Tibiotalocalcaneal arthrodesis with an intramedullary device

An intramedullary fixation device was devised by the senior author (K.A.J.) to use in conjunction with a previously described method for tibiotalocalcaneal arthrodesis. Satisfactory results were obtained in approximately 87% of the initial 30 patients; union was radiographically or clinically evident in all but two patients. Many of these patients had been offered or were considering below the knee amputation; only two ultimately chose this reconstructive option at a follow-up that ranged from 4 to 27 months.

The potential for hormonal prevention trials

Breast and prostate cancer are significant causes of morbidity and mortality and are very similar in etiology, epidemiology, and modalities of treatment. Investigational strategies in the prevention of these malignancies also have strong parallels. The National Cancer Institute is sponsoring several large scale clinical trials involving hormonal manipulation and cancer prevention. In the Breast Cancer Prevention Trial, 16,000 women at high risk for breast cancer are being randomized to receive the antiestrogen agent tamoxifen or placebo for 5 years in an effort to determine if breast cancer development can be inhibited. In a similar trial, the Prostate Cancer Prevention Trial, 18,000 men older than 55 years of age will be randomized to receive finasteride, a 5-alpha-reductase inhibitor, or placebo to determine if inhibition of dihydrotestosterone synthesis in the prostate over a prolonged period will lead to a decreased incidence of prostate cancer. Both clinical trials offer the possibility of demonstrating that a hormonal intervention can decrease an individual's risk of developing breast or prostate cancer. They also have the potential of providing critical information about cancer risk, etiology, screening, and genetics, as well as quantifying the risks and benefits of specific preventive interventions.

Lisinopril overdose and management with intravenous angiotensin II

OBJECTIVE

This report describes a case of lisinopril overdose managed in part with an infusion of angiotensin II in a patient with dilated cardiomyopathy and reviews other literature reporting angiotensin-converting enzyme (ACE) inhibitor overdose.

DATA SOURCES

Information concerning this patient was obtained through review of the medical chart, conversation with the attending physician, and personal involvement late in the course of the patient's therapy. We conducted MEDLINE and PAPERCHASE searches of the English language literature (restricted to human studies) from 1976 to the present, manually searched Current Contents and references from each publication reviewed, and contacted the manufacturer of lisinopril for any further references they could provide.

STUDY SELECTION

All case reports that described an ACE inhibitor overdose.

DATA EXTRACTION

Case reports were evaluated for the ACE inhibitor involved, amount ingested, and therapeutic management.

DATA SYNTHESIS

Ten patients with ACE inhibitor overdose have been reported, most of whom required only intravenous fluids for blood pressure support. The case presented here is the second report in which the patient's blood pressure was not adequately controlled with fluid and traditional vasopressors and required an infusion of angiotensin II.

CONCLUSIONS

Although only a few cases of ACE inhibitor overdose have been reported, it is possible that with widespread use of these agents, overdose may become a more common problem. Management of ACE inhibitor overdose should include general supportive care, gut decontamination when possible, intravenous fluids, and vasopressors if necessary. Intravenous angiotensin II may be effective in situations in which traditional vasopressors fail, and is a physiologically rational treatment.

Biomechanical study of canine spinal fracture fixation using pins or bone screws with polymethylmethacrylate

Five configurations of pins or screws interconnected with polymethylmethacrylate (PMMA) were applied to isolated canine lumbar spines (L2 to L5) in which a complete fracture-luxation had been produced at L3 to L4. Twenty-five repaired spines and five intact control spines were subjected to four-point bending and tested once to failure in ventral flexion. The purpose of this study was to determine the effects of pin number, pin angle, and use of 3.5-mm cortical bone screws instead of smooth 3.2-mm diameter pins on rigidity and ultimate strength of spinal fractures repaired by the implant-PMMA fixation technique. Bending moment versus the angular deformation curves were recorded. Rigidity, bending moment at 10 degrees angular deformation, moment at failure, and deformation at failure of each type of fixation were compared using analysis of variance. Spinal segments stabilized with eight pin-PMMA fixation had significantly greater rigidity and strength at failure than four pin-PMMA fixations (P < .05). Furthermore, spinal segments stabilized with eight pins angled away from the fracture failed at significantly greater bending moment than those with eight pins angled toward the fracture (P < .05). However, for four-pin fixation, greater strength was achieved by angling pins in the bone toward the fracture site (P < .05). Screw-PMMA fixations failed by screw bending and were less rigid and weaker at failure than the corresponding configuration of pin-PMMA fixation (P < .05).

