Claudication distance is poorly estimated and inappropriately measured

BACKGROUND

Claudication distance is the commonest measure of the disability caused by lower-limb occlusive arterial disease. The accuracy of claudication distance as a surrogate for handicap has been assessed.

METHODS

Seventy patients who attended a specialist vascular clinic with intermittent claudication were studied prospectively. Patients were asked to estimate their claudication distance and maximum walking distance before undergoing both a patient-controlled corridor walk and a fixed-speed treadmill walk.

RESULTS

The claudication distance reported by patients bore little relation to the distance recorded in the medical correspondence. There was no correlation between the estimated distance and the actual distance walked on either a patient-controlled corridor walk or a fixed-speed treadmill walk. Most patients were able to walk substantially further at their own speed on the corridor than on the treadmill at a slower speed.

CONCLUSION

Claudication distance is spuriously estimated, inaccurately reported, falsely recorded, inappropriately measured and usually misinterpreted. It is of little value in judging the need for treatment. Objective measures of the handicap caused by the disability of reduced walking distance are required if rational management decisions are to be made.

Successful use of size-mismatched liver allografts in children by delayed primary closure of the abdominal wall

Children who are too ill to await a liver graft of suitable size may be transplanted with a relatively oversized graft by leaving the abdominal wound partially open, the defect reduced being bridged with polypropylene mesh and the mesh reduced in stages until it can be removed and the wound directly closed. This technique has been used in seven children who received nine grafts (five reduced and four full size). Their mean age was 7.3 (range 0.5-11) months and mean weight 5.8 (range 2.3-7.2) kg. Progressive reduction in the size of the transplanted liver made primary closure possible in survivors in up to four stages. Over a follow-up period of 3 to 58 months, five of the nine grafts and five of the seven patients survived. No significant complications attributable to the technique were encountered. The technique of delayed primary abdominal wall closure may be of benefit in children at risk of graft failure because of a size-mismatched graft.

Differential activation of STATs 3 and 5 during mammary gland development

We have investigated the activity of STAT family members throughout a mammary developmental cycle. Transcripts for Stat 5 were upregulated during pregnancy whilst STAT1 and STAT3 mRNAs were expressed at constant levels. DNA binding complexes containing both STAT5a and 5b showed differing affinities for two naturally occurring STAT5 binding sites. In the involuting mammary gland STAT5 activity decreased whereas STAT3 was specifically activated. These observations reveal a complex pattern of activation of STAT factors during mammary growth, differentiation and remodelling and provide the first evidence for the involvement of STAT3 in development of the mammary gland.

Regulation of surface and soluble TNF receptor expression on human monocytes and synovial fluid macrophages by IL-4 and IL-10

By regulating monocyte and macrophage production of IL-1, its receptor, and its receptor antagonist, IL-4 and IL-10 may exert significant anti-inflammatory activity. We determined whether a similar multicomponent process controlling TNF activity was regulated by IL-4 and IL-10 in nonadherent monocytes and synovial fluid macrophages. Previous studies differed in their conclusions. For both the p75 and p55 TNF receptors, mRNA levels, surface receptor expression, and soluble receptor levels were measured for blood monocytes incubated in vitro for 17, 40, or 64 h with IL-4 or IL-10. The predominant TNF receptor on monocytes, the p75 receptor, was down-regulated by IL-4 at the mRNA level. In turn, both surface and soluble receptor levels on LPS-stimulated cells were reduced and the inhibitory effects were maintained for at least 64 h. In contrast, IL-10 increased surface and soluble p75 TNF receptor levels on monocytes for approximately 40 h, which reflected an increase in receptor mRNA. These studies suggest that IL-4 and IL-10 do not directly regulate the cleavage of TNF receptors from monocytes and macrophages. Addition of an Ab to IL-10 suggested that the stimulatory effects of LPS on p75 TNF receptor expression were due, at least in part, to LPS stimulation of IL-10 production and that IL-4 acted, in part, by decreasing IL-10 production. IL-4 was down-regulatory and IL-10 stimulatory for TNF receptor expression by synovial fluid macrophages. By increasing surface receptor levels, IL-10 enhanced the activities of TNF on monocytes for IL-1beta production. By increasing soluble TNF receptor levels, IL-10 may limit only temporarily the activity of other TNF-responsive cells. This study questions the benefit of IL-10 to resolving TNF-associated inflammation.

