Human Blood and Tonsil Plasmacytoid Dendritic Cells Display Similar Gene Expression Profiles but Exhibit Differential Type I IFN Responses to Influenza A Virus Infection

Influenza A virus (IAV) infection constitutes an annual health burden across the globe. Plasmacytoid dendritic cells (PDCs) are central in antiviral defense because of their superior capacity to produce type I IFNs in response to viruses. Dendritic cells (DCs) differ depending on their anatomical location. However, only limited host-pathogen data are available from the initial site of infection in humans. In this study, we investigated how human tonsil PDCs, likely exposed to virus because of their location, responded to IAV infection compared with peripheral blood PDCs. In tonsils, unlike in blood, PDCs are the most frequent DC subset. Both tonsil and blood PDCs expressed several genes necessary for pathogen recognition and immune response, generally in a similar pattern. MxA, a protein that renders cells resistant to IAV infection, was detected in both tonsil and blood PDCs. However, despite steady-state MxA expression and contrary to previous reports, at high IAV concentrations (typically cytopathic to other immune cells), both tonsil and blood PDCs supported IAV infection. IAV exposure resulted in PDC maturation by upregulation of CD86 expression and IFN-α secretion. Interestingly, blood PDCs secreted 10-fold more IFN-α in response to IAV compared with tonsil PDCs. Tonsil PDCs also had a dampened cytokine response to purified TLR ligands compared with blood PDCs. Our findings suggest that tonsil PDCs may be less responsive to IAV than blood PDCs, highlighting the importance of studying immune cells at their proposed site of function.

Trismus in patients with head and neck cancer and 5-year overall survival

BACKGROUND

Trismus is a common complication of radiotherapy for head and neck cancer but its impact on survival is unknown.

AIMS/OBJECTIVES

This prospective study evaluates the incidence of trismus in patients with head and neck cancer receiving radiotherapy and the impact of trismus on 5-year overall survival.

MATERIAL AND METHODS

Two hundred forty-four patients with head and neck cancer were included. All patients received instructions on jaw exercises and were evaluated before initiation of radiotherapy and at 2, 6, and 12 months after termination of radiotherapy.

RESULTS

One year after treatment 25% had a reduced maximum interincisal opening (MIO) of 13 mm or more as compared to the pretreatment MIO. Trismus was most prevalent in patients with oral and oropharyngeal cancer. A trend towards worse 5-year overall survival was seen among patients with trismus.

CONCLUSIONS

The trismus rate was approximately 30% at 12 months. Jaw exercises should primarily be offered to patients with oral and oropharyngeal cancer who are most likely to benefit. Further studies are required to investigate the effect of trismus on survival.

SIGNIFICANCE

This study identifies patients likely to benefit from jaw exercises and provides basis for further research on trismus and survival.

Human papillomavirus prevalence in mouthwashes of patients undergoing tonsillectomy shows dominance of HPV69, without the corresponding finding in the tonsils

BACKGROUND

The role of human papillomavirus (HPV) in tonsillar squamous cell carcinomas (TSCC) is of interest, since a considerable proportion of TSCC in Sweden and other Western countries is HPV positive. Nevertheless, the natural history of HPV in normal tonsils, and the progression from localized infection to pre-malignant lesion to cancer are poorly understood. The aim of this study was to investigate whether HPV types found in mouthwash samples correlated to those in tonsillar tissue from the same individuals undergoing tonsillectomy.

METHODS

Mouthwash samples from 232 patients, aged 3-56 years, undergoing tonsillectomy, the majority with chronic tonsillitis, were collected at the time of surgery and analysed for the presence of 27 HPV types by a bead based multiplex assay.

RESULTS

An HPV prevalence of 10.3% (24/232) was observed in mouthwash samples, with HPV 69 being the dominant type (10/24). Ten patients were positive for high risk HPV (HPV 16, 33, 35, 45, 56, 59). None of the tonsils resected from patients with HPV-positive mouthwash samples were positive for HPV.

CONCLUSIONS

Despite an oral HPV prevalence of 10.3% in mouthwash samples from tonsillectomized patients, with dominance of HPV 69, none of the corresponding tonsillar samples exhibited the presence of HPV.