Circadian clock locus frequency: protein encoded by a single open reading frame defines period length and temperature compensation

The frequency (frq) locus encodes a key component, a state variable, in a cellular oscillator generating circadian rhythmicity. Two transcripts have been mapped to this region, and data presented here are consistent with the existence of a third transcript. Analysis of cDNA clones and clock mutants from this region focuses attention on one transcript encoding a protein. FRQ, which is a central clock component: (i) mutations in all of the semidominant frq alleles are the result of single amino acid substitutions and map to the open reading frame (ORF) encoding FRQ; (ii) deletion of this ORF, or a frameshift mutation within it, results in a strain with a recessive clock phenotype characterized by the loss of rhythm stability and compensation. Single amino acid substitutions within, or disruption of, this single ORF are thus sufficient to drive major alterations in both period length and temperature compensation, two canonical characteristics of circadian systems. The 989-amino acid FRQ protein species the circadian function of frq in the assembly of the Neurospora biological clock.

Error-prone replication of repeated DNA sequences by T7 DNA polymerase in the absence of its processivity subunit

We have examined the effect of thioredoxin, an accessory protein that confers high processivity to bacteriophage T7 DNA polymerase, on the fidelity of DNA synthesis. In the presence of thioredoxin, exonuclease-proficient T7 DNA polymerase is highly accurate. In fidelity assays that score errors that revert M13mp2 lacZ alpha-complementation mutants, error rates are < or = 2.2 x 10(-6) for base substitution and < or = 3.7 x 10(-7) and < or = 4.5 x 10(-7) for frameshifts that revert mutations in the +1 and -1 reading frames, respectively. Rates are more than 10-fold higher during synthesis by polymerase.thioredoxin complex lacking 3'-->5' exonuclease activity, demonstrating that frameshift as well as substitution errors are subject to proofreading. The contribution of thioredoxin to accuracy has been examined by comparing the fidelity of the exonuclease-deficient polymerase in the presence or absence of the accessory protein. Thioredoxin either enhances or reduces fidelity, depending on the type of error considered. In the absence of thioredoxin, T7 DNA polymerase is 3-fold more accurate for base substitutions and > or = 27-fold and 9-fold more accurate, respectively, for 1- and 2-nt deletion errors at nonreiterated nucleotide sequences. Higher fidelity for all three errors may reflect the inability of the polymerase to continue synthesis from the premutational intermediates in the absence of the accessory protein. In marked contrast, the rate for frameshift errors wherein one or more nucleotides has been added to a repeated DNA sequence increases 46-fold when thioredoxin is absent from the polymerization reaction. The error rate increases as the length of the repeated sequence increases, consistent with a model where strand slippage creates misaligned template-primers. Thus, replicative expansion of repetitive sequences occurs in the absence of a replication accessory protein.

Localization of a kinesin-related protein to the central pair apparatus of the Chlamydomonas reinhardtii flagellum

Affinity-purified polyclonal antibodies raised against the conserved motor domain of Drosophila kinesin (alpha HD) recognized a 110 kDa component of the Chlamydomonas flagellar axoneme. Whole-mount immunogold labeling of splayed axonemes showed the striking localization of this antigen along one of the two microtubules of the central pair apparatus. Interestingly, the alpha HD antigen was also localized along the central axis of mutant axonemes lacking the central pair microtubules. These results suggest that a 110 kDa kinesin-related protein is a structural component of the flagellar central pair apparatus and that it is correctly targeted even in the absence of the central pair microtubules.

A neural network classifier for cerebral perfusion imaging

Artificial neural networks have been applied to a variety of pattern recognition tasks in medical imaging and have been shown to be a powerful classification tool. The potential usefulness to discriminate normal from abnormal cerebral perfusion patterns was investigated.