Regulation of surface and soluble TNF receptor expression on human monocytes and synovial fluid macrophages by IL-4 and IL-10

By regulating monocyte and macrophage production of IL-1, its receptor, and its receptor antagonist, IL-4 and IL-10 may exert significant anti-inflammatory activity. We determined whether a similar multicomponent process controlling TNF activity was regulated by IL-4 and IL-10 in nonadherent monocytes and synovial fluid macrophages. Previous studies differed in their conclusions. For both the p75 and p55 TNF receptors, mRNA levels, surface receptor expression, and soluble receptor levels were measured for blood monocytes incubated in vitro for 17, 40, or 64 h with IL-4 or IL-10. The predominant TNF receptor on monocytes, the p75 receptor, was down-regulated by IL-4 at the mRNA level. In turn, both surface and soluble receptor levels on LPS-stimulated cells were reduced and the inhibitory effects were maintained for at least 64 h. In contrast, IL-10 increased surface and soluble p75 TNF receptor levels on monocytes for approximately 40 h, which reflected an increase in receptor mRNA. These studies suggest that IL-4 and IL-10 do not directly regulate the cleavage of TNF receptors from monocytes and macrophages. Addition of an Ab to IL-10 suggested that the stimulatory effects of LPS on p75 TNF receptor expression were due, at least in part, to LPS stimulation of IL-10 production and that IL-4 acted, in part, by decreasing IL-10 production. IL-4 was down-regulatory and IL-10 stimulatory for TNF receptor expression by synovial fluid macrophages. By increasing surface receptor levels, IL-10 enhanced the activities of TNF on monocytes for IL-1beta production. By increasing soluble TNF receptor levels, IL-10 may limit only temporarily the activity of other TNF-responsive cells. This study questions the benefit of IL-10 to resolving TNF-associated inflammation.

Involvement of microtubules in prothoracicotropic hormone-stimulated ecdysteroidogenesis by insect (Manduca sexta) prothoracic glands

Secretion of ecdysteroid molting hormones by insect prothoracic glands is stimulated by neuropeptide prothoracicotropic hormones (PTTH). Studies reported here were conducted to assess the effects of microfilament and microtubule inhibitors on in vitro ecdysteroidogenesis by prothoracic glands of Manduca sexta. Microfilament inhibitors (cytochalasins B and D) had no effect on basal or big PTTH-stimulated ecdysteroidogenesis. Microtubule inhibitors (colchicine, podophyllotoxin, nocodazole) had no effect on basal ecdysteroid secretion, but suppressed PTTH-stimulated secretion in a concentration-dependent manner. The effect of nocodazole was partially reversible, suggesting it was not due to nonspecific toxicity. Colchicine had no effect on glandular ecdysteroid levels, indicating that inhibition was not due solely to blockage of secretion. The combined results are consistent with the hypothesis that microtubule-mediated transport of ecdysteroid precursors plays a critical role in stimulation of ecdysteroidogenesis by PTTH.

Radionuclide studies in intestinal transplantation. Diagnosis of rejection and assessment of permeability

Three patients who received intestinal allografts were studied using two distinct radionuclide investigations. In the first, 111In or 99mTc-labeled leukocyte scanning was performed to assist in the diagnosis of rejection. It was able to demonstrate the occurrence of rejection in the transplanted intestine, and the response to antirejection therapy. In 1 case, the abnormality on the scan preceded the histological confirmation of rejection. The second technique studied mucosal integrity by serial 51Cr-EDTA/14C-mannitol permeability tests. These studies demonstrated the initial marked impairment and the slow return to normal function of the intestinal mucosal barrier. In 1 patient, this occurred by 91 days; in another, it took 232 days. A single assay performed in the third patient at the time of allograft rejection was also abnormal. Both radionuclide tests were helpful in the care of these complicated cases.

