Meniscal repair in the goat model. The use of healing adjuncts on central tears and the role of magnetic resonance arthrography in repair evaluation

We evaluated the effect of adjunctive healing measures on central tears of the adult goat medial meniscus and the role of magnetic resonance arthrography in the assessment of menisci that have undergone a repair. Peripheral tears were made unilaterally in the medial menisci of seven goats in Group I and repaired with nonabsorbable suture. Six Group II goats had central medial meniscal tears repaired as in Group I plus an exogenous fibrin clot. Eight Group III goats had central tears plus abrasion of the parameniscal synovium and tear edges. Six months after surgery, a magnetic resonance imaging scan and a magnetic resonance arthrogram were obtained and the menisci were examined grossly. Group I goats showed healing in all seven knees. Central tears repaired with a fibrin clot (Group II) showed healing in one of six knees (17%). Central tears repaired with abrasion (Group III) showed healing in seven of eight knees (87.5%). Magnetic resonance arthrography was 100% accurate in detecting the presence or absence of complete residual tears. This study supports the current trend of using adjunctive measures for repair of central tears. Furthermore, abrasion of the parameniscal synovium and the tear edges appears to be more effective than the use of an exogenous fibrin clot. Magnetic resonance arthrography is useful in the evaluation of menisci that have undergone repair.

Sequence profiles of immunoglobulin and immunoglobulin-like domains

Immunoglobulins (Ig) are highly modular proteins, consisting of variable and constant domains, which have clear, conserved sequence patterns. These sequence patterns have allowed T-cell receptor (TCR) and major histocompatibility complex (MHC) molecule domains, as well as some cell adhesion, cell surface receptor and muscle protein domains, to be identified as forming a superfamily of related proteins together with the Ig-domains. The domains of these proteins have been grouped into four sets: variable (V-set), constant-1 (C1-set), constant-2 (C2-set) and intermediate (I-set). X-ray and NMR studies have shown that these domains form a Greek-key beta-sandwich structure with the sets differing in the number of strands in the beta-sheets as well as in their sequence patterns. The conserved sequence elements in the major sets of Ig and Ig-like molecules have previously been reported as general sequence profiles. This work examines the variability within these sets. Detailed sequence profiles and consensus sequences for these sets and groups have been constructed and a novel form of presentation has been developed to overcome some of the drawbacks of current methods of presenting consensus sequences. The profiles that were constructed allow a comparison of the similarities and differences among the sets of Ig and Ig-like sequences and provide a means by which sequences can be tested for compatibility with Ig-like sequence motifs. As well, the sequence separations of the main residues in the characteristic "pin" structure of Ig-like molecules were examined for variation among the groups. From the profiles constructed here, measures of the degree of conservation within the groups of molecules were determined. These measures were used to assist in a reconsideration of possible evolutionary pathways between the major structural groups of the Ig-superfamily.

Identification of a ligand-binding site on the granulocyte colony-stimulating factor receptor by molecular modeling and mutagenesis

Granulocyte colony-stimulating factor (G-CSF) initiates its effects on cells of the neutrophil lineage by inducing formation of a homodimeric receptor complex. The structure of the G-CSF receptor has not yet been determined, therefore we used molecular modeling to identify regions of the receptor that were likely to be involved in ligand binding. The G-CSF receptor sequence was aligned with all the available sequences of the gp130 and growth hormone receptor families and a model of the cytokine receptor homologous domain was constructed, based on the growth hormone receptor structure. Alanine substitution mutagenesis was performed on loops and individual residues that were predicted to bind ligand. Mutant receptors were expressed in factor-dependent Ba/F3 cells and assessed for proliferation response and ligand binding. Six residues were identified that significantly reduced receptor function, with Arg288 in the F'-G' loop having the greatest effect. These residues formed a binding face on the receptor model resembling the growth hormone receptor site, which suggests that the model is reasonable. However, electrostatic analysis of the model provided further evidence that the mechanism of receptor dimerization is different from that of the growth hormone receptor.

Interleukin-4 or interleukin-10 expressed from adenovirus-transduced syngeneic islet grafts fails to prevent beta cell destruction in diabetic NOD mice

BACKGROUND

We performed ex vivo adenoviral gene transfer in a mouse pancreatic islet transplant model to test the efficacy of this expression system. We then determined whether adenoviral-mediated expression of mouse interleukin (IL) 4 or IL-10 from transduced syngeneic islet grafts could prevent disease recurrence in diabetic nonobese diabetic (NOD) mice.

METHODS

An adenoviral vector expressing beta-galactosidase (AdCMV betaGal) was used to transduce BALB/c islets (2.5 x 10(3) plaque-forming units/islet), which were analyzed for glucose responsiveness, islet cell recovery, and efficiency of gene transfer. In vivo function and reporter gene expression were examined with AdCMV betaGal-transduced islet grafts in alloxan-induced diabetic syngeneic recipients. Adenoviruses expressing either IL-4 or IL-10 were used in a similar fashion to infect NOD islets, which were characterized in vitro, as well as transplanted into diabetic syngeneic recipients.

RESULTS

In vitro functional studies showed no significant difference between control or transduced islets, with 50+/-4% of AdCMV betaGal-infected islet cells staining positive for beta-galactosidase. Transplant recipients became nomoglycemic within 48 hr after transplant, and, although beta-galactosidase expression decreased over time, it was detectable in the graft for up to 8 weeks. Despite the nanogram quantities of IL-4 or IL-10 produced/day from each graft equivalent in vitro, transduced and transplanted NOD islets failed to prevent disease recurrence.

CONCLUSIONS

These results suggest that adenoviruses are efficient for at least medium term gene expression from islets in vivo, but neither IL-4 nor IL-10 alone can prevent autoimmune disease recurrence in NOD mice.

Design and baseline participant characteristics of the Human Immunodeficiency Virus Epidemiology Research (HER) Study: a prospective cohort study of human immunodeficiency virus infection in US women

The prospective, multisite human immunodeficiency (HIV) Epidemiology Research Study was established to define the biologic, psychologic, and social effects of HIV infection on the health of US women. From 1993 to 1995, a total of 871 HIV-infected women and 439 demographically matched, uninfected women aged 16-55 years, half of whom reported injection drug use and half of whom reported only sexual risk behaviors, were recruited in four US cities. Two sites recruited primarily from medical/drug therapy care settings, and two recruited from community sources. Women consented to biannual interviews; physical examination; blood, urine, and cervicovaginal specimen collection and repository; laboratory assays; and abstraction of outpatient and inpatient medical records to document HIV and acquired immunodeficiency syndrome-related diagnoses. Retention was greater than 88% at the third 6-month follow-up. Lower retention was associated with currently injecting drugs, not having dependent children, and not being infected with HIV at enrollment. In addition to the core study, a variety of nested studies are under way, some in collaboration with other HIV cohorts and various Public Health Service agencies. This cohort is distinct from other HIV longitudinal cohorts in the diversity of its participants and the comprehensive range of measures to study prospectively the biomedical, social, and emotional effects of the HIV epidemic on infected women and those whose behavior puts them at high risk of infection.

