Endothelin receptor mRNA expression in renal medulla identified by in situ RT-PCR

Three subtypes of endothelin (ET) receptors have been identified by cDNA cloning, namely ET-RA, ET-RB, and ET-RC. In the current study the precise cellular distribution of the ET receptor subtypes in the renal medulla was explored by detecting the corresponding polymerase chain reaction (PCR)-amplified cDNAs by in situ reverse transcription (RT)-PCR. The PCR-amplified cDNAs were detected either by direct incorporation using digoxigenin-dUTP (dig-dUTP) as a nucleotide substrate in the PCR reaction or by in situ hybridization with the dig-dUTP-labeled probe. ET-RB mRNA was detected exclusively in the epithelial cells of the inner and outer medullary collecting duct. In contrast, ET-RA message was observed primarily in interstitial cells and pericytes of the vasae rectae in the outer and inner medulla. Southern blot analysis of PCR-amplified cDNAs reverse transcribed from extracted RNA of rat renal medulla confirmed the specificity of the RT-PCR products. ET-RC mRNA was not detected. We conclude that ET-RB is the major ET receptor found in rat renal medulla and is expressed exclusively on inner medullary collecting duct cells. The pattern of ET receptor mRNA expression described suggests different physiological actions for ET on the diverse cellular structures of the renal medulla.

Age and migration percentage as risk factors for progression in spastic hip disease

Age and migration percentage were evaluated as risk factors for the progression of spastic hip subluxation in patients with cerebral palsy. Three age-groups were defined: group 1 (two to eight years), group 2 (nine to 18 years), and group 3 (over 18 years). Four subluxation groups were defined by migration percentage: group A (< 30 per cent), group B (30 to 60 per cent), group C (60 to 90 per cent), and group D (> 90 per cent). The risk of progression was the same in groups 1A and 2A, and both of these were higher than the risk in group 3A. All group B hips had similar risks for progression, and all group C hips progressed to group D (> 90 per cent migration percentage). Groups 1A, 1B, 2A, 2B and 3B hips need close radiographic follow-up to detect progressive subluxation. All group C hips required surgical treatment for progression to dislocation to be avoided.

Recurrence of immunoglobulin A-kappa crystalline deposition disease after kidney transplantation

Cases of immunoglobulin A heavy chain and kappa light chain deposition disease are rare and their clinical presentations vary. We report one patient with histopathologic and clinical findings of a microangiopathic glomerulonephritis due to immunoglobulin A-kappa deposition. Ultrastructural studies revealed highly ordered deposits in the capillary lumen, mesangium, and basement membrane. The disease recurred at 2.5 years after a cadaveric kidney transplantation. Pulse steroid therapy was repeatedly effective in retarding further progression of renal deterioration in this patient.

Induction of plasmacytomas in genetically susceptible mice with silicone gels

Silicone gels injected intraperitoneally into strains of mice related to BALB/c develop plasmacytomas in approximately the same numbers and with similar phenotypes as previously obtained with pristane. Silicone gels produce few side effects and are well tolerated for long periods. Silicone gels contain several components that are potentially biologically active: residual vinyl groups and platinum. Microscopic and histological evidence suggests the silicone gel is degraded over a long period of time. Preliminary studies with long chain liquid dimethylpolysiloxanes with viscosities of 1000 cSt and 12,500 cSt have not produced plasmacytomas as yet. The plasmacytomagenic action of the gel appears to be due to the release of liquids from the gel matrix.

Unilateral unitary inflatable penile prosthesis to correct impaired tumescence and severe penile deformity resulting from traumatic rupture of 1 corpus cavernosum

Nonsurgical management of a penile fracture can result in penile deformity due to plaque, and impaired tumescence due to corporeal fibrosis and altered erectile hemodynamics. We describe the correction of penile deformity and impaired tumescence by extensive resection of corporeal fibrosis and insertion of a unilateral unitary inflatable prosthesis. A possible role is proposed for correcting penile angulation secondary to unilateral disease using a unilateral unitary inflatable penile prosthesis.

