Lesser metatarsalgia evaluation and treatment

Anatomic and biomechanical aspects of the complex topic of metatarsalgia are reviewed. Cause is classified as structural, functional, and a combination of both. Evaluation of the lesion symptom complex is presented and light is shed on reasons for complications after metatarsal osteotomy. Ways to avoid complications are also discussed. The oblique osteotomy with rigid fixation performed at the distal surgical neck or the proximal metaphysis is recommended.

Pulsed dye laser treatment of telangiectases with and without subtherapeutic sclerotherapy. Clinical and histologic examination in the rabbit ear vein model

The treatment of leg telangiectases with the carbon dioxide or argon laser results in a low success rate and an unacceptable risk of scarring. Sclerotherapy is effective; however, pigmentation and telangiectatic matting induced by extravasation of RBCs and excessive posttreatment inflammation are common. We conducted a clinical and histologic study of therapy with the 585 nm pulsed dye laser alone and in combination with subtherapeutic sclerotherapy in the rabbit ear vein model. The pulsed dye laser alone was effective when 10 joule/cm2 was used. In combination with immediate injection of the sclerosant, effective endosclerosis occurred with all tested laser energies (8 to 10 joule/cm2).

Electroejaculation in spinal cord injury patients: simplified new equipment and technique

A new simplified electrostimulation system for rectal probe electroejaculation has been developed and tested 17 times in 13 patients. Seminal emissions were obtained easily from 13 of 17 studies and partial emissions were obtained in 4. Patients with cauda equina and conus lesions with partial intact sensorium also could achieve successful ejaculation by longer stimulation from 2 to 5 minutes with lower currents that could be maintained easily and were tolerated by the patient--a feature unique to our new computerized equipment. The simplicity of operation reduces the number of trained personnel for an electrostimulation procedure, which can be done even in an outpatient setting.

A comparison of sclerosing agents: clinical and histologic effects of intravascular sodium tetradecyl sulfate and chromated glycerin in the dorsal rabbit ear vein

The dorsal marginal rabbit ear vein was injected with 0.25 ml of 0.1% or 0.25% sodium tetradecyl sulfate (STS) (Sotradecol Injection) or undiluted or 50% Scleremo (Scl) (chromated glycerin). Only the 50% Scl solution failed to produce clinical or histologic thrombosis at 1 hour. Clinical fading was observed in STS-treated vessels at 10 days postinjection. Histologically, early thrombus formation with focal endothelial necrosis was replaced by fibrosis and microangiopathic recanalization. Although undiluted Scl caused similar, yet milder histologic findings, luminal recanalization after 10 days resulted in a clinically unfaded vessel. The use of 50% Scl produced no endothelial damage with no subsequent change in vessel appearance. Cutaneous necrosis or extravasation of erythrocytes was not observed.

Mandibular prognathism

The use of the vertical subcondylar osteotomy for correction of uncomplicated mandibular prognathism is reviewed. Techniques for use in more complicated cases such as when a set back of greater than 10 mm is required are also described.

Cardiovascular evaluation before circulatory arrest for removal of vena caval extension of renal carcinoma

The use of cardiopulmonary bypass, deep hypothermia and circulatory arrest has decreased the risks of hemorrhage, tumor embolization, incomplete thrombus resection, and warm hepatic and renal ischemia associated with resection of renal cell carcinoma extending into the inferior vena cava above the hepatic veins. Patients about to undergo this operation frequently have significant coronary artery and carotid artery disease, and are at risk for perioperative myocardial infarction and stroke. Preoperative evaluation of the coronary artery and carotid artery circulation by coronary angiography, duplex carotid artery scan and digital subtraction carotid angiography is recommended. Depending upon the severity and location of the cardiovascular disease a sequential or simultaneous operation may be performed. This surgical approach can be used in selected patients to facilitate complete tumor thrombectomy with a low operative risk.

The effect of a standardized premedication on oxygen saturation in the cardiac patient before transfer to the operating room

The effect of premedication with morphine and scopolamine on arterial hemoglobin oxygen saturation (SaO2) was measured continuously in 26 undisturbed patients in their hospital rooms before coronary artery bypass surgery. Two hours preoperatively each patient received morphine, 0.1 mg/kg, and scopolamine, 0.2 or 0.4 mg. SaO2 was continuously recorded using pulse oximetry from one-half hour before premedication until 1 1/2 hours after premedication. The lowest SaO2 measured both the evening before surgery and one-half hour before premedication was 95% +/- 0.5% (mean +/- SEM). After administration of premedication, the lowest SaO2 for the patient population decreased to 93% +/- 0.4% (P less than 0.001 compared with that before premedication), and occurred 52 +/- 2 minutes after premedication was given. Two patients (8%) had an SaO2 less than 90% (lowest SaO2 for both was 88%). It is concluded that the dose of morphine/scopolamine premedication used was associated with a low risk of clinically important hypoxemia in the patient population studied.

