Hinge total knee replacement revisited

OBJECTIVE

To determine if aseptic loosening is a major problem in hinge total knee replacement.

DESIGN

A cohort study.

SETTING

A university-affiliated institute, specializing in elective orthopedic surgery.

PATIENTS

Fifty-eight patients, mainly those requiring revision, in whom the conditions were such that it was felt only a totally constrained implant was appropriate. In 7 patients the implant was press-fitted; in the remainder it was cemented. Five patients required fusion or revision, and 8 died less than 2 years after implantation, leaving 45 for review. Follow-up was 2 to 13 years.

INTERVENTION

Total knee replacement with a Guepar II prosthesis.

MAIN OUTCOME MEASURES

Radiolucency determined by the Cameron system and clinical scoring using the Hospital for Special Surgery system.

RESULTS

Of the cemented components, 91% of femoral stems were type IA (no lucency), 9% were type IB (partial lucency), with no type II or III lucency. Tibial lucency was 87% type IA and 13% type IB, with no type II or III lucency. Of the noncemented components, 58% of femoral components were type IA and 42% type IB. Tibial lucency was 71% type IA and 29% type IB. Lucency was mainly present in zones 1 and 2 adjacent to the knee. Clinical rating was 18% excellent, 20% good, 20% fair and 42% poor. Postoperative complications included infection (13%), aseptic loosening (7%), quadriceps lag (16%) and extensor mechanism problems (16%).

CONCLUSIONS

Aseptic loosening is an uncommon problem in hinge total knee replacement. The complication rate in cases of sufficient severity as to require a hinge replacement remains high. Current indications for a hinge prosthesis are anteroposterior instability with a very large flexion gap, complete absence of the collateral ligaments and complete absence of a functioning extensor mechanism.

p16 overexpression: a potential early indicator of transformation in ovarian carcinoma

OBJECTIVE

The recently cloned gene p16 (MST1) has been identified as a putative tumor suppressor gene that binds to CDK4 and CDK6 (cyclin-dependent kinases), preventing their interaction with cyclin D1 and thereby preventing cell cycle progression at the G1 stage. In addition, the p16 gene has been shown to have a high frequency of mutation in some tumor cell lines; however, it has also been shown that a much lower frequency of mutation occurs in primary tumors. This study investigated the mRNA expression level and mutation status of the p16 gene in ovarian tumors.

METHODS

We performed quantitative polymerase chain reaction and direct cDNA sequencing analysis. To confirm the p16 protein level in ovarian tumors, Western blotting and immunohistochemical staining were performed. Expression levels of mRNA for the p16 gene relative to the beta-tubulin gene were examined in 32 ovarian tumors (24 carcinomas, six low malignant potential tumors, and two benign tumors) and six normal ovaries.

RESULTS

The mRNA expression level of p16 was significantly elevated in 28 ovarian tumors (22 carcinomas, five low malignant potential tumors, and one benign tumor) compared with that of normal ovaries. Western blotting analysis and immunohistochemical staining confirmed elevated p16 protein levels in ovarian tumor samples. Among 32 ovarian tumors, cDNA sequencing of the p16 gene showed no p16 mutation resulting in a coding error, although one silent mutation and three polymorphisms were found.

CONCLUSIONS

Although p16 is seldom mutated in ovarian tumors, the overexpression of p16 in most ovarian tumor cases indicates a dysfunction in the regulatory complex for G1 arrest. Therefore, overexpression of p16 may be an important early event in the neoplastic transformation of the ovarian epithelium.

