Colorectal Cancer Screening in African American HOPE VI Public Housing Residents

This study explores whether colorectal cancer screening outreach via home visits and follow-up calls is effective among public housing African American residents. It reports on the proportion of returned Fecal Immunochemical Test kits, on the characteristics of study participants, and on their primary reasons for returning the kit. By conducting home visits and follow-up calls, our colorectal cancer-screening outreach resulted in a higher Fecal Immunochemical Test kit return rate than anticipated. Findings suggest that a more personalized outreach approach can yield higher colorectal cancer-screening rates among urban minority populations, which are at higher risk to be diagnosed with late-stage colorectal cancer.

Temporal Estimates as a Function of Difficulty of Mental Arithmetic

This study was designed to assess the effects of specific types of mental arithmetic on subjects' estimates of how long they worked on the problems. It was hypothesized that the more demanding problems would produce the greatest underestimates of duration of work. The factorial design included types of task (1 digit × 1 digit and 2 digit × 1 digit), levels of difficulty (easy and hard, defined in terms of size of multiplier), and work periods of 8, 12, 16, and 20 sec. An empty reproduction paradigm was employed; results indicated only partial support for the hypothesis in that the 2 digit × 1 digit easy problems produced maximal underestimates of work periods. Results are interpreted in terms of response strategies and attentional hypotheses.

Applications of Cone-Beam Computed Tomography in Oral and Maxillofacial Surgery: An Overview of Published Indications and Clinical Usage in United States Academic Centers and Oral and Maxillofacial Surgery Practices

PURPOSE

The American Association of Oral and Maxillofacial Surgeons appointed a task force to study the indications, safety, and clinical practice patterns of cone-beam computed tomography (CBCT) in oral and maxillofacial surgery (OMS). The charge was to review the published applications of CBCT in OMS, identify the current position of academic thought leaders in the field, and research the adoption and usage of the technology at the clinical practitioner level.

MATERIALS AND METHODS

This study reviewed the CBCT world literature and summarized published indications for the modality. A nationwide survey of academic thought leaders and practicing oral and maxillofacial surgeons was compiled to determine how the modality is currently being used and adopted by institutions and practices.

RESULTS

This report summarizes published applications of CBCT that have been vetted by the academic and practicing OMS community to define current indications. The parameters of patient safety, radiation exposure, accreditation, and legal issues are reviewed. An overview of third-party adoption of CBCT is presented.

CONCLUSION

CBCT is displacing 2-dimensional imaging in the published literature, academia, and private practice. Best practices support reading the entire scan volume with a written report defining results, patient exposure, and field of view. Issues of patient safety, ALARA ("as low as reasonably achievable"), accreditation, and the legal and regulatory environment are reviewed. Third-party patterns for reimbursements vary widely and seem to lack consistency. There is much confusion within the provider community about indications, authorizations, and payment policies. The current medical and dental indications for CBCT in the clinical practice of OMS are reviewed and an industry guideline is proposed. These guidelines offer a clear way of differentiating consensus medical indications and common dental uses for clinicians. This matrix should bring a predictable logic to third-party authorizations, billing, and predictable payments for this emerging technology in OMS.

A comparison of percutaneous needle fasciotomy and collagenase injection for dupuytren disease

PURPOSE

To compare percutaneous needle fasciotomy (PNF) with collagenase injection in the treatment of Dupuytren contracture.

METHODS

A retrospective review was performed for patients with Dupuytren disease treated with PNF or collagenase. Range of motion, patient satisfaction, and complications were recorded.

RESULTS

There were 29 patients in the collagenase group with mean baseline contractures of 40° for 22 affected metacarpophalangeal joints and 50° for 12 affected proximal interphalangeal joints. The PNF group was composed of 30 patients with mean baseline contractures of 37° for 32 affected metacarpophalangeal joints and 41° for 18 affected proximal interphalangeal joints. All patients were observed for a minimum of 3 months. Clinical success (reduction of contracture within 0° to 5° of normal) was accomplished in 35 of 50 joints (67%) in the PNF group and in 19 of 34 joints (56%) in the collagenase group. Patient satisfaction was similar between groups. Only minor complications were observed, including skin tears, ecchymosis, edema, pruritus, and lymphadenopathy.

CONCLUSIONS

In the short term, both PNF and collagenase have similar clinical outcomes and patient satisfaction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Design of T-cell receptor libraries with diverse binding properties to examine adoptive T-cell responses

Adoptive T cell therapies have shown significant promise in the treatment of cancer and viral diseases. One approach, that introduces antigen-specific T cell receptors (TCRs) into ex vivo activated T cells, is designed to overcome central tolerance mechanisms that prevent responses by endogenous T cell repertoires. Studies have suggested that use of higher affinity TCRs against class I MHC antigens could drive the activity of both CD4⁺ and CD8⁺ T cells, but the rules that govern the TCR binding optimal for in vivo activity are unknown. Here we describe a high-throughput platform of “reverse biochemistry” whereby a library of TCRs with a wide range of binding properties to the same antigen is introduced into T cells and adoptively transferred into mice with antigen-positive tumors. Extraction of RNA from tumor-infiltrating lymphocytes or lymphoid organs allowed high-throughput sequencing to determine which TCRs were selected in vivo. The results showed that CD8⁺ T cells expressing the highest affinity TCR variants were deleted in both the tumor infiltrating lymphocyte population and in peripheral lymphoid tissues. In contrast, these same high-affinity TCR variants were preferentially expressed within CD4⁺ T cells in the tumor, suggesting they played a role in antigen-specific tumor control. The findings thus revealed that the affinity of the transduced TCRs controlled the survival and tumor infiltration of the transferred T cells. Accordingly, the TCR library strategy enables rapid assessment of TCR binding properties that promote peripheral T cell survival and tumor elimination.

