[Experience with suturing the outer ligament of the upper ankle joint under local anesthesia]

An efficient approach to the treatment of fibular ligamentous rupture is to approximate the torn edges of the ligament. Conservative management with immobilization by fixed dressings or orthopaedic footwear to maintain the foot in pronation may allow ligamentous union to occur; however, the results are relatively often unsuccessful, and delayed surgical correction is difficult and unreliable. Operative repair of the ruptured ligament is successful in the vast majority of cases, and is generally recognized as a better therapeutic approach, but it may be criticized on the grounds of the high cost of treatment, especially if general anaesthesia is used. The use of local anaesthesia offers a good compromise, as it is considerably less expensive and allows the advantages of surgical repair to be exploited.

[Cardiotonically Active Principles from Spigelia anthelmia1.]

From the upper parts of SPIGELIA ANTHELMIA L. besides some widely distributed phenolcarboxylic acids and flavonoids two volatile alkaloids have been isolated and identified as isoquinoline and an iridoid compound of the actinidine type. In the water extract choline, benzoylcholine and 3,3-dimethyl-acryloylcholine could be identified. Preliminary pharmacological investigations revealed that the alkaloids are involved in the cardiotonic activity of the plant.

[Emergency indications for cesarean section]

It must be kept in mind that there are few situations that demand immediate surgery. Regarding indications for most caesarean sections, there is enough time for the anaesthesist to administer speedy, but nevertheless orderly premedication and judge the indications for anaesthesia. The anaesthetic technique should be determined in agreement with the obstetrician. In most hospitals, general anaesthesia can probably be performed more quickly than intrathecal or extrathecal anaesthetics. However, this article will not deal with the details involved in these methods.

Splenic irradiation in the treatment of patients with chronic myelogenous leukemia or myelofibrosis with myeloid metaplasia. Results of daily and intermittent fractionation with and without concomitant hydroxyurea

Seventeen patients with either chronic myelogenous leukemia (CML) or myelofibrosis with myeloid metaplasia (MMM) received 24 courses of splenic irradiation at this institution from 1973 to 1982. Eleven of the 17 patients had received prior chemotherapy. Patients were treated with 60Co gamma rays or 6 MV photons. The fraction size ranged from 15 to 100 rad and the total dose per treatment course from 15 to 650 rad, with the exception of one patient who received 1650 rad. Fourteen of 19 courses (71%) given for splenic pain yielded significant subjective relief while 17 of 26 courses given for splenomegaly obtained at least 50% regression of splenic size. Blood counts were carefully monitored before each treatment to limit hematologic toxicity. From this experience, the authors conclude that splenic irradiation effectively palliates splenic pain and reverses splenomegaly in the majority of patients with CML and MMM. Intermittent fractionation (twice or thrice weekly) is more convenient for the patient, appears to be as effective as daily treatment, and may be associated with less hematologic toxicity. Preliminary results of concurrent treatment with splenic irradiation and oral hydroxyurea show promise and warrant further study.

[Bovine serum albumin conjugates of the new progestagen dienogest, synthesis and immunogenic properties]

In order to develop a radioimmunoassay for the new progestagen dienogest (STS 557, 17 alpha-cyanomethyl-17 beta-hydroxy-estra-4,9-dien-3-one), bovine serum albumin (BSA) conjugates of STS 557-3-carboxymethyloxime and of STS 557-11-hemisuccinate were synthesized as antigens for the production of antisera. It was proved that an excess of isobutylchlorocarbonate in the coupling reaction using the "mixed anhydride method" results in an acylation of free NH2-groups in the BSA. By the immunization of rabbits with the STS 557-antigen-antisera of high specificity and affinity to STS 557 were produced. Endogenous steroids show no cross reaction with the STS 557-antisera. Steroids with a 17 alpha-CH2CN-group, being obtained by chemical synthesis or microbial transformation, compete with STS 557 for the binding positions of the antibodies to a different extent.

[Effect of homeopathic drugs on the phagocytic activity of human granulocytes. In vitro tests in a controlled single-blind study]

Four homeopathic drug preparations with extract dilutions between D1 and D30 (expression for the homeopathic grade of potencies) and some additives (minerals and animal toxins) were investigated, using two in vitro and one in vivo phagocytosis models. All preparations enhanced significantly the activity of phagocytosis in all used systems. In controlled prospective single-blind studies with the preparations C and D performed on 12 and 14 verum and 13 male placebo volunteers respectively with i.v. injections within a 5-day treatment the phagocytosis indices were measured during 11 days using the microscopic smear method. In both investigations the maximum of phagocytosis activity was reached between the 4th and 5th day of injection. After the 4th or 5th (next to the last or last) injection, a rapid decrease of activity occurred which reached normal values on the 11th day. Other laboratory parameters investigated were not influenced.