Differential ability of T cell subsets to undergo activation-induced cell death

Human T cell clones were analyzed for their susceptibility to activation-induced cell death (AICD) in response to CD3/T cell receptor ligation. AICD was observed only in Th1 clones and was Fas-mediated, whereas Th2 clones resisted AICD. Analysis of a panel of Th0 clones, characterized by their ability to secrete both Th1 and Th2 cytokines, revealed that this subset included both AICD-sensitive (type A) and -resistant (type B) clones. Resistance to AICD by Th2 and Th0-type B clones was not due to lack of expression of either Fas receptor or its ligand. Paradoxically, the AICD-resistant clones were susceptible to apoptosis when Fas receptor was directly ligated by anti-Fas antibodies. However, prior activation of the resistant clones by monoclonal antibodies to CD3/TCR complex induced resistance against Fas-mediated apoptosis. Thus, the Fas-FasL pathway is critical for the induction of AICD in T cells, and moreover this pathway can be negatively regulated in the AICD-resistant clones by signals that are generated from ligation of the CD3/TCR complex.

Characterization of constitutive and inducible transcription factors binding to the P2 NF-AT site in the human interleukin-4 promoter

Interleukin-4 (IL-4) is a pleiotropic immunomodulatory cytokine secreted by T helper 2 cells. The IL-4 promoter contains multiple sites with DNA sequences homologous to the IL-2 NF-AT binding site. One of these sites--the P2 site--located between -173 and -150 was previously found to be flanked by two octamer-like motifs. NF-ATp/c and octamer proteins were suggested to bind to this region and to cooperatively activate the promoter activity (Chuvpilo et al., 1993). To precisely analyze the P2-binding factors we used antibodies against NF-ATp, NF-ATc, Fos, Jun, Oct-1 and Oct-2 in EMSA. We show here that nuclear extracts from T-cells form two P2-binding complexes--a PMA/ionomycin-inducible and a constitutive one. The PMA/ionomycin-inducible complex contains NF-ATp/c, Fos and Jun. No octamer binding factors could be detected in either of the two complexes. Analysis of the precise DNA contact points of the two complexes showed that both complexes are formed in the center of the NF-AT consensus site. No DNA contact points could be detected in the octamer-like motif site. Furthermore, purified recombinant POU domains of Oct-1 and Oct-2 failed to bind to the P2 site, suggesting that this site is not an independent octamer-binding site. Therefore, the DNA sequence at -173 to -150 of the IL-4 promoter is a binding site for NF-ATp/c and AP-1. Octamer proteins are unlikely to cooperate with NF-ATp/c at this site.

Clinical significance of the immunohistochemical detection of p53 protein in endoscopic biopsy specimens

OBJECTIVE

To evaluate the utility of immunohistochemical staining of p53 expression in endoscopic biopsy specimens in clinical practice.

METHODS

Using a streptavidin-peroxidase (S-P) conjugate method with monoclonal p53 antibody Do-7, the expression of p53 was investigated immunohistochemically in 150 endoscopic biopsies and paired brushings from patients with benign and malignant gastric diseases. Among them, 22 cases with gastric carcinoma underwent the gastrectomy and the immunohistochemistry was repeated in the resected cancerous tissues of the same patient.

RESULTS

p53 expression in endoscopic specimens was detectable in 35.7% cases of gastric carcinoma (n = 70), 5.9% of gastric polyps (n = 17), 16.7% of gastric mucosal dysplasia (n = 18) and 4.0% of chronic atrophic gastritis (n = 25), but no protein expression was observed in cases of chronic active gastritis (n = 20). In 22 patients with tumor resection, 8 (36.4%) were identified with p53 expression in endoscopic specimens before surgery, while 10 (45.5%) were identified with the same expression in surgical specimens, the real positive rate was 80.0%, no false positives were observed in endoscopic specimens. Furthermore, p53 expression in gastric carcinoma was closely correlated with clinical stage and lymph nodes involvement, but did not correlate with histologic type.

CONCLUSIONS

Assay of p53 by immunohistochemistry in endoscopic biopsy specimens and brushings is an easy and reliable technique to assess p53 status in gastric carcinoma, and thus could serve as a marker to foresee the prognosis in these patients and assist in the diagnosis of malignancy before surgery. It may also be a valuable marker in screening patients with high risk of gastric carcinoma.

