Image-based dosimetry for [225Ac]Ac-PSMA-I&T therapy and the effect of daughter-specific pharmacokinetics

PURPOSE

Although 221Fr and 213Bi have sufficient gamma emission probabilities, quantitative SPECT after [225Ac]Ac-PSMA-I&T therapy remains challenging due to low therapeutic activities. Furthermore, 221Fr and 213Bi may underlie a different pharmacokinetics due to alpha recoil. We conducted a quantitative SPECT study and a urine analysis to investigate the pharmacokinetics of 221Fr and 213Bi and the impact on image-based lesion and kidney dosimetry.

METHODS

Five patients (7.7 ± 0.2 MBq [225Ac]Ac-PSMA-I&T) underwent an abdominal SPECT/CT (1 h) at 24 and 48 h (Siemens Symbia T2, high-energy collimator, 440 keV/218 keV (width 20%), 78 keV (width 50%)). Quantitative SPECT was reconstructed using MAP-EM with attenuation and transmission-dependent scatter corrections and resolution modelling. Time-activity curves for kidneys (CT-based) and lesions (80% isocontour 24 h) were fitted mono-exponentially. Urine samples collected along with each SPECT/CT were measured in a gamma counter until secular equilibrium was reached.

RESULTS

Mean kidney and lesion effective half-lives were as follows: 213Bi, 27 ± 6/38 ± 10 h; 221Fr, 24 ± 6/38 ± 11 h; 78 keV, 23 ± 7/39 ± 13 h. The 213Bi-to-221Fr kidney SUV ratio increased by an average of 9% from 24 to 48 h. Urine analysis revealed an increasing 213Bi-to-225Ac ratio (24 h, 0.98 ± 0.15; 48 h, 1.08 ± 0.09). Mean kidney and lesion absorbed doses were 0.17 ± 0.06 and 0.36 ± 0.1 Sv RBE = 5 /MBq using 221Fr and 213Bi SPECT images, compared to 0.16 ± 0.05/0.18 ± 0.06 and 0.36 ± 0.1/0.38 ± 0.1 Sv RBE = 5 /MBq considering either the 221Fr or 213Bi SPECT.

CONCLUSION

SPECT/CT imaging and urine analysis showed minor differences of up to 10% in the daughter-specific pharmacokinetics. These variances had a minimal impact on the lesion and kidney dosimetry which remained within 8%.

Estimation of relative biological effectiveness of 225Ac compared to 177Lu during [225Ac]Ac-PSMA and [177Lu]Lu-PSMA radiopharmaceutical therapy using TOPAS/TOPAS-nBio/MEDRAS

AIM

Over recent years, [225Ac]Ac-PSMA and [177Lu]Lu-PSMA radiopharmaceutical therapy have evolved as a promising treatment option for advanced prostate cancer. Especially for alpha particle emitter treatments, there is still a need for improving dosimetry, which requires accurate values of relative biological effectiveness (RBE). To achieve that, consideration of DNA damages in the cell nucleus and knowledge of the energy deposition in the location of the DNA at the nanometer scale are required. Monte Carlo particle track structure simulations provide access to interactions at this level. The aim of this study was to estimate the RBE of 225Ac compared to 177Lu. The initial damage distribution after radionuclide decay and the residual damage after DNA repair were considered.

METHODS

This study employed the TOol for PArtcile Simulation (TOPAS) based on the Geant4 simulation toolkit. Simulation of the nuclear DNA and damage scoring were performed using the TOPAS-nBio extension of TOPAS. DNA repair was modeled utilizing the Python-based program MEDRAS (Mechanistic DNA Repair and Survival). Five different cell geometries of equal volume and two radionuclide internalization assumptions as well as two cell arrangement scenarios were investigated. The radionuclide activity (number of source points) was adopted based on SPECT images of patients undergoing the above-mentioned therapies.

RESULTS

Based on the simulated dose-effect curves, the RBE of 225Ac compared to 177Lu was determined in a wide range of absorbed doses to the nucleus. In the case of spherical geometry, 3D cell arrangement and full radionuclide internalization, the RBE based on the initial damage had a constant value of approximately 2.14. Accounting for damage repair resulted in RBE values ranging between 9.38 and 1.46 for 225Ac absorbed doses to the nucleus between 0 and 50 Gy, respectively.

CONCLUSION

In this work, the consideration of DNA repair of the damage from [225Ac]Ac-PSMA and [177Lu]Lu-PSMA revealed a dose dependency of the RBE. Hence, this work suggested that DNA repair is an important aspect to understand response to different radiation qualities.

Biodistribution and dosimetry for combined [177Lu]Lu-PSMA-I&T/[225Ac]Ac-PSMA-I&T therapy using multi-isotope quantitative SPECT imaging

PURPOSE

Quantitative SPECT for patient-specific dosimetry is a valuable tool in the scope of radionuclide therapy, although its clinical application for ²²⁵Ac-based treatments may be limited due to low therapeutic activities. Therefore, the aim of this study was to demonstrate the feasibility of clinical quantitative low-count SPECT imaging during [¹⁷⁷Lu]Lu-PSMA-I&T/[²²⁵Ac]Ac-PSMA-I&T treatment.