Continuous oxygen saturation monitoring during cardiac catheterization in adults

Arterial hypoxemia may contribute to morbidity during cardiac catheterization. Therefore, we measured arterial hemoglobin oxygen saturation (SaO2) continuously using pulse oximetry in 29 patients (age range, 21 to 83 years) undergoing cardiac catheterization. Baseline SaO2 was 96 +/- 0.4 percent. All patients had a decrease in SaO2 at some time during the procedure. Eleven patients (38 percent) had episodes of arterial hypoxemia, defined as a decrease in SaO2 below 90 percent. In these 11 patients, the mean number of episodes of hypoxemia was 16 +/- 7, and the mean duration of each episode was 53 +/- 25 seconds. Multiple stepwise regression analysis showed that the minimum SaO2 during catheterization for any patient was significantly associated with the baseline SaO2, duration of the procedure, and end-diastolic volume (EDV) as described by the following regression equation: minimum SaO2 = 46.8 - 0.0580 (duration of procedure in minutes) + 0.5362 (baseline SaO2) - 0.0159 (EDV). Based on our finding of arterial hypoxemia in greater than one third of our patients, we would consider continuous SaO2 monitoring or supplemental oxygen during cardiac catheterization, especially for those patients with poor ventricular function or low resting SaO2 or those expected to have long procedures.

Fibronectin enhances healing of excised wounds in rats

Fibronectin (Fn) is a normal plasma and extracellular matrix glycoprotein that is involved in each phase of wound healing. For example, it is incorporated into both fibrin and collagen fibers; it opsonizes circulating tissue debris for removal by the reticuloendothelial system; it is used by macrophages, fibroblasts, and epithelial cells to move into the wound; and fragments of Fn are chemotactic for fibroblasts. In this study, experiments with rats showed that excised lesions treated with Fn healed more rapidly than paired control lesions treated with the carrier alone. Applications of Fn once a day for two days were as effective in speeding healing as twice-daily applications of Fn for 12 days. A single treatment with Fn soon after the initial injury was nearly as effective as more prolonged treatment regimens.

Tissue debris at the injury site is coated by plasma fibronectin and subsequently removed by tissue macrophages

Fibronectin (Fn) is a normal plasma and extracellular matrix glycoprotein that is thought to be important in reticuloendothelial system function as well as in promoting adhesion of various cell types to basement membranes and to each other. Plasma Fn levels are depressed following almost any type of trauma. It opsonizes circulating tissue debris for removal by the fixed cells of the reticuloendothelial system. It has been assumed but not proven that Fn also opsonizes tissue debris at the site of the injury for subsequent phagocytosis by tissue macrophages. In this study, rats were given intracardiac injections of Fn coupled with fluorescence isothiocyanate (Fn-FITC) and human serum albumin-rhodamine isothiocyanate (HSA-RITC). Abdominal Rebuck skin windows were then prepared. Within 24 hours, debris at the sites of injury were observed to be coated with Fn-FITC but not HSA-RITC. This Fn-labeled debris was subsequently ingested by macrophages at the site. No macrophages were found that had taken up HSA-RITC. Thus, Fn is seen to coat tissue debris and effete cells within the wound, and the coated material is subsequently removed by tissue macrophages.

Induction of expression of cell-surface homologous restriction factor upon anti-CD3 stimulation of human peripheral lymphocytes

Homologous restriction factor (HRF) is a 65-kDa membrane protein that inhibits transmembrane channel formation by the membrane-attack complex of complement and by the complement component C9-related cytolytic lymphocyte protein. Stimulation of resting peripheral human lymphocytes with the anti-CD3 monoclonal antibody OKT3 has been shown to induce cytotoxicity in the CD8+ subpopulation. As demonstrated here, OKT3 stimulation also induces expression of cell-surface HRF by CD4+ and CD8+ T lymphocytes. The small proportion of Leu 19+ natural killer lymphocytes present in peripheral blood mononuclear cells was found to express HRF prior to stimulation. Whereas unstimulated peripheral blood mononuclear cells were susceptible to lysis by the membrane-attack complex or by the C9-related protein, OKT3-stimulated peripheral blood mononuclear cells were relatively resistant to both the membrane-attack complex and C9-related protein. This acquired resistance was abrogated by blocking surface HRF with F(ab')2 anti-HRF, suggesting that resistance was due to lymphocyte-membrane HRF. By using solid-phase anti-HRF, a 65-kDa protein was isolated from the activated peripheral blood mononuclear cells and shown to be capable of conferring upon sheep erythrocytes the characteristic activity of human HRF.