Differential interaction of nuclear factors with the PRE-I enhancer element of the human IL-4 promoter in different T cell subsets

The immunomodulatory cytokine IL-4 affects cells of most hemopoietic lineages. IL-4 is secreted by activated Th2 but not Th1 cells and plays a major role in the immune response by modulating the differentiation of naive Th cells toward the Th2 phenotype. We have previously identified an enhancer element, PRE-I, that is essential for the function of the human IL-4 promoter. To investigate the mechanisms responsible for tissue-specific expression of the IL-4 gene, we analyzed nuclear factors binding to the PRE-I site and compared the binding activities of these factors to the IL-4 promoter of Th1 and Th2 cells. We show that PRE-I interacts with PMA- and PMA/ionomycin-inducible, cyclosporin A-sensitive nuclear factors. Using anti-C/EBPbeta (NF-IL6), anti-C/EBPdelta (NF-IL6beta), anti-NF-ATc, anti-NF-ATp, anti-Fos, and anti-Jun Abs we demonstrate that the previously identified PRE-I binding factor POS-1 is composed of different transcription factors in different Th cell subsets. In the IL-4-producing Th0-like human Jurkat and mouse EL-4 cells, POS-1 (designated POS-1a) contains NF-IL6beta and Jun. In the mouse Th2 D10 cells and in the human Th2 clones, POS-1 (designated POS-1b) contains NF-IL6beta, Jun, and NF-ATc/p. In contrast, POS-1 was not found in nuclear extracts of human Th1 clones. These findings suggest that PRE-I may play a role in the differential regulation of IL-4 gene expression levels.

Differential interaction of nuclear factors with the PRE-I enhancer element of the human IL-4 promoter in different T cell subsets

The immunomodulatory cytokine IL-4 affects cells of most hemopoietic lineages. IL-4 is secreted by activated Th2 but not Th1 cells and plays a major role in the immune response by modulating the differentiation of naive Th cells toward the Th2 phenotype. We have previously identified an enhancer element, PRE-I, that is essential for the function of the human IL-4 promoter. To investigate the mechanisms responsible for tissue-specific expression of the IL-4 gene, we analyzed nuclear factors binding to the PRE-I site and compared the binding activities of these factors to the IL-4 promoter of Th1 and Th2 cells. We show that PRE-I interacts with PMA- and PMA/ionomycin-inducible, cyclosporin A-sensitive nuclear factors. Using anti-C/EBPbeta (NF-IL6), anti-C/EBPdelta (NF-IL6beta), anti-NF-ATc, anti-NF-ATp, anti-Fos, and anti-Jun Abs we demonstrate that the previously identified PRE-I binding factor POS-1 is composed of different transcription factors in different Th cell subsets. In the IL-4-producing Th0-like human Jurkat and mouse EL-4 cells, POS-1 (designated POS-1a) contains NF-IL6beta and Jun. In the mouse Th2 D10 cells and in the human Th2 clones, POS-1 (designated POS-1b) contains NF-IL6beta, Jun, and NF-ATc/p. In contrast, POS-1 was not found in nuclear extracts of human Th1 clones. These findings suggest that PRE-I may play a role in the differential regulation of IL-4 gene expression levels.

Superior dislocation of mandibular condyle into the middle cranial fossa. A case report

A case of superior dislocation of the mandibular condyle into the middle cranial fossa is presented. A modified method of reducing the mandibular condyle was used, and restitution of the perforated glenoid fossa was achieved by a combination of titanium plate and repair of the articular disk.

Solitary ulcers in reflux esophagitis: radiographic findings

BACKGROUND

Some patients with reflux esophagitis have solitary ulcers in the distal esophagus. This study was undertaken to characterize further the radiographic features of these ulcers and to determine whether or not they have a predisposition to develop on the posterior esophageal wall.