Detection of rearranged T cell receptor beta-chain gene and induction of cytolytic function in interleukin 2-responsive day 14-15 murine fetal thymocytes

A subpopulation of interleukin 2 (IL 2) receptor-positive day 14-15 murine fetal thymocytes can be induced by recombinant IL 2 to proliferate over prolonged time periods in dissociated cell cultures. The proliferating day 14-15 fetal thymocytes exhibit no cytolytic effector function, nor do they rearrange T cell receptor beta chain genes. This contrasts with thymic organ cultures in which day 14-15 thymocytes do rearrange beta chain genes and give rise to immunocompetent cells. However, such events can also take place in dissociated cell cultures, provided the IL 2-responsive thymocytes are cultured on syngeneic feeder cells in the presence of IL 2 and the mitogen concanavalin A. Under such conditions rearrangement of the beta chain gene complex becomes detectable and cytolytic effector cells are generated. The frequency of inducible cytolytic precursor cells in day 14-15 thymocytes is 1/7000. These data either imply that immunocompetent cells are already present in the day 14-15 fetal thymus, or differentiation from precursors to immunocompetent cells must occur in dissociated cell cultures.

Influence of blood-brain barrier opening to proteins on development of post-ischaemic brain injury

The effect of the BBB opening to proteins on development of post-ischaemic brain injury was assessed in 32 cats subjected to one hour MCA occlusion. The CBF was measured by hydrogen clearance from electrodes inserted in the caudate and the cerebral cortex within the MCA territory. In 16 animals, a prevention of subsequent reactive hyperaemia was attempted by hypovolaemia, produced by withdrawal of blood just before the release of MCA occlusion. The hypovolaemia was successful in prevention of post-ischaemic hyperaemia in five out of eight cats sacrificed at 3 h and in six out of eight animals killed after 3 and 14 days. In cats sacrificed 3 h after release of MCA occlusion, ischaemic sites, associated with reactive hyperaemia, showed evidence of BBB breakdown to proteins and significantly more severe oedema than at the ischaemic sites without reactive hyperaemia, which otherwise failed to reveal leakage of EB tracer. In the cats sacrificed at 3 and 14 days, the ischaemic sites which showed reactive hyperaemia after release of MCA occlusion, revealed much more severe ischaemic brain tissue injury than was observed at the sites without reactive hyperaemia, which also did not show any EB leakage. The present study indicates that reactive hyperaemia, which follows release of major cerebral artery occlusion, may play a significant role in the breakdown of the BBB to proteins, and in increasing the severity of post-ischaemic oedema and of ischaemic brain tissue injury.

Exogenous IL2 partially reverts CML non-reactivity acquired during prophylactic immunosuppression with cyclosporin A of human allograft recipients

Proliferative and cytolytic lymphocyte responses and the influence of exogenous interleukin 2 (IL2) on cell-mediated lympholysis (CML) reactivity were evaluated in 12 allograft recipients. Responses were induced by mitogenic lectins or by donor and third-party cells. Patients were tested immediately before transplantation (Tx) and one and three months after grafting. Prophylactic immunosuppression consisted of Cyclosporin A (CyA) and low-dose prednisone (P). Analysis of post transplant cells revealed a reduced overall proliferative T cell responsiveness induced by both alloantigens and mitogenic lectins. No evidence for donor-specific reduction of MLC responses was seen. Overall CML reactivity of post-Tx lymphocytes was also impaired. This was accompanied by donor-specific CML non-reactivity in six of seven patients with quiescent grafts. In these patients, the cytolytic potential against donor cells could be restored when maximal T cell help via exogenous IL2 was provided.

Management of vascular complications of bacterial endocarditis

Peripheral arterial emboli that result from bacterial endocarditis may be silent or catastrophic. Cardiac surgical intervention may prevent embolism, but the guidelines for timing of intervention are unclear. An accepted approach is to intervene only if two episodes of peripheral embolism occur. Our recent experience suggests a more refined approach is in order. Eight children with active bacterial endocarditis have been treated with embolic complications. One patient with abdominal pain and GI bleeding was treated with heparin for multiple peripheral mesenteric emboli. Four patients had femoral embolectomies, one twice. Three patients developed embolomycotic aneurysms of the aorta in two cases and the common iliac in one; all were ruptured and two survived with staged reconstruction in one and extra-anatomic bypass in the other. Staph aureus and Strep viridans were the organisms involved most often. A review of the details of care in these patients leads to the following conclusions: angiographic survey reveals that most patients have multiple emboli; early embolectomy may prevent formation of infected aneurysms; Staph aureus infected patients are at risk for development of infected aneurysms; patients with large floppy vegetations in the left heart on echocardiography are at high risk for embolism; and 2 to 3 weeks from onset of endocarditis is the peak time for embolic risk.