Early self-care rehabilitation of head and neck cancer patients

Conclusions: No positive effects of early preventive rehabilitation could be identified. The results do not contradict the proposition that rehabilitation based on self-care can be effective but it is important to establish evidence-based training programs and identify proper instruments for selection of patients and evaluation of intervention. Objectives: Patients with head and neck cancer suffer from functional impairments due to intense treatment. In this study, we investigated the effectiveness of an experimental early preventive rehabilitation using hard, objective end points in a nonselective, longitudinal, prospective cohort study. Methods: In all, 190 patients were included in the program and received instructions for training before the start of treatment with the aim of reducing swallowing problems and reducing mouth opening and stiffness in the neck. A control group of 184 patients was recruited. Results: There was no difference in weight loss and 2-year survival between the two groups. No positive effects concerning functional impairments were found in patient-reported outcome measures.

Morbidity of supraomohyoidal and modified radical neck dissection combined with radiotherapy for head and neck cancer: a prospective longitudinal study

BACKGROUND

The purpose of this study was to show the investigated impact of supraomohyoidal neck dissection and modified radical neck dissection, both combined with radiotherapy, on cervical range of motion (CROM), mouth opening, swallowing, lymphedema, and shoulder function.

METHODS

One hundred eight patients who had neck dissections and 98 patients who had non-neck dissections were evaluated in a prospective, nonselective, longitudinal cohort study by a physiotherapist and a speech-language pathologist (SLP) before the start of radiotherapy and up to 12 months after treatment.

RESULTS

The incidence of shoulder disability after neck dissection was 18%. Supraomohyoidal neck dissection had no significant effect on the evaluated parameters at any time point. Modified radical neck dissection significantly reduced CROM and mouth opening 2 months after treatment, but after 12 months only cervical rotation was still significantly reduced.

CONCLUSION

In patients treated with external beam radiation (EBRT), modified radical neck dissection induced additional morbidity regarding CROM but not regarding mouth opening, swallowing, and lymphedema 1 year after treatment. Both modified radical neck dissection and supraomohyoidal neck dissection induced shoulder disability.

Esophageal stricture after radiotherapy in patients with head and neck cancer: experience of a single institution over 2 treatment periods

BACKGROUND

Risk factors for development of a stricture of the upper esophagus after radiotherapy for head and neck cancer are poorly defined.

METHODS

This was a retrospective case-control study of patients diagnosed and treated for esophageal stricture after radiotherapy for head and neck cancer.

RESULTS

The incidence of esophageal stricture after external beam radiation therapy (EBRT) was 3.3%. Seventy patients with stricture and 66 patients without stricture were identified. A multivariate analysis showed that there was increased risk of stricture in receiving enteral feeding during EBRT or in receiving a mean dose of >45 Gy to the upper esophagus.

CONCLUSIONS

Enteral feeding during EBRT is strongly associated with the development of stricture of the esophagus, as is a mean dose of >45 Gy to the upper esophagus. Treatment of the stricture with Savary-Gilliard bougienage or through scope balloon dilatation is safe and successful but often has to be repeated.

Dose-response relations for stricture in the proximal oesophagus from head and neck radiotherapy

BACKGROUND AND PURPOSE

Determination of the dose-response relations for oesophageal stricture after radiotherapy of the head and neck.

MATERIAL AND METHODS

In this study 33 patients who developed oesophageal stricture and 39 patients as controls are included. The patients received radiation therapy for head and neck cancer at Karolinska University Hospital, Stockholm, Sweden. For each patient the 3D dose distribution delivered to the upper 5 cm of the oesophagus was analysed. The analysis was conducted for two periods, 1992-2000 and 2001-2005, due to the different irradiation techniques used. The fitting has been done using the relative seriality model.