Anesthetic management for cardiac transplantation in North America--1986 survey

Cardiac transplantation has become an established part of the therapy of end-stage heart disease. The number of cardiac transplants performed, as well as the number of centers performing them, has increased dramatically in the past 2 years. A paucity of literature on the anesthetic management of patients undergoing cardiac transplantation prompted this survey of 46 United States and Canadian institutions. The report summarizes the perioperative anesthetic management of a total of 1,273 transplant recipients in 34 institutions. Generally, similar anesthetic techniques and agents were used. One notable exception was the percentage of institutions using perioperative pulmonary artery catheter monitoring. As determined from this survey, right ventricular failure remains the leading cause of inability to terminate cardiopulmonary bypass in this patient population. Further, in surveyed institutions, cardiac transplantation expends more physician as well as hospital resources per patient than coronary artery bypass surgery.

The effect of halothane/nitrous oxide/oxygen mask induction on arterial hemoglobin saturation in cyanotic heart disease

The effect of a halothane/nitrous oxide/oxygen mask induction on arterial hemoglobin saturation (SaO2) was studied in 25 patients with cyanotic congenital heart disease. During this induction the SaO2 increased from 80% +/- 2 (mean +/- SEM) in awake patients breathing room air to 86% +/- 1 after induction of anesthesia, with an average increase of 6.8% +/- 2 (absolute) (N = 25; P < .005). Patients were retrospectively divided into two groups, A and B. Group A patients had pulmonic infundibular stenosis (PIS) (N = 13) with the potential for variable pulmonary outflow tract obstruction. These patients had awake SaO, values of 76% +/- 3 that increased significantly after induction to 86% +/- 1, with an average increase of 10% +/- 4 (absolute) (P < .01). Group B patients did not have PIS; they had an awake SaO2 of 83% +/- 2, which rose insignificantly after induction to 87% +/- 1, with an average increase of 4% +/- 2 (absolute) (P > .1). Thus, the significant increase in SaO2 during induction for the entire group was primarily due to the large response of patients with PIS. No correlation was found between SaO2 and systolic blood pressure for the entire study population as well as for groups A and B separately. The lack of correlation between systolic blood pressure and SaO2 may indicate that relaxation of pulmonic infundibular stenosis is an important mechanism explaining the observed increase in SaO2 during anesthetic induction in group A (PIS) patients. Six patients had clinically important decreases in SaO2 during the induction of anesthesia, and airway obstruction was usually the cause. Anesthetic induction with halothane/nitrous oxide/oxygen leads to an increase in SaO2 in patients with many forms of cyanotic heart disease, but especially those with the potential for variable pulmonary outflow tract obstruction.

Induction of cytotoxicity in human peripheral blood mononuclear cells by monoclonal antibody OKT3

It has been previously reported from this laboratory that incubation of PBMC with OKT3 generates potent cytotoxic lymphocytes that can be targeted by using antibody heteroconjugates consisting of anti-target cell antibody and OKT3. In the present study these conjugates were used to explore the kinetics of induction of cytotoxicity in PBMC and the subpopulations of lymphocytes involved. It was found that in addition to conjugate-dependent cytotoxicity, a considerable amount of conjugate-independent cytotoxicity was generated during OKT3 stimulation. Although the conjugate-dependent activity resided in the CD8+ population, the conjugate-independent cytotoxicity was found to be a function of CD4-/CD8- natural killer-like cells. Being largely CD3-, those cells were most likely activated by lymphokines produced by OKT3-stimulated CD3+ cells. They were capable of killing not only tumor cells but also autologous lymphocytes. The CD4+ cells of some donors were found to exhibit low but clearly demonstrable cytotoxicity. Induction of cytotoxicity was characterized as an early event in T cell activation, correlating with the kinetics of RNA synthesis. Cytotoxicity, interleukin 2 receptor expression, and DNA synthesis declined after 3 days of activation with OKT3, indicating the existence of as yet undefined regulatory mechanisms.