Interleukin-6: structure-function relationships

Interleukin-6 (IL-6) is a multifunctional cytokine that plays a central role in host defense due to its wide range of immune and hematopoietic activities and its potent ability to induce the acute phase response. Overexpression of IL-6 has been implicated in the pathology of a number of diseases including multiple myeloma, rheumatoid arthritis, Castleman's disease, psoriasis, and post-menopausal osteoporosis. Hence, selective antagonists of IL-6 action may offer therapeutic benefits. IL-6 is a member of the family of cytokines that includes interleukin-11, leukemia inhibitory factor, oncostatin M, cardiotrophin-1, and ciliary neurotrophic factor. Like the other members of this family, IL-6 induces growth or differentiation via a receptor-system that involves a specific receptor and the use of a shared signaling subunit, gp130. Identification of the regions of IL-6 that are involved in the interactions with the IL-6 receptor, and gp130 is an important first step in the rational manipulation of the effects of this cytokine for therapeutic benefit. In this review, we focus on the sites on IL-6 which interact with its low-affinity specific receptor, the IL-6 receptor, and the high-affinity converter gp130. A tentative model for the IL-6 hexameric receptor ligand complex is presented and discussed with respect to the mechanism of action of the other members of the IL-6 family of cytokines.

MR imaging of musculoskeletal tumors and tumor mimickers with intravenous gadolinium: experience with 242 patients

PURPOSE

This pictorial essay reviews our experience with MR scans with gadolinium in patients with musculoskeletal tumors and tumor mimickers.

DESIGN

Review of 242 MR scans obtained in the initial evaluation of a possible primary musculoskeletal neoplasm. All scans included a T1-weighted, fat-suppressed sequence following intravenous administration of gadolinium.

RESULTS

MR scans with gadolinium did not contribute to differential diagnosis or patient management in 89% of the patients in this series. However, intravenous gadolinium did assist in guiding the biopsy of bulky lesions and evaluating treated tumor beds for possible recurrence. MR scans with gadolinium were sometimes helpful when the differential diagnosis included synovitis, Morton's neuroma or intramuscular myxoma, and when it was important to differentiate cystic from solid lesions.

CONCLUSIONS

Routine use of gadolinium in every initial MR examination of a possible musculoskeletal mass is not warranted. However, there are appropriate selected indications for gadolinium administration as outlined above.

Host genes and HIV: the role of the chemokine receptor gene CCR5 and its allele

Since the late 1970s, 8.4 million people worldwide, including 1.7 million children, have died of AIDS, and an estimated 22 million people are infected with human immunodeficiency virus (HIV)(1). During 1995 and 1996, major clinical and laboratory discoveries regarding HIV pathogenesis provided new hope for the prevention and treatment of HIV infection. One major discovery was that members of the chemokine receptor family serve as cofactors for HIV entry into cells. We describe the role of allelic polymorphism in the gene coding for the CCR5 chemokine receptor with regard to susceptibility to and disease course of HIV infection. We also examine the effect of this discovery on medical and public health practices.

Anatomic significance of magnetic resonance imaging findings in hip fracture

This study was done to determine the histologic etiology for the linear black signal seen on magnetic resonance imaging at the site of proximal femoral fractures. No previous satisfactory explanation for this black line exists in the literature. To determine the pathologic etiology of this linear black signal, the magnetic resonance imaging appearances of osteotomies and fractures of proximal femora were correlated with gross and histologic appearances in 12 freshly frozen porcine hips. In phase 1, a unilateral femoral neck osteotomy was performed in 1 hip, and a sham operation was performed on the contralateral hip. The radiologist was able to easily determine the site and side of the osteotomy using magnetic resonance imaging. In phase 2, the remaining 8 femoral specimens were stressed using the 1125 Instron Materials Testing Machine in a compression mode. In the 8 specimens, 4 fractures were created that were visible on magnetic resonance imaging and plain radiographs; 2 fractures were apparent only on magnetic resonance images, and 2 specimens did not have fractures identified by plain radiographs or magnetic resonance images. Gross and microscopic analysis of the specimens confirmed the magnetic resonance imaging findings in all 8 cases (6 fractures and 2 nonfractures). Histologic evaluation showed trabecular impaction at the 6 fracture sites corresponding to the linear black signal on magnetic resonance images. No edema or hemorrhage was present in these postmortem specimens. The authors conclude that the low signal band seen with proximal femoral fractures is produced by impaction of the trabecular bone and is not the result of perifracture edema or hemorrhage.

Sublabral recess of the superior glenoid labrum: study of cadavers with conventional nonenhanced MR imaging, MR arthrography, anatomic dissection, and limited histologic examination

PURPOSE

To evaluate size, location, and appearance of the sublabral recess of the superior glenoid labrum, which mimics a superior labral tear oriented in the anterior to posterior direction (SLAP) lesion with conventional magnetic resonance (MR) imaging, MR arthrography, gross dissection, and limited histologic evaluation.

MATERIALS AND METHODS

Twenty-six cadaveric shoulder specimens that were freshly frozen were examined with nonenhanced MR imaging and with MR arthrography after intraarticular injection of dilute contrast material with gadolinium. In all specimens, the appearance of the superior glenolabral junction was categorized and was correlated to that seen at gross anatomic dissection. Histologic sections were obtained of two shoulders with large sublabral recesses in the plane of the MR sections.

RESULTS

A sublabral recess was present in 19 (73%) shoulders and was deeper than 2 mm in 10 (39%). MR arthrography better demonstrated the sublabral recess than nonenhanced MR imaging. In 16 of 19 shoulders, the sublabral recess was located in the most anterior section obtained through the superior labrum. There was no definite correlation between subject age and sex and glenolabral junction type. At histologic examination of the two shoulders, a synovial lining of the sublabral recess was seen and there was no evidence of fibrosis to suggest a traumatic cause.

CONCLUSION

A sublabral recess is common in cadaveric shoulders and has an appearance similar to that of published examples of SLAP lesions. Histologic findings were consistent with normal anatomic structure rather than with acquired, posttraumatic lesions.

