Repression of the c-myb gene by WT1 protein in T and B cell lines

The c-myb gene is primarily expressed in immature hematopoietic cells, and it is overexpressed in many leukemias. We have investigated the role of negative regulatory sites in the c-myb promoter in the Molt-4 T cell line and in the DHL-9 B cell line. A potential binding site for either the EGR-1 or WT1 protein was identified by in vivo footprinting in the 5'-flanking region of c-myb in a region of negative regulatory activity in T cells. We showed by electrophoretic mobility shift assay and electrophoretic mobility shift assay Western that WT1, EGR-1, and Sp1 bound to this site. A mutation of this site which prevented protein binding increased the activity of the c-myb promoter by 2.5-fold. In the DHL-9 B cell line, this site was nonfunctional; however, we found a potential EGF-1/WT1 site located more 3' in a region of negative regulatory activity. We showed that WT1, EGR-1, and Sp1 bound to this site, and that mutation of this site increased the activity of the c-myb promoter by 3.2-fold. Cotransfection of a WT1 expression vector repressed the activity of the c-myb promoter in both cell lines, and this repression was relieved when the EGR-1/WT1 sites were removed. Cotransfection of either an EGR-1 or Sp1 expression vector had no significant effect on the activity of the c-myb promoter. We conclude that WT1 is a negative regulator of c-myb expression in both T and B cell lines.

Pulmonary scar carcinoma: report of three cases and review of the literature

Pulmonary scar carcinoma was described as a distinct clinicopathological entity over 50 years ago. There are many theories on the formation of this entity. We present three cases of pulmonary scar carcinoma with a high ratio of adenocarcinoma. One patient had a favorable postoperative course despite a 14-month delay in treatment. Necropsy specimen of another patient showed two primary scar carcinomas unrelated to each other. Literature review and discussion of etiology, diagnosis, and treatment modalities of pulmonary scar carcinoma were done. Pathogenesis and prognosis of the neoplasms associated with apical scars are not clearly understood.

Myb binding sites mediate negative regulation of c-myb expression in T-cell lines

In hematopoietic cell development, the c-myb transcription factor plays an important role. c-myb mRNA is expressed at high levels in immature proliferating cells and in leukemic cells. We have investigated the regulatory role of Myb protein binding to the human c-myb promoter. Three Myb binding sites have been described at approximately 600 bp upstream of the cap site. By transient transfection assays in hematopoietic cell lines, we found that deletion of the previously defined most 5' Myb binding site had no effect on activity, whereas deletion of the region containing the remaining two Myb binding sites resulted in an increase in activity in both a T-cell line and a myeloid cell line. To specifically test the importance of these two Myb binding sites, the activity of three-point mutation constructs was measured. Mutation of either Myb binding site resulted in an increase in activity compared with the wild-type promoter in T cells. Mutation of both sites produced even higher activity. Transfection of the Myb site mutants into the myeloid cell line resulted in no change in activity compared with the wild type construct. Results from gel shift analysis, UV cross-linking, and Western blots showed that both c-Myb and B-Myb bound to the Myb I and II sites. We conclude that the Myb family proteins negatively regulate c-myb expression in T-cell lines in contrast to the positive regulation via these sites, which has been shown in fibroblasts. In addition, in a myeloid cell line, the Myb binding sites are nonfunctional.

Balloon dilatation through the subcutaneously placed afferent limb of a hepaticojejunostomy in patients with resected Klatskin tumors

It is generally conceded that palliation for proximal bile duct tumors (Klatskin) is exceptional if obstruction and the resultant infections can be prevented. Our experience with balloon dilatations thru the subcutaneously placed afferent limb of a choledocho or hepatico jejunostomy in patients with benign strictures suggests that this approach will be effective in patients with malignancies and thus provide long-term control of the obstruction without the need for external tubes. This is a report on one patient who, following a resected Klatskin tumor with positive margins, was treated with transhepatic internal external stents and was converted to a subcutaneous limb following numerous bouts of cholangitis. A schedule for repeat dilatations thru the jejunal limb was established. The patient has remained afebrile with a normal bilirubin and a moderately elevated alkaline phosphatase. Recurrent tumors or postirradiation strictures in patients with resected Klatskin tumors can be effectively controlled by repeated balloon dilatation without the need for external stents.