Incidence and clinical outcomes of tendon rupture following distal radius fracture

PURPOSE

To evaluate the incidence of tendon rupture after nonoperative and operative management of distal radius fractures, report clinical outcomes after tendon repair or transfer, and examine volar plate and dorsal screw prominence as a predictor of tendon rupture.

METHODS

We performed a retrospective chart review on patients treated for tendon rupture after distal radius fracture. We evaluated active range of motion, Disabilities of Arm, Shoulder, and Hand score, grip strength, and pain score, and performed radiographic evaluation of volar plate and dorsal screw prominence in both the study group and a matched control group.

RESULTS

There were 6 tendon ruptures in 1,359 patients (0.4%) treated nonoperatively and 8 tendon ruptures in 999 patients (0.8%) treated with volar plate fixation. At the time of final follow-up, regardless of treatment, we noted that patients had minimal pain and excellent motion and grip strength. Mean Disabilities of the Shoulder, Arm, and Hand scores were 6 for patients treated nonoperatively and 4 for those treated with volar plating.

CONCLUSIONS

We were unable to verify volar plate or dorsal screw prominence as independent risk factors for tendon rupture after distal radius fractures. However, we recommend continued follow-up and plate removal for symptomatic patients who have volar plate prominence or dorsal screw prominence. In the event of tendon rupture, we report excellent clinical outcomes after tendon repair or tendon transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinical outcomes of total wrist arthroplasty

PURPOSE

Current indications for total wrist arthroplasty include patients with symptomatic end stage posttraumatic wrist arthritis, rheumatoid arthritis, and Kienböck disease, as an alternative to wrist arthrodesis. Arthroplasty may have advantage over arthrodesis because of the ability to retain motion. The purpose of this study was to evaluate the short-term clinical outcomes and complications of the Maestro Total Wrist System.

METHODS

We report the results of a retrospective review of 23 total wrist prostheses implanted in 22 patients. We administered the visual analog pain scale and Mayo wrist and Disabilities of the Arm, Shoulder, and Hand questionnaires. We reviewed wrist motion, grip strength, radiographs, and complications.

RESULTS

At a mean follow-up of 28 months (range, 4-55 mo), the Disabilities of the Arm, Shoulder, and Hand score and Mayo wrist score were 31 and 54, respectively. Mean pain scores improved from 8.0 to 2.2. The mean wrist flexion-extension arc was 90°. Radiographs revealed no evidence of prosthetic loosening. Grip strength averaged 60% of the strength of the opposite hand. Complications occurred in 7 of 23 patients. One failure occurred as a result of deep infection in a patient with prior intercarpal fusion, and was successfully converted to a wrist fusion.

CONCLUSIONS

Total wrist arthroplasty performed for pancarpal arthritis as an alternative to wrist arthrodesis can yield successful outcomes with low short-term failure rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Use of lumbar ultrasonography to detect occult spinal dysraphism

OBJECT

Various cutaneous stigmata and congenital anomalies are accepted as sufficient reasons to perform lumbar ultrasonography as a screening tool to rule out occult spinal dysraphism (OSD). The purpose of this study was to correlate presenting cutaneous findings with lumbar ultrasonography results based on a large number of lumbar ultrasonography tests obtained by regional primary care providers.

METHODS

Over the course of 5 years, 1273 infants underwent lumbar ultrasonography screening at a major pediatric tertiary referral center. Of these infants, 1116 had adequate documentation for retrospective chart review. Referral sources included urban academic, urban private practice, and surrounding rural private practitioners. Presence of cutaneous stigmata and/or congenital anomalies and lumbar ultrasonography results were reviewed for all patients. When present, surgical findings were reviewed.

RESULTS

A total of 943 infants were referred for presumed cutaneous stigmata, the most common of which was a sacral dimple (638 patients [68%]) followed by hairy patch (96 patients [10%]). Other reported cutaneous findings included hemangioma, deviated gluteal fold, skin tag, and skin discoloration. In comparison, 173 patients presented with congenital anomalies, such as imperforate anus (56 patients [32%]) and tracheoesophageal fistula/esophageal atresia (37 patients [21%]), most of which were detected prenatally by fetal ultrasonography. A total of 17 infants underwent surgical exploration. Occult spinal dysraphism was diagnosed in 7 infants in the cutaneous stigmata group and in 10 infants in the group with congenital abnormalities. None of the cutaneous stigmata as recorded were found to be indicative of the presence of OSD.

CONCLUSIONS

Cutaneous markers as currently defined by general practitioners are not useful markers for predicting OSD. The vast majority of findings on lumbar ultrasonography studies performed under these circumstances will be negative.

Use of lumbar ultrasonography to detect occult spinal dysraphism

OBJECT

Various cutaneous stigmata and congenital anomalies are accepted as sufficient reasons to perform lumbar ultrasonography as a screening tool to rule out occult spinal dysraphism (OSD). The purpose of this study was to correlate presenting cutaneous findings with lumbar ultrasonography results based on a large number of lumbar ultrasonography tests obtained by regional primary care providers.

METHODS

Over the course of 5 years, 1273 infants underwent lumbar ultrasonography screening at a major pediatric tertiary referral center. Of these infants, 1116 had adequate documentation for retrospective chart review. Referral sources included urban academic, urban private practice, and surrounding rural private practitioners. Presence of cutaneous stigmata and/or congenital anomalies and lumbar ultrasonography results were reviewed for all patients. When present, surgical findings were reviewed.