Coccidioidomycosis in patients infected with human immunodeficiency virus: review of 91 cases at a single institution

We retrospectively evaluated the clinical manifestations, diagnosis, treatment, and outcome of coccidioidomycosis in 91 patients infected with human immunodeficiency virus (HIV) at a single institution. Coccidioidomycosis was the AIDS-defining illness in 37 patients. Fever and chills, weight loss, and night sweats were the most frequent symptoms. The lung was the most frequently involved organ (80%), followed by the meninges (15%). A diffuse reticulonodular infiltrate was seen in 59 patients (65%), and 13 (14%) had focal pulmonary disease; for 15 patients (16%), the chest radiograph was normal. Coccidioidal serologies were positive for 60 patients (68%), while for 23% with proven coccidioidomycosis such tests were negative Most patients were treated with systemic amphotericin B and then an oral azole. The mortality for the whole group was 60%. Patients with diffuse pulmonary disease had the highest mortality (68%), with a median duration of survival of 54 days (P < .05; 95% confidence interval, 147-175 days). The presence of diffuse pulmonary disease and a CD4 lymphocyte count of < 50/microL were independent predictors of death. In our experience, coccidioidomycosis is an important opportunistic infection that causes substantial morbidity and mortality among HIV-infected patients living in an area of endemicity.

MR imaging of occult traumatic fractures and muscular injuries of the hip and pelvis in elderly patients

Recent studies have shown the usefulness of T1-weighted MR imaging for identifying fractures of the proximal femur in elderly patients with negative radiographs after acute trauma [1-4]. The advent of fast spin-echo and fast inversion recovery sequences allows for the rapid identification of a variety of other musculoskeletal injuries of the hip and pelvis that may explain a patient's symptoms but that may not be seen on T1-weighted images. This pictorial essay shows the types of lesions encountered. Lesion prevalence is given for 20 consecutive patients examined.

Large scale isolation, growth, and function of porcine neonatal islet cells

Based upon existing methods of isolating fetal porcine islet tissue, a simple, reliable procedure was developed for the preparation of porcine neonatal islet cell aggregates with a reproducible and defined cellular composition. After 9 d of in vitro culture, tissue from one neonatal pig pancreas yielded approximately 50,000 islet cell aggregates, consisting of primarily epithelial cells (57%) and pancreatic endocrine cells (35%). During the culture period, the total beta cell mass decreased initially, but subsequently increased 1.5-fold between days 3 and 9. Transplantation of grafts consisting of 3 x 10(5) beta cells (1,000 aggregated) under the kidney capsule of alloxan-diabetic nude mice corrected hyperglycemia in 75% (10/13) of the animals, whereas, 100% (20/20) of recipients implanted with 6 x 10(5) beta cells (2,000 aggregates) achieved euglycemia within 8 wk posttransplantation. Nephrectomy of the graft bearing kidney at 14 wk posttransplantation resulted in hyperglycemia in all recipients, and examination of the grafts revealed the presence of numerous well-granulated insulin- and glucagon-containing cells. The cellular insulin content of these grafts was 20 to 30-fold higher than at the time of transplantation. These results indicate that the neonatal porcine pancrease can be used as a source of large numbers of viable islet cells, which have the potential for growth both in vitro and in vivo, and exhibit the metabolic capacity to correct diabetes in nude mice.

Avulsion fractures of the volar aspect of triquetral bone of the wrist: a subtle sign of carpal ligament injury

OBJECTIVE

We report five examples of a triquetral fracture pattern not previously described to our knowledge. These fractures from the volar aspect of the triquetral bone are important because they are easily missed with conventional wrist radiographs and yet are associated with significant ligament injuries and carpal instability.

MATERIALS AND METHODS

Five volar triquetral avulsion fractures occurred in young men (20-28 years old) during falls while playing sports. The initial evaluation consisted of a three-view radiographic series. Subsequently, an instability series was obtained in each case. Four patients were also evaluated by stress videofluoroscopy and arthrography, one by CT, and four by MR imaging.

RESULTS

None of the five fractures was recognized on radiographs obtained in the emergency room. Each fracture was identified on an instability series and involved the radial aspect of the volar surface of the triquetral bone. All four wrists evaluated by stress videofluoroscopy showed lunatotriquetral joint instability. One also showed instability of the scapholunate joint. All four wrists evaluated by arthrography showed tears of the lunatotriquetral ligament and three had an associated tear of the scapholunate ligament. MR examination of four wrists showed a volar capsular ligament attached to the avulsion fracture fragment in each wrist. Two of the patients were treated by arthroscopic debridement and three were treated by prolonged splinting. All five patients had persistent pain and carpal instability of variable severity at least 1 year after injury.

CONCLUSION

This avulsion fracture of the radial aspect of the volar triquetral bone is a subtle, easily missed sign of a significant injury of the perilunate ligaments. When this fracture is identified, we recommend further evaluation for associated ligament injury and carpal instability.

MR imaging of the anterior cruciate ligament: frequency of discordant findings on sagittal-oblique images and correlation with arthroscopic findings

OBJECTIVE

The purposes of this study were to determine the frequency of discordant MR findings of the anterior cruciate ligament (ACL) using sagittal-oblique images and the arthroscopic integrity of the ACL in knees with a discordant MR appearance.

MATERIALS AND METHODS

The frequency of discordant MR features was determined by independently reviewing the sagittal-oblique images of 53 consecutive patients undergoing subsequent arthroscopic surgery. The first 25 consecutive knees were examined using a conventional, dual-echo, T2-weighted spin-echo (SE) sequence; the subsequent 28 consecutive knees were examined using both a T1-weighted SE(T1) and a fat-suppressed, fast spin-echo (FSE) T2-weighted sequence. Two examiners who were unaware of patient identification and arthroscopic results evaluated only the sagittal images that included the ACL. Each reviewer graded the ACL as torn or intact. The MR appearance was considered discordant when one MR sequence showed disrupted or poorly seen ACL fibers and the other sequence showed intact ACL fibers. The arthroscopic integrity of the ACL was determined for the 20 knees with a discordant MR appearance.

RESULTS

A discordant MR appearance of the ACL was seen in 20 of the 53 knees (38%), including 10 knees evaluated using conventional T2-weighted sequences (40%) and 10 knees using T1/FSE T2 (36%) sequences. Arthroscopic examination of these knees showed intact ACL fibers in all 20 knees; the ACL was normal in 18 knees and a partial tear was questioned in two knees.

CONCLUSION

A discordant appearance of the ACL was frequently encountered (38%) using either conventional T2-weighted sequences or T1 and FSE MR sequences in the sagittal-oblique plane. Intact ACL fibers were found during arthroscopy in all 20 knees with a discordant MR appearance.