METHODS

Radiologic files and teaching files at our university hospital and affiliated Veterans Administration hospital revealed 29 patients with solitary reflux-induced ulcers. The radiographs were reviewed retrospectively to determine the size and location of the ulcers as well as the presence or absence of other findings.

RESULTS

Twenty ulcers (69%) were located on the posterior wall, five (17%) on the left or right lateral wall, and four (14%) on the anterior wall. All but two ulcers were located 1-4 cm from the gastroesophageal junction. All of the ulcers were less than 10 mm in width and 5 mm in depth. Other associated findings included hiatal hernias in 11 patients (38%), mucosal nodularity or granularity in 12 (41%), one or more tiny satellite ulcers in three (10%), esophageal intramural pseudodiverticula in three (10%), an inflammatory esophagogastric polyp in one (3%), and scarring or stricture formation in 12 (41%).

CONCLUSION

Our findings suggest that solitary reflux-induced ulcers tend to occur on the posterior wall of the distal esophagus near the gastroesophageal junction, producing characteristic radiographic findings. We postulate that affected individuals sleep primarily in the supine position, so that refluxed acid pools on the dependent or posterior esophageal wall, causing maximal injury in this location.

Spatial and temporal expression of cell surface molecules during nephrogenesis

Cell-to-cell interaction is fundamental to the development of the kidney. Ureteric bud cells, through cell contact or short-distance interactions, induce the metanephric mesenchyme to convert, to epithelia and begin the process of tubulogenesis. To identify new molecules that are involved in these processes, we generated a panel of monoclonal antibodies (MAbs) to the surface of induced mesenchymal cells taken from a day 15 rat embryonic kidney rudiment. MAbs were chosen for further study based either on a distinctive pattern of expression of their antigens or their functional effect on tubulogenesis. We identified a set of MAbs that preferentially stained the glomerular crevice, the first site for formation of the glomerular anlage. Another MAb inhibited tubulogenesis by producing widespread apoptosis in induced mesenchymal cells. This approach promises to identify new molecules that are central to kidney development.

Posterior stabilized knee prosthesis for total knee replacement in patients with prior patellectomy

OBJECTIVE

To determine the outcome of total knee replacement using a posterior cruciate-substituting knee prosthesis in patients who have undergone previous patellectomy.

DESIGN

A cohort study, with a follow-up ranging from 2 to 9 years.

SETTING

A university-affiliated institution specializing in elective orthopedic surgery.

PARTICIPANTS

Sixteen patients with arthritis of the knee who had had patellectomy. All agreed preoperatively to a prolonged postoperative follow-up.

INTERVENTION

A cemented posterior cruciate-substituting knee replacement.

MAIN OUTCOME MEASURES

Stair climbing ability, the Hospital for Special Surgery knee rating system for clinical results and a radiologic rating using a zonal system.

RESULTS

Clinical rating was 69% good or excellent. Eighty-one percent of patients could use the replaced knee as the lead leg on stair climbing. Minor radiolucency, mostly single zone only, was found. Two patients required revision because of pain, but no obvious reasons for this pain were found at operation.

CONCLUSION

In the absence of a patella, a posterior cruciate-substituting prosthesis gives reasonable results.

Results of total knee arthroplasty following takedown of formal knee fusion

Seventeen cases of knee fusion takedown with follow-up periods of 1 to 10 years have been reviewed. Two patients were re-fused for patellar tendon loss and sepsis. One had a chronic low-grade infection but refused re-fusion. Two patients who required immobilization for the first 10 days following total knee arthroplasty had a range of flexion of 35 degrees only. The mean range of flexion in the other patients in 84 degrees. Using The Hospital for Special Surgery rating, 29.4% scored excellent, 29.4% good, 17.6% fair, and 17.6% poor, including the two patients refused. Complications were found in nine patients (53%), six of which were resolved with further surgery. All patients preferred the mobile knee, but the complication rate is so high that the authors remain ambivalent about this procedure.

