[Management of diabetic vasculopathy]

The high prevalence rate of mortality in diabetic patients is explained by atherothrombotic cardiovascular disease. Hyperinsulinemia and insulin resistance, dyslipidemia, chronic hyperglycemia, decrease of endothelial cells and of monocytes-macrophage cell functions, and hypercoagulability are the main side-effects which are involved in the pathogenesis of diabetic atherothrombotic disease. Its clinical manifestations are coronary heart disease, peripheral vascular insufficiency, cerebral vascular insufficiency and reno-vascular hypertension. The common characteristics are a clinical latent period, the frequency of acute complications and the widespread bilateral distal localisation of vascular insufficiency. The therapeutic strategy in diabetic atherothrombotic disease is becoming better codified, leading to screening and prevention. The evaluation of diabetic vascular risk could reduce the prevalence of thrombotic events.

Thymic and extrathymic differentiation and expansion of T lymphocytes following bone marrow transplantation in irradiated recipients

Thymic function is severely impaired in most marrow transplant recipients. To evaluate the impact of thymic hypoplasia on T cell reconstitution following marrow transplantation, we compared the phenotype and function of T lymphocytes in thymectomized recipients with those of euthymic hosts. Irradiated C57BL/6 mice (Thy1.2+, Ly5.1+) received 10(7) T cell-depleted B6.Ly5.2 bone marrow cells (Thy1.2+, Ly5.2+), with or without 3 x 10(5) B6.PL lymph node cells (Thy1.1+, Ly5.1+) as a source of T lymphocytes. Multiparameter flow cytometry analysis showed that in euthymic mice (group 1), T cell reconstitution was carried out by donor hematopoietic stem cells that differentiated in the host's thymus, whereas the production of chimeric T cells in athymic recipients depended on the presence or absence of T cells in the graft. When T lymphocytes were present in the graft (group 2), their progeny constituted the vast majority of splenic T cells on day 100 posttransplant. When the graft did not contain T lymphocytes (group 3), T cell reconstitution resulted from extrathymic maturation of donor hematopoietic progenitors; T cells differentiating along this pathway expressed lower levels of T cell receptor and a large proportion of the CD8+ subset expressed CD8alpha alpha homodimers. The T cell receptor Vbeta profile of all chimeras was similar to that of normal C57BL/6 mice. Compared with T cells found in euthymic recipients, those in mice from groups 2 and 3 were less abundant (particularly with respect to the CD4+ subset), displayed the CD44/CD45 phenotype of activated memory cells, and expressed high levels of IL-2 receptor beta chain. These results show that both the presence or absence of the thymus and the composition of the grafted inoculum determine the source and extent of posttransplant T cell reconstitution. Because they determine the nature of the differentiation pathway taken during T cell development in the host, these two factors can exert a critical influence on the appearance of graft vs. host disease and the level of host immunocompetence.

Minimal endoscopic approach to subperiosteal orbital abscess

OBJECTIVE

To limit endoscopic abscess drainage to the opening of the ethmoid cells involved, adjacent to the subperiosteal orbital abscess.

DESIGN

Prospective study.

PATIENTS

Twenty children with subperiosteal orbital abscess complicating acute sinusitis.

INTERVENTION

Endoscopic opening of the medial wall of the bulla ethmoidalis and of the lamina papyracea.

RESULTS

The limited endoscopic approach allowed subperiosteal orbital abscess drainage in all patients with positive clinical outcomes. Extensive ethmoidectomy was not necessary to achieve drainage.

CONCLUSIONS

Endoscopic subperiosteal orbital abscess drainage does not require complete ethmoidectomy as was previously performed and can be limited to the opening of the bulla ethmoidalis and the lamina papyracea through the bulla ethmoidalis.

On the mechanisms of immunodominance in cytotoxic T lymphocyte responses to minor histocompatibility antigens

