Adult heart transplantation under tacrolimus (FK506) immunosuppression: histopathologic observations and comparison to a cyclosporine-based regimen with lympholytic (ATG) induction

BACKGROUND

Tacrolimus (FK506) is an effective immunosuppressant for human heart transplantation, but information about its effects on cardiac allograft and nonallograft kidney and liver histopathologic study is limited.

METHODS

We therefore reviewed 1145 endomyocardial biopsy specimens and eight autopsy results from 80 heart transplant recipients who received tacrolimus as baseline immunosuppression. These were compared with 619 endomyocardial biopsy specimens and four autopsy results from 51 patients treated with cyclosporine-based immunosuppression with lympholytic induction (CLI) by use of rabbit anti-thymocyte globulin. Twenty-one histologic features including the International Society for Heart and Lung Transplantation histopathologic grade were retrospectively assessed without knowledge of the treatment regimen. The lymphocyte growth index on biopsy specimens obtained from these patients was also compared.

RESULTS

In general, there were no qualitative differences in the histopathologic appearance of various allograft syndromes between tacrolimus- and CLI-treated patients. Thus histopathologic criteria used to diagnose various graft syndromes are applicable under tacrolimus immunosuppression. However, early (between 10 and 30 days) after transplantation, biopsy specimens from patients treated with tacrolimus showed a significantly higher percentage of inflamed fragments (p = 0.02), the inflammation tended to be more severe (p = 0.09), and the rejection grade tended to be slightly higher (p = 0.08). In contrast, during the late transplantation period (275 to 548 days), biopsy specimens from patients treated with CLI showed a significantly higher percentage of inflamed fragments (p = 0.03), more severe inflammation (p = 0.03), higher rejection grades (p = 0.01), and a higher frequency of Quilty lesions (p = 0.05). Although overall freedom from any grade 3A or higher rejection was greater in the CLI-treated arm, tacrolimus was successfully used to treat refractory rejection in three patients from the CLI-treated arm. Concern has been raised in the literature about the possibility of tacrolimus being a direct hepatotoxin and an accelerant of allograft obliterative arteriopathy. However, no evidence to support either of these contentions was detected in this patient population. In contrast, tacrolimus is clearly nephrotoxic, although similar to cyclosporine in this regard.

CONCLUSIONS

Tacrolimus is an effective immunosuppressive drug for heart transplantation. The cardiac allograft histopathologic study of patients treated with tacrolimus immunosuppression does not significantly differ from those given conventional, cyclosporine-based triple therapy with lympholytic induction.

Inhomogeneities of ventilation and the diffusing capacity to perfusion in various chronic lung diseases

Although impairment of gas exchange caused by ventilation-perfusion (VA/Q) mismatch has been extensively analyzed, there have been no systematic studies focused on determining the distributions of diffusion properties in dose connection with those of VA/Q. We attempted to clarify the simultaneous distributions of VA/Q and diffusion capacity to perfusion (D/Q) in patients with idiopathic pulmonary fibrosis (IPF) or chronic obstructive pulmonary disease (COPD). To assess pathologic determinants causing functional abnormalities, we compared VA/Q and D/Q distributions with the findings on high-resolution computed tomography. O2, CO2, and CO together with six foreign inert gases were used as indicator gases. We transformed the measured data on indicator gases in arterial blood into a continuous distribution of Q in the VA/Q-D/Q field. In IPF, active alveolitis or acinitis played a major role in producing low D/Q regions impeding gas exchange via a diffusion limitation, whereas extensive fibrosis with minimal inflammation accounted for low D/Q as well as low VA/Q regions. In COPD, no regions with low D/Q ratios were observed, but an abnormality in the VA/Q distribution with low or high VA/Q ratios was identified. Emphysematous lesions produced high VA/Q regions, whereas peripheral airway involvement yielded low VA/Q regions. These findings suggest that hypoxemia in patients with IPF is caused by inhomogeneous distributions of D/Q in combination with those of VA/Q. Hypoxemia in patients with COPD is attributable primarily to inhomogeneities in VA/Q rather than in D/Q distributions.