Induction of cytotoxicity in human peripheral blood mononuclear cells by monoclonal antibody OKT3

It has been previously reported from this laboratory that incubation of PBMC with OKT3 generates potent cytotoxic lymphocytes that can be targeted by using antibody heteroconjugates consisting of anti-target cell antibody and OKT3. In the present study these conjugates were used to explore the kinetics of induction of cytotoxicity in PBMC and the subpopulations of lymphocytes involved. It was found that in addition to conjugate-dependent cytotoxicity, a considerable amount of conjugate-independent cytotoxicity was generated during OKT3 stimulation. Although the conjugate-dependent activity resided in the CD8+ population, the conjugate-independent cytotoxicity was found to be a function of CD4-/CD8- natural killer-like cells. Being largely CD3-, those cells were most likely activated by lymphokines produced by OKT3-stimulated CD3+ cells. They were capable of killing not only tumor cells but also autologous lymphocytes. The CD4+ cells of some donors were found to exhibit low but clearly demonstrable cytotoxicity. Induction of cytotoxicity was characterized as an early event in T cell activation, correlating with the kinetics of RNA synthesis. Cytotoxicity, interleukin 2 receptor expression, and DNA synthesis declined after 3 days of activation with OKT3, indicating the existence of as yet undefined regulatory mechanisms.

Killing of human melanoma cells by the membrane attack complex of human complement as a function of its molecular composition

The efficiency of the membrane attack complex (MAC) in killing M21 melanoma cells was determined varying the molar ratio of cell-bound C9:C8. It was found that C5b-8 produced functional channels as evidenced by 86Rb release and propidium iodide uptake; cell killing occurred in the absence of C9 with greater than 5 X 10(5) C5b-8/cell; the maximal molar ratio of C9:C8 was 6.6:1; using nonlytic numbers of C5b-8 (4.7 X 10(5)/cell), greater than 90% killing ensued at a C9:C8 molar ratio of 2.8:1 at which approximately 9,000 poly C9/cell were formed, and 50% killing at a ratio of 1:1; (e) when the MAC was assembled on cells at 0 degree C, consisting of C5b-8(1)9(1), and unbound C9 was removed before incubation at 37 degrees C, killing was similar to that observed when poly C9 formation was allowed to occur. Thus, MAC lytic efficiency toward M21 cells may be enhanced by but does not depend on poly C9 formation.

Molecular mechanisms of cytotoxicity: comparison of complement and killer lymphocytes

The membrane attack complex of complement is an amphiphilic fusion product of 5 glycoproteins, C5, C6, C7, C8 and C9. The membrane attack complex forms transmembrane channels that vary in size depending on the number of C9 molecules incorporated into the complex. The C5b-8 complex forms small channels and at high multiplicity can kill nucleated cells. At least 12 C9 molecules are required to form tubular poly C9 which evokes the ultrastructural image of the classical membrane lesion produced by complement. The membranes of erythrocytes and other blood cells contain a 70,000 dalton protein that can inhibit channel formation by the membrane attack complex. This protein is species specific and has been called homologous restriction factor. A cytotoxic protein immunochemically related to C9 was isolated from cytotoxic human large granular lymphocytes and from OKT3 activated human peripheral blood mononuclear cells. In the presence of Ca++, isolated C9 related protein (C9RP) formed circular structures that resembled poly C9. C9RP efficiently killed K562 cells, human melanoma cells, Raji cells and human large granular lymphocytes. The results suggest that the channel forming protein of cytotoxic lymphocytes and C9 of complement have a common evolutionary ancestry.

Induction of synthesis of the cytolytic C9 (ninth component of complement)-related protein in human peripheral mononuclear cells by monoclonal antibody OKT3 or interleukin 2: correlation with cytotoxicity and lymphocyte phenotype

Synthesis of the cytolytic C9-related protein (C9RP) was induced by activation of resting human peripheral T lymphocytes with the anti-CD3 antibody OKT3 or interleukin 2. Comparison of cellular cytotoxicity and C9RP content at various times during activation yielded a coefficient of correlation r = 0.92. During OKT3 stimulation of peripheral mononuclear cells, maximal C9RP content and cytotoxicity were observed by day 2 or 3, with subsequent decline to baseline values by day 5, whereas during interleukin 2 stimulation, both parameters reached the maximal level at days 3-5. After fluorescence-activated cell sorting, C9RP and cytotoxicity were quantitated in CD4+, CD8+, and Leu-19+ subsets. In OKT3-activated CD8+ cells, C9RP increased to approximately 3 X 10(6) molecules per cell, with a corresponding increase in lysis of human melanoma cells mediated by anti-CD3-anti-melanoma monoclonal antibody conjugates. Interleukin 2-stimulated CD8+ cells showed similar increases, but cytotoxicity was conjugate-independent. Activated CD4+ cells showed minimal increase in C9RP content. Leu-19+ cells, which exhibit natural killer cell activity, had a high C9RP content (approximately 2.5 X 10(6) molecules per cell) before stimulation.