Detailed immunohistologic evaluation of a methotrexate-induced nodule

Accelerated nodulosis in patients with rheumatoid arthritis who are receiving methotrexate has become a well-recognized phenomenon, and it appears to occur in both individuals with seropositive and seronegative findings. No histologic differences permit a distinction between seronegative and seropositive nodulosis--either occurring during the natural history of rheumatoid arthritis or when "induced" by methotrexate. We examined such a nodule in a man with seronegative rheumatoid arthritis. Results of immunofluorescence examination were not contributory, but studies of the inflammatory cell populations within the nodule showed 5% of the cells to be lymphocytes with a CD4/CD8 ratio of 25:1. Of the total mononuclear cells, 85% were reactive for Leu-10 (HLA-DQ) and 95% were reactive for HLA-DR, and about 75% of the macrophages were reactive for CD4+. The strong expression of CD4, in conjunction with macrophage markers, and the high T-helper/suppression ratio are of note. We discuss the implications of these findings and the role that they play in the pathogenesis of methotrexate-induced nodules.

Dose response of succinylcholine at the adductor pollicis of children with cerebral palsy during propofol and nitrous oxide anesthesia

Children with cerebral palsy may be resistant to paralysis induced by nondepolarizing neuromuscular blocking drugs. Potency of a bolus of succinylcholine in children with cerebral palsy has not been studied previously. Therefore, we measured the response of the adductor pollicis to succinylcholine in children with cerebral palsy anesthetized with propofol and nitrous oxide. Forty children between the ages of 2 and 10.2 yr with spastic quadriplegic cerebral palsy were randomly assigned to receive 100, 175, 250, or 375 micrograms/kg of succinylcholine during anesthesia with propofol and nitrous oxide. The ulnar nerve was stimulated with a train-of-four supramaximal stimulus every 10 s and the compound electromyogram of the adductor pollicis recorded by a Datex NMT monitor. Plasma cholinesterase activity was measured in all patients with three different substrates (propionylthiocholine, benzoylcholine, and succinylcholine). Dibucaine number was also determined using inhibition of benzoylcholine degradation. ED50 of succinylcholine was 146.8 micrograms/kg with 95% confidence intervals of 111.4-193.7 micrograms/kg. ED95 of succinylcholine was 360.5 micrograms with 95% confidence intervals of 273.3-475.5 micrograms/kg. We conclude that children with cerebral palsy are slightly sensitive to succinylcholine, but probably not sufficiently to be clinically important.

Loin pain-hematuria syndrome with a distinctive vascular lesion and alternative pathway complement activation

We describe a 48-year-old woman with loin pain-hematuria syndrome. Her renal abnormalities included conspicuous microaneurysmal and glomeruloid (plexiform) angiomatous changes. The deposition of both properdin and the C5b-9 complex, as well as the usual C3, in arterioles argues for complement activation. To our knowledge, neither of these features has been previously described. We speculate about the cause of loin pain-hematuria syndrome and note the uncommonness of this entity in the United States as opposed to Great Britain.

Responses to hemorrhagic arterial pressure reduction in different ischemic renal failure models

Renal blood flow (RBF) autoregulation has been found to be impaired in both norepinephrine (NE) and renal artery clamp (RAC) rat ischemic acute renal failure models. However, the decline in RBF at the normal lower limit of autoregulation is greater in NE-ARF. The present study was designed to determine if this difference in autoregulatory profiles has potential functional and morphologic significance. After demonstrating a fall in RBF to renal perfusion pressure reduction to 90 mm Hg that was twofold more in one week NE- than RAC-ARF (p < 0.001), separate rats of both ischemic ARF types with nearly identical levels of azotemia and glomerular filtration rate reduction and sham-ARF rats were subjected to four-hour controlled reduction in mean arterial pressure to 90 by transient phlebotomy at one week. On day 9, two days after mean arterial pressure reduction, blood urea nitrogen (BUN), serum creatinine (SCr) and creatinine clearance (CCr) showed continued improvement in RAC-ARF, but there were significant increases in BUN (46 +/- 22 to 72 +/- 10 mg/dl) and SCr (1.2 +/- 0.2 to 1.5 +/- 0.2 mg/dl) and a decline in CCr (0.434 +/- 0.127 to 0.334 +/- 0.079 ml/min) in the NE-ARF group (all P < 0.02). The mean sum of scores of morphologic indices of ARF was higher in NE- than RAC-ARF kidneys of rats sacrificed on day 9 but interstitial edema was the only individual index that was worse in NE-ARF.(ABSTRACT TRUNCATED AT 250 WORDS)