METHODS

Cerebral perfusion imaging with 99mTc-labeled hexamethylpropyleneimine oxime was performed on 52 normal control subjects, 29 patients with clinically diagnosed Alzheimer's disease (AD) and 25 patients with chronic cocaine polydrug abuse. Each study was registered and scaled to a common anatomic coordinate system, yielding 120 standardized cortical regions. A back-propagation neural network classifier based on regional perfusion was used to classify normal and abnormal perfusion patterns. The neural network was trained to discriminate patients with AD from age-matched normal controls and cocaine polydrug abuse patients from normal controls. The performance of the neural network in these two tasks was evaluated quantitatively by receiver operating characteristic (ROC) analysis using cross-validation.

RESULTS

For patients with AD, the area under the ROC curve was 0.93 +/- 0.04. When testing with the cocaine polydrug abuser data, the area under the ROC curve was 0.89 +/- 0.04.

CONCLUSION

Neural networks provide a potentially useful tool in the decision-making task to discriminate patients with AD and cocaine abuse from normal controls.

Negative feedback defining a circadian clock: autoregulation of the clock gene frequency

The frequency (frq) locus of Neurospora crassa was originally identified in searches for loci encoding components of the circadian clock. The frq gene is now shown to encode a central component in a molecular feedback loop in which the product of frq negatively regulated its own transcript, which resulted in a daily oscillation in the amount of frq transcript. Rhythmic messenger RNA expression was essential for overt rhythmicity in the organism and no amount of constitutive expression rescued normal rhythmicity in frq loss-of-function mutants. Step reductions in the amount of FRQ-encoding transcript set the clock to a specific and predicted phase. These results establish frq as encoding a central component in a circadian oscillator.

Effect of platelet-derived growth factor on tibial osteotomies in rabbits

The effect of exogenous platelet-derived growth factor (PDGF) BB on bone healing was tested in a pilot study using a unilateral tibial osteotomy in rabbits. Each osteotomy was injected with collagen or collagen containing 80 micrograms of PDGF. At 28 days, both tibiae from each rabbit were harvested and subjected to three-point bending to failure. The effect upon bone healing was tested by comparing the healing rates of PDGF-treated and -nontreated osteotomies with their respective normal contralateral bones. Three animals died before 28 days. The remaining 6 experimental and 5 control animals were available for assessment. Radiographically, at 2 weeks and 4 weeks, there was a clear increase in callus density and volume around the PDGF-treated osteotomies compared with the control rabbits' osteotomies. Osteotomies treated with PDGF were not statistically different in strength from their nonoperated contralateral bones. In the control group, however, the osteotomies were statistically weaker than their nonoperated (contralateral) bones. Microscopically, it was generally observed that PDGF-treated tibiae displayed a more florid and advanced state of osteogenic differentiation, both endosteally and periosteally, than the control osteotomies. Radiographic, mechanical, and histopathological data suggest that exogenous PDGF has a stimulatory effect on fracture healing.

