Thrombosis of bileaflet tricuspid valve prosthesis: clinical spectrum and the role of nonsurgical treatment

BACKGROUND

Thrombosis of a mechanical tricuspid valve prosthesis is a potentially hazardous event. This study aimed to explore the incidence and the clinical presentation of tricuspid valve thrombosis occurring in bileaflet valves and to evaluate the diagnostic and the therapeutic approach.

METHODS AND RESULTS

Tricuspid valve thrombosis was sought in 22 late survivors with the CarboMedics valve in a follow-up period of 36.0 +/- 20.8 months. Limited leaflet motion and/or a visible thrombus were considered diagnostic of valve thrombosis. Eight episodes of tricuspid valve thrombosis were diagnosed among 5 patients (12.1 episodes per 100 patient-years). Anticoagulation was inadequate in 3 patients and fair in 2. Florid right heart failure occurred in 3 episodes. Common physical findings included increased jugular venous pulse (5 patients), diastolic tricuspid murmur (4 patients), and peripheral edema (4 patients). The diagnosis was suspected in all clinically and by transthoracic echocardiography and confirmed by fluoroscopy and/or transesophageal echocardiography. In 4 patients, both leaflets were involved. No thrombi were visualized. Three patients received thrombolytic therapy in 4 episodes (complete success in 3, partial success in 1) without hemorrhagic or embolic complications. One patient responded to aggressive anticoagulant therapy. One patient required an emergent repeat surgery. In 1 patient, valve thrombosis recurred thrice.

CONCLUSIONS

In patients with fair or poor anticoagulation, a bileaflet valve in the tricuspid position is associated with a high incidence of valve thrombosis. Hinge entrapment requires only a small amount of thrombotic material. Valve thrombosis may be asymptomatic. Involvement of both leaflets is usually required to produce symptoms. A nonsurgical approach (thrombolysis or intensified anticoagulation) is usually successful. Patients should be instructed about heralding signs of valve thrombosis.

A divalent major histocompatibility complex/IgG1 fusion protein induces antigen-specific T cell activation in vitro and in vivo

Activation of antigen-specific T cell clones in vivo might be possible by generating soluble MHC molecules; however, such molecules do not induce effective T cell responses unless cross-linked. As a first step in generating a soluble MHC molecule that could function as an antigen-specific immunostimulant, the extracellular domains of the murine H-2Kb MHC class I molecule were fused to the constant domains of a murine IgG1 heavy chain, resulting in a divalent molecule with both a TCR-reactive and an Fc receptor (FcR)-reactive moiety. The fusion protein can be loaded with peptide and can induce T cell activation in a peptide-specific, MHC-restricted manner following immobilization on plastic wells or following cross-linking by FcR+ spleen cells. The fusion protein induces partial T cell activation in vivo in a mouse transgenic for a TCR restricted to H-2Kb. This fusion protein molecule may be useful to study peptide-MHC interactions and may provide a strategy for boosting in vivo antigen-specific T cell responses, such as to viral or tumor antigens.

Occurrence of antibiotics in the aquatic environment

The recent monitoring of drug residues in the aquatic environment has gained much interest as many pharmaceutical compounds can frequently be found in sewage treatment plant (STP) effluents and river water at concentrations up to several microgram/l. This article describes the analysis of various water samples for 18 antibiotic substances, from the classes of macrolid antibiotics, sulfonamides, penicillins and tetracyclines. Samples were preconcentrated via lyophilization and quantified using HPLC-electrospray-tandem-mass spectrometry. The investigated STP effluents and surface water samples showed frequent appearance of an erythromycin degradation product, roxithromycin and sulfamethoxazole with concentrations up to 6 micrograms/l. Neither tetracyclines nor penicillins could be detected at concentration levels above 50 and 20 ng/l, respectively. From the large number of ground water samples that were taken from agricultural areas in Germany, no contamination by antibiotics was detected except for two sites. This indicates that intake from veterinary applications to the aquatic environment is of minor importance.

Foot pain and disability in older women

In a study of the relation between foot pain and disability, a cross-sectional analysis was performed using baseline data (1992-1995) from the Women's Health and Aging Study, a population-based study of 1,002 disabled women aged 65 years and older living in Baltimore, Maryland. Chronic and severe foot pain, defined as pain lasting 1 month or longer in the previous year, plus pain in the previous month rated severe (7-10 on a scale of 0 to 10), was reported by 14% of the women. Severe foot pain was more common in women who were younger (aged 65-74 years), obese, or had hand or knee osteoarthritis. Walking speed and five repeated chair stands were slower in women with foot pain. After adjustment for age, body mass index, race, education, self-rated health, smoking status, comorbidities, and number of other pain sites, severe foot pain was independently associated with increased risk for walking difficulty (adjusted odds ratio = 1.69, 95% confidence interval 1.10-2.59) and disability in activities of daily living (adjusted odds ratio = 1.91, 95% confidence interval 1.21-3.01). These findings suggest that severe foot pain may play a key role in disability in older women. Further studies are warranted to confirm these results longitudinally and to determine whether interventions to alleviate foot pain could reduce or prevent disability in older women.

Altered susceptibility to collagen-induced arthritis in transgenic mice with aberrant expression of interleukin-1 receptor antagonist

OBJECTIVE

To determine the effect of overexpression or deletion of interleukin-1 receptor antagonist (IL-1Ra) in collagen-induced arthritis (CIA).

METHODS

Mice overexpressing the IL-1Ra gene under the control of its endogenous promoter, mice lacking IL-1Ra, and normal littermate controls were immunized with bovine type II collagen (CII) and compared in terms of features of CIA.

RESULTS

Mice overexpressing IL-1Ra had a significant reduction in the incidence and severity of CIA. After CII immunization, IL-1Ra messenger RNA was overexpressed in the spleens, but not in the paws, of transgenic mice. Minimal differences were observed in the humoral or cellular immune responses to CII. Mice lacking IL-1Ra had a significantly earlier onset of CIA, with increased severity.

CONCLUSION

Endogenous expression of IL-1Ra is a critical determinant of susceptibility to CIA. These findings suggest potential therapeutic interventions for autoimmune arthritis.