Prolactin signal transduction mechanisms in the mammary gland: the role of the Jak/Stat pathway

Prolactin signal transduction in mammary epithelial cells is mediated by a novel, direct signalling system that links the activation of the prolactin receptor at the cell surface to changes in gene transcription in the nucleus. This recently identified pathway is a variant of the Jak/Stat (for Janus kinase/signal transducer and activator of transcription) pathway used by many other growth factors and cytokines. Current data suggest that the key intracellular components of the prolactin signalling pathway are the kinase Jak2 and the transcription factor Stat5. This discovery has exciting implications for the interaction between prolactin and other extracellular signals in both the mammary gland and other tissues. Here we review work that began with attempts to understand the regulation of milk protein gene expression and ultimately demonstrated the central role of the Jak/Stat pathway in prolactin signal transduction in the mammary gland.

Capacity of insect (Manduca sexta) prothoracic glands to secrete ecdysteroids: relation to glandular growth

The capacity of prothoracic glands to secrete ecdysteroids changes during the last larval stadium of the tobacco hornworm, Manduca sexta. In the present study, the protein content of prothoracic glands was observed to change significantly during this time period. Peaks in glandular protein content occurred on Day 4 (15.4 micrograms/gland) and Day 7 (14.6 micrograms/gland). These correspond to times of maximal ecdysteroid secretion in vitro. Ecdysteroid secretion in vitro was determined as a function of glandular protein content for Day 1, 3, and 7 glands. For unstimulated glands, secretion increased from 0.05 ng/microgram on Day 1, to 0.54 ng/micrograms on Day 3, to 1.37 ng/micrograms on Day 7. For glands incubated with big PTTH, secretion increased from 0.27 ng/micrograms on Day 1, to 2.05 ng/micrograms on Day 3, to 2.60 ng/micrograms on Day 7. The results suggested that developmental changes in secretory capacity are influenced by both the amount and type of glandular proteins. Glandular protein metabolism was assessed by monitoring the incorporation of [35S]methionine. A time course study revealed the rate of incorporation for Day 3 and Day 5 glands was significantly greater than the rate for Day 1 and Day 7 glands. Electrophoretic separation of radiolabeled glandular proteins revealed developmental changes in the pattern of protein synthesis. However, a band whose intensity changed in parallel with developmental changes in glandular secretory capacity was not detected. Finally, incorporation of BrdU by cells of the prothoracic glands was assessed using immunohistochemistry: Incorporation of BrdU was not observed on Days 1 or 7, occurred in only a few cells on Day 5, and was most pronounced on Day 3 (12.3% of the cells were labeled). The combined results indicate that changes in ecdysteroidogenic capacity are associated with (a) a change in glandular protein content, (b) a change in the types of proteins synthesized by prothoracic glands, and (c) a temporally restricted pulse of DNA synthesis, the latter being a possible indicant of cell proliferation.

Stat5 as a target for regulation by extracellular matrix

Transcription of tissue-specific genes in mammary gland requires signals from both prolactin and basement membrane. Here we address the mechanism by which this specialized extracellular matrix regulates transcription. Using mammary cell cultures derived from transgenic mice harboring the ovine beta-lactoglobulin gene, we show that either a basement membrane extract, or purified laminin-1, induced high levels of beta-lactoglobulin synthesis. It is known that prolactin signals through Stat5 (signal transducer and activator of transcription). This transcription factor interacts with gamma-interferon activation site-related motifs within the beta-lactoglobulin promoter, which we show are required for matrix dependence of beta-lactoglobulin expression. The DNA binding activity of Stat5 was present only in extracts of mammary cells cultured on basement membrane, indicating that the activation state of Stat5 is regulated by the type of substratum the cell encounters. Thus, basement membrane controls transcription of milk protein genes through the Stat5-mediated prolactin signaling pathway, providing a molecular explanation for previous studies implicating extracellular matrix in the control of mammary differentiation.