[Calcaneus displacement osteotomy in pediatric flatfoot]

Severe unstable pes valgus that can no longer be treated conservatively can be corrected and stabilized by corrective osteotomy of the calcaneus. An important advantage of calcaneus osteotomy is the conservation of the subtalar joint. Calcaneus displacement osteotomy requires less effort from the surgeon, and the correction is more effective than wedge osteotomy of the calcaneus.

Introduction of a selectable gene into murine T-lymphoblasts by a retroviral vector

A recombinant retroviral vector with an inserted bacterial neomycin resistance (neo) gene was used to transfer in vitro neomycin resistance (neoR) into murine cytotoxic lymphocyte precursors (CLP). The infection protocol involved co-cultivation of mitogen-activated splenic T-blasts with irradiated cells that produced either the recombinant retrovirus plus a helper virus, or exclusively the recombinant retrovirus. Infected T-blasts were subsequently cultured under limiting dilution (LD) conditions that supported clonal in vitro development of a large fraction of murine CLP. In infected T-blast populations, frequency estimates were obtained for CLP that developed into functional cytotoxic T-lymphocyte (CTL) populations under G418-selected or non-selected conditions; from these frequency estimates, an efficiency of transduction of the neoR phenotype into murine CLP of 2-8% was calculated. Some conditions were defined that influenced transduction efficiency, i.e., the density of the infecting monolayer cells; the presence of interleukin 2-containing conditioned medium and mitogenic lectins during the co-culture period; a delayed onset of G418 selection after infection. It was demonstrated that the neoR phenotype of functional CTL populations derived from infected CLP resulted from expressed recombinant retrovirus.

Structural analysis of an RNA molecule involved in replication control of plasmid R1

The replication control circuit of the FII plasmids R1, R100 and R6-5 involves a small untranslated RNA molecule of about 93 nucleotides. This RNA, designated CopA RNA in plasmid R1, acts in vivo as a post-transcriptional inhibitor of the expression of the RepA protein whose synthesis is required for each round of plasmid replication. We have studied the structure of CopA RNA in solution by probing with single-strand- as well as double-strand-specific nucleases. Our data show that CopA RNA has two stem-loop structures connected by a long spacer region and a single-stranded 3'-tail. Enzyme reactions were performed under buffer conditions where we find strong and specific binding of CopA RNA to its target RNA (to be published elsewhere), and the patterns were compared to digests in two other buffer systems. All partial cleavages supported the proposed secondary structure. We also analyzed the stem-loop regions of CopA RNAs from two R1 copy number mutants. The data show that both RNAs have altered loop structures. The implications of these findings are discussed.

[Amiodarone therapy--behavior of serum and fatty tissue concentrations]

Thirty-eight patients with refractory supraventricular and ventricular tachyarrhythmias were administered a mean oral dosage of 400 mg amiodarone daily (200-600 mg). A high-pressure liquid chromatography method was used to measure serum concentrations of amiodarone and its metabolite desethylamiodarone after one week, one month, three months, and then at 6-month intervals. In 24 patients subcutaneous fatty tissue concentrations were also measured. The mean follow-up was 9 months (4 days to 29 months). A linear correlation was found between amiodarone and its metabolite in serum (r = 0.56, p less than 0.001) as well as in subcutaneous fatty tissue (r = 0.67, p less than 0.001). While serum concentrations were dose dependent, tissue concentrations accumulated during chronic therapy (p less than 0.01, both). Clinical efficacy was achieved in 84% of the patients. No statistically significant difference was found between responders and non-responders as regards serum and subcutaneous fatty tissue concentrations. Side effects of amiodarone occurred in 63%. The incidence of adverse effects was related to significantly higher serum and subcutaneous fatty tissue concentrations of amiodarone and its metabolite (p less than 0.001, both). Thus, although the determination of serum and subcutaneous fatty tissue concentrations does not seem to be helpful for assessing clinical efficacy of this antiarrhythmic drug, these values may predict the occurrence of adverse effects.

Function of the CD4 and CD8 molecules on human cytotoxic T lymphocytes: regulation of T cell triggering

The function of the T cell differentiation antigens CD4 (Leu-3/T4) and CD8 (Leu-2/T8) on human cytotoxic T lymphocytes (CTL) is presently seen only in conjugate formation between CTL and target cell via class II or class I MHC antigens rather than in the later killing steps. In this study, human CD4+ and CD8+ CTL clones were used to investigate the effects of monoclonal antibodies against these differentiation antigens on nonspecific triggering of cytotoxicity. Cytotoxicity was induced either by antibodies against the CD3 (T3) antigen or by the lectins Con A and PHA. Anti-CD4 or anti-CD8 antibodies specifically inhibited all types of cytotoxicity of CD4+ or CD8+ CTL, respectively, regardless of the specificity of the CTL for class I or class II HLA antigens and regardless of whether target cells expressed class I or class II antigens. These results are incompatible with an exclusive role of the CD4 and CD8 molecules in MHC class recognition and are discussed with respect to a function as negative signal receptors for these molecules on CTL.