Adenovirus-mediated granulocyte-macrophage colony-stimulating factor improves lung pathology of pulmonary alveolar proteinosis in granulocyte-macrophage colony-stimulating factor-deficient mice

Mutation of the granulocyte-macrophage colony-stimulating factor (GM-CSF) gene by homologous recombination causes progressive pulmonary alveolar proteinosis (PAP) in GM-CSF-deficient mice (GM-/-). The present study tested whether adenovirus-mediated expression of GM-CSF alters the progression of PAP in GM-/- mice. Adult mice were pretreated with an anti-T cell receptor (TCR) antibody to block T cell-mediated immune response, followed by intratracheal instillation of deltaE1-E3 replication-deficient adenovirus expressing mouse GM-CSF (Av1mGM). Mice were killed 1, 3, and 5 weeks after treatment to assess lungs for GM-CSF, surfactant protein B (SP-B), alveolar macrophage maturation, and type II cell proliferation. GM-CSF was detected in BAL fluid from GM-/- mice 1 week after Av1mGM treatment, and GM-CSF mRNA was detected by RT-PCR through 5 weeks. Five weeks after Av1mGM treatment, PAP was improved and SP-B decreased as assessed by ELISA and immunostaining. Increased numbers of alveolar macrophages stained with alpha-naphthyl acetate esterase (alpha-NAE) following treatment with Av1mGM. Local expression of GM-CSF with a recombinant adenovirus ameliorated PAP in the GM-/- mice in association with enhanced maturation of alveolar macrophages.

Diagnosing infantile anorexia: the observation of mother-infant interactions

OBJECTIVE

This study has three objectives: (1) to delineate the diagnostic criteria for infantile anorexia, including the onset of persistent food refusal during the infant's transition to spoon- and self-feeding, acute and/or chronic malnutrition, parental concern about the infant's poor food intake, and mother-infant conflict, talk, and distraction during feeding; (2) to determine the interrater agreement of child psychiatrists when diagnosing infantile anorexia based on these criteria; and (3) to describe the use of the Feeding Scale as a diagnostic tool.

METHOD

One hundred two toddlers, ranging in age from 12 to 37 months, were assessed by two child psychiatrists and assigned the diagnosis of infantile anorexia, picky eater, or good eater. In addition, observers who were masked to the toddler's diagnosis rated mother-infant interactions with the Feeding Scale to permit objective evaluation of those interactions.

RESULTS

Two child psychiatrists were able to assign toddlers to infantile anorexia, picky eating, and healthy, good eating groups with a high level of agreement. The objective scale for rating mother-infant interactions showed a high level of agreement between two masked raters and a good level of agreement between masked raters and the child psychiatrists' diagnostic assessment.

CONCLUSIONS

Infantile anorexia can be diagnosed with high reliability by child psychiatrists. Evaluation of mother-infant interactions is a useful diagnostic tool.

Racial differences in muscle strength in disabled older women

This study examines racial differences in muscle strength, and associations of muscle strength to level of physical activity and severity of disability, among a community sample of 254 black and 665 white, moderately to severely disabled women aged 65 and older. Potential confounders that were adjusted for in the models included age, body weight and height, joint pain, number of chronic conditions, and socioeconomic status. Hand grip, hip flexion, and knee extension forces were measured using portable hand-held dynamometers in the participants' homes. Hand grip strength was measured as the maximal isometric force. Hip flexion and knee extension forces were measured as the greatest force the tester had to apply to break the isometric contraction. A declining strength gradient was observed with increasing severity of disability and for decreasing level of physical activity in both races. At equal levels of disability or physical activity, blacks had better hand grip and hip flexion strength, but knee extension strength did not differ by race. The greater hand grip and hip flexion strength found in black women may be related to their greater muscle mass and known racial differences in body dimensions. No consistent racial differences were observed in the relationship between physical activity and muscle strength, or muscle strength and disability, suggesting that the role of muscle strength in the disablement process does not differ between races. Physical activity and exercise programs may be feasible ways to prevent worsening of disability in blacks and whites.

Establishing the level of digitization for wrist and hand radiographs for the third National Health and Nutrition Examination Survey

In the third National Health and Nutrition Examination Survey (NHANES III) conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention, radiographs of the hands and knees were taken of participants 60 years and older as part of the study of arthritis and musculoskeletal conditions. The purpose of the study was to decide the digitizing resolution to be used for these radiographs. A set of wrist and hand radiographs (N = 49) was graded by two radiologists for degree of bone erosions and served as a "gold standard." The radiographs were then digitized at three resolution levels; low-resolution 150 microns (2001 x 1634 x 12 bit matrix); intermediate-resolution 100 microns (3000 x 2400 x 12 bit matrix); and high-resolution 50 microns (4900 x 3000 x 12 bit matrix). A comparison of the digital images versus the gold standard reading was made at the three resolutions by two radiologists. Kappa statistics suggested fair (K > .4) to excellent (K > .75) agreement between the gold standard and the images at all levels. Intraclass correlation coefficient suggested high agreement between readers (ICC > .5), with minimal individual reader effect. Variance component estimates showed that the major contribution (78-83%) to scoring came from variability in the images themselves, not from the readers. The 100 microns resolution was selected over the 150 and 50 microns on the basis of practical considerations such as storage requirements, display time, and easier manipulation of the digital images by the readers.

Inhibition of collagen-induced arthritis in mice by viral IL-10 gene transfer

Autoimmune arthritides are characterized by an imbalance between pro- and anti-inflammatory cytokines. Viral IL-10 (vIL-10) shares many of the anti-inflammatory properties of mouse and human IL-10, but lacks their immunostimulatory properties and may therefore offer superior immunosuppression. Viral IL-10 has a short half-life; however, genetic modification of cells in vivo offers a potential means of achieving prolonged therapeutic titers. To determine the effects on collagen-induced arthritis of vIL-10 gene transfer, DBA/1 mice were administered i.v. or intra-articular injections of Av(vIL-10), a replication-deficient adenovirus encoding vIL-10. The i.v. injection of Av(vIL-10) before disease onset delayed the onset and reduced the severity of collagen-induced arthritis, but treatment of established disease was ineffective. The preventative effects were not due to decreased anti-type II collagen Ab production. Rather, T cells from mice treated with Av(vIL-10) demonstrated a decreased in vitro proliferative response to type II collagen, and a delay was observed in up-regulation of synovial mRNA for the proinflammatory cytokines IL-2 and IL-1beta. Intra-articular injection of Av(vIL-10) into knee joints did not reduce arthritis in the knees, but inhibited the development of arthritis in the paws. Humoral and cellular immune responses against Av(vIL-10) were observed. These results demonstrate that vIL-10 can significantly alter the course of autoimmune arthritis and emphasize the complexities of using gene transfer as a method of drug delivery for arthritis.