RESULTS

For the treatment period 1992-2005, the mean doses were 49.8 and 33.4 Gy, respectively, for the cases and the controls. For the period 1992-2000, the mean doses for the cases and the controls were 49.9 and 45.9 Gy and for the period 2001-2005 were 49.8 and 21.4 Gy. For the period 2001-2005 the best estimates of the dose-response parameters are D(50)=61.5 Gy (52.9-84.9 Gy), γ=1.4 (0.8-2.6) and s=0.1 (0.01-0.3).

CONCLUSIONS

Radiation-induced strictures were found to have a dose response relation and volume dependence (low relative seriality) for the treatment period 2001-2005. However, no dose response relation was found for the complete material.

Clinical outcome following radiotherapy and planned neck dissection in N+ head and neck cancer patients

CONCLUSIONS

This study confirms earlier findings that patients with viable tumour cells in the neck after external beam radiotherapy (EBRT) have a poor prognosis. The study also indicates that neck dissection (ND) does not change the prognosis for patients with a complete clinical response in the neck. At the moment our guidelines concerning this matter are being reviewed.

OBJECTIVES

The protocol at our institution stipulates a planned ND in patients with metastasis in the neck after EBRT regardless of the response in the neck. As the necessity for a planned ND has not been clarified we wanted to evaluate our results.

PATIENTS AND METHODS

Patients diagnosed from 1998 to 2002 with metastasis in the neck who received EBRT were evaluated for histopathological findings and clinical outcome.

RESULTS

A total of 156 patients were included. Overall survival was 62% and disease-specific survival was 76%. There was a complete response (CR) in the neck in 63 patients (40%); among these 15 had viable tumour cells in the neck. In patients not achieving CR, 40% (37/93) had viable tumour cells left in the neck. Patients with viable tumour cells in the neck after EBRT had disease-specific survival of 48% compared with 90% among patients without viable tumour cells.

[Future cure of hearing disorders? Gene therapy and stem cell implantation are possible new therapeutic alternatives]

Hearing loss is a very common disorder; nearly 10 per cent of the population is affected. Recently, a few findings such as the roles of neurotrophins, nitric oxide, reactive oxygen species and glutamate receptors in the peripheral hearing system have been highlighted. In this review, focus is set on possible mechanisms of peripheral hearing disorders, and on recent advances to prevent and treat hearing loss. Clinically useful treatment strategies, especially gene therapy and the use of embryonic stem cells, are particularly stressed.

Comparison of acute rest myocardial perfusion imaging and serum markers of myocardial injury in patients with chest pain syndromes

BACKGROUND

Newer diagnostic modalities such as serum markers and acute rest myocardial perfusion imaging (MPI) have been evaluated diagnostically in patients with chest pain in the emergency department (ED), but never concurrently. We compared these two modalities in distinguishing patients in the ED with symptomatic myocardial ischemia from those with non-cardiac causes.

METHODS

Serum markers and acute technetium-99m sestamibi/tetrofosmin rest MPI were obtained in 75 patients admitted to the ED with chest pain and nondiagnostic electrocardiograms. Venous samples were drawn at admission and 8 to 24 hours later for total creatine kinase, CK-MB fraction, troponin T, troponin I, and myoglobin. Three nuclear cardiologists performed blinded image interpretation. Coronary artery disease (CAD) was confirmed either by diagnostic testing or by the occurrence of myocardial infarction (MI).

RESULTS

Acute rest MPI results were abnormal in all 9 patients with MI. An additional 26 patients had objective evidence of CAD confirmed by diagnostic testing. The sensitivity of acute rest MPI for objective evidence of CAD was 73%. Serum troponin T and troponin I were highly specific for acute MI but had low sensitivity at presentation. Individual serum markers had very low sensitivity for symptomatic myocardial ischemia alone. In the multivariate regression model, only acute rest MPI and diabetes were independently predictive of CAD.

CONCLUSION

At the time of presentation and 8 to 24 hours later, acute rest MPI has a better sensitivity and similar specificity for patients with objective evidence of CAD when compared with serum markers.