METHODS

Eight prostate cancer patients (1000 MBq/8 MBq [¹⁷⁷Lu]Lu-PSMA-I&T/[²²⁵Ac]Ac-PSMA-I&T) received a single-bed quantitative ¹⁷⁷Lu/²²⁵Ac SPECT/CT acquisition (1 h) at 24 h post treatment (high-energy collimator, 16 projections p. head à 3.5 min, 128 × 128 pixel). The gamma peak at 440 keV (width: 10%) of the progeny ²¹³Bi was imaged along with the peak at 208 keV (width: 15%) of ¹⁷⁷Lu. Quantification included CT-based attenuation and window-based scatter correction plus resolution modelling. Gaussian post-filtering with a full-width-half-maximum of 30 mm and 40-45 mm was employed to match the signal-to-noise ratio of ²²⁵Ac and ¹⁷⁷Lu, respectively.

RESULTS

Kidney (r = 0.96, p < 0.01) and lesion (r = 0.94, p < 0.01) SUV for [¹⁷⁷Lu]Lu-PSMA-I&T and [²²⁵Ac]Ac-PSMA-I&T showed a strong and significant correlation. Kidney SUV were significantly higher (p < 0.01) for [²²⁵Ac]Ac-PSMA-I&T (2.5 ± 0.8 vs. 2.1 ± 0.9), while for [¹⁷⁷Lu]Lu-PSMA-I&T lesion SUV were significantly higher (p = 0.03; 1.8 ± 1.1 vs. 2.1 ± 1.5). For absorbed dose estimates, significant differences regarding the kidneys remained, while no significant differences for lesion dosimetry were found.

CONCLUSION

Quantitative low-count SPECT imaging of the peak at 440 keV during [²²⁵Ac]Ac-PSMA-I&T therapy is feasible. Multi-isotope imaging for [¹⁷⁷Lu]Lu-PSMA-I&T/[²²⁵Ac]Ac-PSMA-I&T therapy indicates accumulation of free ²¹³Bi in the kidneys.

Investigation of image-based lesion and kidney dosimetry protocols for 177Lu-PSMA-I&T therapy with and without a late SPECT/CT acquisition

BACKGROUND

¹⁷⁷Lu-PSMA therapy has been successfully used to prolong the survival of patients with metastatic castration-resistant prostate cancer. Patient-specific dosimetry based on serial quantitative SPECT/CT imaging can support the understanding of dose-effect relationships. However, multiple SPECT/CT measurements can be challenging for patients, which motivates the investigation of efficient sampling schedules and their impact on dosimetry. In this study, different time samplings with respect to the number and timing of SPECT/CT acquisitions with and without a late measurement were investigated.

MATERIALS AND METHODS

In total, 43 lesions and 10 kidneys of 5 patients receiving ¹⁷⁷Lu-PSMA-I&T therapy were investigated. Whole-body SPECT/CT measurements were performed at 1, 2, 3 and 7 days post-injection. For both lesions (isocontour-based segmentation) and kidneys (CT-based segmentation), a reference model was employed including all four time points. To identify the best-matching fit function out of a pre-defined set of models, visual inspection, coefficients of variation and sum of squared errors were considered as goodness-of-fit criteria. Biologically effective doses (BEDs) calculated with different time samplings (days 1, 2, 3/1, 2, 7/1, 3, 7/2, 3, 7 and 1, 2/1, 3/1, 7) were compared to the reference.

RESULTS

The best-fit function was found to be a mono-exponential model for lesions and a bi-exponential model with a population-based parameter and two free parameters for kidneys. The BEDs calculated with the time sampling 1, 3, 7 days showed the lowest deviations from the reference for lesions with 4 ± 5%. Without day 7, still 86% of all lesions showed deviations from the reference < 10%. The outlier deviations showed a positive correlation with the effective half-life of the respective lesions. For kidneys, including days 1, 2, 3 achieved the best results with 0 ± 1%. Generally, deviations for kidneys were found to be small for all time samplings (max. 13%).

CONCLUSIONS

For combined optimization of the SPECT/CT time sampling for kidney and lesion dosimetry during ¹⁷⁷Lu-PSMA-I&T therapy, the sampling with days 1, 3, 7 showed the smallest deviation from the reference. Without a late acquisition, using the schedule with days 1, 2, 3 is likewise feasible.

Cost-effectiveness of additional catheter-directed thrombolysis for deep vein thrombosis

BACKGROUND

Additional treatment with catheter-directed thrombolysis (CDT) has recently been shown to reduce post-thrombotic syndrome (PTS).

OBJECTIVES

To estimate the cost effectiveness of additional CDT compared with standard treatment alone.