Effects of simulated microgravity on human osteoblast-like cells in culture

Physiological strain plays an important role in maintaining the normal function and metabolism of bone cells. It is well know that the mineral content of astronauts' bones decreases during spaceflight. Thus, gravity is one of the important factors in the musculoskeletal system. The vector-free horizontal clinostat has been used to simulate conditions of microgravity for examining such effects on cells in culture. We analyzed the effects of simulated microgravity using a horizontal clinostat on cultured osteoblast-like cells (HuO9 cell line). Total cellular protein, which was measured as an indication of cell proliferation, was not significantly inhibited under simulated microgravity conditions. No morphological changes were detected under microgravity conditions by phase-contrast microscopy. However, the alkaline phosphatase (ALP) activity and osteocalcin production of the HuO9 cells decreased significantly under microgravity conditions. Our data indicate that simulated microgravity directly inhibits some differentiation phenotypes and some functions of osteoblasts. On the other hand, the addition of 1,25-dihydroxyvitamin D3 (1,25-(OH)2-D3) increased ALP activity under simulated microgravity conditions, although the total activity of ALP in the cells treated with 1,25-(OH)2-D3 was still lower under simulated microgravity conditions than that in the control cells. However, the cells under simulated microgravity conditions showed a greater enhancement of ALP activity by treatment with 1,25-(OH)2-D3.

Vibrational Assignment and Anharmonic Resonance Analysis of the Dispersed Fluorescence and Stimulated Emission Pumping Spectra of DFCO (S 0 ) up to 9000 cm-1

Dispersed fluorescence and stimulated emission pumping spectra of jet-cooled DFCO from the 2(1) 6(2) , 5(1) 6(4) , 2(1) 5(1) 6(2) , and 5(1) 6(6) vibrational states of S 1 are presented up to 9000 cm-1 . Progressions are assigned primarily to vibrational states with excitation in the Franck-Condon active modes nu2 , nu5 , and nu6 . The spectrum is perturbed by a 266 (nu2 approximately 2nu6 ), a 233 (nu2 approximately 2nu3 ), and a 3566 (nu3 + nu5 approximately 2nu6 ) anharmonic resonance. These three resonances are increasingly important at high vibrational energies, thus explaining the complexity of the DFCO spectrum compared to that of HFCO. Seventy-five vibrational states are assigned as eigenstates of a 266, 233, and 3566 anharmonic resonance Hamiltonian. The rms deviation in the calculated energies is 1.2 cm-1 . Harmonic frequencies and anharmonic constants are reported. These are compared to constants derived from ab initio potential energy surfaces.

Influence of panel-reactive antibody on survival and rejection after lung transplantation

BACKGROUND

Panel-reactive antibody (PRA) is commonly used before thoracic organ transplantation to estimate a potential recipient's degree of humoral sensitization.

METHODS

To assess the influence of an elevated PRA on survival and the incidence of rejection in pulmonary transplantation, the records of 247 patients that underwent single or double lung transplantation were reviewed.

RESULTS

Twenty-one of 247 patients (8.5%) had PRA values greater than 10%. Survival of this population was not significantly different from that of patients with low PRA levels: 74% (low PRA) vs 65% (elevated PRA) at 1 year and 58% in both groups at 3 years. The acute rejection rates (episodes/first 100 days) for the elevated and low PRA groups were 2.1 and 1.9, respectively (p = NS). Obliterative bronchiolitis developed in 38.9% of the high and 31.2% of the low PRA groups (p = NS). Six of 247 patients had a retrospective positive lymphocytotoxic cross-match result; three had PRA values greater than 10%. Patients with a positive cross-match result experienced similar survival and incidence of rejection as the remainder of the population. Among 957 patients evaluated for lung transplantation, 16 (1.7%) had a PRA (with dithiothreitol) greater than 15%. All had a history of pregnancy, blood transfusion, connective tissue disease, or previous transplantation.