RESULTS

A total of 943 infants were referred for presumed cutaneous stigmata, the most common of which was a sacral dimple (638 patients [68%]) followed by hairy patch (96 patients [10%]). Other reported cutaneous findings included hemangioma, deviated gluteal fold, skin tag, and skin discoloration. In comparison, 173 patients presented with congenital anomalies, such as imperforate anus (56 patients [32%]) and tracheoesophageal fistula/esophageal atresia (37 patients [21%]), most of which were detected prenatally by fetal ultrasonography. A total of 17 infants underwent surgical exploration. Occult spinal dysraphism was diagnosed in 7 infants in the cutaneous stigmata group and in 10 infants in the group with congenital abnormalities. None of the cutaneous stigmata as recorded were found to be indicative of the presence of OSD.

CONCLUSIONS

Cutaneous markers as currently defined by general practitioners are not useful markers for predicting OSD. The vast majority of findings on lumbar ultrasonography studies performed under these circumstances will be negative.

Lip nodules caused by hyaluronic acid filler injection: report of three cases

Many dermal fillers have been used for reducing facial skin lines and for providing lip augmentation, and hyaluronic acid (HA) is one of the most widely used agents. One of the main commercial forms of HA is Restylane (Q Med, Sweden) produced by microbiological engineering techniques. Although HA is non-immunogenic, hypersensitivity and Granulomatous foreign body reactions have been reported. Herein, we report three female patients (average age 56 years) who presented with firm nodular lesions of the lip and a history of injection with HA (Restylane, Q Med, Sweden). Histopathologically, all cases showed pools of amorphous hematoxyphilic material surrounded by bands of densely collagenized connective tissue with no inflammation or foreign body reaction. Histochemical stains confirmed the presence of acid mucopolysaccharides such as hyaluronic acid. We conclude HA (Restylane, Q Med, Sweden) is an inert filler that may persist at an injection site, resulting in a tumor-like nodule.

Engineering T cell receptors for potential therapeutic applications (48.28)

Using T cell receptors (TCRs) for potential therapeutic applications provides an opportunity to target an expanded array of antigens, compared to those now targeted with monoclonal antibodies. Relative to antibodies, TCRs typically exhibit reduced solubility and lower affinity, properties that hamper their production and efficacy. To improve these parameters, we have developed strategies using yeast display engineering. Several different TCRs were cloned as single chain (sc) TCRs and VαCα/VβCβ heterodimers, as each of these display scaffolds has unique advantages for engineering and potential applications. Display of scTCRs, unlike that of scFv fragments, required mutagenesis and selection. Analysis of a collection of mutants revealed distinct regions of the scTCR that require mutations to allow yeast surface display, as well as solubility of purified protein. Although the sc format has several potential advantages such as increased tissue penetration, mutagenesis and selection of displayed mutants can present a technical challenge. To overcome this obstacle, we have recently explored the role of the C domains in driving heterodimer association. In addition, we have developed mutagenic strategies to improve the association of engineered, full λετ γη α and β chains.

Supported by grants from NIH.

Repeated exposures to subthreshold doses of chlorpyrifos in rats: hippocampal damage, impaired axonal transport, and deficits in spatial learning

Organophosphorus (OP) compounds are detectable in the environment for years after use and endanger many populations. Although the effects of acutely toxic doses of many OP compounds are well described, much less is known about repeated low-level exposures. The purpose of these studies was to further evaluate potential toxicological effects of the extensively used OP pesticide chlorpyrifos (CPF) in rats. CPF, across a range of subthreshold doses (i.e., for acute toxicity), reduced rearing and sniffing activity and the magnitude of weight gain over 14 days of repeated exposure. Performance in a spatial learning task was impaired after 14 days of exposure to CPF (18.0 and 25.0 mg/kg) when testing was initiated 24 h after the last injection but not after a 14-day washout. However, inhibition of both fast anterograde and retrograde axonal transport was observed for up to 20 days after exposure to 25.0 mg/kg CPF. Studies using hippocampal cultures indicated that 8 days of continuous exposure to the parent compound, CPF (> or =100 micro M), resulted in cell toxicity and death. Furthermore, a dose (2.5 mg/kg) of CPF that had no effects on weight gain or memory performance when administered 5 days per week over 38 days impaired forelimb grip strength in the later days of testing. Collectively, these results indicate that repeated exposures to subthreshold doses of CPF may lead to growth retardation, behavioral abnormalities, and muscle weakness. Some of these symptoms may be attributed to effects of the OP on axonal transport.

Case series of thrombotic thrombocytopenic purpura in children and adolescents

Thrombotic thrombocytopenic purpura (TTP) is a well-described entity in adults but is rarely observed in children. The authors describe a series of seven children with suspected acquired TTP. Clinical findings included petechiae, purpura, or jaundice ( 6), central nervous system events ( 5), fever ( 3), diarrhea ( 3), renal insufficiency ( 2), and hematuria ( 2). Significant central nervous system events included cerebral vascular accidents ( 2), altered mental status ( 2), seizures ( 1), and hemiparesis ( 1). Patients were treated with daily plasma infusions (1/7) or plasma exchange (5/7). Response was prompt, although relapses were frequent. Decreased vWF-protease activity was found in four of five cases and vWF-protease inhibitors were found in three of five cases. Although rare, TTP is a life-threatening illness that does occur in children and should be considered in the differential diagnosis of thrombocytopenia with hemolytic anemia.

