[Familial congenital horizontal gaze paralysis]

Familial congenital horizontal gaze paralysis is a rare disorder supposedly transmitted in an autosomal recessive fashion. Typically, all horizontal, conjugate eye movements are absent. Most patients are orthotropic with regular binocular function. The complete lack of horizontal eye movements is compensated for by turning the head in the desired direction. Another compensating mechanism is the use of convergent eye movements, when horizontal gaze is attempted. Eye movements in the vertical plane are only mildly affected. The majority of patients suffer from a scoliosis that manifests itself in early infancy and usually requires operative treatment. Maldevelopment of neurons of the abducens nuclei and the caudal longitudinal fascicle is said to be the cause. The possible outcome of the disease and the importance of a prompt diagnosis are discussed.

Localization of the recombination points in a family with two DR/DP recombinations

In a family with a maternal DR/GLO recombination, cellular DP typing showed it to be located between DR and DP. RFLP studies done during the 9th international histocompatibility workshop gave anomalous segregation patterns of DPA and DPB bands that could be interpreted as being due to a second, paternal DR/DP recombination. This assumption was confirmed later by PCR-SSO typing. A more precise mapping has been done by new markers showing the maternal recombination to be within the TAP2 locus and the paternal recombination to be between DQB1 and DQB3. This supports earlier suggestions of a hot spot of recombination in the TAP region. The recombinations involve parental haplotypes that presently show DR/DP linkage disequilibrium in the French population and it is proposed that DR/DP recombinations occur randomly while B/DR recombinations preferentially occur on haplotypes without strong linkage disequilibrium. Existing DR/DP linkage disequilibria in a given population will thus be broken down with time. The mixed lymphocyte culture response towards an isolated DP difference was tested in this and another DR/DP recombinant family. It showed that an alloresponse towards DP may be highly variable and this suggests that it might be important to define the rules for the strength of this reaction and the possible implications for allotransplantation.

Secondary aortoenteric fistulae--changes from 1973 to 1993

AIM

To investigate a series of patients with secondary aortoenteric fistulas and compare it with a previous series (1985-93 vs. 1973-84).

DESIGN

Retrospective study of medical records.

SETTING

Sixteen vascular surgical centers in Sweden.

PATIENTS

Twenty-seven patients were identified making an overall incidence of 0.5% of all aortoiliac operations. Among aneurysm patients the incidence was significantly lower than in the previous series. One patient record could not be identified. Fourteen primary operations were for aortic aneurysm, 12 for occlusive disease and one was an aortorenal vein bypass.

RESULTS

Symptoms of the fistula occurred after a median interval of 90 months which is significantly later than the previous series (32 months; p<0.05). The commonest presentation was bleeding followed by septis. The median diagnostic delay was 10.5 days, which was significantly shorter than in the previous series. Most fistulas involved the duodenum (88%). One patient died before surgery. The postoperative mortality was 28%, significantly lower than in the previous series (58%) (p<0.05). At the end of follow up (median 43 months) significantly more patients were alive than in the previous series (42% vs 18%) (p<0.05).

CONCLUSION

Over a 21 year period there seems to have been a decrease in the frequency of secondary aortoenteric fistulas after aneurysm surgery, a longer interval before they occur, a shorter diagnostic delay, and a better survival.

[Measuring spatial micro-movement of the femur shaft of endoprostheses in relation to the spatial force system]

A precision measurement method (resolution: 0.1 micron) is described that simultaneously tracks spatial movement of the prosthesis and its bending as a function of the spatial force system (three force and three torque components). With this technique, we examined the effects of complete separation between shaft and cement on bending and micromovement. With regard to mechanical stability a completely tied and a loosened prosthesis differ only in respect to torsional load: the loosened prosthesis bears a 2.5-fold larger torsion flexibility. In both cases the shaft does not move like a rigid body: it bends up or down depending on the way the torque acts. It is the torques (that are produced by the forces) rather than the forces themselves that are responsible for the extent of micromovement and bending. In the completely loosened shaft, the shaft's apex only moves either intrusively or extrusively according to the directions of the torque vector: the horizontal movement cannot be resolved. The data suggest that shafts that are freely mounted into its cement quiver load the cement layer in a less damaging fashion than tied shafts.