CONCLUSIONS

Humoral sensitization is uncommon in the lung transplantation population. A modestly elevated PRA does not predict survival or the development of acute rejection or bronchiolitis obliterans. PRA testing before lung transplantation should be reserved for those patients with specific risk factors for humoral sensitization.

Preoperative multidisciplinary treatment with hyperthermia for soft tissue sarcoma

We report the results of phase I/II studies of preoperative multidisciplinary treatment of 14 patients with soft tissue sarcoma using hyperthermia from November 1990 to April 1995. The preoperative treatment was conducted with thermo-radio-chemotherapy in 11 cases of stage III, and with thermo-radiotherapy as well as thermo-chemotherapy in three cases of stages I and II. Hyperthermia was carried out twice a week with totals ranging from 4 to 14 times (average: 8.4 times); each session lasted 60 min. Radiotherapy was administered four or five times per week, and the dose was 1.8 2Gy/fraction, with a total of 30-40 Gy in a four week period. Chemotherapy was mainly in the form of MAID regimen (2-mercaptoethanesulphonic acid (mesna), adriamycin, ifosfamide and dacarbazine). The tumors were surgically resected in all patients after completing the preoperative treatment. The efficacy rate, as expressed by the percentage of either tumors in which reduction rate was 50% or more, or tumors for which post-treatment contrast enhanced CT image revealed low density volumes occupying 50% or more of the total mass, was 71% (ten of the 14 tumors). The mean tumor necrosis rate in the resected specimens was 78%. The tumor necrosis rate was significantly high (P < 0.05) in patients whose Time > or = 42 degrees C was of long duration. Postoperative complications were observed in six patients; among these, two patients developed wound infection that required surgical treatment as a complication of surgery performed in the early stage following the preoperative treatment. After a mean postoperative follow-up of 27 months, distant metastasis occurred in four patients resulting in three fatalities. The three-year cumulative survival rate was 64.3%. No local recurrence was observed in any patient during the follow-up, thus confirming our hypothesis that preoperative multidisciplinary treatment has an excellent local efficacy. We think that it would be valuable to conduct, at many facilities, phase III studies on the treatment of soft tissue sarcoma by a combination of surgery and preoperative multidisciplinary treatment using hyperthermia, paying close attention to the interval between these two modalities.

Imaging assessment of the response of bone tumors to preoperative chemotherapy

Assessment of the response of bone tumors to preoperative chemotherapy is of clinical importance. The authors determined the value of 3 imaging techniques (digital subtraction angiography, thallium scintigraphy, and dynamic magnetic resonance imaging) in guiding patient management by assessing the response of 17 bone sarcomas to preoperative chemotherapy compared with histologic evaluation of the resected specimens. Digital subtraction angiography showed a sensitivity of 87.5%, specificity of 57.1%, and accuracy of 73.3%. Thallium scintigraphy (sensitivity, 85.7%; specificity, 85.7%; accuracy, 85.7%) was superior to angiography in predicting tumor responses. The results of dynamic magnetic resonance imaging were analyzed on the basis of the value of slopes, which represents the percent increase in signal intensity per minute. The differences in slope before and after chemotherapy and the postchemotherapy slope values correlated with the histologic responses. The assessment by dynamic magnetic resonance imaging showed a sensitivity of 100%, specificity of 85.7%, and accuracy of 90.9%. Thallium scintigraphy and dynamic magnetic resonance imaging were considered noninvasive, reliable techniques that had about equal ability to assess the response of bone sarcomas to preoperative chemotherapy. Dynamic magnetic resonance imaging offers major advantages in the spatial resolution and can be more readily quantitated when compared with thallium scintigraphy.

A clinical analysis of malignant schwannoma

In this study, we reviewed the clinical features of 11 patients with malignant schwannoma who were treated in our institute. Five patients had coexistent von Recklinghausen's disease and one of them showed multifocal occurrence. Patients with the centrally located tumors had a poorer prognosis than those with the others. The overall 3-year survival rate was 36%; 40% in patients with von Recklinghausen's disease and 33% in the others. At the time of the last follow-up, 9 patients had died of the tumor, one continued to be tumor free, and one was alive with tumor. Postoperative local recurrence developed in 5 patients (45%); 4 out of 6 patients (67%) who underwent a marginal excision and one out of 3 (33%) who underwent primary amputation. There was no local recurrence in patients after a wide excision with at least 3 cm of normal tissue removed surrounding the tumor in all directions. Nine patients (82%) developed pulmonary metastasis. The effect of adjuvant chemotherapy was not clear in this study. The high risk of pulmonary metastasis in this disease indicates the necessity of more effective adjuvant chemotherapy.

