MAST system: a new condensed cardiopulmonary bypass circuit for adult cardiac surgery

There have been many refinements in cardiopulmonary bypass (CPB) techniques over the past few decades specific to design, materials and function. Despite these improvements, use of the standard length circuit tubing and pump oxygenator alter cellular, biochemical and rheological properties by inducing a systemic inflammatory response, persisting well into the early postoperative phase. We have designed a new condensed CPB circuit, the MAST system, where the oxygenator and the pumps are brought closer to the operating table (within 30 inches) with the help of a series of telescopic swivel steel poles to which they are attached. The control console is retained at the usual remote location of 2ft behind the MAST system. This configuration accomplishes a decrease in tubing length, priming volume and blood circulatory time within the extracorporeal circuit. Early experience of a hundred consecutive cases utilizing the MAST CPB system is presented along with a comparative analysis of prime volume, hemodilution and transfusion parameters of MAST system vs the low prime system, which is another newly developed CPB circuit utilizing a pediatric oxygenator to reduce prime volume and hemodilution.

Food allergens

A number of advances in the scientific knowledge concerning adverse food reactions have been made in the past few years. Understanding about the nature of the food allergen itself, the molecular characterization of the epitopes on these allergens, the pathophysiology of the clinical reaction, and the diagnostic methods have all been significantly enhanced.

Engineering, characterization and in vitro efficacy of the major peanut allergens for use in immunotherapy

BACKGROUND

Numerous strategies have been proposed for the treatment of peanut allergies, but despite the steady advancement in our understanding of atopic immune responses and the increasing number of deaths each year from peanut anaphylaxis, there is still no safe, effective, specific therapy for the peanut-sensitive individual. Immunotherapy would be safer and more effective if the allergens could be altered to reduce their ability to initiate an allergic reaction without altering their ability to desensitize the allergic patient.

METHODS

The cDNA clones for three major peanut allergens, Ara h 1, Ara h 2, and Ara h 3, have been cloned and characterized. The IgE-binding epitopes of each of these allergens have been determined and amino acids critical to each epitope identified. Site-directed mutagenesis of the allergen cDNA clones, followed by recombinant production of the modified allergen, provided the reagents necessary to test our hypothesis that hypoallergenic proteins are effective immunotherapeutic reagents for treating peanut-sensitive patients. Modified peanut allergens were subjected to immunoblot analysis using peanut-positive patient sera IgE, T cell proliferation assays, and tested in a murine model of peanut anaphylaxis.

RESULTS

In general, the modified allergens were poor competitors for binding of peanut-specific IgE when compared to their wild-type counterpart. The modified allergens demonstrated a greatly reduced IgE-binding capacity when individual patient serum IgE was compared to the binding capacity of the wild-type allergens. In addition, while there was considerable variability between patients, the modified allergens retained the ability to stimulate T cell proliferation.

CONCLUSIONS

These modified allergen genes and proteins should provide a safe immunotherapeutic agent for the treatment of peanut allergy.

Cellular and molecular characterization of a major soybean allergen

Soybean proteins share a large number of cross-reacting allergens with other members of the legume family; however, soy-allergic patients rarely react clinically to other members of the legume family. Gly m Bd 30K, an IgE-binding protein with a molecular weight of 30 kD, was identified in soybean extracts by Western IgE-immunoblot analysis. This monomeric allergen was shown to have an N-terminal amino acid sequence and amino acid composition identical to that of the seed 34-kD protein, P34, a thiol protease of the papain family. Electron-microscopic immunolocalization of P34 monoclonal antibodies and IgE binding to sections of soybean seeds showed dense staining throughout the vacuolar bodies, localizing the allergens in protein storage vacuoles of seed cotyledons. We used pooled serum from soybean-sensitive patients to determine the linear IgE-specific epitopes in the 34-kD allergen amino acid sequence. B-cell epitope mapping revealed 10 regions of IgE-binding activity using an overlapping peptide strategy of 15-mers offset by 8 amino acids throughout the P34 sequence. Smaller overlapping peptides, 10-mers offset by 2 amino acids, revealed 16 distinct linear epitopes, 9 of which were mapped to the mature protein. No obvious amino acid sequence motifs could be identified by the smaller IgE-binding epitopes. Using individual patient serum, 5 immunodominant epitopes were identified in this allergen.