Rheumatoid arthritis in the Pima Indians: the intersection of epidemiologic, demographic, and genealogic data

OBJECTIVE

To describe the clinical features and familial distribution of rheumatoid arthritis (RA) in the Pima Indians.

METHODS

From 1965 through 1990, all cases of RA as defined by the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 criteria or all cases of seropositive, erosive disease as defined by the Rome criteria were identified in individuals who were age 20 years and older and were of 50% or more Pima/Tohono-O'odham heritage. Radiographs were reviewed by 2 musculoskeletal radiologists who were blinded to case status. Kinship coefficients were used to evaluate familial aggregation.

RESULTS

Eighty-eight RA cases were identified from this population-based sample. Over 66% of the cases had seropositive disease, over 60% had erosive disease, and over 40% had subcutaneous nodules. Of the 88 RA cases, 40 were members of families with more than 1 RA case. The remainder were simplex cases.

CONCLUSION

In this population, clinical markers of severe RA were present in a majority of cases. The presence of familial aggregation for RA in the Pima Indians suggests underlying genetic factors in disease pathogenesis.

Determination of antibiotics in different water compartments via liquid chromatography-electrospray tandem mass spectrometry

For the determination of 18 antibiotics in water samples down to the lower ng/l range, an analytical multi method is presented. The analytes belong to different groups of antibiotics such as penicillins, tetracyclines, sulfonamides and macrolid antibiotics. Samples were enriched using a universal freeze-drying procedure or a solid-phase extraction facultatively. Analysis was performed by liquid chromatography with electrospray-tandem MS detection. Chromatography required different columns and eluents. Mean recovery rates were in excess of 70%, however, with one exception and a quantitation limit of 50 ng/l for the tetracyclines and 20 ng/l for all other antibiotics were set.

Familial aggregation of osteoarthritis: data from the Baltimore Longitudinal Study on Aging

OBJECTIVE

To evaluate the familial aggregation of osteoarthritis (OA) in a cohort of healthy volunteers drawn from a community setting.

METHODS

Hand radiographs obtained between 1978 and 1991 and bilateral standing knee radiographs obtained between 1984 and 1991 were read for changes of OA, using Kellgren-Lawrence (K-L) scales. The hand sites were distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, and first carpometacarpal (CMC1) joints. For each joint group, the presence of OA in at least 1 joint in a joint group, the number of affected digits in each joint group, and the sum of the K-L grade across all joints were analyzed. Polyarticular OA was recorded if there were OA findings in 2 of 3 hand joint groups plus 1 or both knees. Data from 167 families with hand radiographs, 157 families with knee radiographs, and 148 families with both hand and knee radiographs were analyzed for sib-sib correlations.

RESULTS

After adjustment for age, sex, and body mass index, clinically relevant sib-sib common correlations were found for OA of the DIP, PIP, and CMC1 joints, for OA at 2 or 3 hand sites, and for polyarticular OA (r = 0.33-0.81) when OA was defined according to the number of affected joints or as the sum of the K-L grade across all joints.

CONCLUSION

These results from a cohort of volunteers drawn from a community setting and ascertained without regard to OA status demonstrate familial aggregation of OA and contribute to the evidence for heritability of OA.

Left ventricular malposition of a transvenous cardioverter defibrillator lead: a 3-year follow-up

A case of left ventricular malposition of a transvenous implantable cardioverter defibrillator lead through an atrial septal defect is presented. The patient has been continually anticoagulated with warfarin. A 3-year follow-up has thus far been uneventful.

Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States

OBJECTIVE

To provide a single source for the best available estimates of the national prevalence of arthritis in general and of selected musculoskeletal disorders (osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, the spondylarthropathies, systemic lupus erythematosus, scleroderma, polymyalgia rheumatica/giant cell arteritis, gout, fibromyalgia, and low back pain).

METHODS

The National Arthritis Data Workgroup reviewed data from available surveys, such as the National Health and Nutrition Examination Survey series. For overall national estimates, we used surveys based on representative samples. Because data based on national population samples are unavailable for most specific musculoskeletal conditions, we derived data from various smaller survey samples from defined populations. Prevalence estimates from these surveys were linked to 1990 US Bureau of the Census population data to calculate national estimates. We also estimated the expected frequency of arthritis in the year 2020.

RESULTS

Current national estimates are provided, with important caveats regarding their interpretation, for self-reported arthritis and selected conditions. An estimated 15% (40 million) of Americans had some form of arthritis in 1995. By the year 2020, an estimated 18.2% (59.4 million) will be affected.

CONCLUSION

Given the limitations of the data on which they are based, this report provides the best available prevalence estimates for arthritis and other rheumatic conditions overall, and for selected musculoskeletal disorders, in the US population.

Patterns and potential value of cardiac troponin I elevations after pediatric cardiac operations

BACKGROUND

Perioperative myocardial injury is a major determinant of postoperative cardiac dysfunction for congenital heart disease, but its assessment during this period is difficult. The objective of this study was to determine the suitability of using postoperative serum concentrations of cardiac troponin I (cTnI) for this purpose.

METHODS

Cardiac troponin I levels were measured serially in the serum of patients undergoing uncomplicated repairs of atrial septal defect (n = 23), ventricular septal defect (n = 16) or tetralogy of Fallot (n = 16). The concentrations were correlated with intraoperative parameters (cardiopulmonary bypass time, aortic cross-clamp time, and cardiac bypass temperature), and postoperative parameters (magnitude of inotropic support, duration of intubation, and postoperative intensive care and hospital stay).

RESULTS

Postoperative absolute cTnI levels were lesion specific, with a pattern of increase and decrease similar for each lesion. For the total cohort, significant correlations between postoperative cTnI levels at all times (r = 0.43 to 0.83, p < 0.05) until 72 hours were noted for all parameters, except for cardiac bypass temperature. When evaluated as individual procedure groups, no significant relationships were noted in the atrial septal defect group, whereas postoperative cTnI levels were more strongly correlated with all intraoperative and postoperative parameters in the ventricular septal defect group than in the tetralogy of Fallot group.