Treatment of refractory acute allograft rejection with aerosolized cyclosporine in lung transplant recipients

Lung transplant recipients who have persistent acute cellular rejection are at increased risk for the development of chronic rejection, the leading cause of reduced long-term survival. This study evaluated the use of aerosolized cyclosporine as rescue therapy for unremitting acute rejection. Between June 1993 and March 1996, 18 patients with rejection that failed to resolve after therapy with pulse steroids and antilymphocyte globulin were enrolled in the study. Aerosolized cyclosporine A (300 mg) treatment was initiated for 10 consecutive days followed by a maintenance regimen of 3 days per week. Efficacy was assessed by graft histologic and pulmonary function testing. With the use of linear regression, results in these patients were compared with those in 23 control patients, matched for histologic acute rejection, who had continued to receive conventional rescue therapy. Two patients were unable to tolerate the treatments and were withdrawn from the study. Significant improvement in histologic rejection occurred in 14 of the remaining 16 patients after a mean of 37 days of aerosolized cyclosporine therapy. Measures of forced vital capacity and forced expiratory volume in 1 second (change in percent predicted/100 days plus or minus the standard error) increased over time in the treated patients whereas the condition of control patients declined despite repeated attempts at conventional rescue (forced vital capacity, aerosolized cyclosporine group, 4.6 +/- 2.9 vs control group -8.1 +/- 1.9, p = 0.001; forced expiratory volume in 1 second, aerosolized cyclosporine group, 2.1 +/- 4.4 vs control group -9.8 +/- 2.6, p = 0.043). Renal and hepatic toxicity during cyclosporine therapy was not observed. The incidence of acute histologic rejection (> or = A2) decreased from 2.49 +/- 0.68 episodes/100 days before aerosolized cyclosporine therapy to 0.72 +/- 0.3 episodes/100 days (p < 0.05). In summary, aerosolized cyclosporine is a safe and effective therapy for acute rejection that has failed to improve with conventional treatment.

Isolation and mapping of karyopherin alpha 3 (KPNA3), a human gene that is highly homologous to genes encoding Xenopus importin, yeast SRP1 and human RCH1

From a human fetal-brain cDNA library, we isolated and characterized a novel gene (KPNA3) encoding a protein highly homologous to certain nuclear transport proteins of Xenopus and human. The complete cDNA clone, designated karyopherin alpha 3, contained an open reading frame of 1,563 nucleotides encoding 521 amino acids. The predicted amino acid sequence showed 48%, 45% and 48% identity with Xenopus importin, yeast SRP1 and human RCH1, respectively. The similarities among these proteins suggest that karyopherin alpha 3 may be involved in the nuclear transport system. Eight repeats of the arm motif were well conserved among these proteins. The N-terminal region of the predicted karyopherin alpha 3 product was highly basic and the C-terminal region was strongly acidic. A 4.3-kb transcript was expressed in all adult human tissues examined by Northern blotting. The cDNA clone was assigned to chromosome band 13q14.3 by fluorescence in situ hybridization.

Monoclonal antibody #5-2-26 recognizes the phosphatase-sensitive epitope of rabies virus nucleoprotein

We prepared monoclonal antibodies (MAbs) against the rabies virus N protein, among which one antibody (MAb 5-2-26) was shown to lack reactivity with the phosphatase-treated N protein. The MAb was able to recognize the sodium dodecyl sulfate (SDS)-denatured N protein. The MAb did not recognize the N-protein analogues produced in Escherichia coli (E. coli), indicating that the N-gene products were not normally processed in E. coli after translation. On the other hand, the MAb reacted normally with N-gene products produced in COS-7 cells, but not with those produced in the presence of K-252a (a protein kinase inhibitor of a broad spectrum). The MAb displayed weak cross-reactivity with the Triton-insoluble network structures composed of several components, while another phosphoprotein (M1) of the virus was not recognized at all. These results suggest that MAb 5-2-26 preferentially recognizes a phosphatase-sensitive linear epitope of N protein, which may enable further investigations to be conducted on the mechanism of N-protein phosphorylation and its role(s) in virus replication.