Pre-steady-state kinetics of the microtubule-kinesin ATPase

The pre-steady-state kinetics of the microtubule-kinesin ATPase were investigated by chemical-quench flow methods using the Drosophila kinesin motor domain (K401) expressed in Escherichia coli [Gilbert, S. P., & Johnson, K. A. (1993) Biochemistry 32, 4677-4684]. The results define a minimal mechanism: M.K + ATP in equilibrium with (M).K.ATP in equilibrium with (M).K.ADP.Pi in equilibrium with M.K.ADP + Pi in equilibrium with M.K + ADP, where M, K, and Pi represent microtubules, kinesin, and inorganic phosphate, respectively, with k+1 = 0.8-3 microM-1 s-1, k-1 = 100-300 s-1, k+2 = 70-120 s-1, k+4 = 10-20 s-1, and k+3 >> k-2 and k+3 >> k+4. Conditions were as follows: 25 degrees C, 20 mM HEPES, pH 7.2 with KOH, 5 mM magnesium acetate, 0.1 mM EDTA, 0.1 mM EGTA, 50 mM potassium acetate, 1 mM DTT. The experiments presented do not determine the step in the cycle where kinesin dissociates from the microtubule or the step at which kinesin reassociates with the microtubule; therefore, the steps that may represent kinesin as the free enzyme are indicated by (M). A burst of ADP product formation was observed during the first turnover of the enzyme in the acid-quench experiments that define the ATP hydrolysis transient. The observation of the burst demonstrates that product release is rate limiting even in the presence of saturating microtubule concentrations. The pulse-chase experiments define the time course of ATP binding to the microtubule-K401 complex. At low ATP concentrations, ATP binding limits the rate of the burst. However, at high concentrations of ATP, ATP binding is faster than the rate of ATP hydrolysis with k+2 = 70-120 s-1. The amplitude of the burst of the ATP binding transient reached a maximum of 0.7 per site at saturating concentrations of ATP and microtubules. The amplitude of less than 1 is attributed to the fast k(off) for ATP (k-1 = 100-300 s-1) that leads to a partitioning of the M.K.ATP complex between ATP hydrolysis (k+2) and ATP release (k-1). These results indicate that ATP binds weakly to the M.K complex (Kd,ATP app approximately 100 microM). ADP release (k+4 = 10-20 s-1) is rate limiting during steady-state turnover, indicating that microtubules activate the kinesin ATPase by increasing k(off),ADP from 0.01 s-1 in the absence of microtubules to 10-20 s-1 at saturating microtubule concentrations.

Drinking-induced blackouts among young adults: results from a national longitudinal study

Amnesia drinking episodes among a national probability sample of 12,686 young adults are examined at two points in their lives: when they were ages 19 to 26 in 1984 and 23 through 30 in 1988. Prospective blackout patterns of early onset, late onset, chronicity, and remission were analyzed using logistic regression statistical models. Results indicate that the relative risk of short-term memory loss while drinking is significantly associated with increased alcohol consumption, age of drinking onset, the number of alcoholic relatives, and, principally, with the individual's capacity to control drinking behavior. It is concluded that the blackout remission rate observed among a substantial proportion (68%) of young adults may not fit the progressive, irreversible model of alcoholism.

Offspring of women infected with varicella during pregnancy: a prospective study

Despite the well-recognized association between maternal varicella infection and a specific pattern of malformation in the offspring referred to as fetal varicella syndrome, the full spectrum of this disorder as well as its frequency in the offspring of women infected with varicella during pregnancy is unknown. In order to resolve these issues, we have evaluated pregnancy outcome in 194 women who contacted us during pregnancy, soon after the onset of their infection: 132 (68%) during the 1st trimester and 171 (88%) prior to the onset of the 20th week, the most critical period relative to fetal susceptibility. Of those 171 women, there were 146 liveborn babies, 6 spontaneous abortions, 7 therapeutic abortions (one because of an anencephalic fetus), 2 stillborn infants, and nine pregnancies lost to follow-up. Of the 146 liveborn births, there were 2 with features consistent with the fetal varicella syndrome: one a child with mild cutaneous scars on her face, arms, and legs, Horner syndrome involving her left eye and a scar on her retina, leading to blindness in that eye; and the other, a child with horizontal nystagmus who is otherwise normal at 1 year of age. An additional four liveborn infants had a single major malformation which included unilateral microtia, bowel obstruction secondary to an ileal band, bilateral double ureters, and a thyroglossal duct cyst. This study suggests that prenatal varicella infection is associated with a wider spectrum of severity than has been previously appreciated and indicates that maternal varicella infection prior to the 20th week of pregnancy is associated with only a small risk for the developing fetus.

Overview of U.S. National Cancer Institute (USNCI) chemoprevention research

The National Cancer Institute's (NCI) chemoprevention plan employs a strategy of basic and epidemiologic studies, followed by a structured preclinical process to bring chemopreventive agents into clinical testing. The field of chemoprevention is progressing rapidly and has reached the point where a coordinated international approach for large-scale trials would be useful. At present, NCI is sponsoring nine large trials (over $1 million per year per trial); in addition, nine agents are in phase I or II clinical testing. A number of these agents should be ready soon for phase III testing. Resources required for large-scale trials compel greater attention to efficient trial design, concept development and review, priority setting, management, budgeting, and collaboration.