Solving story-based arithmetic problems: achievement of children with hearing impairment and their interpretation of meaning

This article considers how a sample of Norwegian school children, ages 6 through 10 with hearing impairment, master three different types of elementary arithmetic problems presented in a nonreading format. The article outlines the effect of task-specific factors on the level of difficulty, as well as the children's understanding of problem structures. The results showed that semantic structure of the problems affected the level of difficulty. The problems were not solved significantly better by students from grade 4 than students from grade 1. Qualitative analyses revealed that the children interpreted the meaning of the imposed problems in three different ways: (1) as numbers and procedures, (2) as take-away situations, and (3) as part-part-whole relations.

The 1.8 A crystal structure of the dimeric peroxisomal 3-ketoacyl-CoA thiolase of Saccharomyces cerevisiae: implications for substrate binding and reaction mechanism

The dimeric, peroxisomal 3-ketoacyl-CoA thiolase catalyses the conversion of 3-ketoacyl-CoA into acyl-CoA, which is shorter by two carbon atoms. This reaction is the last step of the beta-oxidation pathway. The crystal structure of unliganded peroxisomal thiolase of the yeast Saccharomyces cerevisiae has been refined at 1.8 A resolution. An unusual feature of this structure is the presence of two helices, completely buried in the dimer and sandwiched between two beta-sheets. The analysis of the structure shows that the sequences of these helices are not hydrophobic, but generate two amphipathic helices. The helix in the N-terminal domain exposes the polar side-chains to a cavity at the dimer interface, filled with structured water molecules. The central helix in the C-terminal domain exposes its polar residues to an interior polar pocket. The refined structure has also been used to predict the mode of binding of the substrate molecule acetoacetyl-CoA, as well as the reaction mechanism. From previous studies it is known that Cys125, His375 and Cys403 are important catalytic residues. In the proposed model the acetoacetyl group fits near the two catalytic cysteine residues, such that the oxygen atoms point towards the protein interior. The distance between SG(Cys125) and C3(acetoacetyl-CoA) is 3.7 A. The O2 atom of the docked acetoacetyl group makes a hydrogen bond to N(Gly405), which would favour the formation of the covalent bond between SG(Cys125) and C3(acetoacetyl-CoA) of the intermediate complex of the two-step reaction. The CoA moiety is proposed to bind in a groove on the surface of the protein molecule. Most of the interactions of the CoA molecule are with atoms of the loop domain. The three phosphate groups of the CoA moiety are predicted to interact with side-chains of lysine and arginine residues, which are conserved in the dimeric thiolases.

Retrofascial nontuberculous psoas abscess

Psoas abscess is usually associated with tuberculous spondylitis, but also occurs in relation to inflammatory bowel disease. We present 17 cases of primary pyogenic psoas abscess seen during a 10 year period at the King Fahd Hospital, Al-Khobar. There were 13 males and 4 females with a mean age of 24.9 years (range one to 55 years). Five patients had sickle cell disease. The average delay in presentation was 4.5 weeks (range 2 to 9 weeks). Pyrexia and a painful hip with a flexion deformity were the most obvious signs. The sedimentation rate and white cell count were markedly raised in every case. Staphylococci were cultured in 10 and anaerobic streptococci, salmonella and E coli in 2 each. Ultrasonography, CT and MR imaging were used to confirm the diagnosis. Early recognition and drainage are important to ensure a rapid recovery.

The scud missile disaster in Al-Khobar, Saudi Arabia, 1991: the orthopaedic experience

The orthopaedic experience of the scud missile disaster in Al-Khobar, Saudi Arabia during the Gulf war is reviewed. This was by far the most severe of 70 scud attacks. The majority of casualties had 'orthopaedic' injuries, fractures and soft tissue lacerations of the extremities and the back. Our experience confirmed the importance of the principles of planning triage beforehand and open wound treatment with secondary suture. Repeated ward rounds with reassessment of the patients proved beneficial. The ready availability of hospital beds in high-risk situations of regional war highly facilitated the management of mass casualties.

Fractured neck of the femur in young adults

This retrospective study at King Fahd University Hospital was undertaken to assess the hospital-based incidence and the complication rate among young Saudi nationals with a fracture of the femur. Hospital records of 17 patients between 17 and 45 years of age (mean 27.4 years) with a fracture of the neck of the femur were studied for the period 1982 to 1988. Factors such as type and severity of injury, associated injuries, delay in internal fixation and the type of implant used, were analysed. Fracture of the neck of the femur in young adults was 28 per cent (22/79) of these fractures in all age groups during the study period. There were no complications encountered, such as avascular necrosis or late segmental collapse.