Axillofemoral bypass graft in a spinal cord injured patient with impending gangrene

The axillofemoral bypass graft, an extra-anatomic graft, connects the axillary artery to the femoral artery and is used in the treatment of significant aortoiliac occlusive disease in poor-risk patients. A common indication for axillofemoral bypass is a "hostile abdomen" (postoperative adhesions, neoplasms or radiation). Less frequent indications are aortic mycotic aneurysm, infected aortobifemoral bypass graft, aortoduodenal fistula, inflammatory aneurysm and extensive retroperitoneal fibrosis. Spinal cord injured patients with peripheral arterial disease have two problems: 1) lack of premonitory symptoms (absence of claudication, paresthesias or rest pain) and 2) difficulty preventing pressure sores in the already poorly perfused limb. Indications for arterial reconstructive surgery are more drastic in this set of patients (impending gangrene and/or ischemic ulcers). Many spinal cord injured patients have sources of possible contamination (cystostomy and/or colostomy) which make intra-abdominal clean surgery impossible. We present a spinal cord injured patient with a permanent cystostomy and impending gangrene of the left foot. He underwent a left axillofemoral bypass graft and had a good postoperative course. We conclude that axillofemoral bypass graft is a good alternative for limb salvage in the spinal cord injured patient, especially when there is a source of possible contamination (colostomy and/or cystostomy) that would interfere with more common bypass grafting. The role of the noninvasive vascular laboratory for early detection of vascular disease is emphasized.

Accelerated fractionation in inoperable non-small cell lung cancer. A phase I/II study

BACKGROUND

A prospective, single-treatment-arm, Phase I/II trial was performed to determine the tumor response to an accelerated regimen and assess the feasibility and toxic effects of this approach in patients with inoperable non-small cell lung cancer (NSCLC).

METHODS

Thirty-seven previously untreated patients with inoperable NSCLC who had no evidence of metastatic disease entered the study. All patients were able to walk and had disease that was measurable or assessable. Patients with palpable supraclavicular disease and weight loss were also eligible. Radiation therapy consisted of an altered fractionation regimen with a concomitant boost technique. The original lung volume received a dose of 40 Gy in 20 daily fractions to the computerized axial tomography (CT)-defined primary tumor and mediastinal nodes. The boost dose (10 Gy) was administered concomitantly with the last five fractions of the original volume treatments, with an interfraction interval of 6-8 hours. The maximal allowed dose to the cord was 46 Gy.

RESULTS

At a median follow-up of 36 months, complete response was achieved in 29% (9 of 31) of the patients and a partial response in 42% (13 of 31). The overall survival rate at 36 months was 10% (median survival time, 8 months). Survival rates were 25%, 8%, and 0% for the complete responders, partial responders, and nonresponders, respectively. Local failure alone was observed in 35.5% of all patients, local and distant failure in 42%, and distant failure only in 13%. Treatments were well tolerated, and all patients were able to complete the planned regimen. Grade 1 and 2 esophagitis occurred in 65% and 26% of the patients, respectively. The clinical condition of two patients (6%) was compatible with radiation pneumonitis. Moist desquamation of the skin occurred in two patients, but most had either mild (55%) or moderate (19%) skin erythema. Late complications have been limited to radiologically detected lung fibrosis.

CONCLUSIONS

The accelerated fractionation schedule used in this trial was well tolerated with shortening of overall treatment time. Local tumor control and overall survival are similar to those resulting from conventional fractionation without an increase in normal tissue effects. These results are encouraging, and additional studies testing higher tumor doses are warranted.

Schistosomiasis and vascular alterations of the colonic mucosa

The diagnosis of schistosomiasis is made by identification of Schistosoma in stool and urine, or by colonic or hepatic biopsies. The authors demonstrate in this paper, however, that it is also possible to suspect this disease by colonoscopy, i.e., by macroscopic observation of the vascular alterations in the mucous membrane of parasite infected patients. Out of 33 patients -21 with schistosomiasis and 12 with other intestinal parasitoses--the endoscopist correctly diagnosed Schistosomiasis in 18 (85.7%) patients, although he had no previous experience of the diagnosis. Since this infection is widespread throughout the world, these endoscopic findings are important; they may help the physician correctly diagnosis schistosomiasis in non-endemic areas where the diagnosis may not be suspected.

Clinical experience with electron pseudoarc therapy

Between November 1986 and June 1990, 24 patients were treated with electron pseudoarc therapy at McGill University. There were 21 females and three males aged 27 to 81 years (median 62 years). 17 patients, nine of whom had received previous conventional locoregional irradiation, were treated palliatively for locally extensive breast carcinoma. Eight of these 17 patients achieved a complete, and six a partial, response to treatment; nine subsequently developed evidence of progressive disease within the treatment field after intervals of one to 27 months (median 5 months) following therapy. Eight patients developed moist desquamation of the treated chest wall, which was extensive in four; one of these patients developed chronic ulceration of the skin. The latter and one additional patient developed radiation pneumonitis. Seven patients were treated with radical intent, two following mastectomy for breast carcinoma, and one each for chest wall lymphoma, chest wall sarcoma, scalp angiosarcoma, scalp lymphoma and posterior cervical soft tissue sarcoma. Local control was achieved in six of these seven patients with minimal toxicity. Electron pseudoarc therapy is a treatment option for selected breast carcinoma patients for palliation of extensive chest wall disease, although morbidity may be considerable. The technique may, however, play a more useful role in other situations where the superficial portion of large curved surfaces is to be treated with curative intent.