Diurnal variations of serotonin and dopamine levels in discrete brain regions of Syrian hamsters and their modification by chronic clorgyline treatment

In Syrian hamsters, chronic administration of the type A monoamine oxidase inhibitor, clorgyline (CLG), alters the intrinsic period and daily pattern of the circadian rhythm of wheel running, and changes the intensity-response curve for phase-shifting of the rhythm by light pulses. Chronic treatment with CLG also decreases hypothalamic and peritoneal temperatures, particularly during the rest phase of the activity-rest cycle. To help identify monoamines that may mediate CLG's effects on circadian rhythms, we measured levels of dopamine (DA) and serotonin (5-HT) at nine time points over a 24-h period in micro-dissected brain regions in chronic CLG-treated or saline-treated hamsters. For 5-HT, a diurnal variation was detected in all regions in saline-treated animals; for DA, no diurnal variation was detected in any region. In all regions, 5-HT levels and, to a lesser extent, DA levels were higher after CLG treatment. The acrophase of the 5-HT rhythm in the suprachiasmatic nucleus (SCN) was delayed by CLG-treatment, while the acrophase in the dorsal raphe nucleus was unchanged. The diurnal variation of 5-HT in the paraventricular nucleus of the hypothalamus, medial preoptic area, and median raphe nuclei was no longer detectable after chronic CLG-treatment. The phase-delay induced by CLG treatment in the daily rhythm of serotonin levels in the SCN, which functions as a circadian pacemaker, may be an important mechanism underlying the drug's capacity to slow the intrinsic rhythm of the pacemaker and to phase-delay behavioral rhythms that are under its control.

Quantitative brain SPECT in Alzheimer's disease and normal aging

To improve the diagnostic utility of brain single-photon emission computed tomography (SPECT) in Alzheimer's disease (AD), we have developed and evaluated an objective method of differentiating patients and healthy elderly controls using a quantitative image analysis protocol. HMPAO-SPECT image datasets from 29 patients with probable AD and 78 age-matched controls were registered to a common anatomic frame of reference. Activity levels within 120 standardized cortical volumes were determined by an automated procedure. Subjects were classified into normal and AD groups by quadratic discriminant analysis using two features: global average activity level and average normalized activity levels within the two clusters of standardized volumes identified as most significantly different in AD by analysis of covariance. The classification used split-half replication to ensure valid results. Classification performance quantified by the area under a binormal ROC curve fitted to the data was 0.923 +/- 0.036; at a threshold likelihood ratio of 1, the sample sensitivity was 91% and specificity was 86%. We conclude that quantitative SPECT accurately distinguishes AD patients from elderly controls.

Kinetic analysis of manganese peroxidase. The reaction with manganese complexes

Manganese peroxidase from the lignin-degrading fungus Phanerochaete chrysosporium catalyzes the H2O2-dependent oxidation of Mn2+ to Mn3+. Presteady-state methods were employed to characterize the reactions of free and chelated Mn2+ with the 2-electron and 1-electron oxidized forms of the enzyme, compounds I and II, respectively. At pH 4.5, the optimum pH for steady-state turnover, the reaction of compound I with Mn2+, either free or complexed, is too rapid to measure by stopped flow methods. The reactions of compound I with Mn2+ can only be monitored under non-optimal conditions of pH 2.5. The reaction of compound II with Mn2+ is much slower than compound I. Chelators such as oxalate, lactate, and malonate facilitated the reaction of Mn2+ with compound II. In contrast, succinate, which does not readily form a complex with Mn2+, and polyglutamate, which is polymeric, were ineffective in stimulating the reaction of Mn2+ with compound II. The 1:1 chelator-Mn2+ complex is the preferred substrate for compound II; this conclusion is based on known formation constants for the various Mn2+ complexes. Steady-state kinetics studies were performed by directly measuring the initial rate of Mn3+ formation. The kcat values for the formation of Mn(3+)-oxalate, Mn(3+)-lactate, and Mn(3+)-malonate are 308, 211, and 220 s-1, respectively. The Km values for Mn(2+)-oxalate, Mn(2+)-lactate, and Mn(2+)-malonate are 13, 41, and 18 microM, respectively. These results collectively indicate that manganese peroxidase does not readily oxidize free (hexa-aquo) Mn2+ as previously proposed (Wariishi, H., Valli, K., and Gold, M. H. (1992) J. Biol. Chem. 267, 23688-23695), but the Mn2+ has to be chelated to support steady-state turnover.

