Antithymocyte globulin in cadaver renal grafts: prophylaxis and antirejection therapy with three different preparations

Three different preparations of antithymocyte globulin were used to treat recipients of cadaver kidney transplants. Twenty patients received Connaught Institute/Armand-Frappier ATG prophylactically beginning on the day of grafting and achieved superior graft and patient survival compared to 18 concurrent controls. Pressimmune as a 5-day course was able to reverse steroid resistant rejections in 20 of 31 recipients as was ATGAM in three of six treated patients receiving it for 10 days. These short courses were associated with a 16% early and a 10% late relapse rate. The combination of high steroid therapy, maintenance azathioprine and ATG was associated with an infection rate of 22%.

A clinical trial of a bead bed system for the prevention of pressure sores in elderly orthopaedic patients

This paper summarizes the results of the trial of the Beaufort Bead Bed system designed to reduce the incidence and severity of pressure sores. Elderly orthopaedic admissions were allocated alternately to the Beaufort system and to the usual trolley, table and bed surfaces, and followed from admission to hospital until separation. The incidence of pressure sores was 15.6% in the 32 'trial' patients, which was significantly less than the 48.8% in the 43 'control' patients, as was the mean maximum diameter of the pressure sores incurred: 6.4 mm for the 'trials' as against 29.5 mm for the 'controls'. In particular the trial group were free from pressure lesions to the heel, which affected 32.6% of the control group. The groups were well matched on a variety of criteria on admission, and we conclude that the Beaufort system successfully reduces the incidence and severity of pressure sores for elderly orthopaedic patients. The system--renamed recently the 'Neumark-Macclesfield Support System'--is now in regular and satisfactory use.

Nasendoscopy: significant refinements of a direct-viewing technique of the velopharyngeal sphincter

The need for a three-dimensional record of velopharyngeal sphincter function in patients with craniofacial anomalies and speech problems is discussed. A refined split-screen video technique using color nasendoscope image, lateral video-fluoroscopy, and synchronous speech recording with the patient awake and in supine position is described. A special signal processor is used to position the color nasendoscopy image. The examination is recorded on 1-in. videotape. The technique allows three-dimensional appraisal of sphincter function with direct viewing and enables assessment of a range of abnormalities, assessment of the effectiveness of pharyngoplasties, and prediction of speech deformities and their management following midface craniofacial surgery.

A method for using microspheres to measure muscle blood flow in exercising rats

A catheter-implantation procedure allowing use of the radiolabeled microsphere (MS) technique for measuring skeletal muscle blood flow (BF) in rats during high-speed treadmill running was desired. Attempts to use existing procedures were unsuccessful. We found that Silastic catheters (0.02 in. ID X 0.037 in. OD) placed in the ascending aorta (for MS infusions) and the renal artery (for reference sample withdrawal) minimized these exercise performance problems. It was then necessary to establish that aortic MS infusions result in good MS-blood mixing. We tested the method with the following: 1) the radioactivities found in reference withdrawal samples taken from two locations in the aorta were compared after left ventricular (LV) infusion and after aortic infusion; 2) BFs to bilaterally paired tissues were compared in anesthetized and conscious rats with LV and aortic infusions; 3) the distribution of MSs in the muscles was studied histologically; and 4) BFs in bilaterally paired tissues were compared in rats with aortic MS infusions during treadmill running. The results indicate that 1) the percent difference between the radioactivities found in the proximal and distal reference withdraw samples was the same for LV and aortic MS infusions; 2) BF to bilaterally paired tissue samples was the same with both LV or aortic MS infusions; 3) the MSs were distributed uniformly within muscles, and MS aggregation was not a significant problem; and 4) BFs to bilaterally paired tissue samples were the same in exercising rats. We conclude that this technique can be used to measure muscle BF in rats running on a treadmill.