METHODS

Using a Markov decision model, we compared the two treatment strategies in patients with a high proximal deep vein thrombosis (DVT) and a low risk of bleeding. The model captured the development of PTS, recurrent venous thromboembolism and treatment-related adverse events within a lifetime horizon and the perspective of a third-party payer. Uncertainty was assessed with one-way and probabilistic sensitivity analyzes. Model inputs from the CaVenT study included PTS development, major bleeding from CDT and utilities for post DVT states including PTS. The remaining clinical inputs were obtained from the literature. Costs obtained from the CaVenT study, hospital accounts and the literature are expressed in US dollars ($); effects in quality adjusted life years (QALY).

RESULTS

In base case analyzes, additional CDT accumulated 32.31 QALYs compared with 31.68 QALYs after standard treatment alone. Direct medical costs were $64,709 for additional CDT and $51,866 for standard treatment. The incremental cost-effectiveness ratio (ICER) was $20,429/QALY gained. One-way sensitivity analysis showed model sensitivity to the clinical efficacy of both strategies, but the ICER remained < $55,000/QALY over the full range of all parameters. The probability that CDT is cost effective was 82% at a willingness to pay threshold of $50,000/QALY gained.

CONCLUSIONS

Additional CDT is likely to be a cost-effective alternative to the standard treatment for patients with a high proximal DVT and a low risk of bleeding.

Escherichia coli ghost production by expression of lysis gene E and Staphylococcal nuclease

The production of bacterial ghosts from Escherichia coli is accomplished by the controlled expression of phage phiX174 lysis gene E and, in contrast to other gram-negative bacterial species, is accompanied by the rare detection of nonlysed, reproductive cells within the ghost preparation. To overcome this problem, the expression of a secondary killing gene was suggested to give rise to the complete genetic inactivation of the bacterial samples. The expression of staphylococcal nuclease A in E. coli resulted in intracellular accumulation of the protein and degradation of the host DNA into fragments shorter than 100 bp. Two expression systems for the nuclease are presented and were combined with the protein E-mediated lysis system. Under optimized conditions for the coexpression of gene E and the staphylococcal nuclease, the concentration of viable cells fell below the lower limit of detection, whereas the rates of ghost formation were not affected. With regard to the absence of reproductive cells from the ghost fractions, the reduction of viability could be determined as being at least 7 to 8 orders of magnitude. The lysis process was characterized by electrophoretic analysis and absolute quantification of the genetic material within the cells and the culture supernatant via real-time PCR. The ongoing degradation of the bacterial nucleic acids resulted in a continuous quantitative clearance of the genetic material associated with the lysing cells until the concentrations fell below the detection limits of either assay. No functional, released genetic units (genes) were detected within the supernatant during the lysis process, including nuclease expression.

Protective immunity against pasteurellosis in cattle, induced by Pasteurella haemolytica ghosts

Pasteurella haemolytica is a cattle pathogen of significant economic impact. An effective vaccine against bovine pneumonic pasteurellosis is therefore of high importance. Apart from economic concerns, pasteurellosis caused by P. haemolytica is a serious disease leading to death in cattle if it remains untreated. In this study P. haemolytica-ghosts are presented as a promising vaccine candidate in cattle. To obtain sufficient vaccination material a fermentation protocol for P. haemolytica-ghost production was established. With the obtained experimental P. haemolytica-ghost vaccine, cattle immunization studies were performed based on a Pasteurella cattle challenge model developed specifically for vaccine validation. It was shown that protective immunization of cattle against homologous challenge was induced by adjuvanted P. haemolytica-ghosts. The level of protection was similar to a commercially available vaccine.

Decreased glomerular expression of agrin in diabetic nephropathy and podocytes, cultured in high glucose medium

AIM

A decrease in glomerular heparan sulfate (HS) proteoglycan (PG), without apparent decrease in HSPG core protein expression, has been reported to occur in diabetic nephropathy (DN). In most studies however, agrin, the major HSPG core protein in the glomerular basement membrane, has not been studied. This prompted us to study the glomerular expression of agrin in parallel to the expression of HS-glycosaminoglycans (GAG) in biopsies of patients with DN. Furthermore, the influence of glucose on agrin production in cultured podocytes and the expression of agrin in fetal kidneys was investigated.

METHODS

Cryostat sections of renal biopsies from patients with DN (n = 8) and healthy controls (HC, n = 8), were stained for agrin and HS-GAG. Sections of fetal kidneys were double stained for agrin and CD35 or CD31. Stainings were performed by indirect immunofluorescence (IIF). The production of agrin by cultured human podocytes was tested by ELISA and IIF.

RESULTS

The expression of agrin, detected by AS46, was significantly reduced in biopsies from patients with DN compared to HC (p < 0.01). Similar findings were observed when monoclonal antibody JM72 was used (p < 0.05). In addition, a significant reduction in the glomerular expression of HS-GAG was detected with JM403 in these patients (p < 0.01). Agrin is expressed in cultured podocytes, the expression hereof was reduced when the cells were cultured in the presence of 25 mM D-glucose (p < 0.01). In biopsies of human fetal kidneys, glomerular expression of agrin coincided with the expression of CD31. In early stages of glomerular differentiation there was a strong staining for agrin and CD31 while CD35 was only slightly positive.