Role of polymorphic residues of human leucocyte antigen-DR molecules on the binding of human immunodeficiency virus peptides

A study was made of the binding properties of 96 human immunodeficiency virus peptides to human leucocyte antigen (HLA)-DR1 and HLA-DR103 molecules, which differ by three amino acids at positions 67, 70 and 71 in the beta chains. The affinity of the peptides was characterized by their inhibitory concentrations in competitive binding assays which displace half of the labelled influenza haemagglutinin peptide HA306-318 (IC50). Among the high-affinity peptides (IC50 < or = 1 microM), seven bound to DR1, three to DR103 and five equally well to both alleles (promiscuous peptides). Thirty-two other peptides showed medium or low affinity for DR molecules. The role of polymorphic residues was analysed using six mutated DR molecules, intermediates between DR1 and DR103 and differing by one or two substitutions at positions 67, 70 or 71. We reached the same conclusions when using DR1-specific or DR103-specific peptides: modification of residue 70 had no effect on peptide affinity, but single substitution at positions 67 or 71 decreased the allele specificity of the peptides while double substitution at 67 and 71 completely reversed the peptide specificity. In functional assays, DR-binding peptides are able to outcompete specific T-cell proliferation. Furthermore, modification at position 67 or 70 significantly affects the T-cell response and mutation at position 71 abolishes completely the T-cell proliferation. Thus, the polymorphic positions 67 and 71 contributed to the peptide binding with direct effects on T-cell receptor (TCR) recognition while position 70 seems to be mostly engaged in TCR interactions. Furthermore, our results suggest that polymorphic residues may select allele-specific peptides and also influence the conformation of promiscuous peptides.

Juvenile progressive scoliosis and congenital horizontal gaze palsy

Eleven articles reporting 39 patients with the combination of progressive scoliosis and familial congenital gaze palsy have now been published. This disorder appears to be caused by a malfunction of the normal equilibrial control mechanism related to the brainstem or the central nervous system. The scoliosis progresses when the children begin to walk. Even when they are treated with physiotherapy or brace, they often require early operation. We consider that progressive juvenile or infant scoliosis associated with familiar congenital horizontal gaze palsy constitutes a clinical entity. We report two sisters with congenital gaze palsy, in one of whom scoliosis of at least 70 degrees (Cobb) developed, and review and analyze all cases published until now.

Fractioned drilling--a technique for wedge osteotomy of the knee

High tibial wedge osteotomies are often followed by transient neurological complications. From a retrospective study of 132 patients it appears that the incidence of this troublesome complication can be reduced after osteotomy with external fixation by using a technique of making consecutive drill holes of increasing diameter followed by osteoclasis. This reduction of neurological complications was most marked when a less extensive surgical approach was used.

[Quantitative follow-up of callus distraction with dual-energy roentgen absorptiometry (DEXA)]

With dual-energy X-ray absorptiometry (DEXA), bone mineralization during and after limb-lengthening procedures with unilateral fixators can be monitored quantitatively and precisely with low radiation exposure. We measured prospectively the bone mineral density (BMD) in the newly formed callus, in the bone adjacent to the callus and in the proximal femur in 21 patients with leg lengthening of the femur and/or tibia with unilateral external fixators. Mineralization showed a typical course with a peak value of 0.365 +/- 0.196 g/cm2 (30.9% of the first value) at 6-8 weeks after the beginning of distraction and a minimum value at the time of maximum distraction. In the consolidation period BMD in the distraction gap increased to 1.020 +/- 0.234 g/cm2 (87%) at the time of fixation removal. BMD in the regenerated bone increased faster in regions of interest (ROIs) opposite the fixator compared to ROIs near it. Dynamization of the fixation device led to a 13% increase in mineralization velocity (VBMD). On the other hand, dynamization caused more homogeneous regeneration equalizing VBMD in the different ROIs as well. BMD in the proximal femur of the leg operated on decreased to 67% and in the contralateral leg to 87% of the preoperative value. We consider DEXA to provide a precise and quantitative assessment of callus and bone mineralization during limb lengthening with unilateral fixators. Since we are well aware of the limitation of the technique. DEXA helps to understand what is happening in limb-lengthening procedures by providing quantitative values.