Magnetic resonance imaging characteristics of a lead pencil foreign body in the hand

Foreign body detection and removal from the hand can present a challenging problem for the hand surgeon. Imaging studies often are of little help and may even be misleading regarding the size and location of the object. This article reports imaging techniques used in the detection of foreign bodies and presents a case in which magnetic resonance imaging was used to localize a lead-pencil foreign body in the hand prior to surgical removal. We also present the results of magnetic resonance imaging analysis of several lead pencils, showing a similar signal that indicates that iron and magnesium were responsible for the artifact seen on the magnetic resonance image.

COS cell expression cloning of Pfg377, a Plasmodium falciparum gametocyte antigen associated with osmiophilic bodies

We report the deduced protein sequence and preliminary characterization of Pfg377, a novel sexual stage antigen of Plasmodium falciparum. An initial cDNA clone (Pfg377-1) encoding the N-terminal 755 amino acids of Pfg377 was isolated by transfecting a 3D7 gametocyte cDNA library into COS7 cells and selecting using a pool of anti-Pfs230 monoclonal antibodies. The protein encoded by Pfg377-1 included an N-terminal hydrophobic signal sequence, but no apparent transmembrane anchor. Instead, the particular cDNA clone selected was fused in-frame at its 3' end with the coding sequence for the human decay acceleration factor membrane anchor, which had been deliberately placed downstream of the vector polylinker in order to attach potential fusion proteins onto the COS cell surface. Northern blots probed with the Pfg377-1 cDNA demonstrated cross-hybridization to a single approximately 9.5-kb transcript, which was present only in sexual stages, and not in a sexual stages. DNA hybridization was used to obtain a series of overlapping genomic clones which collectively yielded the complete DNA sequence for Pfg377. There are no introns within the gene, which contains a 9360-bp open reading frame and encodes a 377-kDa protein. The Pfg377 protein is highly hydrophilic, and has an essentially non-repetitive structure, with only four very limited regions of tandem repeats. The Pfg377 gene resides on chromosome 12, and immunoelectron microscopy with two different anti-Pfg377 polyclonal antisera raised against two separate recombinant sub-fragments of the protein both indicated that the antigen is located in electron-dense organelles of the gametocytes--the osmiophilic bodies--which are proposed to play a role in parasite emergence from the erythrocyte during gametocyte maturation in the Anopheles mosquito midgut. Although it was selected with anti-Pfs230 antibodies, comparison of the sub-cellular locations and protein sequences of Pfg377 and Pfs2 show them to be completely distinct antigens. We hypothesize that Pfg377-1 was initially isolated because it expresses an epitope which is recognized by (i.e., cross-reacts with) one of the anti-Pfs230 monoclonal antibodies used to select the original transfected COS cells.

Mutation or increased copy number of nodE has no effect on the spectrum of chitolipooligosaccharide nod factors made by Rhizobium leguminosarum bv. trifolii

The bacterial gene nodE is the key determinant of host specificity in the Rhizobium leguminosarum-legume symbiosis and has been proposed to determined unique polyunsaturated fatty acyl moieties in chitolipooligosaccharides (CLOS) made by the bacterial symbiont. We evaluated nodE function by examining CLOS structures made by wild-type R. leguminosarum bv. trifolii ANU843, an isogenic nodE::Tn5 mutant, and a recombinant strain containing multiple copies of the pSym nod region of ANU843. 1H-NMR, electrospray ionization mass spectrometry, fast atom bombardment mass spectrometry, flame ionization detection-gas chromatography, gas chromatography/mass spectrometry, and high performance liquid chromatography/UV photodiode array analyses revealed that these bacterial strains made the same spectrum of CLOS species. We also found that ions in the mass spectra which were originally assigned to nodE-dependent CLOS species containing unique polyunsaturated fatty acids (Spaink, H. P., Bloemberg, G. V., van Brussel, A. A. N., Lugtenberg, B. J. J., van der Drift, K. M. G. M., Haverkamp, J., and Thomas-Oates, J. E. (1995) Mol. Plant-Microbe Interact. 8, 155-164) were actually due to sodium adducts of the major nodE-independent CLOS species. No evidence for nodE-dependent CLOSs was found for these strains. These results indicate a need to revise the current model to explain how nodE determines host range in the R. leguminosarum-legume symbiosis.

MR imaging of normal and injured wrist ligaments

MR imaging is a rapidly evolving modality for examining the ligaments of the wrist. Recent improvements in magnet design and receiver coil technology have allowed consistent visualization of the wrist ligaments. Image quality can be optimized by selection of the proper receiver coil, careful attention to patient comfort and positioning, and selection of a dedicated imaging protocol. The carpal ligaments can be classified as capsular or interosseous ligaments, with the most important interosseous ligaments being the SLL and LTL as well as the triangular fibrocartilage. It is important for radiologists to understand the anatomy of the carpal ligaments in addition to the normal range of MR appearances as basis for comparison with torn or degenerated carpal ligaments.

Training obstetricians and midwives to present screening tests: evaluation of two brief interventions

The objective of this study was to assess the effects of two brief training interventions to improve obstetricians' and midwives' explanations to patients of a routine prenatal screening test. Health professionals were randomly allocated to one of two intervention groups or a control group. Information-giving about the test and communication skills were assessed at baseline, post-training and 3-month follow-up from audiotaped consultations. Both intervention groups received a 1-h training session involving small group discussions focused around a video. In addition, one group received individual feedback on their baseline and post-training consultations. Twenty-six midwives and nine obstetricians completed the study according to the protocol. Changes between baseline and post-training, and between baseline and follow-up, were computed. Information-giving and communication skills improved significantly in subjects receiving training and feedback on their performance, with the greatest improvements occurring before feedback was given. Those receiving training without feedback significantly improved their communication skills and showed some improvement in information-giving. These results show that modest improvements in communication can be made with relatively brief training. Greater and more sustained improvements may be found if all staff were trained, and trained on a regular basis.

Comparison of injuries to children with and without disabilities in a day-care center

Injury rates and characteristics of children with and without disabilities in separate day-care programs were studied retrospectively through a record review of injury logs. The study focused on three issues: (1) initial injury rates and multiple injury rates, with comparisons by gender and program; (2) the characteristics of children who were injured compared to those who were not injured; and (3) comparisons between programs on characteristics and consequences of injuries. Injury rates were calculated on the basis of children's exposure time in the day-care setting. Results showed that children with disabilities had higher rates of injury than those without disabilities. Injury prevention in day care should be tailored to the characteristics of children and the types of injuries that occur in this setting.