The dose-response relationship for hypoxic pulmonary vasoconstriction

In 12 pentobarbital anesthetized dogs the lungs were independently ventilated with a double piston ventilator. The right lung was ventilated throughout with 100% oxygen. Blood was drawn from the right atrium and pumped through a bubble oxygenator to a cannula in the ligated left main pulmonary artery. The pressures in the left main pulmonary artery and the left atrium were recorded during constant flow while the oxygen tension in the left lung alveolar gas and the perfusate were varied either to match each other (Protocol 1) or differ (Protocol 2) over the range from "zero" to "100%" oxygen. From the combined data a three dimensional response surface for hypoxic pulmonary vasoconstriction was derived. The maximum increase of pulmonary vascular resistance (r%PVRmax) was defined at a stimulus oxygen tension (PSO2) of 10 mmHg amounting to a 3.15 +/- (0.18)-fold increase of the vascular resistance on "100%" oxygen. The stimulus oxygen tension was shown to be PSO2 = PVO2(0.41) x PAO2(0.59) and the dose-response sigmoid for hypoxic pulmonary vasoconstriction in canine lungs was derived as r%PVRmax = 100 (PSO2(-2.616))/(6.683 x 10(-5) + PSO2(-2.616)) These results appear to reconcile observations from a number of laboratories and to be of quite general application.

Fracture of the spine in patients with ankylosis due to diffuse skeletal hyperostosis: clinical and imaging findings

OBJECTIVE

Only 12 patients with a fracture through a portion of the spine ankylosed by diffuse idiopathic skeletal hyperostosis have been reported. The purpose of this study was to determine the types of causative trauma, spinal sites at risk for fracture, complications mortality, diagnostic difficulties, and abnormalities identified only with special imaging studies in a group of 15 patients with this complication seen at our institution.

MATERIALS AND METHODS

The study included 15 patients with diffuse idiopathic skeletal hyperostosis who had a spinal fracture through an area of ankylosed spine. The criteria for diffuse idiopathic skeletal hyperostosis include flowing calcification or ossification along the anterolateral margin of at least four contiguous vertebral bodies; preservation of disk height in the involved areas; and absence of bony ankylosis of the apophyseal joint and erosion, sclerosis, or bony fusion of the sacroiliac joints. All spinal radiographs, tomograms, CT scans, and MR images obtained in these patients were reviewed to determine diagnostic difficulties, site and level of fracture, displacement of fractures, and extent of anatomic injury. The hospital charts of all patients were reviewed for history, physical examination, clinical status, treatment, and outcome.

RESULTS

Fourteen fractures of the cervical spine, one of the thoracic spine, and one of the lumbar spine occurred in 15 patients. Five fractures were caused by high-energy trauma and 11 fractures by low-energy, seemingly trivial injuries. The spinal fracture caused complete quadriplegia in seven patients, incomplete quadriplegia in one patient, complete paraplegia in two patients, a central cord syndrome in two patients, and no neurologic deficit in three patients. In two of three patients in whom fracture diagnosis was delayed, paraplegia developed during the delay. Three patients died within 1 week and three more died within 6 months after injury. CT and conventional tomography enabled diagnosis of posterior element fractures not seen on plain radiographs in five patients. All fractures healed, except those in the three patients who died within a week of injury.