CONCLUSIONS

Our data argue against a selective dysregulation in HSPG sulfation in DN, but suggest a pivotal role for hyperglycemia in the downregulation of agrin core protein production.

Comparative studies in the promoter and exon 1 regions of tumour suppressor p53 in several mammalian species: absence of mutations in a panel of spontaneous domestic animal tumours

Tumour suppressor p53 is critical in a broad panel of tumour types in human, mouse and other mammals. Regions of the promoter and exon 1 play an important role in expression of p53. In the present study, the DNA sequences of promoter and exon 1 regions of four domestic animal species (dog, cat, horse and cattle) are determined and compared with experimental rodents (mouse, rat and hamster) and man. A broad panel of tumour types have been investigated for mutations in this regulatory area in 90 canine, 136 feline, 25 equine and 10 bovine patients. No mutation was detected in any of the tumours analysed.

Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity

Between 1990 and 1995, 38 patients (42 feet) underwent repair for crossover toe deformity, 31 (35 feet) of whom returned for final examination at an average of 51.6 months (range, 24-81 months). Causes included trauma, iatrogenic, and unknown. Presenting complaints included dorsal pain with either metatarsalgia or joint pain, isolated metatarsophalangeal (MP) joint pain, metatarsalgia, painful plantar callus, metatarsalgia and joint pain, and painful dorsal callus. All patients were treated with one of two operative techniques, either the flexor-to-extensor tendon transfer or the extensor brevis tendon transfer. Choice of procedure depended on the stage of preoperative deformity. Twenty-four patients were completely satisfied with the surgical correction, 6 were satisfied with reservations, and 1 was dissatisfied. The average postoperative AOFAS score for all patients was 85 points (range, 54-100 points), which correlated strongly with patient satisfaction. Twenty-two patients stated that they had no postoperative pain, 8 reported some pain, and 1 had frequent pain at the corrected toe. In 30 feet, there was no recurrence; three patients had mild residual crossover toe deformity, and two patients had recurrent deformity, although all MP joints were stable. Follow-up radiographs demonstrated substantial reduction in MP joint angles in both the AP (from 7 degrees to -1 degree) and lateral (from 45 degrees to 25 degrees) projections. This article reviews the surgical technique of both procedures, proposes specific indications for each, and presents outcomes. Based on our findings, the extensor brevis tendon transfer is appropriate for stage 1, stage 2, and flexible stage 3 deformities. Flexor-to-extensor tendon transfer is appropriate for rigid stage 3 and stage 4 deformities and for all patients with a symptomatic neuroma of the second web space (where the extensor brevis transfer is not possible). Stiffness of the MP joint is a potential problem with the flexor-to-extensor tendon transfer.

Extended recombinant bacterial ghost system

Controlled expression of cloned PhiX174 gene E in Gram-negative bacteria results in lysis of the bacteria by formation of an E-specific transmembrane tunnel structure built through the cell envelope complex. Bacterial ghosts from a variety of bacteria are used as non-living candidate vaccines. In the recombinant ghost system, foreign proteins are attached on the inside of the inner membrane as fusions with specific anchor sequences. Ghosts have a sealed periplasmic space and the export of proteins into this space vastly extends the capacity of ghosts or recombinant ghosts to function as carriers of foreign antigens. In addition, S-layer proteins forming shell-like self assembly structures can be expressed in candidate vaccine strains prior to E-mediated lysis. Such recombinant S-layer proteins carrying foreign epitopes further extend the possibilities of ghosts as carriers of foreign epitopes. As ghosts have inherent adjuvant properties, they can be used as adjuvants in combination with subunit vaccines. Subunits or other ligands can also be coupled to matrixes like dextran which are used to fill the internal lumen of ghosts. Oral, aerogenic or parenteral immunization of experimental animals with recombinant ghosts induced specific humoral and cellular immune responses against bacterial and target components including protective mucosal immunity. The most relevant advantage of recombinant bacterial ghosts as immunogens is that no inactivation procedures that denature relevant immunogenic determinants are employed in this production. This fact explains the superior quality of ghosts when compared to other inactivated vaccines. The endotoxic component of the outer membrane does not limit the use of ghosts as vaccine candidates but triggers the release of several potent immunoregulatory cytokines. As carriers, there is no limitation in the size of foreign antigens that can be inserted in the membrane and the capacity of all spaces including the membranes, peri-plasma and internal lumen of the ghosts can be fully utilized. This extended recombinant ghost system represents a new strategy for adjuvant free combination vaccines.