Sex dimorphisms in the cognitive-enhancing action of the Alzheimer's drug donepezil in aged Rhesus monkeys

Brain acetylcholinesterase has been targeted for the development of novel treatments for memory deficits associated with Alzheimer's disease (AD) and other neurodegenerative disorders. The long-acting AChE inhibitor donepezil (Aricept) is used to improve memory and other aspects of cognition in AD patients. Because donepezil and other cholinesterase inhibitors are effective in a restricted population of AD patients, this study was to designed to determine whether aged females monkeys receive the same level of benefit to the mnemonic action of donepezil as do males. In this study, six male and six female rhesus monkeys (>20 years) who were proficient in the performance of a delayed matching-to-sample task each received an ascending series of four doses of donepezil (0.01-0.1 mg/kg) over 5 weeks. As a group, male subjects exhibited improvement in task accuracy across the three highest doses, with the maximum effect occurring after the 0.025 mg/kg dose. However, the females exhibited increased task accuracy only after the highest dose. When data were combined for sessions run 10 min after drug administration and for sessions run 24 h later (in the absence of drug), improvements in task accuracy were greater on average for males. Most of this difference was attributed to the fact that task accuracy by females actually declined during sessions run after the two lowest doses of donepezil. When task performance after donepezil was determined as the individualized Best Dose, as a group, males responded maximally to less than half the dose that was maximal for females. These findings support the concept that aged males and females respond differently to this class of agents, perhaps representing fundamental sex-related differences in memory processing, or in the manner that age affects these processes.

T-cell activation by soluble MHC oligomers can be described by a two-parameter binding model

T-cell activation is essential for initiation and control of immune system function. T cells are activated by interaction of cell-surface antigen receptors with major histocompatibility complex (MHC) proteins on the surface of other cells. Studies using soluble oligomers of MHC-peptide complexes and other types of receptor cross-linking agents have supported an activation mechanism that involves T cell receptor clustering. Receptor clustering induced by incubation of T cells with MHC-peptide oligomers leads to the induction of T-cell activation processes, including downregulation of engaged receptors and upregulation of the cell-surface proteins CD69 and CD25. Dose-response curves for these T-cell activation markers are bell-shaped, with different maxima and midpoints, depending on the valency of the soluble oligomer used. In this study, we have analyzed the activation behavior using a mathematical model that describes the binding of multivalent ligands to cell-surface receptors. We show that a simple equilibrium binding model accurately describes the activation data for CD4(+) T cells treated with MHC-peptide oligomers of varying valency. The model can be used to predict activation and binding behavior for T cells and MHC oligomers with different properties.

Receptor proximity, not intermolecular orientation, is critical for triggering T-cell activation

Engagement of antigen receptors on the surface of T-cells with peptides bound to major histocompatibility complex (MHC) proteins triggers T-cell activation in a mechanism involving receptor oligomerization. Receptor dimerization by soluble MHC oligomers is sufficient to induce several characteristic activation processes in T-cells including internalization of engaged receptors and up-regulation of cell surface proteins. In this work, the influence of intermolecular orientation within the activating receptor dimer was studied. Dimers of class II MHC proteins coupled in a variety of orientations and topologies each were able to activate CD4+ T-cells, indicating that triggering was not dependent on a particular receptor orientation. In contrast to the minimal influence of receptor orientation, T-cell triggering was affected by the inter-molecular distance between MHC molecules, and MHC dimers coupled through shorter cross-linkers were consistently more potent than those coupled through longer cross-linkers. These results are consistent with a mechanism in which intermolecular receptor proximity, but not intermolecular orientation, is the key determinant for antigen-induced CD4+ T-cell activation.

Neurofilaments are nonessential to the pathogenesis of toxicant-induced axonal degeneration

Axonal neurofilament (NF) accumulations occur before development of symptoms and before other pathological changes among idiopathic neurodegenerative diseases and toxic neuropathies, suggesting a cause-effect relationship. The dependence of symptoms and axonal degeneration on neurofilament accumulation has been tested here in a transgenic mouse model (Eyer and Peterson, 1994) lacking axonal NFs and using two prototypic toxicant models. Chronic acrylamide (ACR) or 2,5-hexanedione exposure resulted in progressive and cumulative increases in sensorimotor deficits. Neurobehavioral tests demonstrated similar expression of neurotoxicity in transgenic (T) mice and their nontransgenic (NT) littermates (containing normal numbers of axonal NFs). Axonal lesions were frequently observed after exposure to either toxicant. Quantitation of ACR-induced lesions demonstrated the distal location of pathology and equal susceptibility of T and NT axons. We conclude that axonal NFs have no effect on neurotoxicity and the pattern of pathology in these mammalian toxic neuropathies. These results also suggest that the role of neurofilament accumulation in the pathogenesis of neurodegenerative diseases requires careful evaluation.

Protractive effects of chronic treatment with an acutely sub-toxic regimen of diisopropylflurophosphate on the expression of cholinergic receptor densities in rats

Individuals chronically exposed to low levels of organophosphate insecticides may present with subtle impairments in cognition. In addition, low level diisopropylflurophosphate (DFP) exposure (0.25 mg/kg per day for 2 weeks) in rats resulted in protracted working memory impairment [29]. The current studies attempt to show a temporal relationship between the DFP-induced impairment in performance of a spatial memory task and the protracted decrease in the expression of cholinergic receptors and acetylcholinesterase in specific brain regions. Cholinergic receptors labeled with the ligands [(3)H]epibatidine and [(3)H]AFDX-384 were affected to a much greater extent and for a longer period of time than were both acetylcholinesterase activities and cholinergic receptors labeled with [(3)H]QNB. Pre-testing administration of nicotine was shown to completely reverse this DFP-induced impairment in memory-related task performance. Additionally, prophylaxis with pyridostigmine bromide (PB) caused DFP-treated animals to exhibit near normal levels of memory-related task performance. These results are consistent with the development of a protracted phase of learning impairment to sub-acute DFP exposure, which may involve the loss of hippocampal nicotinic receptors, and may be prevented or reversed by PB or nicotine, respectively.