Cooperative and anticooperative binding to a ribozyme

The effects of guanosine 5'-monophosphate and 2'-deoxyguanosine 5'-monophosphate on the thermodynamics and kinetics of pyrene-labeled 5' exon mimic (pyCUCU) binding to the catalytic RNA (ribozyme) from Tetrahymena thermophila have been determined by fluorescence titration and kinetics experiments at 15 degrees C. pyCUCU binding to L-21 Sca I-truncated ribozyme is weaker by a factor of 5 in the presence of saturating guanosine 5'-monophosphate, whereas it is 4-fold stronger in the presence of saturating 2'-deoxyguanosine 5'-monophosphate. Results from kinetics experiments suggest that anticooperative effects in the presence of guanosine 5'-monophosphate arise primarily from slower formation of tertiary contacts between the catalytic core of the ribozyme and the P1 duplex formed by pyCUCU and GGAGGG of the ribozyme. Conversely, cooperative effects in the presence of 2'-deoxyguanosine 5'-monophosphate arise primarily from slower disruption of tertiary contacts between the catalytic core of the ribozyme and the P1 duplex. Additional experiments suggest that these cooperative and anticooperative effects are not a function of the pyrene label, are not caused by a salt effect, and are not specific to one renaturation procedure for the ribozyme.

The Rochester bone trephine for small joint arthrodesis in the foot

The Rochester bone trephine is a useful instrument for performing small joint arthrodesis in the foot. The technique involves harvesting a dowel graft from the iliac crest and then inserting the graft into a recipient bed across the small joints in the foot. Minimal surgical trauma and patient discomfort result from this technique. Three cases are presented to illustrate the usefulness and diversity of this system.

Thallium-201 technetium-99m HMPAO single-photon emission computed tomography (SPECT) imaging for guiding stereotactic craniotomies in heavily irradiated malignant glioma patients

SPECT scanning with Tl-201 and Tc-99m offers a unique, inexpensive functional imaging modality to combine with CT stereotactic craniotomy for guiding resection of necrosis and/or tumour in patients treated with escalated doses of radiation (> 6000 cGy) by either brachytherapy or radiosurgery. Thirty-two cases were analyzed, with a detailed description of the imaging and operative techniques.

Circadian rhythms

Circadian rhythms are a ubiquitous adaptation of eukaryotic organisms to the most reliable and predictable of environmental changes, the daily cycles of light and temperature. Prominent daily rhythms in behavior, physiology, hormone levels and biochemistry (including gene expression) are not merely responses to these environmental cycles, however, but embody the organism's ability to keep and tell time. At the core of circadian systems is a mysterious mechanism, located in the brain (actually the suprachiasmatic nucleus of the hypothalamus) of mammals, but present even in unicellular organisms, that functions as a clock. This clock drives circadian rhythms. It is independent of, but remains responsive to, environmental cycles (especially light). The interest in temporal regulation--its organization, mechanism and consequences--unites investigators in diverse disciplines studying otherwise disparate systems. This diversity is reflected in the brief reviews that summarize the presentations at a meeting on circadian rhythms held in New York City on October 31, 1992. The meeting was sponsored by the Fondation pour l'Etude du Système Nerveux (FESN) and followed a larger meeting held 18 months earlier in Geneva, whose proceedings have been published (M. Zatz (Ed.), Report of the Ninth FESN Study Group on 'Circadian Rhythms', Discussions in Neuroscience, Vol. VIII, Nos. 2 + 3, Elsevier, Amsterdam, 1992). Some speakers described progress made in the interim, while others addressed aspects of the field not previously covered.