Cataract free zone and primary health care approach to prevention of blindness in Shunyi county of Beijing

OBJECTIVE

To establish a three-level eye care network, together with a referral and monitor system for the prevention of blindness, with the aim of creating a cataract free zone.

SUBJECTS AND METHODS

Shunyi County with a population of 548364 was chosen as the target site. Our activities included (1) establishment of a County Guiding Committee for the prevention of blindness: (2) training local ophthalmologists and primary eye care personnel: (3) extensive publicity of knowledge for the prevention of blindness: (4) screening for blindness and low vision, (5) cataract surgery as the chief measure for creating a cataract free zone.

RESULTS

A referral and monitor system for cataract blindness was established in 1987. Seven local ophthalmologists, 449 primary eye care health workers and six optometrists were trained. 815 cataract-blind patients were identified. Up to December 1991, 667 patients (737 eyes), accounting for 81.84% of the total, were treated with cataract surgery, 90.64% of these eyes had their sight restored, and 59.66% patients resumed work. A cataract free zone has been created in Shunyi County.

CONCLUSIONS

The prevention of blindness with cataract surgery as the chief measure can dramatically decrease the prevalence of blindness in a relatively short period of time.

In vitro effects of IL-2 on NK-activity, clonogenic potential, blast cell proliferation and cytokine release of MDS bone marrow patients

To evaluate the clinical usefulness of IL-2 in myelodysplastic syndromes (MDS) the in vitro effects of interleukin-2 (IL-2) on blast cell proliferation, clonogenic activity, cytokine release and cell mediated cytotoxicity were examined in 49 MDS patients. Morphological analyses of bone marrow (BM) cytospin preparations showed a significant decrease in the number of blast cells in MDS after incubation with IL-2. Incubation of bone marrow mononuclear cells (BMMNCs) with IL-2 induced a significant increase in the number of CFU-GM in comparison with untreated controls. gamma-IFN and GM-CSF, but not alpha-TNF were found to be released in significant amounts by the BMMNCs cultured with IL-2. No significant differences in the surface phenotypes of fresh lymphocytes were observed between the normal and MDS subjects. After incubation with IL-2, we observed a significant increase in the number of CD3-/CD56+ cells in both normal and MDS subjects. Peripheral blood (PB) and BM NK activity against K562 was significantly greater in MDS after stimulation with IL-2. These data suggest the clinical usefulness of IL-2 in a large subgroup of patients as it may reduce the percentage of blasts and increase clonogenic capacity and cell-mediated cytotoxicity.

Milk carnitine affects organ carnitine concentration in newborn rats

Previous studies suggest that exogenous milk carnitine may be necessary during the suckling period to maintain normal fat metabolism. To characterize the relationship between milk carnitine and carnitine in body organs, newborn rats were fed from birth a rat milk substitute with or without 300 micromol/L L-carnitine, corresponding to the concentration present in rat milk, for either 2 or 4 d. Carnitine concentrations in heart, skeletal muscle, liver and small intestine were compared with levels in rat pups that were never fed (d 0) and those that were nursed by their mothers for 4 d. Carnitine supplementation resulted in significantly higher concentrations of carnitine in all organs studied after 4 d compared with nursed controls. Relative intestinal carnitine pool size was 38.1 +/- 3.0, 22.6 +/- 1.0, 7.9 +/- 0.5 and 2.3 +/- 0.7 micromol/g body wt in supplemented, nursed, unsupplemented and never fed pups, respectively (P < 0.05, compared with one another). These results indicate that carnitine organ concentrations are related to dietary intake during the early suckling period and that the small intestine is a considerable and previously unrecognized proportion of the carnitine pool of suckling animals.