IL-4 mRNA expression by peritoneal cells during episodes of peritonitis in patients on continuous ambulatory peritoneal dialysis

Peritoneal cells were isolated from dialysates drained from nine patients on continuous ambulatory peritoneal dialysis (CAPD) during episodes of peritonitis. Levels of expression of mRNA for the regulatory cytokines, interferon-gamma (IFN-gamma) and IL-4, were investigated daily, where possible, during the first 5 days of peritonitis. Cytokine mRNA levels were compared with those of peripheral blood mononuclear cells (PBMC) stimulated in vitro with phorbol 12-myristate 13-acetate (PMA) plus phytohaemagglutinin (PHA). Peritoneal cells expressed low levels of IFN-gamma mRNA; for four of nine patients, IL-4 mRNA levels greater than those expressed by stimulated PBMC were detected. There was no pattern of cytokine mRNA expression associated with the types of organisms detected in dialysates at initiation of peritonitis. However, in contrast to those patients with a transient, resolving peritonitis, significant IL-4 mRNA expression was detected in cells isolated early in the episodes of peritonitis in patients who suffered recurrent peritonitis within 30 days of the initial peritonitis episode. These results suggest an association between early IL-4 mRNA expression and susceptibility to further infections. The known anti-inflammatory effects of IL-4 may explain this association.

Molecular genetic analysis of a family with a history of Hodgkin's disease and dyschondrosteosis

We describe a family in which two sisters with the autosomal dominant skeletal dysplasia, Leri-Weill dyschondrosteosis (LWD), developed Hodgkin's disease (HD) in late adolescence. In a preliminary attempt to identify HD susceptibility gene(s), HLA-typing and linkage analysis were carried out in the family. Using HLA molecular typing, both sisters were found to have inherited a variant of the HD-susceptibility allele, DPB1*0301, known as DPB1*2001. Following a previous report of a constitutional chromosome translocation (t(2q;8p)) in a family with LWD, preliminary linkage studies were carried out using chromosome 2q and 8p molecular markers. Regions covered by 7/10 chromosome 2 markers and 4/8 chromosome 8 markers were excluded as the location of a candidate LWD gene. Given the rarity of LWD and HD, their simultaneous occurrence is unlikely to have been due to chance. We suggest that a mutation in the LWD gene itself, or a gene closely linked to it, perhaps acting with increased susceptibility to infection conferred by DPB1*2001, resulted in HD in the two sisters.

CsA levels in the early posttransplant period--predictive of chronic rejection in liver transplantation?

The increasing success of clinical liver transplantation has brought rejection to the forefront as a cause of morbidity and graft loss. The relationship of immunosuppressive drug doses and levels to acute and chronic rejection remains a matter of debate. The effect of blood CsA levels and drug doses on the incidence of acute and chronic rejection and the impact of acute rejection episodes on the occurrence of chronic rejection were studied in 146 grafts in 132 patients. These patients were transplanted in the 4-year period from June 1989 using CsA-based immunosuppression (CsA, azathioprine, prednisolone). Liver grafts in patients maintained on median CsA levels (whole blood, trough level) of > or = 175 micrograms/L in the first 28 days posttransplant had a significantly lower incidence of chronic rejection (2 out of 49 vs. 22 out of 97; P = 0.002). There was no significant difference in incidence of graft loss due to fatal sepsis (6% vs. 5%) or nephrotoxicity between the high and low CsA level groups. The overall graft loss rate was lower in the higher CsA level group (22% vs. 37%). The total doses of the individual drugs did not correlate with the incidence of acute or chronic rejection. Although the occurrence of acute rejection itself did not determine later chronic rejection, late occurrence (P < 0.00001) and multiple episodes (two or more; P = 0.0002) of acute rejection were significant risk factors for the occurrence of chronic rejection. We conclude that to minimize graft loss to rejection, CsA levels should be maintained at greater than 175 micrograms/L in the early posttransplant period, and late and recurrent episodes of acute rejection should be prevented.