New strategies for combination vaccines based on the extended recombinant bacterial ghost system

Controlled expression of cloned PhiX174 gene E in Gram-negative bacteria results in lysis of the bacteria by formation of an E-specific transmembrane tunnel structure built through the cell envelope complex. Bacterial ghosts have been produced from a great variety of bacteria and are used as non-living candidate vaccines. In the recombinant ghost system, foreign proteins are attached on the inside of the inner membrane as fusions with specific anchor sequences. Ghosts have a sealed periplasmic space and the export of proteins into this space vastly extents the capacity of ghosts or recombinant ghosts to function as carriers of foreign antigens, immunomodulators or other substances. In addition, S-layer proteins forming shell-like self assembly structures can be expressed in bacterial candidate vaccine strains prior to E-mediated lysis. Such recombinant S-layer proteins carrying inserts of foreign epitopes of up to 600 amino acids within the flexible surface loop areas of the S-layer further extend the possibilities of ghosts as carriers of foreign epitopes. As ghosts do not need the addition of adjuvants to induce immunity in experimental animals they can also be used as carriers or targeting vehicles or as adjuvants in combination with subunit vaccines. Matrixes like dextran which can be used to fill the internal lumen of ghosts can be substituted with various ligands to bind the subunit or other materials of interest. Oral, aerogenic or parenteral immunization of experimental animals with recombinant ghosts induced specific humoral and cellular immune responses against bacterial and target components including protective mucosal immunity. The most relevant advantage of ghosts and recombinant bacterial ghosts as immunogens is that no inactivation procedures that denature relevant immunogenic determinants are employed in the production of ghosts. This fact explains the superior quality of ghosts when compared to other inactivated vaccines. As carriers of foreign antigens there is no limitation in the size of foreign antigens to be inserted and the capacity of all spaces including the membranes, periplasma and internal lumen of the ghosts can be fully utilized. Using the different building blocks and combining them into the recombinant ghost system represents a new strategy for adjuvant free combination vaccines.

Heterologous phi X174 gene E-expression in Ralstonia eutropha: E-mediated lysis is not restricted to gamma-subclass of proteobacteria

E-lysis of Ralstonia eutropha H16, which belongs to the beta-subclass, was undertaken to verify whether transmembrane tunnel formation is possible in bacteria which do not belong to the enterobacteriaceae. For this purpose, a new gene E expression plasmid, pKG12, with two origins of replication, oriV and oriT, from plasmid pRP4, chloramphenicol and kanamycin resistance genes and a casette composed of lambda cI857 and lambda pR gene E was constructed. Temperature upshift of R. eutropha H16 (pKG12) from 28 to 45 degrees C during exponential growth resulted in lysis of the strain with features characteristic of E-mediated lysis of Escherichia coli. The cytoplasmic contents released can easily be separated from the still intact envelope fraction by centrifugation or filtration. As R. eutropha H16 represents an important industrial organism, E-mediated lysis could facilitate procedures for the recovery of intracellular mediators or products like polyhydroxyalkanoates.

Aqueous release and purification of poly(beta-hydroxybutyrate) from Escherichia coli

The poly(beta-hydroxybutyrate) (PHB) biosynthetic genes of Ralstonia eutropha that are organized in a single operon (phaCAB) have been cloned in Escherichia coli, where the expression of the genes in the wild-type pha operon from plasmid pTZ18U-PHB leads to the formation of 50-80% PHB/celldry mass when the cells are grown in Luria-Bertani medium supplemented with 1% glucose (w/v). In combination with the phaCAB genes, expression of cloned lysis gene E of bacteriophage PhiX174 from plasmid pSH2 has been used to release PHB granules produced in E. coli. It was shown that small PHB granules in a semiliquid stage are squeezed out of the cells through the E-lysis tunnel structure which is characterized by a small opening in the envelope with borders of fused inner and outer membranes. All envelope components remain intact after E-lysis and can be removed from the mixture of released PHB granules by density gradient centrifugation. In addition, a modified E-lysis procedure is described which enables the release of PHB from cell pellets in pure water or low ionic strength buffer. PHB granules in aqueous solution can be aggregated by divalent cations. Addition of glassmilk speeds up the agglomeration of PHB granules and binding to glass beads can either be used for collection or further purification of PHB in aqueous solutions.

Radiographic and clinical classification of acquired midtarsus deformities

To develop a classification of midtarsus deformities, clinical examination and weightbearing radiographs were used to evaluate 131 feet in 109 patients (average age, 59+/-11 years) with those deformities. Patients were classified into four types based on anatomic location of the maximum deformity. Type I (N=43) showed deformity at the metatarsocuneiform joints medially and the fourth and fifth metatarsocuboid joints laterally, with plantarmedial and/or medial prominence. Type II (N= 60) had deformity at the naviculocuneiform joint medially and the fourth and fifth metatarsocuboid joints laterally; plantarlateral prominence was characteristic, although one-third had isolated or additional medial prominences. Type III (N=17) had major deformity in the perinavicular region, with a prominence plantarcentrally or plantarlaterally. Type IV (N=11) had deformity at the transverse tarsal joints with variable prominences. Each type was further subdivided into stages A, B, and C based on the severity of the deformity. In stage B, the midtarsus was coplanar with the metatarsocalcaneal plane. In stage A, the midtarsus was above this plane. In stage C, the midtarsus was below this plane. We concluded that midtarsus deformities can be classified as one of four types and one of three stages. Additional study is warranted to correlate this system with prognosis and treatment for this pathologic process.