Retrograde autologous priming for cardiopulmonary bypass: a safe and effective means of decreasing hemodilution and transfusion requirements

OBJECTIVES

The obligatory hemodilution resulting from crystalloid priming of the cardiopulmonary bypass circuit represents a major risk factor for blood transfusion in cardiac operations. We therefore examined whether retrograde autologous priming of the bypass circuit would result in decreased hemodilution and red cell transfusion.

METHODS

Sixty patients having first-time coronary bypass were prospectively randomized to cardiopulmonary bypass with or without retrograde autologous priming. Retrograde autologous priming was performed at the start of bypass by draining crystalloid prime from the arterial and venous lines into a recirculation bag (mean volume withdrawal: 880 +/- 150 ml). Perfusion and anesthetic techniques were otherwise identical for the two groups. The hematocrit value was maintained at a minimum of 16% and 23% during and after cardiopulmonary bypass, respectively, in all patients. Patients were well matched for all preoperative variables, including established transfusion risk factors. Subsequent hemodynamic parameters, pressor requirements, and fluid requirements were equivalent in the two groups.

RESULTS

The lowest hematocrit value during cardiopulmonary bypass was 22% +/- 3% versus 20% +/- 3% in patients subjected to retrograde autologous priming and in control patients, respectively (p = 0.002). One (3%) of 30 patients subjected to retrograde autologous priming had intraoperative transfusion, and seven (23%) of 30 control patients required transfusion during the operation (p = 0.03). The number of patients receiving any homologous red cell transfusions in the two groups during the entire hospitalization was eight of 30 (27%; retrograde autologous priming) versus 16 of 30 (53%; control) (p = 0.03).

CONCLUSIONS

These data suggest that retrograde autologous priming is a safe and effective means of significantly decreasing hemodilution and the number of patients requiring red cell transfusion during cardiac operations.

Isolation and characterization of a clone encoding a major allergen (Bla g Bd90K) involved in IgE-mediated cockroach hypersensitivity

Previous studies have established that atopic individuals living in cockroach-infested housing become sensitized to cockroach aeroallergens and produce IgE antibodies to a variety of proteins. We describe the isolation of a complementary DNA clone from an expression library, constructed with messenger RNA from German (Blattella germanica) cockroaches, which encodes a major allergen involved in mediating cockroach hypersensitivity. Approximately 0.2% of the clones from a lambda ZAP XR cDNA library bound IgE from a patient with cockroach sensitivity. A randomly selected subset of these clones revealed that they were either different isolates of the same gene or members of a closely related gene family. One of the largest clones (a 4 kb insert) from this subset, Bla g Bd90K hybridized to a single mRNA of approximately the same size. DNA sequence analysis showed that this gene consisted of seven 576 bp tandem repeats with a short unique region at either end. No significant sequence homologies were found between the cockroach clone and any other gene reported in the GenBank database. Serum from 17 of 22 (77%) patients with cockroach hypersensitivity identified IgE-binding recombinant protein expressed from clone Bla g Bd90K in Escherichia coli XL-Blue cells as determined by sodium dodecylsulfate-polyacrylamide gel electrophoresis/immunoblot analysis. This recombinant protein migrates with a molecular weight (90 kd) apparently similar to one identified in whole body extracts. We have identified and isolated a cDNA that encodes a major cockroach allergen (Bla g Bd90K) present in German cockroaches.

Cross-reactivity of IgE-binding components between boiled Atlantic shrimp and German cockroach

IgE-antibody reactivity to boiled Atlantic shrimp (Pandalus borealis) and German cockroach (Blattella germanica) of sera from 89 patients, sensitive to one or the other, was investigated with an enzymatic immunoassay for specific IgE detection (CAP-FEIA System, Pharmacia, Sweden). IgE serum levels to both antishrimp and anticockroach allergens were found to be positive in 76 of the 89 (85.4%) tested sera. A positive anticockroach IgE was very rare in the absence of detectable antishrimp IgE (five of 89 sera). Linear regression analysis on antishrimp and anti-German cockroach IgE levels-log plot revealed a correlation coefficient (r) of 0.73. Inhibition experiments showed that boiled Atlantic shrimp extract inhibited CAP with German cockroach, and vice versa. Immunoblotting showed the strongest IgE binding for both allergenic extracts between 30 and 43 kDa. By blot inhibition, the binding capacity of German cockroach was totally abolished by Atlantic shrimp extract, while German cockroach extract only partially IgE binding to Atlantic shrimp. Cross-reactivity exists between shrimp, an important food allergen, and German cockroach, which has an increasing role in allergic asthma. It could be important to determine the clinical significance of cross-allergy to both allergens, in which exposures occur in different ways.