Neurofilaments are non-essential elements of toxicant-induced reductions in fast axonal transport: pulse labeling in CNS neurons

Acrylamide (ACR) and g-diketones (g-DK) produce distal sensory-motor neuropathy in a variety of species, including humans. The specific molecular site and mechanism of toxicant action leading to specific morphological and behavioral abnormalities requires definition. The relative roles of fast anterograde axonal transport and neurofilaments (NF) are investigated using optic nerves of mice, with and without axonal neurofilaments. Segmental analysis, following pulse labeling with 3H-leucine into the vitreous body, was used to detect changes in fast anterograde transport in the optic nerve and tract. Single injections of ACR significantly reduced the quantity of radiolabeled proteins transported in both transgenic (lacking NF) and non-transgenic (containing NF) mice by 68.4% and 46.2%, respectively. Similarly, single injections of 2,5-hexanedione (2,5-HD) reduced the quantity of radiolabeled transport in transgenic and non-transgenic mice by 55.2% and 47.1%, respectively. Equimolar doses of propionamide and 3,4-hexanedione (non-neurotoxic analogues of ACR and 2,5-HD, respectively) produced no changes in the quantity or apparent rate of optic nerve transport. Additionally, no differences in quantity or apparent rate of transport between transgenic and non-transgenic animals were observed under control or experimental conditions. Therefore, ACR and 2,5-HD reduce the quantity of fast anterograde axonal transport in mouse CNS axons in a comparable amount to previously reported reductions in rat PNS axons. The absence of axonal neurofilaments had no effect on normal fast transport. Furthermore, the presence or absence of neurofilaments did not alter the effect of these toxicants on fast axonal transport. We conclude that toxicant-induced reductions in fast axonal transport are unrelated to ACR and g-diketone effects on NF or their accumulation.

Axonal neurofilaments are nonessential elements of toxicant-induced reductions in fast axonal transport: video-enhanced differential interference microscopy in peripheral nervous system axons

Neurofilament modification and accumulation, occurring in toxicant-induced neuropathies, has been proposed to compromise fast axonal transport and contribute to neurological symptoms or pathology. The current study compares the effects of the neurotoxicants acrylamide (ACR) and 2,5-hexanedione (2,5-HD) on the quantity of fast, bidirectional vesicular traffic within isolated mouse sciatic nerve axons from transgenic mice lacking axonal neurofilaments (Eyer and Peterson, Neuron 12, 1-20, 1994) and nontransgenic littermates possessing neurofilaments. Fast anterograde and retrograde membrane bound organelle (MBO) traffic was quantitated within axons, before and after toxicant exposure, using video-enhanced differential interference contrast (AVEC-DIC) microscopy. Addition of 0.7 mM ACR to the buffer bathing the nerve produced a time-dependent reduction in bidirectional transport with a similar time to onset and magnitude in both transgenic and nontransgenic mice. 2,5-HD (4 mM) exposure reduced bidirectional vesicle traffic by a similar amount in both transgenic and nontransgenic animals. The time to onset of the transport reduction was less and the magnitude of the reduction was greater with 2,5-HD compared to ACR. A single 10-min exposure to ACR or 2,5-HD produced a similar reduction in transport to that produced by prolonged (1 h) exposure. Nonneurotoxic propionamide or 3,4-hexanedione (3,4-HD) produced no changes in bidirectional transport in either transgenic or nontransgenic animals. We conclude that ACR or 2,5-HD produces a rapid, saturable, nonreversible, neurotoxicant-specific reduction in fast bidirectional transport within isolated peripheral nerve axons. These actions are mediated through direct modification of axonal component(s), which are independent of toxicant-induced modifications of, or accumulations of, neurofilaments.

Aberrant TCR-mediated signaling in CD45-null thymocytes involves dysfunctional regulation of Lck, Fyn, TCR-zeta, and ZAP-70

CD45 is a transmembrane phosphotyrosine phosphatase expressed on all nucleated hemopoietic cells. Targeting of CD45 exon 9 has generated a mouse line completely lacking CD45 expression (CD45-null) in which there are severe abnormalities in T cell development. Defects in TCR-mediated signals underlying these abnormalities have now been investigated using CD45-null T cells. No T cell proliferation was detected in response to a CD3 mAb. In thymocytes the p56(lck) and p59(fyn) tyrosine kinases were hyperphosphorylated, and p56(lck) was in its inactive conformation. Both basal and TCR-stimulated tyrosine phosphorylation of TCR-zeta and CD3-epsilon were much reduced, and TCR stimulation induced an abnormal p18 phosphoisomer of TCR-zeta previously noted in T cells stimulated by altered peptide ligands. These defects were associated with the failure of ZAP-70 kinase recruitment to the TCR-zeta chain. TCR coupling to the tyrosine phosphorylation of several proteins, including HS1 and p120(cbl), was also much reduced. However, TCR-induced signaling was not ablated, and significant inositol phosphate and calcium signals were observed in CD45-null thymocytes. Our molecular analysis suggests that the threshold for TCR signal transduction is greatly increased in CD45-null T cells, thus explaining the profound defects in thymic development.

Aberrant TCR-mediated signaling in CD45-null thymocytes involves dysfunctional regulation of Lck, Fyn, TCR-zeta, and ZAP-70

CD45 is a transmembrane phosphotyrosine phosphatase expressed on all nucleated hemopoietic cells. Targeting of CD45 exon 9 has generated a mouse line completely lacking CD45 expression (CD45-null) in which there are severe abnormalities in T cell development. Defects in TCR-mediated signals underlying these abnormalities have now been investigated using CD45-null T cells. No T cell proliferation was detected in response to a CD3 mAb. In thymocytes the p56(lck) and p59(fyn) tyrosine kinases were hyperphosphorylated, and p56(lck) was in its inactive conformation. Both basal and TCR-stimulated tyrosine phosphorylation of TCR-zeta and CD3-epsilon were much reduced, and TCR stimulation induced an abnormal p18 phosphoisomer of TCR-zeta previously noted in T cells stimulated by altered peptide ligands. These defects were associated with the failure of ZAP-70 kinase recruitment to the TCR-zeta chain. TCR coupling to the tyrosine phosphorylation of several proteins, including HS1 and p120(cbl), was also much reduced. However, TCR-induced signaling was not ablated, and significant inositol phosphate and calcium signals were observed in CD45-null thymocytes. Our molecular analysis suggests that the threshold for TCR signal transduction is greatly increased in CD45-null T cells, thus explaining the profound defects in thymic development.