Treatment of a human breast cancer xenograft with an adenovirus vector containing an interferon gene results in rapid regression due to viral oncolysis and gene therapy

Treatment of a human breast cancer cell line (MDA-MB-435) in nude mice with a recombinant adenovirus containing the human interferon (IFN) consensus gene, IFN-con1 (ad5/IFN), resulted in tumor regression in 100% of the animals. Tumor regression occurred when virus was injected either within 24 hr of tumor cell implantation or with established tumors. However, regression of the tumor was also observed in controls in which either the wild-type virus or a recombinant virus containing the luciferase gene was used, although tumor growth was not completely suppressed. Tumor regression was accompanied by a decrease in p53 expression. Two other tumors, the human myelogenous leukemic cell line K562 and the hamster melanoma tumor RPMI 1846, also responded to treatment but only with ad5/IFN. In the case of K562 tumors, there was complete regression of the tumor, and tumors derived from RPMI 1846 showed partial regression. We propose that the complete regression of the breast cancer with the recombinant virus ad5/IFN was the result of two events: viral oncolysis in which tumor cells are being selectively lysed by the replication-competent virus and the enhanced effect of expression of the IFN-con1 gene. K562 and RPMI 1846 tumors regressed only as a result of IFN gene therapy. This was confirmed by in vitro analysis. Our results indicate that a combination of viral oncolysis with a virus of low pathogenicity, itself resistant to the effects of IFN and IFN gene therapy, might be a fruitful approach to the treatment of a variety of different tumors, in particular breast cancers.

Expression of estrogen receptor variants in normal and neoplastic human uterus

Estrogen receptor variants lacking internal exons and representing dominant positive and negative activity may be involved in the initiation and/or progression of endocrine dependent tumors. To assess the role of estrogen receptor in uterine disease, we have analyzed both normal and neoplastic uterine samples for the presence of variant estrogen receptors using the sensitive technique of RT-PCR and direct automated DNA sequencing of the amplified products. Our analysis was conducted to determine the presence of spliced variants lacking exons 3 through exon 8. We demonstrate that both the normal and neoplastic human uterus contains a number of spliced variants of the estrogen receptor that co-exist with the wild type receptor. Variants lacking exons 4, 5 and 7 but not exons 3 and 6 were detected. Also, a novel partial deletion in exon 8 was detected in both the normal and neoplastic tissues, although a total deletion of this exon was not observed. In addition another region of exon 8 deletion was found to be present in one tumor tissue which also contained an insertion within this region, however, other tumors did not contain this variant. In addition, double exon deletion variants were observed lacking exons 3 and 4, exons 4 and 5, and exon 7 with part of exon 8. Although our data represents a limited number of samples it suggests that splicing of the estrogen receptor message occurs in the normal physiological setting. There does not appear to be any association between the presence or absence of spliced variants of estrogen receptor and uterine tumor formation at the mRNA level.

Gene therapy with an adeno-associated virus carrying an interferon gene results in tumor growth suppression and regression

Adeno-associated virus (AAV) vectors were constructed containing both a synthetic type I interferon gene, (IFN-con1) and the bacterial neomycin-resistant gene. Recombinant virions were used to infect a number of human tumor cell lines, including 293, Hela, K562, and Eskol (a hairy cell leukemia-like cell), and geneticin-resistant cells were selected. All IFN-con1-transduced cell lines produced low levels of IFN-con1 and grew at the same rate as nontransduced cell lines. Although these cell lines were resistant to IFN in vitro, when injected into nude mice, 293, K562, and Eskol cells failed to form tumors up to 3 months after the initial inoculum, although mice receiving nontransduced cells developed tumors within 7 to 10 days. Transduced Hela cells grew much slower in vivo and formed much smaller tumors than did the parental cells. When equal numbers of transduced and nontransduced cells were injected into nude mice, tumors initially developed slowly and then completely regressed. Treatment of an established Eskol tumor (histologically a malignant immunoblastic lymphoma) with AAV/IFN-con1-transduced 293 cells resulted in tumor regression, whereas treatment of Eskol tumors with IFN-con1 resulted in a small decrease in tumor size. These results indicate that the human IFN-con1 gene in a viral vector can be used successfully in the treatment of tumors both directly and by tumor-targeted gene therapy.