In vitro translation of RNA from the German cockroach Blattella germanica

The translation of mRNA within total RNA of German (Blattella germanica) cockroaches was performed using a rabbit reticulocyte lysate system. Analysis of the translation products by SDS-PAGE and combined autoradiography revealed several synthesized proteins with apparent molecular weights ranging from 20 kD to 110 kD. SDS-PAGE/Western blotting of non-radiolabeled translation products and incubation with human serum with IgE to cockroach allergens showed the presence of a 36 kD and 50 kD allergen. The confirmation of the translation of the cockroach allergens from total RNA is an important first step in the cloning of cockroach allergens.

Onchocerca volvulus: characterization of an immunodominant hypodermal antigen present in adult and larval parasites

Biochemical and immunological data suggest that a relatively limited number of polypeptide antigens of viable Onchocerca volvulus-infective larvae are available to be recognized by the host's immune system. A partial cDNA clone encoding one such antigen, designated lambda RAL-2, was isolated by screening an expression cDNA library with antisera raised against viable O. volvulus L3. The antigen encoded by this clone was subsequently found to be immunogenic in the majority of individuals exposed to O. volvulus. In the present study, the native antigen corresponding to lambda RAL-2 (Ov17) has been characterized. Immunolocalization and in situ hybridization techniques have been used to localize Ov17 in adult and larval stages of the parasite. In adult females, Ov17 was localized primarily in the hypodermis. Ov17 was accessible to surface labeling reagents in viable adult parasites. Full-length cDNA clones encoding Ov17 suggested that the nascent protein contains a putative leader sequence, which is almost immediately followed by a polyglutamine tract. Analysis of antibody reactivity to recombinant proteins containing and lacking the polyglutamine tract demonstrated that this structure was not a significant B cell epitope in individuals exposed to O. volvulus.

cDNA clones of Onchocerca volvulus low molecular weight antigens provide immunologically specific diagnostic probes

We report here a panel of cDNA clones from Onchocerca volvulus which were isolated on the basis of being uniquely recognised by onchocerciasis sera and not by sera from patients infected with the major lymphatic filarial nematode parasite Wuchereria bancrofti. Over 90% of O. volvulus recombinants from a primary screen were found to cross-react with lymphatic filariasis sera and were discarded. The subset of specific clones, selected with pooled sera, was then screened with panels of individual patient sera. Individual onchocerciasis cases showed a highly heterogeneous pattern of recognition of recombinant peptides, but several clones were identified which could be combined in a cocktail of antigenic epitopes to successfully detect all infected cases in the study. All these clones encode low molecular weight proteins of the parasite, confirming earlier reports that antigens of this size class show greater species specificity. Several clones encode proteins of 20-23 kDa, the same molecular weight range as the major surface protein of adult worms. The two most commonly recognised clones, Ov22/31M and Ov20/36M were subcloned into the vector pNGS 8 which produces fusion proteins attached to a polyasparagine leader. The fusion peptides of both Ov22/31M and Ov20/36M were soluble and easily purified by gel filtration. Purified fusion protein was used in ELISA to assess reactivity of infected patients giving 90% sensitivity with 100% specificity.

The Herbert screw for the treatment of scaphoid fractures

Forty-nine patients with fifty fractures of the scaphoid were reviewed more than six months after surgical treatment using the Herbert bone screw. Twenty-nine patients (mainly those with delayed union and non-union) also had bone grafts. The mean period of follow-up was 18.3 months. In 47 patients (94%) the fracture had definitely or probably united. The three patients whose fractures did not unite had proximal pole fractures with pre-existing avascular necrosis and osteoarthritis. Immediate post-operative mobilisation was possible in thirty patients. Wrist function as measured by grip strength and range of motion was excellent or good in most patients. Twenty patients had proximal pole fractures and their results are analysed separately.