CONCLUSION

Trivial trauma was the most common cause of fracture in the spine ankylosed by diffuse idiopathic skeletal hyperostosis. The severity of spinal cord injury in our patients was greater than in previous reports. We suggest that this may be a function of the relatively long segments of ankylosed spine (average, 16 vertebrae) in our patients providing a long lever arm for any traumatic force to act on. Patients with shorter ankylosed segments had less severe cord injuries. Delay in diagnosis of a fracture through an area of ankylosed spine associated with diffuse idiopathic skeletal hyperostosis was common if no neurologic deficit was present, and led to permanent paraplegia in two of three patients. CT and MR studies were useful in determining the anatomic abnormalities present, but were performed only in a limited number of patients.

Fibrogenic growth factors in the eosinophilia-myalgia syndrome and the toxic oil syndrome

BACKGROUND AND DESIGN

We sought to determine if growth factors of potential pathogenetic significance are deposited in the skin, muscle, and peripheral nerve lesions of eosinophilia-myalgia (EMS) and toxic oil syndrome. Immunohistochemical studies using affinity-purified peroxidase-conjugated antibodies to detect transforming growth factor-beta, platelet-derived growth factorAA and growth factorBB, fibroblast growth factor, epidermal growth factor, and interleukin 4 were performed on formalin-fixed, paraffin-embedded specimens. Seven skin biopsy specimens from EMS, six skin biopsy specimens from toxic oil syndrome, nine muscle biopsy specimens from EMS, and one sural nerve biopsy specimen from EMS were studied.

RESULTS

Growth factor staining was noted primarily in the epidermis and periappendageal locations of the dermis. The presence of TGF-beta and platelet-derived growth factorAA in the periappendageal dermis was significantly more prevalent in EMS than toxic oil syndrome (57% vs 0%). Prominent staining of transforming growth factor-beta was also present in the perimysial connective tissue of five (63%) of eight EMS muscle biopsy specimens and one sural nerve biopsy specimen.

CONCLUSIONS

These studies implicate transforming growth factor-beta and platelet-derived growth factorAA as potentially important cytokines in EMS and suggest that the pathogenesis of tissue fibrosis in EMS and toxic oil syndrome may be dependent on different growth factors.

Heterotopic ossification after hip and spine surgery in children with cerebral palsy

We made a retrospective review of 198 children with cerebral spasticity to determine development of heterotopic ossification. Of 61 children undergoing hip adduction lengthening, 21 had mild to moderate grades of heterotopic ossification. Only two of 132 patients who underwent spine fusions had developed heterotopic ossification, but in both it was severe, resulting in hip fusion. Two of five patients undergoing concomitant hip surgery and spine fusion developed heterotopic ossification of severe degree. The occurrence of heterotopic ossification after hip muscle surgery in children with cerebral spasticity is common but usually minor. Heterotopic ossification developing after spine fusion is rare but severe when it occurs, and concomitant hip and spine surgery causes frequent severe occurrences of heterotopic ossification.

Long-term follow-up of triple arthrodesis in patients with cerebral palsy

This study was a long-term retrospective review of patients with cerebral palsy (CP) who had triple arthrodeses as children before 1981. The medical records were reviewed, and the patients were requested to return for reevaluation, during which a radiograph, physical examination, and patient questionnaire were obtained. Twenty-four patients who had triple arthrodesis on 35 feet returned for evaluation. Twenty-three feet had planovalgus deformities and 12 equinovarus deformities. Mean age at operation was 14.2 years, with a mean follow-up of 17.8 years (range 11-45 years). Of the 24 patients questioned, 19 were satisfied and five were dissatisfied with their result. Nine patients had occasional pain; one patient reported frequent pain in one foot. Six patients had limited distance ambulation owing to their feet. Radiographic evaluation demonstrated that 43% of the feet had degenerative changes at the ankle joint. Four of six patients reported ambulatory limitation due to pain. Ankle joint range of motion (ROM) and degenerative arthritis were not correlated with pain, distance limitations, residual deformity, or patient satisfaction. Patient satisfaction was predominantly related to persistent pain, especially pain causing distance limitations in ambulation. Patient satisfaction was also strongly correlated with residual deformity. Persistent pain and distance limitation were also strongly correlated with residual planovalgus deformity.