Although there are numerous minor histocompatibility antigens (MiHA), T cell responses leading to graft-versus-host (GVH) and graft-versus-tumor effects involve only a small number of immunodominant MiHA. The goal of the present study was to analyze at the cellular and molecular levels the mechanisms responsible for MiHA immunodominance. Cytotoxic T lymphocytes (CTL) generated in eight combinations of H2b strains of mice were tested against syngeneic targets sensitized with HPLC-fractionated peptides eluted from immunizing cells. The number of dominant MiHA was found to range from as little as two up to ten depending on the strain combination used. The nature of dominant MiHA was influenced by both the antigen profile of the antigen-presenting cells (APC) and the repertoire of responding CTL. When C57BL/6 dominant MiHA (B6dom) and H-Y were presented on separate APC, they showed similar immunogenicity. In contrast, when they were presented on the same APC, B6dom MiHA totally dominated H-Y. B6dom MiHA did not suppress anti-H-Y responses by acting as T cell receptor antagonists for anti-H-Y CTL, nor were anti-B6dom CTL precursors more abundant than anti-H-Y CTL precursors. Dominance resulted from competition for the APC surface between anti-B6dom and anti-H-Y CTL; the crucial difference between the dominant and the dominated MiHA appears to depend on the differential avidity of their respective CTL for APC. The only B6dom epitope thus far identified is the nonapeptide AAPDNRETF presented by H2-D(b). We found that compared with other known D(b)-binding peptides, AAPDNRETF is expressed at very high levels on the cell surface, binds to the D(b) molecule with very high affinity, and dissociates very slowly from its presenting class I molecule. These data indicate that one cannot predict which MiHA will be dominant or dominated based simply on their respective immunogenicity when presented on separate APC. Indeed, the avidity of T cell/APC interactions appears to determine which antigen(s) will trigger T cell responses when numerous epitopes are presented by the same APC.

[Cervical necrotizing fasciitis disclosing HIV infection]

Necrotizing fasciitis is a rapidly progressing necrotizing process which affects subcutaneous tissue and fascia. The leading cause of these infections in neck is odontogenic infection. Its occurrence is reported to be rare, but often fatal. The therapeutic regimen includes three essential principles: appropriate antimicrobial therapy, prompt surgical treatment, and supportive measures. Two cases of cervical necrotizing fasciitis revealing human immunodeficiency virus (HIV) infection are reported. Clinicians should be aware of this underlying condition, and every patient with cervical necrotizing fasciitis should be tested for HIV.

Fenoterol-induced hepatitis in a pregnant woman: a case report

The case of a pregnant woman in whom hepatitis developed after administration of high-dose fenoterol during the third trimester of a second pregnancy is described.

[Pharmaco-clinical aspects of methadone. Literature review of its importance in treatment of substance dependence]

In order to assess the initial hypotheses of Dole, who set the objectives of methadone maintenance in 1966, this article reviews all research findings available in the field. The side-effects of methadone appear rather infrequent with few long lasting effects. The selection of a dose sufficiently high to block opiat receptors seems make the patient little or not sensitive to heroin intake whereas treatment compliance seems to be dose-related until a plateau of about 120 mg/day. All studies show a dramatic decrease in heroin intake. In contrast, a change in the drug use profile toward an increase in alcoholism and cocaine intake appears in certain subjects. Regarding AIDS, results seem less clear, showing a global decrease in intravenous use as behavior at risk but providing apparently not a total protection unless complete discontinuation. The decrease in antisocial behavior appears clearly, interpreted as a decrease in the economic pressure on the consumer. As a consequence of these results, an assistance in social rehabilitation appears more effective. Whereas the literature regarding withdrawal clearly shows the usefulness of the technique regarding the duration and the persistence of withdrawal symptoms, it remains very blurred regarding long-term results. The average age (about 30 years) and the average duration of drug abuse (about 10 years) of the patients included in those studies lead to the conclusion that only a marginal part of the total population is taken in charge, meaning that these techniques will never be solutions to a problem of society but only individual therapies. This article also raises the problem of the passionate climate associated with these issues--with negative consequences regarding objectivity--and the methodological limitations found in too many studies on this topic.

Immunodominant minor histocompatibility antigens expressed by mouse leukemic cells can serve as effective targets for T cell immunotherapy

Numerous minor histocompatibility antigens (MiHAs) show tissue-specific expression and can induce vigorous T cell responses. They therefore represent attractive targets for leukemia immunotherapy mediated by adoptive transfer of T cells. The main objective of this work was to determine whether MiHAs expressed by normal hematopoietic cells were present on leukemic cells and whether they could trigger lysis by cytotoxic T lymphocytes (CTLs). CTL assays showed that mouse leukemic cells of both lymphoid and myeloid lineages were sensitive to CTLs targeted toward some but not all MiHAs. In four out of four strain combinations in which we primed CTLs against immunodominant MiHAs, effectors killed leukemic blasts, whereas no cytotoxicity was observed when CTLs were targeted toward four immunorecessive MiHAs. Testing of HPLC fractions obtained from normal and leukemic cells provided molecular evidence that leukemic blasts expressed only some of the MiHAs found on normal mouse hematopoietic cells. Decreased density of H-2 class I molecules at the surface of leukemic cells suggests that down-regulation of genes encoding either class I molecules or proteins involved in antigen processing played a role in the aberrant expression of MiHAs. In vivo resistance to the leukemic cells by various strains of mice correlated with in vitro CTL activity. These results show that leukemic cells express only some (immunodominant) MiHAs and suggest that this subset of MiHAs represent prime targets for adoptive immunotherapy.