Nitroprusside treatment of erythromelalgia in an adolescent female

OBJECTIVE

To report a case of erythromelalgia in an adolescent patient successfully treated with nitroprusside.

CASE SUMMARY

A 15-year-old girl with erythromelalgia resistant to aspirin therapy received an infusion of nitroprusside. The response of the erythromelalgia to nitroprusside was dramatic, with complete pain resolution within 17 hours after the start of therapy. No relapse of erythromelalgia was seen when nitroprusside was discontinued and the patient remained well after 6 months.

DISCUSSION

This case adds to existing literature substantiating the benefit of nitroprusside for the treatment of erythromelalgia in pediatric patients. Erythromelalgia in children may represent a different disease entity than that seen in adults, which is commonly responsive to aspirin therapy. The pathogenesis of erythromelalgia is unclear and precludes formulating a proposed mechanism by which nitroprusside has benefit in children.

CONCLUSIONS

Nitroprusside is valuable for erythromelalgia resistant to aspirin therapy in pediatric patients. Because of unanswered questions regarding the disease, aspirin remains the agent of first choice in all patients with this rare disease.

The effect of anterior cruciate ligament graft fixation site at the tibia on knee stability: evaluation using a robotic testing system

Despite its current popularity and relative success, endoscopic reconstruction of the anterior cruciate ligament (ACL) using a bone-patellar tendon-bone (BPTB) graft has not yet been perfected. Using a recently developed robotic/UFS testing system, we assessed the overall stability of porcine knees following ACL reconstruction with different sites of tibial graft fixation--proximal, central, and distal. Testing of the intact knee was performed first to determine the normal anterior-posterior (A-P) displacements and in situ forces of the ACL under 110 N of anterior tibial loading of 30 degrees, 60 degrees, and 90 degrees of knee flexion. The knee was then reconstructed with a BPTB autograft, and the distal end of the graft was fixed sequentially at three different locations in each specimen--proximal, central, distal. A-P testing was repeated for each fixation site, and the resulting knee kinematics and the in situ forces of the grafts were compared to the intact case. The site of tibial fixation was demonstrated to have a significant effect on the resulting anterior displacement and internal rotation of the tibia as well as the in situ forces of the graft. Proximal fixation produced the most stable knee (A-P displacements reduced to 120% of intact at 30 degrees and 170% at 90 degrees), becoming significantly less stable with more distal fixation. These results suggest that proximal graft fixation may provide the most acute stability of the reconstructed knee.

Assessment of posterior cruciate ligament graft performance using robotic technology

We used the information on in situ forces provided by robotics to compare two methods of posterior cruciate ligament graft fixation. Twenty porcine knees were studied using robotic technology to determine and repeat intact, deficient, and reconstructed knee motion under 110 N of posterior tibial loading at 30 degrees, 60 degrees, and 90 degrees of knee flexion. Reconstruction was performed using a bone-patellar tendon-bone graft with the distal end of the graft placed in the posterolateral aspect of the posterior cruciate ligament tibial insertion. Specimens were separated into two groups based on the femoral fixation site: the proximal or anterior aspect of the femoral insertion. Repetition of knee motion allowed measurement of the force in the intact posterior cruciate ligament and graft using the principle of superposition. The forces in the graft and the intact ligament provided additional information to evaluate graft performance. Force in the intact posterior cruciate ligament was significantly greater at 90 degrees than at 30 degrees and 60 degrees of knee flexion. The forces in both graft types were significantly lower than those of the posterior cruciate ligament, but the force in the anteriorly placed graft was significantly greater at 90 degrees than at 30 degrees and 60 degrees of knee flexion, similar to the intact posterior cruciate ligament. Thus, the anteriorly placed graft had a more physiologic increase in tension with knee flexion, when the joint provided less restraint.

Seasonal effects of supplemental fat or undegradable protein on the growth and metabolism of Holstein calves

One summer (heat stress) and one winter (neutral conditions) trial were conducted to assess the effects of varied amounts of RUP and fat on the growth and metabolic responses of calves. In each trial, 190-kg Holstein calves (n = 45) were fed a basal diet of corn and cottonseed hulls supplemented with soybean meal (control) or supplemented with raw or roasted whole soybeans or the basal ration plus prilled hydrogenated tallow either with or without a mixture of feather meal and blood meal. Prilled tallow was more detrimental to fiber digestion and growth performance than were whole soybeans, especially during summer. During winter, calves fed a high (49%) percentage of the dietary CP as RUP had similar BW gain and efficiency of feed usage as did calves fed a moderate percentage (39%), but, during summer, calves fed the high percentage of RUP had greater BW gain and efficiency than did calves fed moderate percentages of RUP. Ruminal concentrations of VFA were parallel to digestibilities of fiber in the total tract. Ruminal concentrations of ammonia or blood concentrations of urea were not consistent with the concentrations of RDP fed. Concentrations of glucose, NEFA, insulin, and thyroid hormones in the blood were primarily affected by season. Data suggested that a higher percentage and AA quality of RUP improved the growth of calves during summer but not during winter.