Preoperative traction for hip fracture: a randomized comparison between skin and skeletal traction in 78 patients

153 consecutive patients with displaced cervical and trochanteric hip fractures were considered for inclusion in this study. 75 were excluded because of senile confusion and the remaining 78 were randomized to skeletal or skin traction preoperatively. The effect on pain alleviation was evaluated with a Visual Analogue Scale (VAS) and by the number of doses of analgesics administered. The processing time through the emergency department, radiographic department and to the ward, as well as time to operation, was registered. No significant difference in the VAS pain evaluation was found. There was a small significant increase in consumption of analgesics of no clinical importance in patients with skin traction, and no effect of traction type on the processing time or time to operation. Fracture type did not affect the outcome. Since half of the patients found the application of skeletal traction painful, compared to one fifth with skin traction, skeletal traction should not be routinely used to alleviate pain preoperatively in these patients.

Molecular biology of S-layers

In this chapter we report on the molecular biology of crystalline surface layers of different bacterial groups. The limited information indicates that there are many variations on a common theme. Sequence variety, antigenic diversity, gene expression, rearrangements, influence of environmental factors and applied aspects are addressed. There is considerable variety in the S-layer composition, which was elucidated by sequence analysis of the corresponding genes. In Corynebacterium glutamicum one major cell wall protein is responsible for the formation of a highly ordered, hexagonal array. In contrast, two abundant surface proteins from the S-layer of Bacillus anthracis. Each protein possesses three S-layer homology motifs and one protein could be a virulence factor. The antigenic diversity and ABC transporters are important features, which have been studied in methanogenic archaea. The expression of the S-layer components is controlled by three genes in the case of Thermus thermophilus. One has repressor activity on the S-layer gene promoter, the second codes for the S-layer protein. The rearrangement by reciprocal recombination was investigated in Campylobacter fetus. 7-8 S-layer proteins with a high degree of homology at the 5' and 3' ends were found. Environmental changes influence the surface properties of Bacillus stearothermophilus. Depending on oxygen supply, this species produces different S-layer proteins. Finally, the molecular bases for some applications are discussed. Recombinant S-layer fusion proteins have been designed for biotechnology.

Bacterial ghosts as multifunctional vaccine particles

Expression of cloned PhiX174 gene E in Gram-negative bacteria results in lysis of the bacteria by formation of an E-specific transmembrane tunnel structure built through the cell envelope complex. Bacterial ghosts have been produced from a variety of bacteria including Escherichia coli. Salmonella typhimurium, Salmonella enteritidis, Vibrio cholerae, Klebsiella pneumoniae, Actinobacillus pleuropneumoniae, Haemophilus influenzae, Pasteurella haemolytica, Pasteurella multocida, and Helicobacter pylori. Such ghosts are used as non-living candidate vaccines and represent an alternative to heat or chemically inactivated bacteria. In recombinant ghosts, foreign proteins can be inserted into the inner membrane prior to E-mediated lysis via specific N-, or C-, or N- and C-terminal anchor sequences. The export of proteins into the periplasmic space or the expression of recombinant S-layer proteins vastly extents the capacity of ghosts or recombinant ghosts as carriers of foreign epitopes or proteins. Oral, aerogenic or parenteral applications of (recombinant) ghosts in experimental animals induced specific humoral and cellular immune responses against bacterial and target components including protective mucosal immunity. The most relevant advantage of ghosts and recombinant bacterial ghosts as immunogens is that no inactivation procedures that denature relevant immunogenic determinants are employed in the production of ghosts used as vaccines or as carriers of relevant antigens. The inserted target antigens into the inner membrane or into S-layer proteins are not limited in size.

Presence of renin within intramitochondrial dense bodies of the rat adrenal cortex

It has been suggested that tissue-specific expression of the genes of the renin-angiotensin system (RAS) leads to local generation of angiotensin (ANG) II with specific physiological implications. We demonstrate here that an intracellular RAS exists in adrenal glomerulosa cells; 60 h after bilateral nephrectomy and hemodialysis, renin and prorenin were eliminated from the circulation, whereas intra-adrenal renin content increased (control rats: 2 +/- 0.5 ng ANG I.mg-1.h-1; anephric rats: 25 +/- 2). Thus renin is produced locally within adrenal cells. We obtained immunocytochemical and biochemical evidence for the presence of renin within intramitochondrial dense bodies of the zona glomerulosa. After nephrectomy, dense bodies increased in number, size, and renin content (control rats: 2.5 +/- 0.7 ngANGI.mg-1.h-1; anephric rats: 43 +/- 7). Angiotensin-converting enzyme (ACE) was also present within mitochondria and their dense bodies. In addition, in adrenal cortex of anephric rats, giant dense bodies were observed, which contain renin and strongly react with an anti-angiotensinogen antibody. The localization of renin, ACE, and angiotensinogen at these sites provides new evidence for the existence of an intracellular adrenal RAS.