The safety of dorsal penile nerve block for neonatal circumcision

BACKGROUND

Dorsal penile nerve block (DPNB) was first described for use in neonatal circumcision in 1978. Since then, many studies have documented its effectiveness in alleviating pain in newborns undergoing circumcision. In 1989, the American Academy of Pediatrics acknowledged that DPNB may relieve the pain and stress of circumcision but stopped short of endorsing its routine use in this procedure, citing lack of data on its safety.

METHODS

To determine the types and rates of complications from DPNB used for neonatal circumcision, the authors conducted a retrospective review of hospital records of 1358 circumcised male infants delivered at an urban medical center during a 1-year period.

RESULTS

Of the 1358 records reviewed, 1222 (90%) had sufficient documentation to be included in the study. DPNB was used in 1022 (84%) of the circumcisions. Complications occurred in 12 cases (11 with small ecchymoses at injection sites and one with excessive bleeding from the needle stick), for a rate of 1.2%. No cases of lidocaine toxicity, voiding delay, or vascular compromise were noted. There was a trend toward increased incidence of injection-site hematomas with the Plastibell as compared with the Gomco technique (P = .07). There were no significant differences in complication rates for DPNB performed by less experienced operators (eg, medical students and residents) compared with more experienced operators (staff physicians).

CONCLUSIONS

This study corroborates findings of smaller case studies, indicating that DPNB is associated with a low rate of minor complications.

T lymphocyte responses to multiple minor histocompatibility antigens generate both self-major histocompatibility complex-restricted and cross-reactive cytotoxic T lymphocytes

Minor histocompatibility antigens (MiHA) may represent ideal targets for cancer immunotherapy since (1) the expression of many MiHA is tissue specific and (2) they can trigger potent T lymphocyte responses. A primary objective of our research program is to characterize T cell responses to cells displaying multiple incompatible MiHA. Early in the course of this work, we observed in various stimulator/responder combinations that immunization versus multiple MiHA generated cytotoxic effectors that killed not only stimulator cells but also a large panel of MHC-identical and MHC-different targets. To characterize the cells responsible for this cytotoxic activity and their specificity, we expanded polyclonal and clonal CD3+ CD4- CD8+ LP anti-C57BL/6 effectors. LP anti-C57BL/6 polyclonal effectors (LPTc cell line) showed strong cytotoxic activity when tested against several H-2b and non-H-2b targets, but displayed, respectively, weak or absent cytotoxicity against MHC class I-deficient cells and syngeneic cells. When used as cold targets, C57BL/6 cells inhibited the lysis of all H-2b and non-H-2b cells. Some H-2b, but no H-2d or H-2k, cold targets inhibited the lysis of C57BL/6 targets. With the exception of LP and C57BL/6, all types of H-2b cells (A.BY, D1.LP and C3H.SW) showed complete reciprocal inhibition of lysis. The same observation was made for non-H-2b targets. The cytotoxicity profile of 12/14 LP anti-C57BL/6 clones was identical to that of the LPTc cell line, while 2/14 clones recognized only H-2b cells. Cytotoxicity was inhibited by incubation of effector cells with anti-CD3 or anti-CD8 antibodies and by incubation of target cells with specific anti-MHC class I antibodies. These results show that immunization against multiple MiHA in the context of self-MHC generates 2 types of CTL: some are strictly self-MHC restricted while others are strongly cross-reactive and recognized MHC-peptide complexes on allogeneic MHC-different targets. This observation has significant implications concerning the use of anti-MiHA T cells in cancer immunotherapy.