Identification of a phosphatase-sensitive epitope of rabies virus nucleoprotein which is recognized by a monoclonal antibody 5-2-26

We have investigated a phosphatase-sensitive sequential epitope of the nucleoprotein (N), one of the phosphoproteins of rabies virus, which is recognized by the monoclonal antibody (MAb) #5-2-26. The epitope was shared in common by all of the rabies virus strains we tested, including the HEP, ERA, CVS and Japanese strains (Nishigahara and Komatsukawa). Thin layer chromatography of the acid hydrolyzates of 32P-labeled N protein showed that the protein contained phosphoserine and phosphothreonine at a molar ratio of about 4 to 1, while no phosphotyrosine was detected. Immunoprecipitation studies with several deletion mutants of the N protein showed that the epitope is located in a region spanning from amino acid 344 to 415. If the phosphatase-sensitive epitope is located at or near the phosphoamino acid, the location of the latter could be narrowed further to a region from amino acid 354 to 389 by comparing the amino-acid sequences among the viral strains. To examine this assumption, point mutation was introduced by amino-acid substitution with alanine at either of five potential phosphorylation sites (i.e., positions 354, 375, 377, 386 and 389) in the 354-389 region. Among those, only one substitution, at position 389, greatly affected the antigenicity. Substitution of serine-389 by threonine also reduced the antigenicity. These results strongly suggest that serine-389 is a phosphorylation site and essential for constructing or stabilizing the antigenic structure for MAb 5-2-26.

Vascular reconstruction in limb salvage operations for soft tissue tumors of the extremities

Eight patients with vascular threatening soft tissue tumors underwent wide excision of the tumors followed by vascular reconstruction. Superficial femoral vessels were resected in 6 patients and popliteal vessels in 2 patients. Arterial reconstruction was performed with a synthetic graft in 4 and a reversed saphenous vein graft in 4. Venous reconstruction was performed with a synthetic graft in 5 and a saphenous vein graft in 2. Adjuvant multimodality treatment was used in 6 patients. After an average of 30 months, the revascularized vessels were found to be patent in 5 patients with arterial reconstruction and in 1 patient with venous reconstruction. Six patients maintained functional extremities. Two other patients had to have amputations, 1 because of a deep infection that involved the grafts and the other because of an acute occlusion of the reconstructed artery. Edema of the leg, which was treated successfully with an elastic support and elevation of the leg, has been observed in all patients after operation. No local recurrence has been observed with an average followup period of 42.5 months. Pulmonary metastasis developed in 2 patients, and 1 of them underwent a pulmonary metastasectomy. Limb salvage in vascular threatening soft tissue tumors using vascular reconstruction techniques is useful and preferable in some patients.

The ipsilateral and contralateral connections of the fifth somatosensory area (SV) in the cat cerebral cortex

THE ipsilateral and contralateral corticocortical connections to the fifth somatosensory area (SV) in the feline cortex were determined from the location of retrogradely labelled cells following a single injection of HRP into SV. The injection was made into physiologically defined components of the body representation in SV. After injection of HRP into the face regions of SV, HRP-labelled cells were located ipsilaterally in areas 6 beta, 3b and 1-2 of the primary somatosensory (SI), in the second somatosensory (SII), third somatosensory (SIII), and fourth somatosensory (SIV) areas, along the ansate sulcus, and in areas 5a and 6a beta of the ipsilateral cortex, as well as in area 1-2 of SI and in SV of the contralateral cortex. On the other hand, after HRP had been injected into the trunk/hindlimb area, HRP-labelled cells were located in areas 3a, 1-2 of SI, in area 5, in SII, in SIII and in SIV of the ipsilateral cortex, as well as in area 1-2 of SI, and in SV of the contralateral cortex. The extent of these interconnections suggests that SV receives multiple sensory inputs and may function to integrate this information.