Immunization with the larger isoform of mouse glutamic acid decarboxylase (GAD67) prevents autoimmune diabetes in NOD mice

The 65-kDa isoform of glutamic acid decarboxylase (GAD65) has been implicated in autoimmune diabetes in NOD mice, but the role of the 67-kDa GAD isoform (GAD67) is less clear. We found that immunization of 4-week-old NOD mice with purified recombinant mouse GAD67 prevented or significantly delayed the onset of diabetes. To further explore this phenomenon, we characterized anti-GAD67 immune responses in naive and GAD-immunized NOD mice. Anti-GAD67 antibodies titers were relatively low in naive mice at all ages, but a single immunization with GAD67 at 4 weeks induced high titers of anti-GAD antibodies by 6 weeks of age. In both 4-week-old and diabetic NOD mice, there were significant endogenous T-cell proliferative responses against purified recombinant mouse GAD67. These T-cell proliferative responses were blocked by anti-I-ANOD and anti-CD4 antibodies. To characterize the anti-GAD T-cell responses in the NOD mice, we established T-cell lines and T-cell clones which recognized GAD67, and we used recombinant subfragments of GAD to localize the predominant T-cell epitopes in GAD67. T-cells from naive NOD mice proliferated in response to all GAD subfragments, whereas T-cells from diabetic mice responded primarily to the COOH-terminal 83 amino acids of GAD67. These results suggest that GAD67 is an autoantigen in IDDM and immunization of prediabetic NOD mice with GAD67 can prevent the onset of diabetes.

Conversion of the biological specificity of murine to human leukemia inhibitory factor by replacing 6 amino acid residues

Mouse and human leukemia inhibitory factor (mLIF and hLIF) have approximately 80% amino acid identity, but mLIF cannot bind to the hLIF receptor (hLIF-R), while hLIF binds to the alpha-chain of the mLIF receptor (mLIF-R) with a much higher affinity than does mLIF. We have previously shown that the same regions confer both these properties of hLIF and map to an area within the predicted third alpha-helix and two of the loops of hLIF (Owczarek, C. M., Layton, M. J., Metcalf, D., Lock, P., Wilson, T. A., Gough, N. M., and Nicola, N. A. (1993) EMBO J. 12, 3487-3495). The present studies, using interspecies chimeras of mLIF and hLIF, have defined 6 residues (Asp57, Ser107, His112, Ser113, Val155, and Lys158) that contribute most of the binding energy involved in the interaction of hLIF and the hLIF-R alpha-chain, and form a surface at one end of the predicted four alpha-helical bundle of the hLIF molecule. Mouse LIF is unable to bind to the hLIF-R alpha-chain or activate the cellular hLIF-R, but when these 6 residues were substituted onto an mLIF framework, they were able to reconstitute both the binding and biological activities specific to hLIF.

Homology modelling and 1H NMR studies of human leukaemia inhibitory factor

Human leukaemia inhibitory factor (LIF) is a glycoprotein with a diverse range of activities on many cell types. A molecular model of LIF has been constructed based mainly on the structure of the related cytokine granulocyte colony-stimulating factor, and refined using simulated annealing and molecular dynamics in water. The model was stable during molecular dynamics refinement and is consistent with known stereochemical data on proteins. It has been assessed by comparison with 1H NMR data on the ionization behaviour of the six histidine residues in LIF, the imidazolium pKa values of which range from 3.6 to 7.4. These pKa values were assigned to individual histidine residues from NMR studies on a series of His-->Ala mutants. The environments of the histidine residues in the model account very well for their observed ionization behaviour. Furthermore, the model is consistent with mutagenesis studies which have defined a group of amino acid residues involved in receptor binding.

Scapholunate interosseous ligament of the wrist: MR appearances in asymptomatic volunteers and arthrographically normal wrists

PURPOSE

To determine if the carpal scapholunate ligament (SLL) can be consistently visualized with commercial magnetic resonance (MR) imaging techniques and to establish the normal range of MR appearances of the SLL as a basis for comparison with SLL tears.

MATERIALS AND METHODS

MR imaging helped identify and characterize the appearance of the SLL in 80 wrists with presumably normal SLLs (54 wrists in 27 asymptomatic volunteers and 26 patients with normal arthrograms). A dual-echo, gradient-echo technique was used.

RESULTS

The SLL was visible in all 80 wrists and was seen on an average of almost four sections. It was delta-shaped in 72 wrists and linear in eight; there was absent signal intensity in 63% or intermediate signal intensity traversing all or part of the SLL in 37%. Distribution and extent of hyaline cartilage signal intensity at the insertion sites into the scaphoid and lunate bones were variable but related to the location within the SLL.

CONCLUSION

The SLL can be consistently identified, but the normal variation in the MR appearance of the lunotriquetral ligament must be appreciated when evaluating wrists with suspected SLL tears.

Lack of knowledge in health professionals: a barrier to providing information to patients?

OBJECTIVE

To assess obstetricians' and midwives' knowledge of routine prenatal screening tests for fetal abnormality and factors associated with such knowledge.

DESIGN

Questionnaire assessment of antenatal clinic staff.

SETTING

Six hospitals within the United Kingdom (four district general hospitals in London, one district general hospital in Wales, and one teaching hospital in Wales), offering routine prenatal screening tests.

SUBJECTS

29 obstetricians and 97 midwives were invited to participate, of whom 21 and 70 respectively responded to the questionnaire.

MAIN MEASURES

Knowledge of prenatal tests, according to 19 item multiple choice questionnaire, reluctance to disclose uncertainty, and clinical experience.

RESULTS

The overall response rate was 72% (91/126). In all, 43% of midwives and 14% of obstetricians obtained correct responses on fewer than half the items. Reluctance to disclose uncertainty to patients was associated in obstetricians with having less knowledge about prenatal testing (r = -0.50; p < 0.025, Pearson product moment correlation) and in midwives with more clinical experience (r = 0.43; p < 0.001).

CONCLUSIONS

Lack of knowledge and greater clinical experience seem to be important barriers to providing patients with information about prenatal screening tests.

Lunotriquetral interosseous ligament of the wrist: MR appearances in asymptomatic volunteers and arthrographically normal wrists

PURPOSE

To determine whether the carpal lunotriquetral ligament (LTL) can be consistently seen and to establish the normal range of LTL appearances at magnetic resonance (MR) imaging as a basis for comparison with LTL tears.

MATERIALS AND METHODS

MR imaging was used to identify and characterize the LTL in 75 wrists with normal LTLs (54 in 27 asymptomatic volunteers, 21 in patients with normal arthrograms).