CONCLUSIONS

This study suggests that cTnI values immediately after operation reflect the extent of myocardial damage from both incisional injury and intraoperative factors. Cardiac tropinin I levels in the first hours after operation for congenital heart disease are a potentially useful prognostic indicator for difficulty of recovery.

Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States

OBJECTIVE

To provide a single source for the best available estimates of the national prevalence of arthritis in general and of selected musculoskeletal disorders (osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, the spondylarthropathies, systemic lupus erythematosus, scleroderma, polymyalgia rheumatica/giant cell arteritis, gout, fibromyalgia, and low back pain).

METHODS

The National Arthritis Data Workgroup reviewed data from available surveys, such as the National Health and Nutrition Examination Survey series. For overall national estimates, we used surveys based on representative samples. Because data based on national population samples are unavailable for most specific musculoskeletal conditions, we derived data from various smaller survey samples from defined populations. Prevalence estimates from these surveys were linked to 1990 US Bureau of the Census population data to calculate national estimates. We also estimated the expected frequency of arthritis in the year 2020.

RESULTS

Current national estimates are provided, with important caveats regarding their interpretation, for self-reported arthritis and selected conditions. An estimated 15% (40 million) of Americans had some form of arthritis in 1995. By the year 2020, an estimated 18.2% (59.4 million) will be affected.

CONCLUSION

Given the limitations of the data on which they are based, this report provides the best available prevalence estimates for arthritis and other rheumatic conditions overall, and for selected musculoskeletal disorders, in the US population.

Hip osteoarthritis prevalence estimates by three radiographic scoring systems

OBJECTIVE

To estimate and compare the age- and sex-specific prevalence of radiographic hip osteoarthritis (RHOA) in a population-based study of the Pima Indians, using 3 atlas-based methods for assessing features of RHOA.

METHODS

Pelvic radiographs from 755 Pima Indians age > or = 45 years enrolled in a population-based study were read using the Kellgren/Lawrence (K/L) grading scale (grade 0-4) and 2 validated individual-radiographic-features (IRF) scales (grades 0-3 for narrowing and osteophytes).

RESULTS

The age- and sex-specific prevalence of RHOA among Pima Indians assessed using the K/L scale was < 10% in all age and sex groups. The prevalence of grade > or = 2 osteophytes assessed using the 2 IRF scales were similar to each other in all age and sex groups. However, differences between the 2 IRF scoring systems were found for the prevalence of grade > or = 2 joint space narrowing.

CONCLUSION

Pima Indians have an age- and sex-specific prevalence of RHOA similar to that found in the US population. Our finding of different joint space narrowing prevalence by the 2 IRF grading scales supports the use of the same atlas-based case definitions for determining disease prevalence for comparative studies.

[Psychiatric aspects in rehabilitation patients and elderly patients]

From a psychiatric point of view reintegration and integration meaning a reorientation of the individual should be the points to be stressed in respect of rehabilitation of elder people. These individuals should be led to finding new positions in their psychosocial context. It would be an easier task to reach having developed some crucial social abilities in earlier stages of life. These abilities should be established already. We want to demonstrate this considering individual activities, social abilities, trusting and flexibility. Getting older is a developmental process. You cannot develop abilities which you never were confronted with before. If you do not seed you will not get a crop. Depending on early set resources individuals will later be able to integrate, reintegrate or not. This is to be set in an early stage of life.

Moderate wine consumption is associated with decreased odds of developing age-related macular degeneration in NHANES-1

OBJECTIVE

To determine the association between alcohol intake and the risk of developing age-related macular degeneration (AMD).

DESIGN

Case control study.

PARTICIPANTS

The sample consisted of 3072 adults 45 to 74 years of age with macular changes indicative of AMD who participated in a nationally representative sample of the first National Health Nutrition and Examination Survey (NHANES-1) between 1971 and 1975: (a) the ophthalmology data set and (b) the medical history questionnaire.

MAIN OUTCOME MEASURES

Alcohol intake and the risk of developing AMD were measured. AMD was determined by staff at the National Eye Institute by fundoscopy examination using standardized protocol.

RESULTS

Overall, 184 individuals (6%) had AMD. We observed a statistically significant but negative association between AMD and the type of alcohol consumed in a bivariate model (OR 0.86; 95% CI 0.73, 0.99). In the same model, age maintained a consistently strong association with AMD (OR 1.08; 95% CI 1.06-1.11; P < .001). Among the different types of alcohol consumed in NHANES-1 (beer, wine, and liquor), the effect of wine, either alone (OR 0.66; 95% CI 0.55-0.79) or in combination with beer (OR 0.66; 95% CI 0.55-0.79) or liquor (OR 0.74; 95% CI 0.63-0.86), dominated the negative association observed between AMD and alcohol type. Additionally, a statistically significant and negative association between wine and AMD was noted after adjusting for the effect of age, gender, income, history of congestive heart failure, and hypertension (OR 0.81; 95% CI 0.67-0.99).

CONCLUSION

Moderate wine consumption is associated with decreased odds of developing AMD. Health promotion and disease prevention activities directed at cardiovascular disease may help reduce the rate of AMD-associated blindness among older people. The nature and pathophysiology of this association warrant further investigation.

Anesthetic management of labor and postpartum bleeding in a patient with Fontan physiology

We describe the obstetric anesthetic management of a patient with complex congenital heart anomaly consisting of transposed great arteries, double inlet left ventricle and subpulmonic stenosis. Successful management of a patient with Fontan physiology mandates a thorough understanding of the hemodynamic consequences of this procedure and the alterations during pregnancy. The major considerations are related to the fact that the systemic venous return reaches the pulmonary vasculature without the augmentation of a functioning ventricle.

Enlarged acetabular labra in the Pima Indians

OBJECTIVE

To report the descriptive epidemiology of acetabular labral enlargement and analyze associations of other variables with this variant.

METHODS

Pelvis radiographs from 761 Pima Indians aged > or = 45 years enrolled in a population based study were read by Kellgren-Lawrence global and individual radiographic features grading scales for osteoarthritis (OA) at separate settings. In total, 722 radiographs remained eligible for this study after excluding 12 unreadable radiographs and 27 cases of radiographic hip OA (Kellgren-Lawrence grade > or = 2). Enlarged acetabular labra were recorded during readings of individual radiographic features.