ECMO support for adult patients with acute respiratory failure

The authors analyzed factors that may influence the outcome of adult patients with respiratory failure who were treated with ECMO. Between December 1990 and July 1995, the authors used ECMO to support 33 patients (age range, 17-56 years) with respiratory failure from adult respiratory distress syndrome (ARDS; n = 9), primary graft failure after lung transplantation (n = 16), late graft failure after lung transplantation (n = 5), and miscellaneous reasons (n = 3). Twenty (61%) patients were successfully weaned from ECMO, and 13 (39%) survived to hospital discharge. Venoarterial ECMO was used in 46% of survivors, compared with 60% of nonsurvivors (p = 0.43). The time on mechanical support before ECMO and the duration on ECMO for survivors and nonsurvivors was 2.9 +/- 1.8 days vs 5.0 +/- 1.3 days (p = 0.35), and 6.5 +/- 1.8 days vs 5.7 +/- 1.1 days (p = 0.68), respectively. Compared with the nonsurvivors, survivors had higher PF ratios (PaO2/FIO2; 104 +/- 33 vs 81 +/- 8, p = 0.43) before ECMO was initiated, although the differences were not significant. Among the patients who received ECMO for primary graft failure, 75% were weaned from ECMO, and 56% survived to discharge. ECMO is beneficial for adult patients with respiratory failure, especially those with primary graft failure after lung transplantation.

Studies on unusual cytoplasmic structures which contain rabies virus envelope proteins

We investigated unusual structures produced in BHK-21 cells infected with rabies virus (HEP-Flury strain). Sellers' staining of the cells revealed, in addition to Negri body-like structures (inclusion bodies), production of a fuchsin-stained cytoplasmic structure (FCPS) which encircled the nucleus. The frequency of the FCPS-forming cells increased as replication progressed. The FCPS was different from the inclusion body because the former contained the viral glycoprotein (G) and matrix protein (M2) antigens, while the latter contained nucleocapsid antigens. In the early phase of infection, we observed accumulation of viral envelope antigens in a cytoplasmic structure that was considered to be expanded rough endoplasmic reticulum (rER) because of its concomitant increase in BiP content. Time-course studies suggested that the envelope antigen-containing structure, which was not stained with basic fuchsin, translocated to the perinuclear region to form the FCPS. FCPS formation was dependent on incubation temperature and was decreased at 30 degrees C, while the development of virus-induced cytopathic effect (CPE) was delayed. When the incubation temperature was shifted up to 37 degrees C, FCPS formation was induced again and progression of CPE was accelerated in approximate proportion to the increasing number of FCPS-positive cells. From these studies, we conclude that viral G proteins gradually accumulate in the rER with M2 protein and the expanded rER converts eventually into the FCPS, which may be closely related to accelerated host cell death.

[Pathological evaluation of superselective one-shot intra-arterial infusion chemotherapy for head and neck tumors]

Since 1992, we have treated 43 patients with head and neck tumors by superselective intra-arterial infusion chemotherapy (SIIC) via femoral artery. In 8 patients among then, operation was performed thereafter with/without radiation therapy (RT). CDDP and/or CBDCA were utilized as the chemotherapeutic modality. Only SIIC or RT showed Grade (Gr.) 0-2b pathological effects on Oboshi-Shimosato classification scheme, while a combination of SIIC and RT exhibited Gr. 2b-4 pathological effects. We conclude that a combination of SIIC and RT was most effective and had induced degeneration or necrotic changes in the tumor tissue.