The results of ankle arthrodesis

The results are presented of 47 compression arthrodeses of the ankle performed for osteoarthritis in 44 patients. In 26 cases the transverse anterior incision of Charnley had been used and in 21 cases medial and lateral incisions with division of the malleoli. Complications included infection (19%), non-union (14.9%) and malposition requiring a further procedure (8.5%). Three patients (6.4%) eventually had an amputation. Clinical assessment using a standard grading method showed that the functional result was not related to the angle of plantar flexion of the ankle, but was related to the varus/valgus position of the heel, the neutral position being associated with the best results. The anterior approach was more reliable in avoiding varus or valgus of the heel.

Donor site morbidity following resection of the fibula

Ten adults were studied two to seven years after resection of a fibula for use as a free vascularised bone graft. Six had no symptoms in the donor leg, four had some aching, weakness or paraesthesia and three had definite weakness of the long toe flexors and extensors. All knees and ankles were clinically and radiologically stable, but the distal fibular remnant was osteoporotic in nine patients. Gait analysis of the donor leg and the contralateral normal leg showed definite differences, which could be attributed to weakness of the deep muscles caused by loss of their normal origin and to the change in load transmission through the fibula.

Localization and immunogenicity of tubulin in the filarial nematodes Brugia malayi and B. pahangi

Tubulin was identified in the filarial nematodes Brugia malayi and B. pahangi by several approaches. Initially, a monoclonal antibody (6D8) was selected for its unusual binding to B. malayi microfilariae in indirect immunofluorescence assays: 6D8 showed granular, heterogeneously dispersed fluorescence on fixed parasites but did not bind to unfixed microfilariae. The microfilarial sheath did not bind 6D8, although it did bind fluoresceinated wheatgerm agglutinin. By Western blotting against microfilarial sonicate, 6D8 reacted with a 50,000-55,000 mol. wt protein, and also bound to purified chicken brain beta-tubulin. Additionally, this monoclonal antibody reacted with a recombinant fusion protein expressed by a clone (Bpa-7) originally isolated from an adult B. pahangi cDNA expression library by its reaction with chronic human filariasis serum. This clone encodes a small 40 amino acid C-terminal segment corresponding to residues 409-449 of beta-tubulin, and shows complete amino acid sequence homology with vertebrate beta-tubulin from 409 to 430 but 55% divergence (six amino acid substitutions, four insertions and one deletion) from human and chicken beta-tubulin over positions 431-449 at the C terminus. Antibody to both parasite and vertebrate (chicken) tubulin was found in filarial infection sera, with higher levels of autoreactive antibody apparent in amicrofilaraemic individuals. Immunogold electron microscopy was then used to localize beta-tubulin in B. malayi microfilariae and adult worms. Tubulin was shown not to be exposed on the microfilarial sheath or in the cuticle of either stage, but was found to be abundant in the somatic tissues. In microfilariae, 6D8 bound myofibril structures under the hypodermal layer, and also bound within cell nuclei. In the adult stage, tubulin was associated with muscle blocks, as well as the intestinal brush border and the embryonic uterine microfilariae.

Radial reconstruction in segmental defects of both forearm bones

Seven patients with segmental defects of both bones of the forearm had reconstruction operations using a vascularised fibular graft to bridge the radius. Reasonable forearm rotation was preserved with full elbow movements and satisfactory hand function.

Long-term results of total ankle replacement

The results are reported of 19 total ankle replacements in 18 patients with rheumatoid or other inflammatory arthritis. After a mean follow-up period of 54.4 months (minimum, 24 months), three arthroplasties had failed, all because of loosening. Although all of the remaining patients were improved in terms of pain and function, there was radiographic evidence of loosening in a further eight patients. Indications for the operation are discussed.

Unusual electron microscopy findings in liver biopsies from patients with viral hepatitis B

Electron microscopy of 57 needle biopsies from livers of 55 patients with chronic hepatitis, mostly of type B, revealed, in addition to typical hepatitis B virus nucleocapsids in 34 cases, also atypical intranuclear inclusions in 9 biopsies. These inclusions consisted of electron-dense particles similar in size to hepatitis B virus nucleocapsids. The possibility of an involvement of a hepatitis non-A non-B virus is discussed.