[Cementless cup anchorage in hip endoprostheses. Comparative study of 3 cup systems with titanium surface]

A wealth of commercially available hip endoprotheses makes it difficult for the practitioner to choose the best implant for each individual case. In a multi-centre study, in which 22 hospitals took part, a cementless stem was used 1172 times and was combined with 3 different cementless cup components. The follow up period ranged from 1-8 years. In 321 cases the spherical Mecring cup, in 208 cases the spherical CLS-expansion cup and in 643 cases the conical Weill-ring was implanted. The predominant indication for the THR was primary coxarthrosis (767 patients). Evaluation of clinical results was based on the Merle d'Aubigné score. Good or excellent results were found in 82% for the Mercring, in 85% for the Weill-ring and in 91% when the CLS-expansion cup was used. Whereas 88% of the patients with the Mecring or Weill-ring had minimal or no pain, 94% of the patients had minimal or no pain when the CLS-expansion cup was implanted. Aseptic loosening was found in 1.25% for the Mecring and 1.5% with the Weill-ring. In the CLS-expansion cup group, 2 cases with radiological signs of loosening were seen, but neither patient required revision. The CLS-expansion-cup with the press fit system shows better medium follow-up results in this study, than the Mecring or Weill-ring systems.

[A case of an old posterior shoulder luxation]

Posterior dislocation of the shoulder is rare. Only 2-3% of dislocated shoulders are displaced posteriorly. It is a diagnostic trap for young doctors. Over 60% of the cases are not diagnosed initially. This is a case report of a patient treated with physical therapy and even mobilisation in anesthesia for 2 years and then needed a total shoulder replacement.

[Results of treatment after traumatic shoulder dislocation. Thoracic abduction plaster case or Desault dressing]

In 80 patients with primary traumatic shoulder dislocation treated at the Heidelberg Orthopaedic University Hospital we had a follow-up examination. We wanted to know about age and sex of the patients, the number of redislocations in correlation to time and way of fixation. We had 70% male and 30% female patients with 97.5% of anterior dislocation. The minimum age was 16 and the maximum 87 years with an average of 44 years. 48 patients had a Desault bandage for 2 weeks and 32 had a shoulder-arm plaster cast for 3 weeks. There was no difference between both ways of fixation. We also could not see any better results after more than a 3 weeks' fixation. The most important fact for redislocation is the age and activity of the patients. A young man has a very high risk of redislocation within the first year.

Treatment of calcifying tendinitis of rotator cuff by extracorporeal shock waves: a preliminary report

This study examined the effects of high-energy shock wave treatment on the course of calcifying tendinitis of the shoulder. Twenty patients were included in the protocol. Shock waves were applied to the calcifications with a lithotripter in two sessions of 2000 pulses each. The energy that produced the shock wave was 18 to 22 kV. Six and 12 weeks after treatment the subjective and functional state was assessed with the Constant score. All patients underwent radiographs and magnetic resonance imaging. At the 12-week follow-up evaluation 15 patients had a marked reduction of symptoms with an average of 30% improvement in the Constant score. Radiographs showed a complete elimination of the calcifications in seven patients, and in five cases a partial disintegration was seen. The overall morbidity was low; 14 patients had a transient subcutaneous hematoma. Magnetic resonance imaging did not show any lasting damage to bone or soft tissue.

[Survey of materials in hip endoprosthesis]

While bone cement debris has been recognised as an important factor in aseptic loosening of prosthetic components, the interest is now focused on the impact of debris and wear-off particles from polyethylene and metal alloys. As an optimal lubrication cannot be generated yet, direct contact between the components produces wear particles, depending on the materials used. The materials reported on include alloys based on iron, cobalt, titanium and polyethylene, bone cement and ceramics. These all show the problem of debris, friction, corrosion (except ceramics) and load failure, related to the work up process. The practitioner is given an overview and tables are presented to compare the used material.