RESULTS

Enlarged acetabular labra were present in 16% of study participants without OA and were significantly associated with female sex, but not with the variables age, body mass index, clinical hip joint involvement, diabetes, or serum insulin concentrations.

CONCLUSION

Acetabular labral enlargement is common in the Pima Indians, and although not in excess of other reported acetabular margin anomalies, it differs in appearance and is not associated with age. Recognition of this structural variant is important because it can mimic fractures or osteophytes.

Echocardiography can detect cloth cover tears in fully covered Starr-Edwards valves: a long-term clinical and echocardiographic study

The incidence of cloth cover tears in fully covered Starr-Edwards valves, as assessed by autopsy or repeat surgery, is approximately 1% per patient-year. However, no echocardiographic study has explored this phenomenon. This study was designed as a one-time observational study and aimed to explore the ability of two-dimensional transthoracic echocardiography to identify cloth cover tears in 35 late survivors with 38 fully covered Starr-Edwards valves who had been operated on 20 to 24 years earlier. The hemodynamic profile, clinical status, and valve-related complications in this highly selected group of late survivors were also studied. Five patients also underwent transesophageal echocardiography. An elongated echogenic mass attached to the prosthetic valve cage and floating downstream was considered indicative of cloth tear. There were 16 patients with aortic valve prostheses, 16 with mitral valve prostheses, and three with double prosthetic valves. In six (17.1%) patients (four with aortic valve prostheses, two with mitral valve prostheses), an echogenic mass suggestive of cloth cover tear was detected, which was confirmed by transesophageal echocardiography in three patients. In two patients the echocardiographic finding was confirmed at surgery. The initial presentation of these six patients was endocarditis, possible embolism, unexplained dyspnea, and weakness in one patient each. Two patients were asymptomatic. There was no evidence of significant prosthetic valve malfunction in any patient. The transvalvular gradients were similar in patients with and without cloth cover tears. Echocardiographic findings highly suggestive of cloth cover tears are not uncommon and can be detected in the third postoperative decade in patients with fully covered Starr-Edwards valves. A prospective study to evaluate the clinical significance of an incidental echocardiographic finding suggestive of cloth cover tears in asymptomatic patients with these valve models is warranted.

[Prosthetic heart valve thrombosis: a 3-year experience]

A series of 12 patients with 16 episodes of prosthetic heart-valve thrombosis over 3 years is presented. Most episodes affected mitral or tricuspid bileaflet prostheses. All patients were inadequately anticoagulated at the time of thrombosis. The clinical presentation was acute and severe in 6 patients, and subacute or chronic in the rest. Physical examination was suggestive of stuck valves in most cases. Transthoracic echocardiography revealed increased transvalvular gradients in most. However, clearer evidence of valve thrombosis was obtained from transesophageal echocardiography or fluoroscopy. 9 patients eventually had their valves re-replaced successfully, and the preoperative diagnosis was confirmed in all. 5 patients were operated as soon as the diagnosis was established. and an additional 4 were operated after failure of anticoagulation. In 4 patients the valve leaflets became completely mobile after a course of thrombolysis. Prosthetic valve thrombosis is a severe and potentially fatal complication in patients with mechanical heart valves. Alertness of physicians at all levels- the general practitioner, the internist and the cardiologist- to the possibility of valve thrombosis and to its clinical presentation may lead to prompt and earlier diagnosis and to comprehensive therapy.

The impact of disability in older women

As the size of the older population grows and mortality rates continue to decline, an unprecedented number of women will live to very old age. Recent research has provided a better understanding of the impact of disability in the older population, risk factors for disability, and the consequences of disability. Older women have consistently been found to have higher prevalence rates of disability than men of the same age. This difference does not result from women developing disability more often than men, but rather surviving longer with their disabilities. This effect may be explained at least in part by the differences in the diseases underlying disability in older women and men. Interventions that can reduce the burden of disability in the aging population are now being explored. In the next century, it will be increasingly important to develop new prevention and treatment strategies that address the functional consequences of chronic disease in the population of women living to older and older ages.

Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury

OBJECTIVE

To establish normal values and determine the impact of congenital or acquired heart disease on serum cardiac troponin I (cTnI).

METHODS

Concentrations of cTnI were measured in two groups of children. Group A represented ambulatory pediatric patients with no apparent cardiac disease (n = 120) and patients in stable condition with known congenital or acquired cardiac abnormalities (n = 96); group B was composed of patients admitted to intensive care units with normal echocardiograms (n = 16), with abnormal echocardiograms (n = 36), and those with blunt chest trauma who were thought to have cardiac contusions (n = 7).

RESULTS

The cTnI concentrations were generally less than 2.0 ng/ml in group A and frequently below the level of detection for the assay (1.5 ng/ml). There was no statistical difference between the two outpatient subgroups (p = 0.66). Nine intensive care patients had cTnI values greater than 2.0 ng/ml. Six of these patients, all with abnormal echocardiograms, had values less than 7.7 ng/ml. All improved and had subsequent normal cTnI concentrations. None of the three remaining patients (two with systemic illness (trauma and sepsis) and one with severe pulmonary hypertension), all with values greater than 8.0 ng/ml, survived. Three of the four patients with high likelihood of cardiac contusion had cTnI concentrations greater than 2.0 ng/ml (including one patient who died).

CONCLUSIONS

Cardiac troponin-I values are generally not elevated in children with stable cardiac disease or general pediatric conditions. In the context of severe acute illness, significant elevation of cTnI may be an indicator of poor outcome. Elevation of cTnI may also have diagnostic value in cases when cardiac contusion is suspected.