Inhibition of alveolar macrophages by pentoxifylline

BACKGROUND AND METHODS

Pentoxifylline can inhibit blood leukocyte functions in vitro, and some inflammatory processes in the lung in vivo. Therefore, we examined the effects of pentoxifylline on alveolar macrophage functions in vitro. Alveolar macrophages were harvested from normal rat lungs by airway lavage. The dose-response relationship of varying concentrations of pentoxifylline and in vitro cell functions were examined. Macrophage functions studied included adherence to nylon wool, random (unstimulated) and zymosan-activated serum-stimulated migration through 5 microns millipore filters, and superoxide generation induced by zymosan-activated serum as assayed by cytochrome c reduction.

RESULTS

Pentoxifylline inhibited superoxide generation and stimulated migration (but not random migration or adherence) in a dose-dependent fashion. Statistically significant inhibition was demonstrated at 0.5 mM and 5.0 mM concentrations of pentoxifylline, respectively, for stimulated migration and superoxide generation.

CONCLUSIONS

Pentoxifylline can inhibit some alveolar macrophage functions in vitro. These effects may inhibit some forms of inflammatory lung injury, particularly when iv infusion of high doses of pentoxifylline are utilized. However, potentially adverse effects on inflammatory defense mechanisms must be considered as well.

Physical aspects of the angle-beta concept in electron arc therapy

A technique for the determination of treatment parameters that are required to achieve a desired depth dose distribution in electron arc therapy is discussed and a method for calculating isodose distributions is presented. Both the treatment technique and the dose calculation method rely on the angle beta concept, which uniquely describes the dependence of the radial percentage depth doses in electron arc therapy on the nominal field width, isocenter depth, and virtual source-axis distance. The angle beta concept is discussed in detail and the electron pseudo-arc therapy technique used at McGill is described. Also presented is the method used to achieve dose homogeneity in target volumes treated with the pseudo-arc technique.

Detection of clinically suspected deep vein thrombosis using light reflection rheography

Venography is the current standard for the diagnosis of deep vein thrombosis (DVT). Noninvasive tests have differing sensitivity and specificity, are technically demanding, and may be subject to variability in interpretation. Light reflection rheography (LRR) is a noninvasive method utilizing light-emitting diodes and a sensor to measure light reflected from the skin surface. The intensity of reflected light establishes a graphic pattern that indirectly quantifies parameters of venous function by measuring changes in the microcirculation. Seventy-two patients who underwent contrast venography at our institution were also evaluated with LRR. Twenty-four patients were found to have DVT as demonstrated by venography. Of these, 23 also had DVT detected by LRR. No evidence of thrombus was seen in 45 patients studied by venography; in this group, 35 had normal venous emptying indicated by LRR. Using LRR, a sensitivity of 96% was achieved in the evaluation of clinically suspected DVT. This sensitivity is comparable with other noninvasive tests. In addition, LRR is easy to operate, portable, inexpensive, and not technically demanding. Further investigation is needed to confirm these data and further define the role of LRR in the evaluation of clinically suspected DVT.

A randomized trial of induction chemotherapy plus high-dose radiation versus radiation alone in stage III non-small-cell lung cancer

BACKGROUND

For patients with locally or regionally advanced non-small-cell lung cancer radiation is the standard treatment, but survival remains poor. We therefore conducted a randomized trial to determine whether induction chemotherapy before irradiation improves survival.

METHODS

All the patients had documented non-small-cell cancer of the lung with Stage III disease established by clinical or surgical staging. Eligibility requirements included excellent performance status, minimal weight loss, and visible disease on radiography. Patients randomly assigned to group 1 received cisplatin (100 mg per square meter of body-surface area given intravenously on days 1 and 29) and vinblastine (5 mg per square meter given intravenously on days 1, 8, 15, 22, and 29) and then began radiation therapy on day 50 (60 Gy over a 6-week period). Patients assigned to group 2 received the same radiation therapy but began it immediately and received no chemotherapy.

RESULTS

The eligible patients in group 1 (n = 78) and group 2 (n = 77) were comparable in terms of age (median, 60 years), sex, performance status, histologic features, stage of disease, and completeness of radiation therapy. The median survival was greater for those in group 1-13.8 versus 9.7 months (P = 0.0066 by log-rank test). Rates of survival in group 1 were 55 percent after one year, 26 percent after two years, and 23 percent after three years, as compared with 40, 13, and 11 percent, respectively, in group 2. Those in group 1 had a higher incidence of serious infections requiring hospitalization (7 percent, vs. 3 percent in group 2) and severe weight loss (14 percent vs. 6 percent), but there were no treatment-related deaths.