[Abnormalitis in the distributions of ventilation-perfusion ratios and diffusing capacity-perfusion ratios in three types of chronic obstructive pulmonary disease]

To assess whether diffusion-limited gas exchange plays a significant role in hypoxemia in various types of chronic obstructive pulmonary disease(COPD), we analyzed the distribution of ventilation-perfusion (VA/Q) ratios and of diffusing capacity-perfusion (G/Q) ratios. We compared VA/Q and G/Q distribution in patients with three basic types of COPD: emphysematous changes, bronchiolar involvement, and airway hypersecretion, which were classified based on symptoms and on findings of high-resolution CT. The results were that 1) hypoxemia was not caused by diffusion-limited gas exchange with low G/Q regions in any type of COPD, that 2) hypoxemia was not caused by inhomogeneities in VA/Q distribution, that 3) emphysematous changes and bronchiolar involvement were associated with high and low VA/Q regions, respectively, and that 4) either hypersecretion itself or related airway abnormalities may cause low VA/Q regions to form.

Clinicopathology of chondrosarcoma

We conducted a clinicopathological analysis of chondrosarcomas in 17 patients treated in our institute. The 5- and 10-year overall survival rates of the patients were 72.3% and 61.9%, respectively. The significant prognostic factors were size and histologic grade of the tumor. Sex, age, location of the primary tumor, or the presence of a preceding exostosis did not affect the treatment results significantly. Chondrosarcomas of histologic grades I and II did not metastasize, while all grade III and dedifferentiated chondrosarcomas metastasized to the lung. The local recurrence rate depended on the surgical margin. Wide excision with an adequate surgical margin is important to achieve local control of the chondrosarcoma.

Polyostotic fibrous dysplasia. A long-term follow up of 8 patients

Eight patients who had polyostotic fibrous dysplasia were followed up for more than 10 years. One had the Albright syndrome. Two of 3 proximal femoral lesions which were treated before puberty by either curettage and bone grafting or by osteotomy, developed progressive deformity during the growth period. One of 2 proximal femoral lesions treated by curettage and bone grafting after the age of 18 also developed a deformity. Two tibial lesions operated on at the age of one and 30 years remained stable. The histological findings showed more active lesions in young patients compared with adults.

Ulnar buttress arthroplasty for reconstruction after resection of the distal ulna for giant cell tumour

A giant cell tumour of the distal end of the ulna was treated by en bloc resection. The resected distal end of the ulna was replaced by an iliac bone graft, preserving the triangular fibrocartilage complex. The wrist was pain-free and had a full range of motion 6 months postoperatively.

Transplant candidate's clinical status rather than right ventricular function defines need for univentricular versus biventricular support

We have studied our experience since 1988 with 31 patients who required a mechanical circulatory bridge to transplantation and also had biventricular failure (mean right ventricular ejection fraction 11.8%) to better define the need for biventricular or total artificial heart support versus univentricular support. Clinical factors including preoperative inotropic need, fever without detectable infection, diffuse radiographic pulmonary edema, postoperative blood transfusion, and right ventricular wall thickness were compared with hemodynamic parameters including cardiac index, right ventricular ejection fraction, central venous pressure, mean pulmonary arterial pressure, and total pulmonary resistance for ability to predict need for mechanical or high-dose inotropic support for the right ventricle. Patients were grouped according to need for right ventricular support after left ventricular-assist device implantation: none (group A, 14) inotropic drugs (group B1, 7), and right ventricle mechanical support (group B2, 10). There were no differences in preimplantation hemodynamic variables. Groups B1 and B2 had significantly lower mixed venous oxygen saturation (39.2% vs 52.5% in group A; p < 0.001), greater level of inotropic need (p < 0.02), greater impairment of mental status, and lower ratio of right ventricular ejection fraction to inotropic need (0.37 vs 0.56 for group A; p < 0.02) before left ventricular-assist device implantation. A significant discriminator between groups B1 and B2 was the presence of a fever without infection within 10 days of left ventricular-assist device implantation (43% in group B1 vs 70% in group B2). Group B2 had more patients with preimplantation pulmonary edema seen on chest radiography and a greater requirement for postoperative blood transfusion (5 units of cells in group B1 vs 14.8 units in group B2. Right ventricular wall thickness at left ventricular-assist device explantation was 0.83 cm in group B2 vs 0.44 cm in group B1 (p < 0.05). Transplantation rates after bridging were 100% in group A, 71% in group B1, and 40% in group B2. Clinical factors that reflect preimplantation degree of illness and perioperative factors that result in impairment of pulmonary blood flow or reduced perfusion of the right ventricle after left ventricular-assist device implantation are now considered to be more predictive of the need for additional right ventricular support than preimplantation measures of right ventricular function or hemodynamic variables.