Parallel regulation of constitutive NO synthase and renin at JGA of rat kidney under various stimuli

Four chronic experiments were performed to assess changes in the activity and gene expression of type I nitric oxide synthase (NOS) at the macula densa (MD) and of renin expression and immunoreactivity (IR) at the juxtaglomerular apparatus (JGA) of rat kidney, as follows: 1) two-kidney, one-clip Goldblatt hypertension (2K1C, for 3 and 40 days; sham operation for controls), 2) furosemide treatment (150 mg/kg-1.day-1 ip for 5 days), 3) chronic low-salt diet (0.02%) vs. high-salt diet (3%; both for 11 days), and 4) chronic blockade of NOS by nitro-L-arginine methyl ester (L-NAME, 40 mg.kg-1.day-1 for 2 mo). NOS and renin gene expression, NOS enzyme activity and renin IR were semiquantitatively evaluated with histochemical methods (NADPH diaphorase, in situ hybridization, immunohistochemistry). In 2K1C, marked increases were induced in NOS and renin in the ischemic vs. contralateral kidneys both after 3 and 40 days, respectively (P < 0.05). Related to controls, significant increases in the ischemic kidney were encountered after 3 and 40 days, whereas contralateral suppression of NOS and renin was found only after 40 days. Furosemide treatment resulted in a marked increase of both NOS and renin levels compared with controls (P < 0.05). Salt restriction induced a significant elevation of NOS levels compared with salt loading (P < 0.05), whereas only minor changes were evident in renin levels. L-NAME treatment resulted in a moderate reduction of NOS activity (not significant), whereas renin levels were markedly reduced (P < 0.05). These results show that NOS activity and gene expression are inversely related to chronic changes in renal perfusion, salt balance, and salt transport at the distal tubule in parallel with the known response of renin to these changes. Inhibition of NOS decreases renin levels at the JGA. The histochemical findings support previous concepts that MD-derived NO is involved in the control of renin synthesis.

[Significance of serum troponin T in the differential diagnosis of myocardial infarct vs rhabdomyolysis vs renal insufficiency]

HISTORY AND FINDINGS

A 30-year-old man in renal failure due to focal sclerosing glomerulonephritis was, after a seizure with subsequent rhabdomyolysis, found to have an increase not only of creatinekinase (CK) activity (> 100,000 U/l) but also of cardiac troponin T (cTnT) concentration in serum (13 micrograms/l; normal: < 0.1 microgram/l), in the absence of any cardiac symptoms.

COURSE

Raised concentration of cTnT is known to occur in patients with renal failure but no cardiac symptoms. In our patient, despite increased creatinine levels, serum cTnT gradually fell to normal within 3 weeks, i.e. the raised creatinine played no part in the elevation of cTnT, which in this patient was probably due to crossreaction between cardiac and skeletal TnT, or transient fresh synthesis of cTnT in regenerating skeletal musculature.

CONCLUSIONS

In patients with extensive rhabdomyolysis and renal failure the assessment of the clinical status and the ECG, to exclude myocardial infarction, are of crucial importance. The cTnT level by itself is of only limited value in such cases.

Measurement of the forefoot with roentgen stereophotogrammetry in hallux valgus surgery

Eight hallux valgus patients were marked with tantalum markers in conjunction with hallux valgus surgery (seven proximal osteotomies and one chevron osteotomy). Changes on weightbearing before surgery as well as corrective changes after surgery were analyzed with roentgen stereophotogrammetry (RSA) and with standard x-rays. RSA is accurate to 0.6 degrees in rotational changes and 0.3 mm in translation. Weightbearing changes were inconsistent, and minimal with both standard x-rays and RSA. It was possible to analyze the correction at the osteotomy site with RSA. In half the cases, the correction measured by RSA corresponded with that measured with standard x-rays, within measurement error; in the other cases, RSA showed that the correction was of a different size or direction than that measured on standard x-rays. Corrective changes in hallux valgus surgery are complex, including angular and translational changes at several levels and in several joints in order to produce a clinical resultant. Rotational changes can be evaluated with RSA. Although RSA in an optimal situation is very accurate, it is still limited to a laboratory setting.

Measuring hallux valgus: a comparison of conventional radiography and clinical parameters with regard to measurement accuracy

To assess the repeatability and error of conventional x-ray measurements, intra- and interobserver evaluations of measurement accuracy were done on 20 preoperative and 40 postoperative (20 chevron and 20 proximal osteotomy) x-rays of hallux valgus patients. Standard x-rays showed an average interobserver error of measurement of 6.4 degrees for the hallux valgus angle, 5.4 degrees for the intermetatarsal angle, and 2.0 mm for the intermetatarsal distance. The intraobserver error did not differ greatly. The repeatability and error of two clinical measurements, ball circumference, and dorsal to plantar range of motion of the first metatarsophalangeal joint were evaluated for 20 healthy volunteers. The ball circumference had an average measurement error of 1.1 cm, whereas the dorsal and plantar range of motion of the great toe had an average measurement error of 12 degrees in dorsiflexion and 16 degrees in plantarflexion. In both clinical and radiographic parameters, linear measurements were more accurate than angular measurements. Although x-rays are of value in hallux valgus surgery, standard x-rays are less accurate than previously assumed. Small changes produced by osteotomies may be hidden by the postoperative measurement error. The results of hallux valgus surgery should primarily be evaluated clinically. When clinical and radiological evaluations are made, linear measurements may be preferable.

