and neutron data. In both molecules A and B hydrogen bonds involving the water molecule stabilize the macrocyclic ring structure, one involving the macrocyclic O(9) as a donor. Close contacts between the water and macrocyclic O atoms in each molecule also suggest the presence of two bifurcated hydrogen bonds, involving water HW2 to both O(16) and O(18), and water HW1 to both O(18) and O(20), respectively, with considerable variation in the geometry being present. Both molecules A and B exhibit very close pseudosymmetry across a plane perpendicular to the molecular plane and through atoms C(9) and O(18), and in addition are predominantly planar structures. The X-ray analysis failed to reveal one H atom per water molecule, each being subsequently included after location and refinement in the neutron analysis.

The halophilic methanogen Methanohalophilus portucalensis synthesizes three distinct zwitterions, (beta)-glutamine, N(sup(epsilon))-acetyl-(beta)-lysine (NA(beta)Lys), and glycine betaine, as osmolytes when it is grown at high concentrations of external NaCl. The selective distribution of these three species was determined by growing cells in the presence of osmolyte biosynthetic precursors. Glycine betaine is formed by the stepwise methylation of glycine. Exogenous glycine (10 mM) and sarcosine (10 mM), although internalized, do not bias the cells to accumulate any more betaine. However, exogenous N,N-dimethylglycine (10 mM) is available to the appropriate methyltransferase and the betaine generated from it suppresses the synthesis of other osmolytes. Precursors of the two zwitterionic (beta)-amino acids ((beta)-glutamate for (beta)-glutamine and (alpha)-lysine and diaminopimelate for NA(beta)Lys) have only small effects on (beta)-amino acid accumulation. The largest effect is provided by L-(alpha)-glutamine, suggesting that nitrogen assimilation is a key factor in osmolyte distribution.

During a prolonged outbreak of meningococcal disease caused by serogroup B serotype 15 sulphonamide-resistant strains in one British health district, there was considerable variation in attack rates by town. General practitioner (GP) antibiotic prescribing rates were compared in high and low incidence towns. The only significant difference found was that erythromycin prescribing was more frequent in the high incidence towns (rate ratio 4.0, 95% CI 3.2-4.8, in March 1987 and 3.0, 95% CI 2.4-3.7, in November 1987). This was probably due to increased GP consultation rates for upper respiratory tract infection (URTI), but higher erythromycin usage may have increased meningococcal acquisition rates or susceptibility to meningococcal disease. Antibiotic prescribing rates should be further investigated in defined areas of high and low incidence of meningococcal disease.