Combination chemotherapy, radiotherapy, and BCG immunotherapy in limited small-cell carcinoma of the lung: a Southwest Oncology Group Study

From November 1976 to March 1979 the Southwest Oncology Group treated 298 patients with limited (disease confined to the chest and encompassed by one radiotherapy port) small-cell carcinoma of the lung with combination chemotherapy and radiotherapy with or without BCG immunotherapy. Two induction chemotherapy programs were utilized: (1) cyclophosphamide, vincristine, methotrexate, fluorouracil; or (2) cyclophosphamide, doxorubicin, and vincristine. Patients received 4500 rads of radiation therapy to the bulk primary tumor and 3000 rads to whole brain followed by maintenance chemotherapy. One-half of all the patients were randomized to receive one vial (5 x 10(8)) of high viability Pasteur BCG by scarification technique given on days 8 and 15 of each 21--28 day treatment cycle. Increased granulocytopenia accompanied the addition of BCG immunotherapy. Patients receiving BCG achieved a response rate of 49% vs. those patients not receiving BCG of 44% (P = 0.579). Median response duration was 40 weeks for the BCG arms and 38 weeks for the arms without BCG; survival was no different, 42 weeks for the BCG arms vs. 50 weeks for the arms without BCG. In patients who responded to therapy and survived longer than one year, those who continued to receive BCG therapy demonstrated a slight, yet significant, survival benefit over those patients not receiving BCG (93 weeks vs. 81 weeks, P = 0.03). It appears that BCG immunotherapy has no beneficial effect on response rate, duration of response, or survival in programs using chemotherapy and radiotherapy for control of limited small-cell carcinoma of the lung except in this small group of long-term survivors.

Antigen presentation by Ia+ B cell hybridomas to H-2-restricted T cell hybridomas

The Ia+, H-2d BALB/c lymphoma cell line L10.A 2J was fused to T cell-depleted spleen cells from mouse strains bearing other H-2 haplotypes. A portion of the selected hybrids expressed Ia antigens of the normal spleen cell partner in the fusion as evidenced by their presentation of various antigens to a set of antigen-specific I-region-restricted T cell hybridomas. Three cloned hybrids were studied in detail. Antigen presentation was shown to be inhibited specifically by monoclonal anti-Ia antibodies. Both I-A and I-E molecules were expressed, including in the one case examined hybrid I-A and I-E molecules between the H-2d and H-2b haplotypes. These Ia+ B cell hybridomas provide a useful set of tools for studying the role of I-region-encoded molecules in antigen presentation to T cells.

Survey of pulmonary tuberculosis in south and west Wales (1976-8)

In routine clinical practice 20% of patients with pulmonary tuberculosis were treated with the regimen recommended by the British Thoracic Association after the British trial of short-course chemotherapy. Despite the use of several regimens that could be considered inadequate, no patients from the survey within south and west Wales appears to have relapsed yet. Deaths from pulmonary tuberculosis continue at the same rate as 10 years ago. Patient default remains a difficult problem even with modern, less toxic, short-course regimens.

Inhibition of Semliki forest virus penetration by lysosomotropic weak bases

The effect of five lysosomotropic weak bases (chloroquine, amantadine, tributylamine, methylamine and NH4C1) on Semliki Forest virus (SFV) infection has been studied in BHK-21 cells. When present at concentrations equal to or greater than 0.1, 0.5, 2, 15 and 15 mM respectively, the agents inhibited SFV infection by more than 90%. The effect was reversible and involved a process occurring within the first 60 min of virus-cell contact. The agents did not have a direct virucidal effect nor did they affect virus binding to the cells, receptor-mediated endocytosis of prebound virus, intracellular distribution of virus after endocytosis, or the low pH-induced membrane fusion activity of the virus spike glycoproteins. The step blocked by chloroquine and NH4C1 occurred intracellularly and was identified as the release of the virus nucleocapsid into the cytoplasm or the uncoating process. On the basis of these results, our previous studies on SFV entry, and the known effects of lipophilic amines on lysosomes, we conclude that the agents affect entry by a common mechanism: they prevent the transfer of the virus nucleocapsid into the cytoplasm by increasing the lysosomal pH above the critical value needed to trigger a low pH-dependent fusion reaction between the membranes of the lysosome and the virus.