Differences in viral distribution and cell adhesion molecule expression in the intestinal tract of rhesus macaques infected with pathogenic and nonpathogenic SIV

We investigated SIV infection and expression of adhesion molecules in the small intestine of rhesus macaques infected with pathogenic SIV (SIVmac) or nonpathogenic clone (SIV1A11). There was a wider dissemination and marked difference in tissue localization of SIVmac relative to SIV1A11. Our results also indicate that viral pathogenicity is associated with increased migration of inflammatory cells expressing VLA-alpha 4, LFA-1 alpha, Mac-1 alpha, ICAM-1, and beta 2 integrin into the intestinal mucosa.

Alteration of carbamazepine pharmacokinetics in patients with traumatic brain injury

All patients admitted to a rehabilitation unit with closed-head injury over a 3-year period were reviewed for carbamazepine use exceeding 30 days in the hospital. Nine patients met the study inclusion criteria for age and duration of carbamazepine therapy. On review of the dose:serum concentration relationship, significant changes were noted in four patients. An initial increase in the dose:serum concentration ratio during the first few months of therapy was thought to reflect the well-known auto-induction of carbamazepine metabolism. However, unexplainable decreases in the dose:serum concentration occurred in the following months, and suggested alteration of carbamazepine pharmacokinetics in patients with traumatic brain injury. The finding may be important in determining the optimal approach to therapeutic drug monitoring of carbamazepine in brain-injured patients.

Development of malabsorption and nutritional complications in simian immunodeficiency virus-infected rhesus macaques

OBJECTIVE

To assess the development and cause of malabsorption in rhesus macaques following experimental simian immunodeficiency virus (SIV) infection and to evaluate its impact on nutritional status.

DESIGN

Clinical malabsorption tests and serial jejunal aspirates and biopsies were obtained from nine SIV-infected and three uninfected animals prior to infection and at 1, 2, 4, 8, 12, 24, 40 and 52 weeks postinoculation.

METHODS

Malabsorption was measured by sucrose breath hydrogen (H2) analysis and blood assay of D-xylose. Digestive enzyme activity was determined in jejunal mucosal homogenates. Bacterial and protozoal flora were determined in jejunal aspirates. Nutritional assessment was evaluated using specific blood micronutrient values. Cellular targets of SIV in the jejunum were determined by combined in situ hybridization and immunohistochemistry.

RESULTS

Eight out of nine SIV-infected monkeys, including asymptomatic animals, exhibited malabsorption by either increased breath H2 and/or decreased blood D-xylose. All animals that died of AIDS had diarrhea, D-xylose malabsorption and decreased sucrase activity. Significant changes in nutritional status were associated with malabsorption. Bacterial overgrowth was not considered to be a cause of malabsorption. Histopathological biopsy findings included dilated villus lacteals, excessive cellular debris, lymphoplasmocytic infiltrates and cytoplasmic vacuoles in crypt epithelial cells. SIV-infected T cells and macrophages were detected as early as 1 week postinoculation.

CONCLUSIONS

SIV-associated malabsorption can occur prior to clinical complications of disease. Severe intestinal complications are associated with malabsorption and malnutrition in the terminal stages of AIDS. The high proportion of macaques experiencing malabsorption without detectable pathogens, suggests an enteropathogenic role for SIV.

Sex differences in central cholinergic and angiotensinergic control of vasopressin release

In conscious, unrestrained rats, the intracerebroventricular injection of the cholinergic agonist, carbachol, or angiotensin II resulted in the transient stimulation of vasopressin secretion, elevation of mean arterial blood pressure, and reduction of heart rate. After the injection of carbachol (25 ng) into a lateral cerebral ventricle, the plasma vasopressin concentration in male rats was increased to twice that of female rats in each phase of the estrous cycle; mean arterial blood pressure was elevated more in males than females, whereas heart rate fell to the same extent in both sexes. In contrast, the increase in the plasma vasopressin concentration of males after the injection of angiotensin II (20 ng) was one-half that of females, and the hypertensive and bradycardic responses were similar in both sexes. Phase of the female estrous cycle had no effect on the responses to either agent. These findings indicate that central cholinergic and angiotensinergic mechanisms controlling vasopressin release are influenced differently by gender. The role of the gonadal steroid hormones in these mechanisms remains to be determined.

Sex differences in central adrenoreceptor-mediated vasopressin response to hemorrhage

Hemorrhage-induced changes in the plasma vasopressin concentration and mean arterial blood pressure (MABP) were studied in conscious rats of both sexes with and without central alpha 1-adrenoreceptor blockade. Rats were subjected to two sequential hemorrhages (H1 and H2), each 0.8% of body weight after an intracerebroventricular injection of the alpha 1-adrenoreceptor antagonist corynanthine or of vehicle. H1 stimulated vasopressin secretion more in proestrous females than in males; there were no significant sex-related differences in responses to H2. Corynanthine pretreatment attenuated the vasopressin response to H2 in males, potentiated this response in proestrous females, but had no effect in estrous females. MABP decreased after H1 in all female groups and in corynanthine-pretreated males. After H2, all groups were hypotensive to the same extent. These data indicate that central alpha 1-adrenoreceptor-mediated pathways participate in vasopressin and blood pressure responses to hemorrhage, but their role is complex and is dependent on gender and on the phase of the estrous cycle.

Carbamazepine hypersensitivity reaction

Carbamazepine is an anticonvulsant that is being used more frequently in the treatment of various psychiatric disorders. The drug has been associated with serious adverse reactions that appear to have an immunological pathogenesis. A case report describing a patient suffering an adverse reaction to carbamazepine is presented, to illustrate the various body systems typically affected in the apparent hypersensitivity reaction. The importance of laboratory and patient monitoring during the initial 3 months of carbamazepine therapy is reinforced.