RESULTS

The LTL was identified in all wrists and was linear in 63% and delta-shaped in 35%. The LTL had homogeneous low signal intensity in 73% and linear intermediate signal intensity traversing all or part of the LTL in 25%. Fluid signal intensity traversed the LTL in only one wrist. MR appearance of the osseous insertion sites varied. Distribution of hyaline cartilage signal was related to location within the LTL.

CONCLUSION

The LTL can be consistently identified at MR imaging, but its appearance varies, which must be appreciated when evaluating wrists with suspected LTL tears.

NMR studies of a murine-human chimera of leukaemia inhibitory factor (LIF). Comparison with human LIF

Leukaemia inhibitory factor (LIF) is a polyfunctional cytokine active on many cell types. We present here 1H NMR studies on the solution properties and stability of MH35, a chimera of murine and human LIF which can be expressed at high levels in Escherichia coli, thus enabling efficient labelling of the protein with the stable isotopes 13C and 15N. MH35 has 85% sequence identity with human LIF and similar activity in biological assays. The 1H chemical shifts of the 12 conserved aromatic residues and the pKa values of the five conserved histidine residues in MH35 and human LIF are very similar. Temperature dependence studies indicate that both proteins are stable, with significant conformational changes occurring only above 70 degrees C. These results show that these proteins have a similar overall structure and stability and that MH35 is therefore a suitable analogue of human LIF for structural studies in solution.

Laparoscopic injection of fibrin glue to arrest intraparenchymal abdominal hemorrhage: an experimental study

The laparoscope offers a novel avenue for the diagnosis of intra-abdominal injury and the use of fibrin glue (FG) as a treatment for hemorrhage in trauma patients. This study was undertaken to assess the practicality and effectiveness of FG injection under laparoscopic direction to arrest hemorrhage in solid viscera. Twenty dogs were randomized into a control group (CG) and a treatment group (TG). All animals underwent laparotomy to surgically induce uniform injuries to the hepatic and splenic parenchyma. The TG animals (n = 12) were allowed to hemorrhage for 30 minutes. The injuries were then visualized and FG injected intraparenchymally under laparoscopic direction. The average duration of the procedure was 25 minutes (range, 15-50). No hemostatic interventions were performed on the CG animals (n = 8). Mortality in the CG was 63% (5 of 8); there were no deaths in TG animals prior to sacrifice. Necropsy of TG animals revealed progressively healing hepatic and splenic injuries with no gross evidence of pulmonary FG emboli, intraparenchymal microemboli, or increased adhesion formation. No other complications were noted. This study demonstrates that hemorrhage from the liver and spleen can be successfully controlled using the laparoscope to direct the intraparenchymal injection of FG. In this experimental model, the procedure can be performed expeditiously. It is associated with reduction of mortality to zero when compared with controls. No complications associated with laparoscopy or FG injection were recognized. This technique may have potential for application in the management of stable patients who manifest evidence of intraperitoneal hemorrhage as a result of solid organ injury.

Injuries to preschool-age children in day-care centers. A retrospective record review

OBJECTIVES

To increase our understanding of the epidemiologic nature of injuries to children in day-care settings by examining injury logs and to determine appropriate methods for calculating injury rates.

DESIGN

Retrospective, with data collected through a review of 1 year's records.

SETTING

Four suburban day-care centers in the upper Midwest.

PARTICIPANTS

Five hundred twenty-seven preschool-age children, 275 of whom experienced one or more injuries during the study period.

SELECTION PROCEDURE

Convenience sample.

MEASUREMENTS/RESULTS

Injury rates were calculated based on the number of hours spent in day care in the study year. More than 1000 injuries were reported for 527 children. Injury rates ranged from 0.006 to 0.049 per child per standardized 8-hour day in a day-care center (or six to 49 injuries per 1000 children per 8 hours of exposure). However, most injuries were minor, and none resulted in a fatality or hospital admission. Using this method, injury rates were examined by gender and month.

CONCLUSIONS

Future research should determine exposure time based on the actual number of hours a child spends in attendance to determine injury rates. Exposure time should also be carefully considered in determining product- and location-specific rates of injury.

Volar carpal ligaments of the wrist: normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging

OBJECTIVE

Three-dimensional Fourier transform MR imaging techniques can produce much thinner contiguous slices than are obtainable with standard two-dimensional Fourier transform MR imaging techniques. The improved spatial resolution and capabilities for interactive multiplanar displays allow better visualization of small, complex anatomic structures, such as the carpal ligaments. The purposes of this study were twofold: (1) to determine if the volar carpal ligaments can be consistently visualized when using three-dimensional Fourier transform MR imaging techniques with multiplanar reconstructions and (2) to evaluate the size, shape, orientation, and right-to-left symmetry of the volar carpal ligaments in both wrists of 25 asymptomatic volunteers as a basis for future comparison when patients with suspected ligament injuries are seen.

SUBJECTS AND METHODS

Both wrists of 25 asymptomatic volunteers were imaged with a three-dimensional Fourier transform MR imaging technique with commercially available equipment. A three-dimensional graphic workstation was used to reconstruct oblique two-dimensional images in the long axes of the major volar carpal ligaments. The size, shape, orientation, and right-to-left symmetry of the ligaments were determined from the reconstructed two-dimensional images.

RESULTS

Six of the eight volar ligaments were visualized in more than 95% of the 50 wrists: the radioscaphocapitate, radiolunotriquetral, radiolunate, ulnolunate, ulnotriquetral, and triquetroscaphoid ligaments. The radioscaphoid and radioscapholunate ligaments were less well defined and were recognizable as ligaments in only 66% and 26% of wrists, respectively.

CONCLUSION

The major volar carpal ligaments can be visualized consistently with three-dimensional Fourier transform MR imaging techniques and multiplanar reconstructions. The volar carpal ligaments are usually symmetric between the right and left sides; therefore, MR images of a patient's injured wrist can be compared with MR images of the contralateral wrist. The size and shape of the volar carpal ligaments shown in this article can be used as a basis for comparison when patients with suspected ligamentous injuries are examined. This information will be useful for detecting ligamentous injuries on MR images.

Dorsal carpal ligaments of the wrist: normal appearance on multiplanar reconstructions of three-dimensional Fourier transform MR imaging

OBJECTIVE

Three-dimensional Fourier transform MR imaging techniques can produce much thinner contiguous slices than are obtainable with standard two-dimensional Fourier transform MR imaging techniques. The improved spatial resolution and capabilities for interactive multiplanar displays allow improved visualization of small, complex anatomic structures such as the carpal ligaments. The purposes of this study were twofold: (1) to determine if the dorsal carpal ligaments can be visualized consistently with three-dimensional Fourier transform MR imaging techniques with multiplanar reconstructions and (2) to evaluate the size, shape, orientation, and right-to-left symmetry of the dorsal carpal ligaments in both wrists of 25 asymptomatic volunteers as a basis for future comparison when patients with suspected ligament injuries are seen.