Osteoarthritis of the hip and knee in Saudi Arabia

The records of 4721 patients, who were registered at a Primary Health Care Centre in the Eastern Province of Saudi Arabia during a 18 month period, were reviewed. One hundred and sixty-six (3.5%) had osteoarthritis of the hip or knee. The ratio of hip to knee was 1:80 which is very low compared to other populations, and the possible causes for this are discussed.

The anatomical pattern of gonarthrosis in Saudi Arabia

Fifty patients in Saudi Arabia with primary gonarthrosis were randomly selected in order to study the anatomical pattern of the disease. Anteroposterior and lateral radiographs were taken with the patients nonweight-bearing and weight-bearing; axial projections of the patello-femoral joint were also taken. Involvement of more than one compartment was significantly more common than it was in a Swedish series. The patello-femoral joint was affected in 80% compared with 48% of the Swedish knees. Different living habits are suggested as a contributory cause for the different patterns of gonarthrosis in the two countries.

On geographical variations in the normal range of joint motion

Fifty Saudi Arabian men 30 to 40 years of age without present or previous history of injury or disease related to the lower extremities were randomly selected for measurement of the range of motion in the basic planes of hip, knee, and ankle joint. The results were compared to a similar study from Scandinavia. There was a highly significant difference in external rotation of the hip, flexion of the knee, and dorsiflexion of the ankle. Cultural differences in the activities of daily life are suggested to explain the differences in the range of motion.

The syndrome of osteopetrosis, renal acidosis and cerebral calcification in two sisters

The syndrome of osteopetrosis associated with renal tubular acidosis and cerebral calcification, inherited as an autosomal recessive disorder, as seen in two sisters, is described. The primary defect in this rare syndrome is deficiency of carbonic anhydrase (CA) II. Significant reduction in blood levels of CA II were found in both parents and another sister, suggesting that these individuals are heterozygotic carriers.

Computed tomography in hemophilic pseudotumor

Computed tomography was used in 4 cases of hemophilic pseudotumor. Three of the patients were operated upon. The method proved to make the differential diagnosis safe and to yield valuable information on the extent of the lesion and the involvement of the skeleton and contiguous organs. The information facilitated the decision whether surgery was indicated and the planning of the operation as well as the follow-up of the conservatively treated case.

Radiologic evaluation of prophylaxis in severe haemophilia

The effect of prophylactic treatment of severe haemophilia A and B was evaluated with a recently described radiologic score system for assessing the severity of arthropathy. The severity of the arthropathy was assessed in 50 patients with severe haemophilia receiving prophylaxis with factor VIII or IX (25--30 units factor VIII or IX/kg bodyweight at 4--7 day intervals), and in 9 in whom the condition was complicated by inhibitors and who were thus not receiving prophylaxis. The score values found in a recent investigation of the natural course of haemophilia served as controls in the evaluation of the effect of the prophylaxis. In the group with severe haemophilia receiving prophylaxis changes appeared only exceptionally in joints not affected already before the prophylaxis, and the course of the arthropathy and its severity according to age did not vary to any noteworthy extent from that in the control group with moderate haemophilia. In the cases complicated by inhibitors the joints were most often worse than those in the control group with severe haemophilia. It is concluded that prophylaxis has a considerable effect on the course of the arthropathy and the prophylaxis should be instituted at an early stage of the disease, when the joints are still unaffected.