Elevated levels of members of the STAT family of transcription factors in breast carcinoma nuclear extracts

The transcription factor, milk protein binding factor (MPBF/Stat5), is a member of the STAT family of signalling molecules which mediates prolactin signal transduction in lactating mammary gland by binding to GAS (gamma-interferon activation site) DNA elements. We have determined the levels of STAT factors in nuclear extracts from a variety of human breast tissues including carcinoma and normal 'resting' breast by electrophoretic mobility-shift assay. The results show that the level of STAT binding activity is low in normal 'resting' breast and benign lesions while carcinoma samples have significantly higher (P < 0.01) amounts of STAT binding activity. Supershift analysis suggests that Stat1 and possibly other members of the STAT family of signalling factors, including Stat3, are activated in breast cancer tissues.

Physical therapy management of isolated serratus anterior muscle paralysis

This case report presents a patient who developed right shoulder pain following strenuous upper-extremity exercise. Approximately 6 weeks later his pain resolved, he noticed persistent right upper-extremity weakness. He was referred to physical therapy for evaluation and treatment. Physical therapy evaluation revealed isolated serratus anterior muscle paralysis. A long thoracic neuropathy was subsequently confirmed by electromyographic testing. The etiology, pathophysiology, and pathokinesiology of serratus anterior muscle paralysis are reviewed. A case is presented, illustrating how the clinical decision making is based on the pathokinesiology and pathophysiology. The patient was followed over the course of 17 months and has recovered full right shoulder active range of motion. His serratus anterior muscle strength has increased to Good minus, and he reports significantly improved functional use of the upper extremity.

Cis-urocanic acid synergizes with histamine for increased PGE2 production by human keratinocytes: link to indomethacin-inhibitable UVB-induced immunosuppression

There is considerable evidence that suppression of the immune system by UVB (280-320 nm UV) irradiation is initiated by UVB-dependent isomerization of a specific skin photoreceptor, urocanic acid (UCA), from the trans to the cis form. Previous studies have confirmed that cis-UCA administration to mice 3-5 days prior to hapten sensitization at a distant site, suppresses the contact hypersensitivity (CHS) response upon challenge. This study demonstrates in mice that cis-UCA, like UVB, suppresses CHS to trinitrochlorobenzene by a mechanism partly dependent on prostanoid production. In vitro experimentation showed that human keratinocytes, isolated from neonatal foreskin, increased prostaglandin E2 (PGE2) production in response to histamine but not UCA alone. However, cis-UCA synergized with histamine for increased PGE2 production by keratinocytes. Cis-urocanic acid also increased the sensitivity of keratinocytes for PGE2 production in response to histamine. Prostaglandin E2 from keratinocytes exposed to cis-UCA and histamine may contribute directly, or indirectly, to the regulation of CHS responses by UVB irradiation.

Liver transplantation in patients with situs inversus

Seven patients with situs inversus abdominis and one with situs inversus totalis underwent liver transplantation; all are alive at follow-up of between 7 months and 5 years. Two patients required retransplantation within the first 3 weeks (for primary non-function and thrombotic infarction). Seven had additional abnormalities associated with the polysplenia-biliary atresia syndrome. Liver transplantation in these patients involved selection of relatively small donor organs or use of reduced-size grafts. Delayed abdominal wall closure was necessary in two patients and all required a modification of the 'piggy-back' technique of suprahepatic vena caval anastomosis to overcome recipient venous anomalies. Biliary drainage by Roux-en-Y choledochojejunostomy was the preferred technique. Although technically challenging, situs inversus is not a contraindication to liver transplantation and patients should expect full recovery.