SUBJECTS AND METHODS

Both wrists of 25 asymptomatic volunteers were imaged with a three-dimensional Fourier transform MR imaging technique with commercially available equipment. A three-dimensional graphic workstation was used to reconstruct oblique two-dimensional images in the long axes of the radiotriquetral and dorsal intercarpal ligaments in all 50 wrists. The size, shape, orientation, and right-to-left symmetry were determined by the author using the reconstructed two-dimensional images.

RESULTS

The radiotriquetral ligament and dorsal intercarpal ligament were visualized in all 50 wrists. The radiotriquetral ligament consisted of a single band arising from the distal radius (next to Lister's tubercle) in 84% and had dual origins from the styloid process of the radius and Lister's tubercle in 16%. The dorsal intercarpal ligament consisted of a single broad band in 14% of wrists, was a branched structure with separate triquetroscaphoid and triquetrotrapezial fascicles in 44%, had completely separate triquetroscaphoid and triquetrotrapezial fascicles in 38%, and had a triquetrotrapezial fascicle larger than the triquetroscaphoid fascicle in 4%. The dorsal intercarpal ligamentous anatomy was symmetric in 16 of 25 volunteers.

CONCLUSION

The major dorsal carpal ligaments can be visualized consistently when using three-dimensional Fourier transform MR imaging techniques and multiplanar reconstructions. The dorsal carpal ligaments are usually symmetric in size and morphology; therefore, MR images of the contralateral wrist may be used for comparison with MR images of a patient's injured wrist. The size and shape of the dorsal carpal ligaments are described for comparison with findings in patients who have suspected ligamentous injuries.

Anatomic features of the carpal scaphoid: validation of biometric measurements and symmetry with three-dimensional MR imaging

The goals of reconstructive surgery for scaphoid fracture nonunions include restoration of normal scaphoid length and shape by use of the contralateral scaphoid bone as a geometric model. A literature search revealed limited documentation of normal biometric measurements and no validation of scaphoid anatomic symmetry. A study was performed to provide normative data and evaluate the right-to-left symmetry of specific geometric measurements of the scaphoid. One hundred normal carpal scaphoid bones in 30 healthy subjects and 40 patients were examined with three-dimensional magnetic resonance (MR) imaging. Standardized oblique projections were reconstructed from each three-dimensional data set, and seven biometric measurements of each scaphoid were obtained. Normative data from the study group were obtained by means of analysis of all 100 scaphoids. Right-to-left symmetry was validated with the biometric measurements of both scaphoids in the healthy subjects. These data validate scaphoid symmetry and provide 95% confidence intervals for specific biometric measurements that are used for preoperative planning of surgical reconstruction of scaphoid nonunions.

The discipline of teams

Groups don't become teams because that is what someone calls them. Nor do teamwork values by themselves ensure team performance. So what is a team? How can managers know when the team option makes sense and what they can do to ensure team success? In this article, drawn from their recent book The Wisdom of Teams, McKinsey partners Jon Katzenbach and Douglas Smith answer these questions and outline the discipline that makes a real team. The essence of a team is shared commitment. Without it, groups perform as individuals; with it, they become a powerful unit of collective performance. The best teams invest a tremendous amount of time shaping a purpose that they can own. The best teams also translate their purpose into specific performance goals. And members of successful teams pitch in and become accountable with and to their teammates. The fundamental distinction between teams and other forms of working groups turns on performance. A working group relies on the individual contributions of its members for group performance. But a team strives for something greater than its members could achieve individually. In short, an effective team is always worth more than the sum of its parts. Katzenbach and Smith identify three basic types of teams: teams that recommend things--task forces or project groups; teams that make or do things--manufacturing, operations, or marketing groups; and teams that run things--groups that oversee some significant functional activity. For managers, the key is knowing where in the organization real teams should be encouraged. Team potential exists anywhere hierarchy or organizational boundaries inhibit good performance.(ABSTRACT TRUNCATED AT 250 WORDS)

Unexplained opportunistic infections and CD4+ T-lymphocytopenia without HIV infection. An investigation of cases in the United States. The Centers for Disease Control Idiopathic CD4+ T-lymphocytopenia Task Force

BACKGROUND

The clinical and public health importance of recent reports of patients with CD4+ T-lymphocytopenia without human immunodeficiency virus (HIV) infection is unclear. We conducted investigations to determine the demographic, clinical, and immunologic features of patients with idiopathic CD4+ T-lymphocytopenia; whether the syndrome is epidemic or transmissible; and the possible causes.

METHODS

We reviewed 230,179 cases in the Centers for Disease Control and Prevention (CDC) AIDS Reporting System and performed interviews, medical-record reviews, and laboratory analyses of blood specimens from adults and adolescents who met the CDC case definition of idiopathic CD4+ T-lymphocytopenia (< 300 CD4+ cells per cubic millimeter or a CD4+ cell count < 20 percent of total T cells on two occasions and no evidence of infection on HIV testing), their sexual contacts, household contacts, and persons who had donated blood to them.

RESULTS

We interviewed 31 of the 47 patients identified with idiopathic CD4+ T-lymphocytopenia and 23 of their contacts. There were 29 male and 18 female patients, with a mean age of 43 years (range, 17 to 78); 39 were white, 4 were Asian, 2 were Hispanic, and 2 were black. Eighteen patients (38 percent) had one or more risk factors for HIV infection: seven had hemophilia, six had engaged in homosexual sex, six had received blood transfusions, and two had had heterosexual sex partners who were at risk for HIV infection. The other 29 patients (62 percent) had no identified risk factors for HIV infection. Nineteen persons (40 percent) had AIDS-defining illnesses (18 had opportunistic infections), 25 (53 percent) had conditions that were not AIDS-defining, and 3 (6 percent) were asymptomatic. We tested blood from 28 patients: 8 (29 percent) were found to have CD4+ T-lymphocyte counts of less than 300 cells per cubic millimeter, and 6 had CD8+ T-lymphocytopenia (< 250 cells per cubic millimeter). Ten sex partners, three household contacts, and four children of the patients, as well as six persons who had donated blood to the patients, were immunologically and clinically normal.

CONCLUSIONS

This investigation of patients with idiopathic CD4+ T-lymphocytopenia and unexplained opportunistic infections indicates that the disorder is rare and represents various clinical and immunologic states. The investigation of contacts revealed no evidence of a new transmissible agent that causes lymphocytopenia.