CONCLUSIONS

In patients with Stage III non-small-cell lung cancer, induction chemotherapy with cisplatin and vinblastine before radiation significantly improves median survival (by about four months) and doubles the number of long-term survivors, as compared with radiation therapy alone. Since three quarters of the patients still die within three years, however, further improvements in systemic and local therapy are needed.

Hepatic cirrhosis and hepatitis: MR imaging enhanced with superparamagnetic iron oxide

Superparamagnetic iron oxide was applied as a reticuloendothelial contrast agent in the diagnosis of cirrhosis and hepatitis in seven patients. Three patients had compensated cirrhosis, and four had active hepatitis. T1- and T2-weighted spin-echo magnetic resonance images were obtained before and 1 hour after the administration of iron oxide. Eight patients without diffuse liver disease served as a control group. Normal liver tissue showed a 75% +/- 9% reduction in signal intensity after the administration of iron oxide, and the liver appeared homogeneously hypointense. Cirrhotic liver tissue showed a smaller response (P less than .05) to iron oxide, with a 52% +/- 13% reduction in liver signal intensity. Inhomogeneous structures could be observed in enhanced images and are thought to represent fibrous bands or regenerating nodules. Liver tissue with active hepatitis showed a markedly reduced response to iron oxide (11% +/- 2%) (P less than .05), and the parenchyma appeared homogeneous. The authors conclude that the uptake of iron oxide particles is inhomogeneously altered in cirrhosis because of structural changes and homogeneously decreased in hepatitis because of functional changes of hepatic parenchyma.

[Epidemiological and clinical features of brucellosis in 39 family groups]

Clinical epidemiological evaluations on brucellosis, done during the last five years in endemic areas in Lima (Peru), in 39 families with 232 members, have let us observe a high rate of symptomatic infection 118/232 (50.9%) and has also let us identify, as risk factors to contract the disease; age older than 10 years 97/190 (56.3%) versus 11/42 (26.1%); in younger than 10 years of age (p less than 0.05) and families with 5 or less members 40/54 (74.0%) versus 78/175 (44.5%) of more numerous families (p less than 0.001), and also to be exposed to a common source as a form to contract the disease. We observed the importance of an adequate treatment in early stages of the disease. We detected major clinical gravity in women 23/55 than in men 5/38 (p less than 0.01), specially in brucellar arthritis (p less than 0.05). Period of time between the appearance of index case and secondary cases was of 33.8 days, but range was of 1-115 days. The heterogeneous aspects of the disease between members of the same family, suggest that response of host, more than bacterial virulence, is so important in the clinical course of the disease.

Rapid serial enzyme measurements in evaluation of patients with suspected myocardial infarction

Because clinical and laboratory criteria cannot accurately establish the presence or absence of acute myocardial infarction (AMI) at the time of initial presentation, this diagnosis is not confirmed in the majority of patients admitted to coronary care units. To study the effectiveness of serial changes in enzyme activity in specimens taken at presentation and 8 hours later in establishing the likelihood of AMI, the results in 1,214 patients with acute cardiac symptoms of less than 24 hours' duration were retrospectively evaluated. In 1,007 patients with initially normal creatine kinase (CK), an increase in CK (positive delta-CK) occurred in 98% of patients with AMI and 16% of patients without AMI. In 196 patients with elevated total CK, a low ratio of CK to aspartate aminotransferase was found in 98% of patients with AMI and 33% of patients without AMI. These 2 enzyme ratios had a sensitivity greater than 90% in patients with typical and atypical histories. The overall predictive value of serial enzyme measurements for AMI was 53%, compared with 18% in patients selected for admission. These results suggest that serial enzyme measurements could be used in the initial evaluation of patients with suspected AMI, and have the potential to reduce the number of patients admitted to coronary care units who do not have AMI.

Results of surgery for obstructing carcinomatosis of gastrointestinal, pancreatic, or biliary origin

Results of operation for obstructing carcinomatosis of gastrointestinal (GI), pancreatic, or biliary origin were reviewed to assess relief of symptoms, management of re-obstruction, and duration of hospitalization. A retrospective review (1977 to 1986) identified 89 patients, 59 (66%) of whom had tumors originating in the colon, and 19 (21%) in the stomach. Normal bowel function was restored for a median of 102 days in 66 patients (74%) and all but four (94%) were discharged. Forty-one (46%) patients remained unobstructed until death. Twenty-three (26%) were not relieved by operation and died a median of 33 days later (P less than .005). Forty-eight (81.4%) of the 59 colon cancer patients and ten (52.6%) of 19 with gastric cancer (P less than .05) were benefited by the operation, although comparison of duration of function was less striking (P less than .1). In-hospital mortality was 13% and complications occurred in 44%. Obstruction recurred in 38% of those relieved by the initial operation. Normal bowel function was restored in six (46%) of 13 patients undergoing a second laparotomy (median, 158 days) and in six of 13 (46%) treated with nasogastric suction. Obstruction recurred again in four of the latter six patients (median, 39 days). Hospitalization averaged 31 days (median, 25 days) for the first procedure and 41 days (median, 39 days) for patients operated for recurrent obstruction. These results justify laparotomy for intestinal obstruction in known or suspected carcinomatosis, particularly of colonic origin, if performance status is compatible with a reasonable quality of life.