The role of MHC-associated self-peptides in transplantation and immunosurveillance

The antigen-binding site of most major histocompatibility complex (MHC) class I and II antigens is occupied by self-peptides that are derived from the proteolysis of endogenous proteins following instructions provided by the molecules of the MHC themselves. Together with MHC proteins, self-peptides define our immunological self and shape the repertoire of both T cells that recognize "nonself," and NK cells that may recognize "no self." Endogenous proteins of all cell compartments (nucleus, cytosol, organelles, surface membrane) can yield self peptides whose expression may be either ubiquitous or lineage-specific. Their expression allows the binary recognition mechanism of T and NK cells to check the integrity of the cell genome. A better understanding of the molecular bases of the distinction between self and nonself permits us to anticipate the possibility of modifying their expression and/or their recognition in order to: (i) make the nonself acceptable as self, thereby establishing specific transplantation tolerance, (ii) reestablish tolerance of the self lost in autoimmune diseases, and (iii) induce the rejection as nonself of neoplastic cells. These objectives are particularly pertinent to the area of bone marrow transplantation, where the ultimate goal is aimed at modulating host cell allorecognition in such a way as to both potentiate the graft-versus-leukemia reaction and prevent GVHD.

[Endocrine and metabolic consequences of massive obesity]

Massive obesity is always accompanied by insulin resistance with hyperinsulinaemia in proportion to the amount of visceral fat, which has repercussions on oxidative and non-oxidative glucose metabolism. The increase of free fatty acids in direct relation to the adipocytic mass reduces the hepatic insulin uptake; it increases the suprahepatic glucose flow and the production of very low density lipoproteins. The adipose tissue exerts a feminizing effect in men and a masculinizing effect in women. Women have disorders of ovulation and hirsutism, with increase of free testosterone and elevation of luteotropic hormone levels. Men have hypoandrism due to excessive aromatization of androgens and oestrogens. The adipose tissue accelerates the turnover of cortisol and facilitates cortisone production, which stimulates ACTH secretion and maintains stimulation of the adrenal cortex. Hyperinsulinism and resistance to insulin also intervene in hormonal regulation. They elevate the insulin-like growth factor 1 (IGF-1) which inhibits the production of growth hormone and reduces its plasma half-life; hyperinsulinism and IGF-1 facilitate ovarian androgen production; hypothalamic disturbances occur by diminution of sensitivity to hypoglycaemia, and there are abnormalities in monoaminergic and serotoninergic control. Bone tissue density is preserved for a long time, as it is in proportion to the fatty mass and to the oestrogen and IGF-1 levels, but it may be gradually reduced by secondary hyperparathyroidism. Thyroid function and thyrotropic regulations are unaffected.

Plasma lipid response and nutritional adequacy in hypercholesterolemic subjects on the American Heart Association Step-One Diet

OBJECTIVES

To determine the efficacy of the American Heart Association Step-One Diet for lowering blood lipid levels and to assess its nutritional adequacy in younger (< 50 years old) and older (> or = 50 years old) subgroups.

STUDY DESIGN

A prospective cohort study; 383 subjects were instructed in the American Heart Association Step-One Diet. Adherence to the diet was assessed at 6 weeks. Eighty-seven subjects continued the diet for an additional 12 weeks.

SETTING

General community participants: volunteers from community cholesterol screening programs and chart reviews at family practice clinics.

STUDY PARTICIPANTS

Men and women, aged 20 to 70 years, with baseline low-density lipoprotein cholesterol levels between the 50th and 95th percentile, and excluded if receiving any medications that affect blood lipid levels or if there was a history of diabetes, gout, peptic ulcer, or liver disease.

INTERVENTION

Instruction by a registered dietitian and adherence to the American Heart Association Step-One Diet for 6 (n = 383) and 18 weeks (n = 87). This diet involves an intake of total fat not to exceed 30% of calories, saturated fatty acids not to exceed 10% of calories, and dietary cholesterol limited to 300 mg/d.

RESULTS

Subjects aged 50 to 70 years averaged a reduction in total cholesterol level and low-density lipoprotein cholesterol level of 4% after 6 weeks. At the end of 18 weeks, mean total cholesterol and low-density lipoprotein cholesterol levels in subjects younger than 50 years exceeded their baseline levels, and in those older than 50 years returned to baseline lipid levels. Inadequate intake of several micronutrients were reported, notably, zinc, calcium, and vitamins A, D, and E.

CONCLUSIONS

When recommending the American Heart Association Step-One Diet to persons with hyperlipidemia, baseline dietary behavior should be assessed to determine whether that diet offers therapeutic advantage over the persons's self-selected diet. Follow-up should include monitoring of lipid response and nutritional adequacy. Special emphasis should be placed on selection of foods with appropriate micronutrient content.