A prospective trial of tacrolimus (FK 506) in clinical heart transplantation: intermediate-term results

Between January 1, 1989, and December 31, 1994, we have treated 122 primary heart recipients with FK 506 (group I) and 121 with cyclosporine (group II). Fifty patients in the cyclosporine (CyA) group received no lympholytic induction (CyA alone) and 71 others received lympholytic induction with either rabbit antithymocyte globulin or OKT3 (CyA+LI). The mean follow-up was longer in the FK 506 group than in the CyA groups (3.2 +/- 1.3 vs 2.3 +/- 1.8 years; p< 0.01). Patient survival did not differ on the basis of the type of immunosuppression used. At 3 months after transplantation, the freedom from rejection in the FK 506 group was higher than that of the CyA-alone group (47% vs 22%, p < 0.01) but similar to that of the CyA+LI group (47% vs 53%). The linearized rejection rate (episodes/100 patient-days) of the FK 506 group (0.09 episodes) was lower (p < 0.05) than that of the CyA-alone group (0.26) and the CyA+LI group (0.13). The requirement for pulsed steroids to treat rejection was less in common in the FK 506 group than in either CyA group. Eighteen patients in the CyA group had refractory rejections; all resolved with FK 506 rescue. Two patients in the FK 506 group had refractory rejection that resolved with total lymphoid irradiation (n=1) and methotrexate therapy (n=1). Patients receiving FK 506 had a lower risk of hypertension and required a lower dose of steroids. Although the mean serum creatinine concentration at 1 year was higher in the FK 506 group, this difference disappeared after 2 years. No patients required discontinuation of FK 506 because of its side effects. Our intermediate-term results indicate that FK 506 compares favorably with CyA as a primary immunosuppressant in heart transplantation.

Chemosensitive medullary neurones in the brainstem--spinal cord preparation of the neonatal rat

1. Using the isolated medulla and spinal cord of the neonatal rat, the response to CO2-induced changes in superfusate pH was examined in whole cell and perforated patch recordings from ventral medullary neurones which were identified by injection of Lucifer Yellow. The respiratory response to changing the CO2 concentration (from 2 to 8%) consisted of an increase in phrenic burst frequency, which could be accompanied by an increase, decrease or no change in burst amplitude. 2. Five classes of neurone - inspiratory, post-inspiratory, expiratory, respiration-modulated and ionic - were distinguished on the basis of their membrane potential and discharge patterns. Almost all (112 of 123) responded rapidly to 8% CO2 with a sustained change in membrane potential. Depolarizing responses (3-18 mV) occurred in inspiratory, respiration-modulated and 45% of tonic neurones. Hyperpolarizing responses (2-19 mV) occurred in expiratory and post-inspiratory neurones. The remaining tonic neurones were inhibited or showed no response. 3. In representatives of each class of neurone, membrane potential responses to 8% CO2 were retained when tested in the presence of tetrodotoxin (n = 7), low (0.2 mM) Ca(2+)-high (5 mM) Mg2+ (n = 23) or Cd2+ (0.2 mM) (n = 3)-containing superfusate, implying that they are mediated by intrinsic membrane or cellular mechanisms. 4. Neurones were distributed between 1200 microns rostral and 400 microns caudal to obex, and their cell bodies were located between 50 and 700 microns below the ventral surface (n = 104). Almost all responsive neurones (n = 78) showed dendritic projections to within 50 microns of the surface. 6. These experiments indicate that significant numbers of ventral medullary neurones, including respiratory neurones, are intrinsically chemosensitive. The consistency with which these neurones show surface dendritic projections suggests that this sensitivity may arise in part at this level.