Absence of infection with human immunodeficiency virus in Peruvian prostitutes

We serologically tested 140 female prostitutes (mean age, 30 years) from the port city of Callao, Peru, for evidence of infection with human immunodeficiency virus (HIV), Chlamydia trachomatis, Treponema pallidum, herpes simplex viruses (HSV) I and II, and hepatitis B virus. The women had worked as prostitutes for an average of 5 years; one-fourth serviced foreign visitors exclusively, mainly sailors. Only 4 women used condoms, and only 1 woman gave a history of parenteral narcotic abuse, although 53% were regularly exposed to unsterile needles outside the medical setting for injections of vitamins, antibiotics, or steroids; another 29% are thought to probably use unsterile needles. None of the 140 prostitutes screened was seropositive for HIV, despite a very high prevalence of antibody to T. pallidum (24%), C. trachomatis (97%), HSV I and II (100%), and hepatitis B (51%); 5% were HbsAg positive. These data indicate that HIV has not yet been introduced into female prostitutes in the Peruvian port city. We believe that widespread use of unsterile needles in developing countries, such as Peru, represents a serious health threat and will amplify the spread of HIV, once introduced.

Regional isolated limb perfusion of melanoma intransit metastases using mechlorethamine (nitrogen mustard)

Forty-two patients with intransit metastases of melanoma in a limb were treated by isolated regional perfusion chemotherapy using mechlorethamine (nitrogen mustard). Group 1 (n = 12) underwent treatment at low dose, less than 0.35 mg/kg, or low temperature, less than 38 degrees C. Group 2 (n = 30) received higher doses, 0.35 to 0.6 mg/kg, plus heat at 38 degrees C to 41 degrees C. No patient had evidence of disease outside the limb at the time of perfusion. The median follow-up time was 48 months (range, 1 to 9 years). Of the 42 patients, 29 had measurable lesions that responded as follows: group 1, complete response (CR) in two of ten and partial response (PR) in none; group 2, CR in six of 19 and PR in six of 19. The combined CR and PR rate of 12 of 19 in group 2 was significantly higher than that of group 1 (P less than .05). CR lasted only 2 months in the two patients of group 1, but persisted in the six patients of Group 2, four of whom are still alive free of disease at 16, 21, 33, and 40 months. Relapse-free control of disease in the limb was achieved in 36% of the patients in group 2 at 24 months, compared with 0% in group 1 (P less than .05). An overall survival of 74% at 48 months was observed in group 2, significantly higher than that of 64% for group 1 (P less than .05). The status of the regional lymph nodes (RLN) and the number of metastases did not affect tumor response. However, 77% of RLN-negative patients survived 48 months, in contrast to only 38% of RLN-positive patients (P less than .05). One patient died postoperatively of myocardial infarction. No serious systemic toxicity developed. Two patients who underwent repeat salvage perfusions developed a reversible peripheral neuropathy in the limb. Limb function was good after treatment, and dramatically improved in patients who had advanced satellitosis that responded to treatment. These results suggest that heated limb perfusion using mechlorethamine at an adequate dose can offer long-term control of intransit metastases in approximately one third of these patients, with preservation of good limb function and possible prolongation of survival.

Perfluoroctylbromide as a contrast agent for computed tomographic imaging of septic and aseptic arthritis

Perfluoroctylbromide (PFOB), a perfluorocarbon macrophage-labeling contrast agent, was applied to computed tomographic imaging of septic and aseptic arthritis models in rabbits. Marked enhancement of induced pyarthrosis was observed in both the knee and the sacroiliac joint. Moderate enhancement was noted in tetracycline-induced synovitis of the knee. Sterile synovitis of the sacroiliac joint and simple knee joint effusion showed no enhancement. These results suggest that PFOB is a useful contrast medium for the diagnosis of and distinction between septic and sterile arthritis.

An evaluation of diagnostic methods for brucellosis--the value of bone marrow culture

Fifty patients, eventually diagnosed as having brucellosis, were studied prospectively for comparison of a simple culture of bone marrow aspirate from the iliac crest (0.5-1.0 ml) with two cultures of blood (5-10 ml) taken 30-60 min apart and with a tube-agglutination test. Cultures of bone marrow and blood were positive in 92% and 70% of the patients, respectively (P less than .001). Bacteria multiplied significantly faster in bone marrow cultures (4.32 vs. 6.65 days; P less than .001). All isolates were identified as Brucella melitensis biotype 1. Serological diagnosis was established in 86% of the patients. The efficacy of cultures of blood decreased significantly with chronic and subacute forms of infection, whereas that of bone marrow culture decreased only in chronic forms. Prior use of antibiotics reduced the positivity of cultures of blood but did not affect bone marrow culture. Bone marrow culture is recommended for patients with fever of unknown origin, negative serology, and unexplained articular or hematologic involvement, and patients in whom brucellosis is suspected.