Evaluation of in vitro cytotoxic T lymphocyte assays as a predictive test for the occurrence of graft vs host disease

The potential value of in vitro cytotoxic T lymphocyte (CTL) assays for predicting the occurrence of graft vs host disease (GVHD) following allogeneic bone marrow transplantation was evaluated in 12 mouse donor-host combinations associated with various degrees of GVHD. These donor-host combinations were selected after evaluation of GVHD triggered by minor histocompatibility antigens (MiHA) in 24 allogeneic strain combinations derived from six strains of H-2b mice. Recipients (n = 475), previously submitted to total body irradiation (9.5 Gy), were transplanted with 10(7) bone marrow cells along with 5 x 10(7) spleen cells. While lethal GVHD was observed in half of the strain combinations, it was possible to select 12 donor-host combinations characterized by severe, mild, or absent GVHD. When levels of anti-host CTL activity were assessed following in vivo priming and in vitro boosting, strong CTL-mediated cytotoxicity was observed in all combinations whether they developed GVHD or not. CTL frequency measured by limiting dilution analysis (LDA) ranged from 1/16880-1/306. The Spearman rank test revealed no positive correlation between GVHD intensity and donor anti-host CTL activity assayed either in bulk culture experiments or in LDA conditions. These results indicate that MiHA capable of triggering potent CTL responses in vitro do not necessarily initiate GVHD, and that in vitro measurement of donor CTL activity against host-type Con A blasts is not a predictive assay for anti-MiHA GVHD. However, the possibility to recruit CTL populations targeting host MiHA expressed specifically on hematopoietic cells suggests a novel therapeutic strategy for the cure of hematopoietic malignancies. Indeed, transplantation of donor hematopoietic stem cells supplemented with T cells aimed at MiHA specifically expressed by host hematopoietic cells, could possibly potentiate the desirable graft vs leukemia effect without increasing the risk of GVHD.

The effects of social support on women's health during pregnancy, labor and delivery, and the postpartum period

This review of the literature on social support and its relationship to maternal health indicates that emotional, tangible, and informational support are positively related to mothers' mental and physical health around the time of childbirth. The importance of various types of support changes with the changing needs of women as they move from pregnancy to labor and delivery, and then to the postpartum period. During pregnancy, emotional and tangible support provided by the spouse and others is related to the expectant mother's mental well-being. In addition, informational support in the form of prenatal classes is related to decreased maternal physical complications during labor and delivery, and to improved physical and mental health postpartum. Mothers who have the support of a companion during labor and delivery experience fewer childbirth complications and less postpartum depression. Mothers' postpartum mental health is related to both the emotional support and practical help (eg, housework and child care activities) provided by the husband and others. Health care providers are in a unique position to educate prospective parents about the importance of social support around the time of childbirth and may play a critical role in mobilizing support systems for new mothers.

Preconception health care: a critical task for family physicians

Health care leaders in the United States have recently advised that preconception care be made available to all prospective parents because health in pregnancy depends on health status prior to pregnancy. Prenatal care usually begins after the early critical period of pregnancy has passed, and optimal early prenatal care can be achieved only through preconception care. Family physicians, who are ideally suited to provide this care, can readily integrate it into the routine health maintenance they currently provide for their patients of childbearing age. This review highlights components of the medical, family, and social histories, current health, and physical examination that are important to preconception health. There is good evidence that attention to patients' health needs before conception is related to improved perinatal outcomes.

Dorsal penile nerve block for newborn circumcision

Dorsal penile nerve block with lidocaine is safe and effective for reducing the pain associated with newborn circumcision. Administering the anesthesia adds little time or expense to the overall routine. Complications are minor, limited to local bleeding and hematoma formation. Family physicians performing circumcision should be prepared to use penile nerve block and to advocate it to parents who choose newborn circumcision.

Family-centered postpartum care

The birth of a baby is a significant event for a family and may result in physical, emotional, or social changes for any family member. The medical community has traditionally focused its attention on the infant and the mother during this period. This paper discusses postpartum health changes that may be experienced by mothers, fathers, and siblings, and proposes a method for integrating the entire family into postpartum care routines. Expanding the traditional view of postpartum change and recovery to include the entire family promotes the well-being of each individual family member, as well as that of the family unit as a whole.