Chevron osteotomy for hallux valgus not improved by additional adductor tenotomy. A prospective, randomized study of 84 patients

We investigated 106 feet in 84 patients in a prospective randomized series where the clinical and radiographic results of the original chevron osteotomy were compared to the same procedure with the addition of an adductor tenotomy in patients averaging 47 years of age and with a mean follow-up of 3 years. Clinically there was no difference in the satisfaction rate of the two groups, with 58 satisfied and partially satisfied in the 62 operated by chevron osteotomy alone, and 42 of 44 in the group where adductor tenotomy was added. The hallux valgus angle decreased by 7.5 degrees in the group operated with chevron osteotomy and by 9.8 degrees (P 0.04) when an adductor tenotomy was added. The major objective factor affecting satisfaction was the attainment of a decreased ball circumference, shown by the fact that dissatisfied patients had a greater postoperative ball circumference than both satisfied and partially satisfied patients, whereas there were no radiographic correlations to satisfaction. We cannot recommend adding adductor tenotomy to the chevron osteotomy.

The diagnostic efficacy of magnetic resonance imaging and ultrasonography in Morton's neuroma: a radiological-surgical correlation

All patients operated upon for Morton's neuroma during 1991 who were examined with both magnetic resonance imaging and ultrasonography were included in this prospective study. The object of the study was to evaluate the diagnostic value of these two modalities. The preoperative diagnosis was purely clinical. Histology confirmed surgical findings. A 0.3 T scanner was used for the magnetic resonance imaging, and a 7.5 MHz linear transducer was used for the ultrasonography. The study includes nine patients. Eight neuromas were found at surgery. Of these, only five were diagnosed with magnetic resonance imaging and three with ultrasonography. This indicates that false negative diagnoses are common. At present we find these modalities of little or no value, but, with improved equipment and experience, they may become valuable.

Circulatory disturbance of the first metatarsal head after Chevron osteotomy as shown by bone scintigraphy

Distal osteotomies, such as Chevron osteotomies, have a potentially high risk for circulatory disturbance, since they transect part of the circulatory apparatus. An increased risk of up to 40% of avascular necrosis diagnosed radiographically has been reported when the osteotomy is combined with adductor tenotomy. On the other hand, new circulatory studies indicate that the circulation does not go in direct proximity to the adductor tendon. In this prospective study, 38 consecutive patients (41 feet) were randomized to Chevron osteotomy alone or Chevron osteotomy with adductor tenotomy. They were investigated 2 to 9 days postoperatively with 99mTc-methylene diphosphonate scintigraphy as well as x-rays and clinical examination. The average follow up was 19 months (range 12-48 months). Three defects were found in those operated with Chevron osteotomy alone, and one defect was found in a patient operated with Chevron osteotomy and adductor tenotomy. None of the patients had symptoms attributable to reduced circulation of the metatarsal head. Repeat scans showed healing in all four cases. Radiographs failed to show any signs of necrosis. Thus, Chevron osteotomy is a safe method in the treatment of hallux valgus which can be combined with adductor tenotomy without increasing the risk for circulatory disturbance.

The treatment of tarsometatarsal injuries

In order to analyze the value of operative treatment for tarsometatarsal injuries, 31 consecutive fracture-dislocation injuries from 1975 to 1988, and 11 cases of undislocated injuries were reviewed. Forty patients (41 injuries) could be contacted. The average follow up was 5 years. Twenty-two of the dislocated injuries were treated with open reduction and fixation, usually K-wires. All injuries were classified radiologically. By means of a questionnaire, it was found that 7 had excellent results, 13 good, and 21 poor. No case where anatomical reduction was not achieved could be classified as excellent, and half (5 of 10) received full disability pension. When anatomical reduction was achieved, half had good or excellent results and only 5 of 20 received a disability pension. Initially undislocated injuries had a better prognosis, with 8 of 11 having excellent or good results, and none receiving pension. These injuries should be treated aggressively with open reduction and fixation when there is any displacement. Despite this treatment, one-half of patients with dislocated injuries as well as one-fourth of those with initially undislocated injuries will still suffer from pain and permanent disability probably due to soft tissue damage and instability.

Proximal closing wedge osteotomy and adductor tenotomy for treatment of hallux valgus

After 2 to 4 years, 25 patients (27 feet) who had a proximal closing wedge osteotomy of the first metatarsal and an adductor tenotomy were reviewed. A total of 20 patients (22 of 27 feet) were completely satisfied; 5 patients not completely satisfied had metatarsalgia because of dorsal displacement of the first metatarsal head. Radiographic measurements showed a narrowing of the forefoot rather than a large change in the intermetatarsal angle. The recovery period was long, an average of 11 weeks. Pin inflammation occurred in 5 patients and incisional neuromas in 2 patients. The risk of these complications must be taken into consideration when using this operation.