Cloning of a novel surface antigen from the insect stages of Trypanosoma brucei by expression in COS cells

Trypanosoma brucei cDNA libraries constructed in the vector pCDM8 were screened selectively for insect (procyclic) stage surface antigen cDNAs by transient expression in mammalian COS-7 fibroblasts and "panning" with a rabbit polyclonal antiserum. This strategy yielded two surface antigen cDNAs termed PSSA-1 and PSSA-2. The PSSA-1 cDNA encoded an isotype of procyclin, the major phosphatidylinositol-linked stage-specific glycoprotein antigen of the tsetse fly infective forms of T. brucei. The PSSA-2 cDNA encoded a new and previously unidentified stage-specific surface antigen with the features of a typical transmembrane glycoprotein but with an unusual cytoplasmic tail composed of a proline-rich tandem repeat. Fluorescent antibody staining of PSSA-1 transfected COS cells with a panel of procyclin-specific monoclonal antibodies confirmed that the protein was located on the outer surface of the plasma membrane. Furthermore, the antigen on COS cells was insensitive to treatment with phosphatidylinositol-specific phospholipase C suggesting that the inositol of the glycosylinositol phospholipid-lipid anchor contained the same fatty acyl modification reported recently for the procyclin molecule in cultured procyclic trypanosomes. In contrast the PSSA-2 antigen on COS cells was stained very weakly by whole parasite antisera. Northern blot hybridization revealed that the PSSA-2 antigen was encoded by a single 1.7-kilobase transcript which was present in parasites from the insect procyclic stage of the life cycle but not from the animal bloodstream stage. Southern blot hybridization analysis of DNA from procyclic stage trypanosomes indicated that the gene for PSSA-2 may be present in more than one copy in procyclic trypanosomes.

Escherichia coli has two homologous glutamate decarboxylase genes that map to distinct loci

Degenerate oligonucleotides based on the published Escherichia coli glutamate decarboxylase (GAD) protein sequence were used in a polymerase chain reaction to generate a DNA probe for the E. coli GAD structural gene. Southern blots showed that there were two cross-hybridizing GAD genes, and both of these were cloned and sequenced. The two GAD structural genes, designated gadA and gadB, were found to be 98% similar at the nucleotide level. Each gene encoded a 466-residue polypeptide, named, respectively, GAD alpha and GAD beta, and these differed by only five amino acids. Both GAD alpha and GAD beta contain amino acid residues which are highly conserved among pyridoxal-dependent decarboxylases, but otherwise the protein sequences were not homologous to any other known proteins. By restriction mapping and hybridization to the Kohara miniset library, the two GAD genes were located on the E. coli chromosome. gadA maps at 4046 kb and gadB at 1588 kb. Neither of these positions is in agreement with the current map position for gadS as determined by genetic means. Analysis of Southern blots indicated that two GAD genes were present in all E. coli strains examined, including representatives from the ECOR collection. However, no significant cross-hybridizing gene was found in Salmonella species. Information about the DNA sequences and map positions of gadA and gadB should facilitate a genetic approach to elucidate the role of GAD in E. coli metabolism.

Transtriquetral perihamate ulnar axial dislocation and palmar lunate dislocation

Transtriquetral perihamate ulnar axial dislocation associated with palmar lunate dislocation is a rare condition. We could find no other similar cases reported. The mechanism of injury was a combined anteroposterior crushing force that caused axial disruption of the carpus and the metacarpals and wrist hyperextension that caused the transtriquetral lunate dislocation. Our patient was treated with open reduction and internal fixation with good result.

Vitamin A in hypercholesterolemia

This study evaluated the relationship between plasma vitamin A and cholesterol in 48 patients with hypercholesterolemia studied before and after treatment with a cholesterol-lowering diet, with or without lipid-lowering medication. Plasma vitamin A levels were higher in hypercholesterolemic subjects than in healthy controls (2.58 +/- 0.15 vs. 1.82 +/- 0.14 mmol/L, p = 0.025) despite similar values for retinol binding protein (RBP). Successful cholesterol lowering, defined as greater than 25% reduction in low density lipoprotein cholesterol, was achieved in 16 patients. In this subset, plasma vitamin A declined from 3.00 +/- 0.32 (pretreatment) to 2.34 +/- 0.15 mmol/L (post treatment; p = 0.018). A nonsignificant increase in RBP was observed, resulting in a significant decrease in the molar ratio of vitamin A to RBP (1.05 +/- 0.06 vs. 0.80 +/- 0.05, p = 0.013). These data suggest an interaction between vitamin A and cholesterol that is independent of the transport mechanisms for vitamin A in association with chylomicrons (post absorptive) and with RBP. Further examinations of the form or forms of vitamin A (retinol, retinyl ester), its distribution within the plasma lipoproteins, and the mechanisms of origin and removal are warranted to explain these findings.

Physician's and dietitian's role in obese care

In the Surgeon General's Report on Nutrition and Health, of the ten leading causes of death in the United States, five are nutrition related. Instead of nutritional deficiencies as seen in the 1940s, the national diet has shifted to dietary excesses and imbalances. Dietary excesses and imbalances are reflected in obesity, a major health problem affecting approximately 30% of the United States' population. Unfortunately, the diet industry is not regulated and, hence, patients have many avenues from which to choose. Many of these leave patients lost and confused as to why they have failed in maintaining their weight loss. It is well documented that the recidivism rate in the obese is high with only 5% maintaining their weight loss after one year. The following is a review of the physician's and dietitian's roles in long-term weight maintenance.

HIV disease as a cause of death for African Americans in 1987 and 1990

Using death certificate data for 1987 and 1988 from the National Center for Health Statistics, combined with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) surveillance data through December 1990 from the Centers for Disease Control, this article reports ranked mortality causes as a measure of the impact of the HIV epidemic within the African-American community. In 1987, while HIV/AIDS ranked 15th as a cause of death for all Americans, for African Americans the disease ranked 10th overall (third for African-American men, fifth for African-American women between 25 and 34 years of age, and ninth for African-American children ages 0 to 14). By 1990, it can be estimated that for all Americans HIV disease was the eight leading cause of death, but for African-Americans it ranked sixth overall. For African-American men between the ages of 35 and 44, HIV disease became the leading cause of death, accounting for 23.5% of all deaths. This disease was the second leading cause of death for African-American men and women between the ages of 25 and 35, and the eighth leading cause of death for African-American children ages 0 to 14. The implications of these findings are discussed.

Community resources in obese care

Community resources can augment care provided by physicians and dietitians for the obese. The well-distributed community resources in Florida are reviewed. They are well-established and provide emotional support, peer group dynamics, a variety of formats and prices, and information about food and life-style changes.