Vertebral venous channels: CT appearance and differential considerations

A comprehensive study of the anatomy, radiologic images, and pathology of venous channels in the thoracic and lumbar vertebral bodies was performed using cadavers and patients. These structures may be mistaken for fractures, lytic lesions, or other abnormalities on high-resolution axial computed tomographic (CT) scans of the spine. A distinct osseous wall, absence of extension over multiple contiguous levels, lack of displacement, and predominant localization in the mid-axial plane of the vertebral body are characteristic features of venous channels. An understanding of the normal intraosseous venous anatomy should prevent misinterpretation of clinical CT studies in most instances.

The skeletal manifestations of clubbing: a study in patients with cyanotic congenital heart disease and hypertrophic osteoarthropathy

The skeletal manifestations of clubbing of the digits have been occasionally noted and only briefly discussed in the literature. We investigated the radiographic features of digital clubbing in 37 patients with diverse diseases including cyanotic congenital heart disease, lung malignancy-associated hypertrophic osteoarthropathy, and idiopathic cases. We identified two types of bone changes--osteolysis or bone dissolution, and bone formation or hypertrophy. The changes were more evident in the feet than in the hands, and the degree of soft tissue change did not always reflect the underlying osseous abnormalities. The relationship of these changes (ie, osteolysis, hypertrophy) to each other appear to depend in part on the underlying disease as well as the time course or disease duration. Thus, clubbing and hypertrophic osteoarthropathy may not represent distinct entities; our data suggest that they may be stages in an evolving, more generalized process of new bone formation or hypertrophy followed by osteolysis or atrophy affecting many parts of the skeleton.

Confirmation of the posterolateral technique to decompress and fuse thoracolumbar spine burst fractures

A posterolateral technique to decompress retropulsed bone from the spinal canal has been employed in nine patients, confirmed with intraoperative canal inspection and pre- and postoperative computed axial tomographic (CAT) evaluation. This technique has allowed reduction of retropulsed bony elements from the spinal canal, assessment of canal decompression and reestablishment of vertebral body alignment. The approach permits posterior fusion at the same operation. If the postoperative CAT scan continues to show spinal cord embarrassment from anterior bony elements, an anterior approach can be performed for additional decompression and fusion. The posterolateral approach does not necessarily improve neurologic function. However, when compared with posterior instrumentation alone, it does help ensure canal reduction and alignment, which may aid recovery and hasten rehabilitation.

Computed tomography demonstration of retroperitoneal contrast material extravasation complicating translumbar aortography

The computed tomography appearance of contrast material extravasated in the right perirenal space is presented. The complication occurred during test injection prior to translumbar aortography. The computed tomography findings were those of a right prerenal collection with high attenuation numbers representing contrast extravasation. Concurrent displacement of the second portion of the duodenum and inferior vena cava was present. No other retroperitoneal abnormalities were noted. The importance of computed tomography for early recognition and follow-up are emphasized.

Computed and conventional arthrotomography of the glenohumeral joint: normal anatomy and clinical experience

The glenohumeral joint was studied in 25 cadavers and 136 patients using computed arthrotomography (CAT) and conventional arthrotomography (AT) to assess shoulder instability. Cadaver shoulders were injected with air or latex, sectioned with a band saw, and normal articular anatomy outlined. CAT was performed in 81 patients and characterized the glenoid labrum as normal, abnormal, or detached in 38 of the 44 patients who had surgery or arthroscopy (sensitivity, 96%; accuracy, 86%). Hill-Sachs defects were seen in 20 out of 29 patients with anterior labral abnormalities, while bicipital tendon abnormalities were evident on CAT in 6. Of 55 patients who had AT, the status of the labrum was clarified in 13 of the 16 patients who had surgery or arthroscopy (sensitivity, 86%; accuracy, 81%). Both methods can characterize the labrum; however, CAT is more comprehensive and appears ideal for both detection of Hill-Sachs defects and imaging the bicipital tendon. CAT requires less technical expertise and radiation than AT and is tolerated better by patients in pain.

Vertebral burst fractures: CT analysis of the retropulsed fragment

Ten cases of retropulsed thoracolumbar vertebral body fragments that had been documented by CT were reviewed to define and characterize the nature, appearance, and position of the retropulsed fragment. All of the retropulsed fragments arose from the superior aspect of the vertebral body. Five of ten patients had a vertical fracture within the retropulsed fragment. Three of ten fragments had anteriorly rotated 90 degrees +/- 60 degrees, so that the cartilaginous end plate faced anteriorly; also, they had migrated 3-8 mm in a craniad or caudad direction. Six of ten patients had an associated vertical or Y-shaped fracture originating from the region of the basivertebral foramen and passing into the inferior one-half of the vertebral body. The presence of a retropulsed fragment is nearly pathognomonic of an axial compression injury. Characteristics of this lesion that may hinder surgical reduction are the intra-fragment fracture, rotation, and craniocaudad movement.