Anti-T cell receptor antibody prolongs transgene expression and reduces lung inflammation after adenovirus-mediated gene transfer

Replication-deficient delta E1a-E3 adenovirus mediates efficient gene transfer to the mouse lung; however it induces a host immune response mediated, in part, by T cells. This immune response is associated with loss of transgene expression. Monoclonal antibodies (mAb) against the T cell receptor (TCR) complex can inhibit both CD4+ and CD8+ T cell responses in vivo and are the most potent anti-T cell agents in clinical use. To determine whether such mAbs can be used to prolong adenovirus-mediated transgene expression, the vector Av1Luc1 (delta E1a-E3 recombinant adenovirus encoding the firefly luciferase gene) was administered intratracheally to C57BL/6 mice on day 0. Three days prior to adenovirus administration (day -3), mice were treated with a single i.p. injection of the anti-TCR mAb H57. Controls received phosphate-buffered saline. Animals were sacrificed on days 3, 14, 28, and 56 and lungs were assessed for transgene expression and histopathology. Luciferase activity decreased markedly in the controls by day 14, but was maintained at high levels in animals receiving anti-TCR mAb. A mild, focal, predominantly neutrophilic inflammation was observed in the alveoli of all mice 3 days after virus administration. In PBS-treated controls, this inflammation progressed to a moderate to severe multifocal, perivascular and peribronchiolar lymphoid infiltration at 14 days. B cells and T cells were present in approximately equal numbers, with CD4+ T cells predominating over CD8+ T cells by 3- to 28-fold. Treatment with H57 resulted in near-complete prevention of the lymphocytic inflammatory infiltrate and increased luciferase activity throughout the 56-day study period, in association with TCR modulation and T cell depletion. Thus, anti-TCR mAb decreases inflammation and prolongs gene expression following adenovirus-mediated gene transfer.

Infant and donor organ growth after heart transplantation in neonates with hypoplastic left heart syndrome

BACKGROUND

There is little published data regarding somatic growth and changes in allograft size after heart transplantation in infants with hypoplastic left heart syndrome.

METHODS

We evaluated the somatic growth of 26 infants with hypoplastic left heart syndrome who underwent heart transplantation over a 5-year period and measured changes in left ventricular dimensions in 22 of those infants. Age at transplantation was 27 +/- 17 days (mean +/- standard deviation), and the follow-up period was 43 +/- 14 months. Growth and echocardiographic data were converted to standard deviation (Z) scores for comparison with normal populations.

RESULTS

Height and weight were always within normal limits (two standard deviations), with a trend toward smaller size throughout the follow-up period. The somatic growth of infants on low-dose maintenance steroids was not significantly different from that of infants withdrawn from chronic steroid regimens. Initial left ventricular posterior wall and septal dimensions were greater than two standard deviations (+4.3 and +6, respectively), probably the result of routine use of oversized donors, but the dimensions decreased to within the normal range during the first year. They then remained within normal limits during follow-up. With one exception at 2 years after transplantation, left ventricular diastolic dimensions were always within two standard deviations of the mean. Left ventricular dimensions of patients with hypertension, rejection, or acute graft failure were not significantly different from patients without these complications.

CONCLUSIONS

Neonates with hypoplastic left heart syndrome who undergo heart transplantation can be expected to have somatic growth within normal limits. However, the trend toward growth retardation is worrisome. Left ventricular wall dimensions adjust to smaller recipient size during the first year after transplantation and then remain appropriate for the recipient's size over time.

Antifection: an antibody-mediated method to introduce genes into lymphoid cells in vitro and in vivo

We have developed a simple, safe and versatile method, termed antifection, by which antibodies are used as delivery vehicles to introduce genes into cells expressing specific surface antigens. Antibodies directed against CD3, CD34 or surface immunoglobulins were covalently coupled to plasmids containing marker genes (neoR, beta-galactosidase). Such conjugates were used in vitro and/or in vivo to antifect (transfect using antifection) cells bearing the respective targeted epitope on either normal splenic B lymphocytes or lymphoid-related cell lines. In these conditions the expression of the protein encoded by the marker gene was readily detected. Antifection is a method of delivering genes through a physiological cellular pathway, receptor-mediated endocytosis, into specific cell types, and thus may be considered as an alternative for gene therapy strategy.

Tumor necrosis factor-alpha decreases surfactant protein B mRNA in murine lung

Respiratory failure secondary to acute lung inflammation is associated with quantitative and qualitative abnormalities of pulmonary surfactant. The surfactant-associated proteins (SP)-A, -B, and -C are critical for normal surfactant function, synthesis, and metabolism. Tumor necrosis factor-alpha (TNF-alpha), a primary mediator of acute lung inflammation, decreased SP gene expression in vitro (32, 34). In the present in vivo study, transient T cell activation and TNF-alpha release were initiated by intraperitoneal administration of anti-CD3 antibody 145-2C11. Serum TNF-alpha was elevated 2 h after injection of the antibody. SP-B and -C mRNA were decreased 12 and 24 h after antibody treatment. Intratracheal murine TNF-alpha also resulted in decreased SP-B and SP-C mRNA levels in the bronchiolar and alveolar epithelium of adult FVB/N mice, as demonstrated by S1 nuclease protection and in situ hybridization assays, despite minimal histological inflammation. SP-A mRNA was not significantly altered after anti-CD3 antibody and was only mildly decreased after TNF-alpha. As previously reported, intercellular adhesion molecule-1 mRNA was elevated after intratracheal TNF-alpha. SP insufficiency contributes to the pathogenesis of pulmonary diseases associated with increased TNF-alpha, such as adult respiratory distress syndrome and pneumonia (8). TNF-alpha-mediated decrease in SP gene expression may contribute to the surfactant dysfunction and atelectasis observed in inflammatory lung diseases.

Human immunodeficiency virus-associated atypical mycobacterial skeletal infections

The clinical and laboratory features of six human immunodeficiency virus (HIV)-positive patients with atypical mycobacterial skeletal infections, seen at a county outpatient HIV facility or university outpatient clinic, are reviewed and compared with other reported cases. Atypical mycobacterial skeletal infections are a manifestation of advanced HIV disease, with most cases having CD4 counts < 100/mm3 at the time these infections become clinically apparent. Multiple sites are frequently involved, and concomitant skin infection with the same organism is common, especially with Mycobacterium haemophilum. The incidence of atypical mycobacterial skeletal infection in HIV-infected individuals was significantly higher than in the general county hospital district patient population, whereas the frequency of Myobacterium tuberculosis skeletal infection did not differ significantly between the two populations. The clinician therefore should maintain a high index of suspicion for atypical mycobacteria in a patient presenting with skeletal infection in the setting of a markedly depressed CD4 count.