[Effect of extracorporeal shockwave therapy on tendinosis calcarea of the shoulder. A preliminary report]

The aim of a prospective study was to examine the effects of high energetic shock wave treatment on the course of calcareous tendinitis of the shoulder. 20 patients were entered into the study. Shock waves were applied to the calcifications with a Lithotripter MFL 5000 in two sessions of 2000 impulses each. The shock wave producing energy was 18 kV-22 kV. 6 and 12 weeks after treatment subjective and functional condition was checked by means of a 100-points functional score; all patients underwent x-ray control and MRI imaging.

RESULTS

After 12 weeks 14 patients showed a marked improvement of symptoms, the average improvement on score measuring 25 points. The x-rays of 7 patients showed a complete resorption of the calcifications, in 5 cases partial disintegration of the calcium deposits was seen. The overall morbidity was low with 14 patients developing transient hematomas; MRI imaging showed no severe damages of bone and soft tissue.

Promiscuous and specific binding of HIV peptides to HLA-DR1 and DR103. Impact on T-cell repertoire of nonimmunized individuals

The binding of immunogenic peptides to DR molecules is influenced by residues that point into the peptide-binding groove. The T-cell response toward a peptide complexed to an MHC molecule depends on the presence of a sufficient number of T cells reactive with peptide-MHC complex on the surface of APCs. From 96 overlapping HIV peptides, we have selected 11 that show a significant binding to either DR1, DR103, or both. These two DR molecules are identical except for three amino acids at positions 67, 70, and 71 on the beta chain. Peptide-specific T-cell lines and clones were generated with cells from nonimmunized donors homozygous for DR1 or DR103 by using either individual peptides or peptide pools for the in vitro priming. Three of the peptides induced T-cell-specific proliferative response in both individuals, and these peptides were not among those with highest affinity. Most of the peptides induced strong responses against autologous APCs. This might reflect cross-reactivity between HIV and self-peptides. Definition of peptides that both show promiscuous binding to DR and elicit a strong T-cell response is important for design of efficient synthetic vaccines.

Recombination fractions in the HLA system based on the data set 'provinces Françaises': indications of haplotype-specific recombination rates

In the large genetic survey "Provinces Françaises' the recombination fractions in the HLA system have been estimated by a family analysis programme (FAP). A total of 1332 families were analysed and in general the findings were in agreement with recombination fractions reported previously. The maternal recombination rates were on average 1.8 times higher than the corresponding ones for males. The comparison of the recombination fractions with the corresponding physical distances suggests the existence of hot spots of recombination. The analysis did not show deviations from expected values for HLA-A and B alleles on HLA-A/B recombinant haplotypes. However, analysis of HLA-B/DR recombinant haplotypes showed a skewed distribution of B and DR alleles. The significance of the findings is difficult to evaluate as all results are estimated numbers and frequencies but a manual analysis of the recombinant families confirmed the observations. HLA-B/DR recombinant haplotypes carried often HLA-DR3 and DR11 whereas DR2 and DR7 were more rarely present on recombinant haplotypes. DR4 had an increased incidence on BF/DR recombinant haplotypes but not on A/B or B/BF recombinant haplotypes. Some of the haplotypes with the strongest linkage disequilibria as A1,B8,DR3 and A3,B7,DR2 seem to be less frequently involved in recombinations than other haplotypes. Variations of recombination rates depending on certain alleles or haplotypes might partially explain the conservation of some haplotypes or part of haplotypes in Caucasoids.

[Successful combination therapy in bronchial asthma. Anti-obstructive and anti-inflammatory treatment]

METHOD

In a post-marketing surveillance study, patient data were documented with the aim of assessing the effect of a combination of both anti-inflammatory and bronchodilatory treatment with inhaled beclomethasone dipropionate and a sustained-release theophylline preparation. A total of 2,166 patients with mild-to-moderate bronchial asthma (FEV1 about 60%) were included in the multicenter open study.

RESULTS

It was found that treatment with inhaled glucocorticoid and sustained-release theophylline resulted in a clear improvement in symptom scores. More than 90% of the physicians and patients rated the treatment "very good" or "good". Only 4.6% of the participants had side effects.

CONCLUSION

It may be concluded that combination therapy with inhaled glucocorticoid and sustained release theophylline is a safe and effective form of treatment of mild-to-moderate asthma.