Function of the CD4 and CD8 molecules on human cytotoxic T lymphocytes: regulation of T cell triggering

The function of the T cell differentiation antigens CD4 (Leu-3/T4) and CD8 (Leu-2/T8) on human cytotoxic T lymphocytes (CTL) is presently seen only in conjugate formation between CTL and target cell via class II or class I MHC antigens rather than in the later killing steps. In this study, human CD4+ and CD8+ CTL clones were used to investigate the effects of monoclonal antibodies against these differentiation antigens on nonspecific triggering of cytotoxicity. Cytotoxicity was induced either by antibodies against the CD3 (T3) antigen or by the lectins Con A and PHA. Anti-CD4 or anti-CD8 antibodies specifically inhibited all types of cytotoxicity of CD4+ or CD8+ CTL, respectively, regardless of the specificity of the CTL for class I or class II HLA antigens and regardless of whether target cells expressed class I or class II antigens. These results are incompatible with an exclusive role of the CD4 and CD8 molecules in MHC class recognition and are discussed with respect to a function as negative signal receptors for these molecules on CTL.

A human lymphokine released by mononuclear blood cells upon contact with CEA

As revealed by the macrophage electrophoretic mobility (MEM) technique mononuclear blood cells from certain cancer patients respond to carcinoembryonic antigen (CEA). This phenomenon appeared to be due to a specific lymphokine release. In this study, the lymphokine activity of supernatant pools was stepwise enriched by gel filtration on Sephadex. The mediator activity was recovered within a molecular mass region less than 47 kDA. The lymphokine was highly enriched during further gel filtration steps and showed a single activity peak in the molecular mass region of 23.5 kDa. Gel filtrations of appropriate control supernatants resulted in biologically inactive fractions. The lymphokine was heat-labile at 56 degrees C, showed a clear-cut, dose-dependent effect on macrophages, and could be blocked by fucose. Preparative gel electrophoresis of radiolabeled and unlabeled lymphokine resulted in two corresponding peaks of biological activity and radioactivity.

[Detection and quantitative determination of lectins and viscotoxins in mistletoe preparations]

Mistletoe lectins and viscotoxins, which up to now have been isolated only from plant material, were detected and quantitatively determined in the mistletoe preparation Iscador and in a fermented mistletoe extract. Lectins were isolated by affinity chromatography and analyzed by isoelectric focussing. Thus, in Iscador and in the fermented mistletoe extract only the mistletoe lectins ML II/III were found whereas typical proteins of the ML I complex were missing. The lectin content of the preparation and the extract was determined by "single radial immunodiffusion" (SRID). For identification and quantitative determination of viscotoxins, a HPLC method was designed.

Host-reactive cytotoxic T lymphocyte precursors in long-lived fully allogeneic mouse bone marrow chimeras

Fully H-2-incompatible chimeric mice were constructed by grafting lethally (950 rad) irradiated germ-free (GF) CBA (H2k) mice with anti-Thy 1 antibody plus complement-treated allogeneic C57Bl/6 (B6) (H2b) bone marrow cells. These chimeric mice were kept for more than 11 months, either under GF conditions or under barrier-sustained specific-pathogen-free (SPF) conditions. Controls included nonirradiated, nontransplanted, sex- and age-matched CBA and B6 mice raised under SPF conditions, and syngeneic chimeric mice of the CBA----CBA type kept under GF and SPF conditions. All chimeric mice were completely repopulated with donor-type lymphoid cells and showed no clinical or histological evidence of graft-versus-host disease. From the fully allogeneic chimeric mice, we enumerated the numbers of splenic cytotoxic T lymphocyte precursors (CTL-p) that could be clonally expanded under limiting dilution conditions in response to third-party alloantigens, or nonmodified and trinitrophenyl (TNP)-modified stimulator cells bearing host or donor H-2 antigens. The existence of high numbers of alloreactive and host- or donor-type H-2-restricted TNP-specific CTL-p in the spleens of fully allogeneic chimeras indicated almost normal immunocompetence. The surprising finding, however, was that large numbers of host (CBA)-reactive splenic CTL-p were inducible under limiting dilution conditions in healthy long-lived allogeneic chimeras, although these chimeric mice were devoid of any histological or clinical signs of graft-versus-host disease.