Anti-T cell receptor monoclonal antibody prolongs transgene expression following adenovirus-mediated in vivo gene transfer to mouse synovium

There are no cures for rheumatoid arthritis (RA) or other inflammatory autoimmune arthropathies. Gene transfer to the synovium would allow administration of anti-inflammatory gene products directly to the articular space where they could exert a local down-regulatory effect on the autoimmune process. Several well-characterized murine models of arthritis closely resemble RA immunologically, genetically, and histopathologically. To determine whether the mouse could serve as a model for gene transfer to the synovium, a methodology was developed to reproducibly inject a 5-microliter volume into the articular space of the mouse knee. Using this approach, Av1LacZ4, an E1a-E3-deleted adenoviral (Ad5) vector expressing the lacZ transgene, was delivered intra-articularly (5 x 10(8) pfu). lacZ expression was observed in the articular synovium for at least 14 days. Biochemical quantitation demonstrated a gradual loss of transgene expression, associated with an early, predominantly neutrophilic, inflammatory response that progressed to a lymphocytic infiltrate, followed by gradual resolution over a 3-week period. Pretreatment with the anti-TCR monoclonal antibody (mAb) H57 resulted in a significant reduction in lymphocytic infiltration and a prolongation of transgene expression. These data demonstrate that transgenes can be delivered to the mouse knee joint space, affording a powerful tool to test the potential of gene therapy as a therapeutic modality for RA. As in other systems, the immune response against recombinant adenoviral vectors may limit the extent and duration of gene expression in the synovium. Anti-T cell mAbs may be useful in inhibiting this immune response.

Safety of adenovirus-mediated transfer of the human cystic fibrosis transmembrane conductance regulator cDNA to the lungs of nonhuman primates

To define the toxicity of cystic fibrosis transmembrane conductance regulator gene (CFTR) gene therapy with a replication-deficient recombinant adenovirus (Av1Cf2) in a nonhuman primate model, 10(10) plaque forming units (pfu) were instilled directly through a bronchoscope into the right lung of 5 macaques, and a lower dose of 4 x 10(6) pfu was administered to the right lung of 1 macaque. One sham-treated control received phosphate-buffered saline (PBS). The macaques were evaluated sequentially by clinical examination, vital signs, weight, hematology, blood chemistry, chest radiography, pulse oximetry, and bronchoalveolar lavage (BAL) at baseline and 3-28 days post-treatment. After the period of observation, macaques were sacrificed for autopsy and histological examination. The macaques tolerated the experimental therapy clinically with no changes in body temperature, oxygen saturation, heart rate, body weight, or blood pressure. However, 1 macaque with visible evidence of aspiration at the time of initial bronchoscopy developed tachypnea with right lower lobe (RLL) pneumonia on chest radiograph and by histology. There were no changes in Hgb, Wbc, BUN, plasma electrolytes, bilirubin, or hepatic transaminases. In the macaques that received 10(10) pfu, there was a progressive increase in the number of CD8+ lymphocytes in BAL that was maximal at 28 days. Histological examination of the treated lungs of the high-dose macaques at 3 days showed marked peribronchial and perivascular cuffing by inflammatory cells and alveolar accumulation of neutrophils and macrophages. The alveolitis appeared to be resolving at 28 days, although the perivascular and peribronchial aggregates of mononuclear cells were still present. In the high-dose macaques, BAL interleukin-8 (IL-8) was increased at all time points (256-388 pg/ml versus 1-84 pg/ml at baseline and in control), whereas IL-1 beta was increased only at days 21 and 28 (341-852 pg/ml versus 30-92 pg/ml at baseline and in control). There were no increases in BAL cell counts, IL-1 beta or IL-8, and histological changes were mild in the macaque that received 4 x 10(6) pfu. Evaluation for Av1Cf2-derived human CFTR expression using RS-PCR demonstrated expression at 3, 10, and 21, but not 28 days in macaques treated with 10(10) pfu of Av1Cf2. In situ hybridization analysis demonstrated human CFTR mRNA in the alveolar regions of the lobes that received the vector at 10 and 21 days. There was no evidence of expression after treatment with 4 x 10(6) pfu. This study showed that high-dose adenoviral vector administration to the lung achieved CFTR gene transfer and expression but was associated with increased concentrations of cytokines in BAL and alveolar inflammation. A low dose, equivalent to the maximum clinical dose currently proposed for phase I trials in human subjects, was not associated with cellular or cytokine evidence of inflammation, and histological abnormalities were mild.

Association of hand and knee osteoarthritis: evidence for a polyarticular disease subset

OBJECTIVE

To examine the association between hand and knee osteoarthritis (OA) in a community based population.

METHODS

Radiographs of 695 participants aged > or = 40 years in the Baltimore Longitudinal Study of Aging were read for changes of OA, using Kellgren-Lawrence grade > or = 2 as the case definition.

RESULTS

Logistic regression analyses, adjusting for age, gender and body mass index, revealed a significant association between OA in the knee and the following joint groups: distal and proximal interphalangeal (DIP, PIP) and Hand2 (OA in two or more hand joint groups) for grade 2-4 and grade 3-4 disease, and the first carpometacarpal (CMC1) joint for grade 3-4 disease.

CONCLUSION

There is an association between OA in hand sites and the knee. The strength of the associations increases with increasing disease severity. For the PIP site, there is a trend toward increasing strength of association for increasing numbers of affected joints and bilateral disease.

Contrasting in vivo effects on T helper cell functions induced by mitogenic (intact) versus nonmitogenic (F(ab')2) anti-CD3 monoclonal antibody

Anti-CD3 mAbs are potent inhibitors of T cell function; however, administration of mitogenic mAb can cause significant morbidity secondary to T cell activation and cytokine release. Nonmitogenic anti-CD3 mAb is immunosuppressive in mice without inducing detectable morbidity, and may thus be preferable for in vivo T cell immunosuppression. The precise mechanisms of action of these two forms of mAb have not been fully defined. To further characterize and compare the in vivo functional effects of mitogenic and nonmitogenic anti-CD3 mAbs, mice were treated with the intact (mitogenic) form of the anti-murine CD3 mAb, 2C11, or with F(ab')2 fragments (nonmitogenic). Effects on T cell phenotypes and the secretion of Th1-derived cytokines were compared. Nonmitogenic mAb induced a prolonged downregulation of secretion of interleukin (IL)-2 and interferon (IFN)-gamma from CD4+ T cells, and of IL-2 secretion from CD8+ T cells, and preferential depletion of CD4+ T cells. In marked contrast, mitogenic mAb induced a prolonged upregulation of IL-2 and IFN-gamma secretion from both CD4+ and CD8+ cells, and preferential depletion of CD8+ T cells. Both forms of mAb induced a shift in the T cell populations from a naive to a memory phenotype; however, this shift was not responsible for the observed changes in cytokine secretion. These results demonstrate that mitogenic and nonmitogenic forms of 2C11, while binding to the identical epitope, differentially affect T cell functions, and have implications for the use of anti-CD3 mAbs in the clinical setting.