Laparoscopic cholecystectomy in transplant patients

Acute cholecystitis is a serious condition in transplant patients and elective cholecystectomy is generally recommended when gallstones are found. We reviewed the results of laparoscopic cholecystectomy (LC) in 10 immunosuppressed transplant patients (6 heart, 4 kidney) and compared them to the results of open cholecystectomy performed in 26 transplant patients (14 heart, 11 kidney, 1 kidney/pancreas). The LC group had a 20% incidence of minor complication with no major complications and no deaths. The open-cholecystectomy group experienced 19% minor complications, 23% major complications, and 15% deaths. The average postoperative length of stay for the LC patients was 4.6 days (2 days for the 5 straightforward cases) as compared to 9.1 days after open cholecystectomy (4 days for the 13 straightforward open cases). Oral immunosuppression was stopped prior to operation but could be restarted within 29 hours after operation in the LC patients and 68 h in the open cases. The findings at LC were helpful in assessing whether acute cholecystitis and/or choledocholithiasis was the source of fever, liver-function abnormalities, or pancreatitis in these immunosuppressed transplant patients. We conclude that LC can be performed safely in transplant patients, but that in 10-20% of patients, the operation will be converted to an open procedure. The advantages of LC in these patients are a shorter hospitalization and less delay to resumption of preoperative oral immunotherapy than after open cholecystectomy.

Isometric exercise increases strength and does not produce sustained creatinine phosphokinase increases in a patient with polymyositis

A patient with active stable idiopathic polymyositis received a 4-week supervised right quadriceps and biceps isometric strengthening program. He demonstrated a significant increase in isometric peak torque without a sustained rise in creatinine phosphokinase (CPK). A significant decrease in postexercise CPK occurred at the end of the exercise program. We conclude a randomized clinical trial using a nonexercised patient group vs an exercised patient group may be useful.

Reversible renal failure in the primary antiphospholipid syndrome--a report of two cases

The primary antiphospholipid/anticardiolipin syndrome is a recently described entity wherein multiorgan thrombotic events occur in the absence of objective evidence of systemic lupus erythematosus. The spectrum of renal involvement remains poorly described. Two patients with coagulation abnormalities consistent with the primary antiphospholipid/anticardiolipin syndrome who developed profound renal insufficiency are reported. Striking microangiopathic lesions were documented on renal biopsy. Renal function improved concomitant to the institution of steroid therapy. Reversible renal failure should be added to the spectrum of clinical manifestations of this entity. The diagnosis of the primary antiphospholipid/anticardiolipin syndrome should be contemplated in individuals with unexplained acute renal failure.

Proximal femoral resection for older children with spastic hip disease

Thirteen patients (19 hips) who underwent proximal femoral resection arthroplasty for symptomatic subluxation or dislocation of the hip were reviewed retrospectively. All had severe neurological involvement, and when older were non-ambulatory with spastic quadriplegia or myelodysplasia. Resections were either at the level of the neck (nine hips) or in the subtrochanteric region (10 hips). The latter provided a better operative result than did the former. Poor clinical results noted were continued pre-operative pelvic obliquity, postoperative adduction contracture, and bony contact between the pelvis and the remaining proximal femur or its heterotopic ossification.

Femoral version and neck shaft angle

We measured femoral anteversion by the Kingsley-Olmsted method in 24 unpaired, dry femurs. When the head and neck of the same femurs were measured by computed tomography (CT) scan, measurement was 5 degrees less than the Kingsley-Olmsted method, whereas ultrasound of the head and neck was 5 degrees higher. An anterior flat plane was also defined to help measure anteversion in patients with a high neck shaft angle. Physical and ultrasound measurement correlated well with the previous measurement by the Kingsley-Olmsted method and CT scan of anteversion. Although measurement by CT scan and ultrasound are different their results are both reproducible and measure the same parameters; however, ultrasound measurement yields a number approximately 10 degrees higher.