Sex differences in central adrenergic control of vasopressin release

Central adrenoreceptor-mediated regulation of vasopressin secretion and cardiovascular function was studied in male rats and female rats in specific estrous cycle phases. In conscious, unrestrained rats with intracerebroventricular (icv) cannulas and femoral artery and vein catheters, plasma arginine vasopressin concentration (PAVP), mean arterial blood pressure (MABP), and heart rate (HR) were determined before and 5 and 15 min after icv injection of 10 micrograms norepinephrine or 50 micrograms phenylephrine. Norepinephrine (icv) increased PAVP in proestrus and metestrus four and three times (P less than 0.01 and 0.05, respectively) more than in males. Norepinephrine induced similar MABP elevations (P less than 0.01) in males and females in all cycle phases; HR decreased only in proestrus, estrus, and metestrus (P less than 0.01). The increase in PAVP after icv phenylephrine was four and three times greater in proestrous and diestrous females (P less than 0.01 and 0.05, respectively) than in males. The proestrous MABP rise was three times that in males (P less than 0.05); HR decreased similarly in diestrus, proestrus, and males. These results suggest gonadal steroid hormones influence adrenoreceptor-mediated control of vasopressin secretion, MABP, and HR.

Stress and depression: a test of the buffering model of social support

The buffering model of social support states that effective social support networks lessen the adverse psychological consequences of stress. Among a large community sample (N = 1,000) of Los Angeles County adults interviewed in 1979, life-event losses and perceived strain were positively related to depressive symptomatology, while close relationships and perceived support were negatively related to these symptoms. In all models tested, these effects were found to be direct effects, not interaction effects as predicted by the buffering model. The effects of stress on depressive symptomatology were similar among those with low and high levels of social support. Social support, instead of merely protecting an individual against the negative impact of stress, may itself be important in ameliorating depressive symptoms. Moreover, assuming that lack of perceived or actual social support is not just a manifestation of depression itself, our findings support the corollary that the lack of social support contributes to the creation of depressive symptoms.

Racial/ethnic differences in access to health care: further comments on the use-disability ratio

Indicators of access to health care generally fall into one of two broad groups. The first group of indicators focuses on factors responsible for differential rates of use and often are assessed through reports of patient satisfaction. The second group of indicators focuses more specifically on actual rates of use, and therefore represents a more objective measure of access. One of the most widely used objective indicators of access is the use-disability ratio. This article illustrates some problems in using this ratio in health services research and some strategies one might adopt to minimize these problems. The data reported below were obtained from an analysis of racial/ethnic differences in use of services that was conducted as part of the 1979 Los Angeles Health Survey (N = 1003). Our findings suggest that 1) blacks had greater access to health care than either white/Anglos or Hispanics, particularly for respiratory and musculo-skeletal problems, and 2) the use-disability ratio should be used cautiously, since it is sensitive to subgroup differences in the chronicity and cause of the disability

Single-stage reconstruction of mandibular and soft tissue defects using a free osteocutaneous groin flap

Microvascular reconstruction of the mandible and soft tissues using the composite groin flap is ideal in selected patients. No other available bone so closely approximates the mandible in both thickness and curvature as does the iliac crest. The soft tissues are available for reconstruction and may allow the surgeon to avoid a second flap, except in cases where both lining and cover are needed. The deep circumflex artery is of generous size, usually 2 to 2.5 mm in diameter, allowing greater reliability in the microvascular anastomoses. The flap has a fairly long vascular predicle, 6 to 8 cm. The ability of this flap to withstand irradiation and infection because of its blood supply permits early institution of postoperative radiotherapy and prevents bone loss due to small intraoral wound dehisicence or total flap loss. Although the donor site requires extensive dissection, it can be closed primarily, eliminating the need for skin grafts or other flaps. As further experience is gained with this flap, both the functional and cosmetic results should be improved. In patients undergoing resection of the remaining portion of the mandible, the symphysis or the anterior portion of the mandible, a procedure of this type should be done primarily to prevent deformity and to minimize disability for the patient.

Annoyance response of nonsmokers to cigarette smoke

In three experiments, nonsmoking subjects rated their annoyance by task environments while either exposed or not exposed to ambient tobacco smoke. In Exps. 1 and 2 subjects rated annoyance with the environment while exposed to three intensities of noise, and in Exp. 3 subjects rated annoyance while performing multiplication problems under conditions of high and low task motivation. The source of the ambient smoke in Exp. 1 was a smoke pump. For Exps. 2 and 3, the source of the smoke was confederate subjects. No differences in annoyance were obtained in Exps. 1 and 2 as a function of exposure to smoke. Exp. 3 showed that nonsmokers' annoyance to a task environment is dependent upon task motivation and exposure to ambient smoke. In Exp. 3 nonsmokers exposed to smoke were more annoyed than those not exposed under low motivating conditions. When nonsmokers were highly motivated in the task environment those exposed to smoke were significantly less annoyed than those not exposed.

Information processing and estimation of short time intervals

Duration estimates were assessed by the method of reproduction with filled reproduction intervals. Mental arithmetic, reading and mirror-image drawing were used in pairs as initial and/or reproduction tasks. All nine possible pairs of tasks were used in a 9 X 5 X 5 mixed design with five Ss per task pair and five interruption intervals for each initial task. Results indicated that, when arithmetic was used as the initial task, Ss underestimated the duration of the initial interval. When arithmetic was used as the reproduction task, Ss overestimated the duration of the initial interval. A significant correlation was obtained between arithmetic outputs and the lengths of the duration estimates. Results are interpreted as supportive of Burnside's (1971) interpretation of Ornstein's (1969) storage-size hypothesis.