Triplane fracture of the distal tibial epiphysis: radiographic and CT studies

We analyzed six cases of triplane fracture of the ankle and reviewed the literature. A previously undescribed fracture pattern was identified in one patient. CT studies proved to be useful diagnostic tools in the evaluation of triplane fractures when operative reduction was contemplated.

Digital arthrography in the evaluation of painful joint prostheses

Digital arthrography was accomplished in 16 patients who had painful prostheses. In each instance, resulting arthrographic abnormalities were compared with those apparent on subsequent overhead radiographs. Results indicate the potential value of the digital technique in this clinical setting. The examination is easy to perform and rapid, and allows the examiner to view the changing images in the subtraction mode. Image manipulation and enhancement are also possible.

Replantation of digits or hands followed by destructive joint disease

The clinical records and radiographs of 45 patients who had undergone replantation of a total hand, or a part thereof, were reviewed in order to determine the prevalence and the type of articular changes occurring distal to the site of anastomoses. In three patients, destructive joint changes were observed, consisting of bony fragmentation, spiculation, and cystic or erosive lesions. These changes, which developed between five and ten months after replantation, are most likely neuropathic or osteonecrotic in pathogenesis.

Digital arthrography of the wrist: a radiographic-pathologic investigation

An analysis of digital arthrography of the wrist was accomplished in 10 cadaveric specimens. In each case, images were obtained during a 30-sec period in which a small amount of contrast material was introduced into the radiocarpal compartment; films were reviewed with and without subtraction technique. Pathologic examination of the sectioned specimens documented the accuracy of this arthrographic method. The sequence of contrast opacification of the various compartments of the wrist and the location and size of the defects within ligamentous and cartilaginous structures were ideally seen with digital arthrography. A previously unemphasized pattern of communication, that between the midcarpal and pisiform-triquetral compartments, was seen in two instances. Digital wrist arthrography seems to represent an excellent method to evaluate the patient with suspected soft-tissue injury.

Investigation of a new arthrographic contrast agent: Iotrol

A new nonionic dimer (Iotrol; Schering AG) and diatrizoate meglumine-diatrizoate sodium (Renografin-60; Squibb) were compared as arthrographic agents by injecting these substances into the knees of rabbits. Three experienced arthrographers judged the image quality produced by Iotrol to be superior to that of Renografin-60. Following animal sacrifice, histologic examination of the synovium revealed a significant difference in the inflammatory response evoked by the contrast agents: Iotrol caused less inflammation. In a second group of rabbits, methylprednisolone was subcutaneously injected 24 hours before the arthrographic studies. The methylprednisolone significantly reduced the inflammation in the Renografin-60 subgroup when compared with the nonmedicated counterparts. No significant effect was noted in a like comparison with Iotrol. In addition, the administration of methylprednisolone led to a deterioration of the radiographic images. Based upon our data, we believe Iotrol is superior to Renografin-60 as an arthrographic agent.

Diagnosis of typhoid fever using a string capsule device

Cultures were made from blood, bone marrow, stool and duodenal contents (obtained with string capsules) from 36 patients with bacteriologically proven typhoid fever on admission to hospital. Duodenal content cultures proved to be as sensitive in diagnosis (86%) as bone marrow (75%) and more effective than blood (42%) and stool (26%) cultures in recovery of Salmonella typhi. The sensitivity of duodenal content cultures was not modified by the duration of illness at admission or by previous antibacterial therapy. Even on the seventh day of effective treatment with chloramphenicol, the culture of duodenal contents remained positive in 8 of 17 patients, whereas salmonellae were isolated from stool cultures in only 2 of the same patients. The results obtained with the string capsule, together with the simplicity, economy and acceptability of the procedure, the fact that it can be performed with minimal facilities and the advantages of bacteriological recovery for antibiotic sensitivity testing, suggest that its adoption would be very helpful in efforts to control this disease.

Intracapsular pressure monitoring during arthrographic evaluation of painful hip prostheses

Aspiration-arthrography with continuous monitoring of intraarticular pressure and volume was performed on 10 consecutive patients with painful total-hip arthroplasties. Five of these patients demonstrated clinical and arthrographic evidence of adhesive capsulitis, a condition that was associated with a dramatic rise of intraarticular pressure as increasing amounts of contrast material were introduced. The precise etiology of adhesive capsulitis is not clear.