Comparison of in vivo efficacy and mechanism of action of antimurine monoclonal antibodies directed against TCR alpha beta (H57-597) and CD3 (145-2C11)

Monoclonal antibodies (mAbs) directed against the T cell receptor (TCR)-associated CD3 chains and against the TCR-alpha beta heterodimer can inhibit allograft rejection in humans and in experimental animals. Since the effects of stimulation through these cell surface structures may differ, it has been suggested that there could be advantages to targeting one structure versus the other. In order to directly compare two such mAbs for in vivo immunosuppressive properties and mechanisms of action, C57BL/10 mice were treated with mAbs H57-597 (H57, anti-alpha beta) or 145-2C11 (2C11, anti-CD3), either as intact mAb or as F(ab')2 fragments. F(ab')2 fragments of both mAbs had similar effects. Both prolonged skin allograft survival, preferentially depleted CD4+ T cells, downregulated IL-2 secretion, and failed to inhibit CTL. In contrast, the effects of the intact form of the two mAbs differed significantly. Intact H57 was far more effective than 2C11 in prolonging skin allograft survival and in inhibiting cytokine secretion and CTL function. This increased immunosuppressive effect was associated with a significantly more complete and prolonged depletion of both CD4+ and CD8+ T cells and down-modulation of TCR expression on remaining T cells. A markedly greater half-life was observed for H57, associated with reduced immunogenicity. These data suggest that the increased immunosuppressive properties of H57 are due to its reduced immunogenicity, rather than to differences in signal transduction, and support the argument that reducing the immunogenicity of mAbs in the clinical setting by "humanization" may result in improved efficacy.

Kawasaki disease

This article is an up-to-date review of issues surrounding Kawasaki disease, with particular emphasis on the immunologic aspects. Kawasaki disease is now the leading cause of acquired heart disease in children in most developed countries.

Systolic rightward displacement of the left anterior descending artery: a novel cineangiographic sign for tricuspid regurgitation

A new sign for the detection of tricuspid regurgitation (TR) is described. The systolic displacement of the left anterior descending (LAD) artery during coronary angiography in left anterior oblique (LAO) view was quantitatively calculated in 3 groups of 20 patients each with either TR, mitral stenosis, or normal coronary arteriograms. The mean LAD displacement in the TR group was significantly rightward compared to the other groups. Uniform rightward displacement of the lower two-thirds of the LAD had a 90% sensitivity and 90-95% specificity for the presence of TR. Such displacement is probably the angiographic counterpart of the systolic paradoxical septal displacement demonstrated by echocardiography in patients with right ventricular volume overload. There was a positive correlation between the severity of TR and the magnitude of LAD displacement. Attention to the LAD displacement on LAO view may raise suspicion of TR, and indicate its severity.

T cell receptor repertoire differences between African Americans and Caucasians associated with polymorphism of the TCRBV3S1 (V beta 3.1) gene

The generation of TCR diversity occurs primarily through rearrangement of germline DNA. Genetic polymorphism of the TCR chains appears to be a rarer mechanism for generating repertoire differences between races. Flow cytometric analysis of the TCR V beta repertoire in a population of healthy African Americans (n = 30) and Caucasians (n = 30) revealed a significant difference in the frequency of cells bearing V beta 3.1, but not V beta 2, V beta 5.1, V beta 5.2-5.3, V beta 6.7, V beta 8.1-8.2, V beta 12.1, V beta 13.3, or V beta 19. African Americans had a significantly lower frequency of V beta 3.1+ cells, in both the CD4+ (2.55 +/- 0.36% vs 4.85 +/- 0.43%, p = 0.0001) and the CD8+ (3.03 +/- 0.54% vs 5.32 +/- 0.57%, p = 0.004) population than did Caucasians, and this difference was independent of the age of the individuals. Analysis of genomic DNA revealed that the observed difference in frequency of V beta 3.1+ cells correlated with a recently described polymorphism of the recombination signal sequence of the TCRBV3S1 gene. Allele 1, associated with a lower frequency of V beta 3.1+ cells, was more commonly present in African Americans (0.68 vs 0.43), whereas allele 2, associated with a higher frequency of V beta 3.1+ cells, was more commonly present in Caucasians (0.31 vs 0.56). This study demonstrates the potential for TCR repertoire differences, based on genetic polymorphism, between African Americans and Caucasians.

T cell receptor repertoire differences between African Americans and Caucasians associated with polymorphism of the TCRBV3S1 (V beta 3.1) gene

The generation of TCR diversity occurs primarily through rearrangement of germline DNA. Genetic polymorphism of the TCR chains appears to be a rarer mechanism for generating repertoire differences between races. Flow cytometric analysis of the TCR V beta repertoire in a population of healthy African Americans (n = 30) and Caucasians (n = 30) revealed a significant difference in the frequency of cells bearing V beta 3.1, but not V beta 2, V beta 5.1, V beta 5.2-5.3, V beta 6.7, V beta 8.1-8.2, V beta 12.1, V beta 13.3, or V beta 19. African Americans had a significantly lower frequency of V beta 3.1+ cells, in both the CD4+ (2.55 +/- 0.36% vs 4.85 +/- 0.43%, p = 0.0001) and the CD8+ (3.03 +/- 0.54% vs 5.32 +/- 0.57%, p = 0.004) population than did Caucasians, and this difference was independent of the age of the individuals. Analysis of genomic DNA revealed that the observed difference in frequency of V beta 3.1+ cells correlated with a recently described polymorphism of the recombination signal sequence of the TCRBV3S1 gene. Allele 1, associated with a lower frequency of V beta 3.1+ cells, was more commonly present in African Americans (0.68 vs 0.43), whereas allele 2, associated with a higher frequency of V beta 3.1+ cells, was more commonly present in Caucasians (0.31 vs 0.56). This study demonstrates the potential for TCR repertoire differences, based on genetic polymorphism, between African Americans and Caucasians.