Membrane fusion activity of influenza virus

A simple assay is described to monitor fusion between fowl plague virus (FPV, an avian influenza A virus) and liposomes which allows the simultaneous quantitation of both lytic and non-lytic fusion events. As in fusion between viruses and the plasma membrane and in FPV-induced cell-cell fusion, the reaction only occurs at pH 5.5 or below, and it is fast, highly efficient, and essentially non-lytic when fresh virus and liposomes are used. The fusion occurs over a broad temperature range, and has no requirement for divalent cations. The fusion factor of influenza virus is a hemagglutinin (HA) spike which protrudes from the virus membrane and which is also responsible for virus binding to the host cell. The finding that fusion occurs as efficiently with liposomes containing or lacking virus receptor structures, further emphasizes the remarkable division of labor in the HA molecule: the receptor-binding sites are located in the globular HA1 domains and the fusion activation peptide is found at the N-terminal of HA2 in the stem region of the protein. The mechanism of fusion is discussed in terms of the three-dimensional structure of the HA and the conformational change which the protein undergoes at the fusion pH optimum.

Dementia of the Alzheimer type. Clinical genetics, natural history, and associated conditions

Relatives of 125 probands, who had dementia of the Alzheimer type as proved by autopsy, were subjects of a genetic investigation. The relatives exhibited an excess of dementing illness consistent with genetic transmission. Risk to relatives decreased sharply as severity of the proband's illness decreased. Also, when compared with a control group and the general population, the relatives had excesses of Down's syndrome, lymphoma, and immune diatheses. These associated conditions also were more likely to be present when the proband had severe illness. Mortality at all ages was increased among the relatives.

Cell fusion by Semliki Forest, influenza, and vesicular stomatitis viruses

Representatives of three families of enveloped viruses were shown to fuse tissue culture cells together. These were: Semliki Forest virus (SFV, a togavirus), vesicular stomatitis virus (a rhabdovirus), and two myxoviruses, fowl plaque virus and Japan influenza virus (Japan)/A/305/57). Unlike paramyxoviruses, whose fusion activity is known to occur over a broad pH range, fusion by these viruses was restricted to mildly acidic pH. The pH thresholds for the four viruses were 6.0, 6.1, 5.5, and 5.1, respectively. The precursor form of Japan influenza, which is not infectious and which contains the uncleaved hemagglutinin, had no fusion activity. This result suggested a role for the influenza hemagglutinin in the low-pH-dependent membrane fusion activity. Taken together, our results show that low-pH-induced fusion is a widespread property of enveloped animal viruses and that it may play a role in the infective process. The fusion reactions with all four viruses were fast, efficient, and easy to induce. With UV-inactivated SFV, the fusion was shown to be nonlytic and the polykaryons were viable for at least 12 h. 30 ng of SFV/1 x 10(6) BHK-21 cells were required for 50% fusion, and 250 ng sufficed to fuse the entire culture into a single polykaryon.

Antigen-inducible, H-2-restricted, interleukin-2-producing T cell hybridomas. Lack of independent antigen and H-2 recognition

We developed a method for production of antigen-specific, H-2-restricted T cell hybrids. The tumor cell partner in the fusions was itself a T cell hybrid, FS6-14.13.AG2 (or its derivatives), which could be induced to produce the growth factor, interleukin-2 (IL-2), in response to a challenge with concanavalin A, but had no known antigen specificity. The normal T cell partner in the fusions was a population of lymph node T cell blasts that had been highly enriched in antigen-specific, H-2-restricted T cells by in vivo immunization, followed by in vitro challenge with antigen and clonal expansion in IL-2-containing medium. These fusions produced hybrids that grew constitutively in culture. A sizable proportion of the hybrids demonstrated the ability to produce IL-2 in response to a challenge with specific antigen presented by irradiated spleen cells of the appropriate H-2 type. Four cloned antigen/H-2-specific hybrid lines were produced. AO-40.10 responded to chicken ovalbumin (OVA) when presented by I-A(k)-bearing cells. DC1.18.3 responded to the apo form of beef cytochrome c when presented with I-A(d). AODK-10.4 responded to keyhole limpet hemocyanin (KLH) presented with I-A (d). AODK-1.16 also responded to KLH presented by a product of the I region of H-2(d), but the data were consistent with either a product of the I-J-I-E(d) region or a combinatorial molecule with elements from both I-A(d) and I-E(d)/I-C(d). Coincidentally, AO-40.10 was shown to have an unexpected alloreactivity with a product of H-2(b) mapping to the K-I-A region. These hybrids should prove invaluable as sources of monoclonal material for the study of the receptor(s) on T cells with H-2-restricted antigen specificities. We also generated T cell hybrids with two antigen/H-2 specificities by fusing an azaguanine-resistant clone of AO-40.10 to normal T cells with a different antigen/H-2 specificity. Many of the hybrids retained reactivity to OVA plus H-2(a) and to the second antigen/H-2 combination. None reacted to either OVA plus the second H-2 type or to the second antigen plus H-2(a). One of these hybrids was successfully cloned to produce the line AOFK- 11.11.1. It retained the ability to recognize OVA plus I-A(k) inherited from one parent, and KLH plus IA(f) inherited from the other. It did not recognize OVA plus IA(f) or KLH plus I-A(k). These results have some bearing on models describing the nature of T cell receptors for antigen recognized in association with H-2 products. They do not support models in which antigen and H-2 are recognized separately by two independent T cell receptors.