Hand and wrist arthropathies of hemochromatosis and calcium pyrophosphate deposition disease: distinct radiographic features

Radiographic features of hand and wrist involvement in 26 patients with hemochromatosis and in 26 patients with idiopathic calcium pyrophosphate dihydrate (CPPD) crystal deposition disease were compared. Two radiologists independently examined the radiographs without knowledge of the specific group to which the patient belonged. The results of this study clearly establish that structural joint diseases in the two disorders are not identical. Characteristic findings allow the radiologist to favor one diagnosis over the other. These radiographic differences indicate that the arthropathy of hemochromatosis is related to factors additional to the presence of CPPD crystals, specifically, the more prevalent narrowing of the metacarpophalangeal joint spaces, including those in the fourth and fifth digits, peculiar hook-like osteophytes on the radial aspect of the metacarpal heads, and less prevalent separation of the scaphoid and the lunate.

Melorheostosis of the axial skeleton with associated fibrolipomatous lesions

Two patients with melorheostotic-like lesions of the axial skeleton are described. In each case adjacent soft tissue masses containing both fatty and fibrous tissues were evident. The presence of such soft tissue tumors as well as other soft tissue abnormalities in melorheostosis emphasizes that the disease should not be regarded as one confined to bone. The precise pathogenesis of the osseous and soft tissue abnormalities in melorheostosis remains obscure.

Analysis of auranofin as a rheumatoid remitting agent

To assess the therapeutic potential of Auranofin (AF), we examined the results of 7 early short term clinical trials involving 104 rheumatoid arthritis (RA) patients; radiographic analyses were performed on 16 of these patients followed for 4 years. This agent suppressed RA in 2/3-3/4 of patients followed for periods up to 1 year; thereafter emergence of RA activity occurred despite maintenance medication. Serious toxicity was nonexistent. Radiographic analyses indicated a minority of patients may have arrested disease demonstrated by lack of erosion progression. Thus, AF has a similar therapeutic profile to conventional chrysotherapy but the drug is more useful because of absence of serious toxicities.

Arthritides affecting the foot: radiographic--pathological correlation

Arthritic disorders affect the bones and soft tissues of the foot just as they affect the bones and soft tissues of the hand. However, the resulting characteristic patterns of involvement have been largely neglected in previous descriptions of radiographic and pathological findings in articular diseases. This article reviews the pathogenesis of the microscopic and gross pathology of some common arthritides affecting the foot, and supports the pathological material with correlating radiographs. Rheumatoid arthritis, the seronegative spondylarthropathies, crystal-induced arthritis, degenerative joint disease, and septic arthritis are covered.

Synovial plicae of the knee

Synovial plicae are remnants of synovial tissue found in the adult knee which in early development partitioned the joint into three compartments. The most common types are the suprapatellar, medial patellar, and infrapatellar plicae. Although they are normally found in up to 60% of adult knees, plicae may become pathologically thickened and symptomatic, resulting in the "plicae syndrome." In addition, persistence of these structures in their embryonic form as complete septa may give rise to a variety of intra-articular compartmental syndromes, medial patellar, and infrapatellar plicae. Although they are normally found in up to 60% of adult knees, plicae may become pathologically thickened and symptomatic, resulting in the "plicae syndrome." In addition, persistence of these structures in their embryonic form as complete septa may give rise to a varietellar, medial patellar, and infrapatellar plicae. Although they are normally found in up to 60% of adult knees, plicae may become pathologically thickened and symptomatic, resulting in the "plicae syndrome." In addition, persistence of these structures in their embryonic form as complete septa may give rise to a variety of intra-articular compartmental syndromes. This report describes the anatomy and embryology of synovial plicae, as well as the clinical and radiographic findings associated with abnormal plicae in a variety of clinical entities.

Angiographic findings in systemic necrotizing vasculitis

Angiographic studies were carried out on 21 patients with systemic necrotizing vasculitis. Four basic arterial anomalies were found: (1) saccular microaneurysms appeared in 62% of the patients (2) arterial thrombosis was seen in 81% of patients; (3) arterial stenosis occurred in 81%; and (4) lumen irregularities occurred in 90%. Alterations in the renal vascular flow were also observed in accordance with changes in the cortical medullary differentiation, heterogeneous nephrogram, and prolonged washout. Two patients showed regression of microaneurysms after immunosuppressive therapy. We found angiography to be a low-risk technique of use for diagnosis and followup studies on vasculitis.

Spinal vacuum phenomena: anatomical study and review

"Vacuum" phenomena relate to the accumulation of gas, principally nitrogen, in crevices within the intervertebral disk or vertebra. Their appearance does not uniformly indicate "degenerative" disk disease (primary intervertebral osteochondrosis), as gaseous collections may accompany other processes (vertebral osteomyelitis, Schmorl node formation, spondylosis deformans, vertebral collapse with osteonecrosis) affecting the disk and adjacent vertebral bodies. The location and appearance of the "vacuum" phenomena are helpful indicators as to the precise nature of the spinal disorder.