Severe cranio-facial deformities and their management

Historical attitudes to cranio-facial deformities are discussed. A simple nosology of cranio-facial deformities is given, the main groups being craniosynostosis syndromes, facial clefts, tumours, trauma, facial microsomias, and midface hypoplasias. Each group is briefly discussed, with emphasis on the craniosynostosis syndromes and facial clefts. Cases from these two groups are illustrated before and after surgery, showing the dramatic improvement offered by cranio-facial techniques. The basic principles of cranio-facial surgery are briefly discussed, and the complications discussed. The South Australian Cranio-Facial Unit experience with complications is discussed, especially blindness and persistent C S F leaks. The necessity for only a few cranio-facial units each with a high workload is reiterated, and new directions for cranio-facial surgery discussed, including the use of microvascular techniques and early surgery to minimise later deformity, particularly in cases with plagiocephaly.

Immune thrombocytopenia in severe neonatal infections

Thrombocytopenia occurs frequently in newborn infants with sepsis, but the exact mechanism remains obscure in those infants who do not have evidence of disseminated intravascular coagulation. Since recent work has suggested a possible immune mechanism for thrombocytopenia observed in adults with sepsis, we have investigated the role of platelet-associated immunoglobulin in severe neonatal infections. To detect PAIgG we use a method employing protein A and peroxidase-antiperoxidase as a labeled antibody. PAIgG was quantitated by phase contrast microscopy and expressed as a reactive index. Our control group included 16 normal newborn infants whose mean RI was 0.65 +/- 0.01 SE. In addition to the control group, five infants with nonimmune thrombocytopenia were included; their mean RI was 0.66 +/- 0.01 SE. Seventeen newborn infants with severe infections were assayed for PAIgG. Eight of nine infants with bacterial infections had increased RI, with a mean of 1.16 +/- 0.03 SE (P less than 0.01). Six of the eight infants with viral infections had elevated RI, with a mean of 1.23 +/- 0.03 SE (P less than 0.01). These findings suggest that an immune mechanism may be involved in the thrombocytopenia of severe neonatal infection.

Combination chemotherapy, radiotherapy, and BCG immunotherapy in extensive (metastatic) small cell carcinoma of the lung. A Southwest Oncology Group study

From November 1976 to November 1978, the Southwest Oncology Group treated 254 patients with extensive (metastatic) small cell carcinoma of the lung with combination chemotherapy and radiotherapy with and without BCG immunotherapy. Patients receiving BCG achieved a response rate of 50% versus those patients not receiving BCG of 46% (P = .704). Response duration was 20 weeks for the BCG arms and 23 weeks for the no-BCG arms; survival was 28 weeks for the BCG arms versus 29 weeks for the no-BCG arms. An adverse effect in patients surviving more than one year was detected; those continuing to receive BCG had significantly shorter survival, 60 weeks versus 85 weeks (P = .019). Toxicities of the programs were not affected by the addition of BCG immunotherapy. It appears that BCG immunotherapy has no beneficial effect on response rate or duration of response in programs using chemotherapy and radiotherapy for control of metastatic small cell carcinoma of the lung. In addition, because of the adverse effect on long-term survival, we do not recommend the addition of BCG immunotherapy as a treatment modality in this tumor type.