A procedure for removing high titer antibodies by extracorporeal protein-A-sepharose adsorption in hemophilia: substitution therapy and surgery in a patient with hemophilia B and antibodies

A 37-yr-old hemophiliac with factor IX antibody in high titer required operation for a pseudotumor growing invasively into the bone in his left elbow. Exchange plasma-pheresis was not feasible, mainly because of possible stimulation of factor IX inhibitor. In addition, the patient had antibodies against tissue antigens. The factor IX antibodies were of IgG type and adsorbable to protein-A-agarose. The antibodies were removed by extracorporeal adsorption of the plasma (separated intermittently in a cell centrifuge) to sterile protein-A-Sepharose in columns, operated by a computer. The treated plasma was retransfused. In this manner, a total of 6000 ml of plasma was depleted of antibodies, and the antibody titer, as well as the total immunoglobulin content, decreased to one-fifth of the original values. The remaining antibodies were neutralized by infusion of factor IX concentrate. Conventional substitution therapy, in combination with immunosuppression, was then possible. The operation was performed without complications. No signs of hemolysis, complement activation, or activation of the coagulation system occurred. In principle, the same form of treatment can be used in patients with other forms of antibodies.

Secondary operations after knee joint replacement

In 254 knee joint arthroplasties performed during the period between 1972 and 1977, secondary operations were done in 31 knee joints, a frequency of 12%. In the rheumatoid group the frequency was 6%, in those with osteoarthritis, 18%. Loosening was the indication for reoperation in 14 cases and infection in seven. Hinge prostheses required reoperations more often than the other types (Geomedic, St. Georg). Obesity and a previous operation on the same knee increased the risk of complication leading to reoperation. Reoperation involved exchange of prosthesis in 17 patients, arthrodeses in three, irrigation drain in three, femur amputation in one, and minor intervention in the remaining seven. The results of the reoperations were classified as good in 13 cases, fair in 12 and bad in six.

Late results of ankle fusion

Forty-four ankle joint fusions performed in the period 1950-1972 at the Department of Orthopedic Surgery, Malmö General Hospital, were evaluated. Thirty-one patients were re-examined. The mean follow-up time was 12.3 years (6.4-28 years). Two-thirds of the patients were much better or better than before operation, but still a lot of problems existed. Two-thirds of the patients had some kind of pain localized to the subtalar region. Three out of four patients had to use special footwear. The rate of forefoot deformities was not increased. In conclusion, patients with ankle fusion often have persistent trouble; therefore technical and clinical development of total ankle joint replacement seems to be indicated.

A radiologic classification of hemophilic arthropathy

A new, exclusively radiologic classification of hemophilic arthropathy is based on a review of 54 patients who had had repeated radiologic examinations of all great joints before the institution of any specific treatment. In terms of a score, the severity of the arthropathy may be assessed in a single joint, in a single patient, or in a group of patients. Using the score system, the natural course of hemophilic arthropathy demonstrated that the severity of the arthropathy increased with age and degree of coagulation defect. All patients over 5 years of age with severe hemophilia were affected and the radiologic changes were progressive. There was a good correlation between the radiologically assessed severity of the arthropathy and the clinical findings.

Preoperative normovolaemic haemodilution with dextran 70 as a thromboembolic prophylaxis in total in hip replacement

The effect of preoperative normovolaemic haemodilution with dextran 70 in 57 patients undergoing total hip replacement for osteoarthritis, was evaluated with respect to the production of thrombosis and pulmonary embolism. The patients were randomly allocated to one group undergoing preoperative haemodilution and one control group receiving 500 ml dextran 70 during operation and again on the second postoperative day. Before operation blood was replaced by dextran 70 to lower the hematocrit to between 25 and 30. The blood drained from the patients was used to replace blood lost at operation. Between 10 and 14 days after operation the patients were examined by perfusion lung scan, chest radiography and bilateral phlebography. Twelve patients also had 133Xe ventilation scans. The incidence of deep vein thrombosis in the two groups did not differ significantly. Pulmonary embolism was significantly decreased in the preoperative haemodilution group. One patient in the control group had clinical symptoms of, and died from, pulmonary embolism.

Synoviorthesis with radioactive gold in hemophiliacs. Clinical and radiological follow-up

Twenty-seven patients with hemophilia treated with intra-articular injection of radioactive gold were followed up clinically and radiologically for 3 to 9 years after treatment. To assess the radiological changes, a new classification was designed, with a score describing the severity of the changes in a more accurate manner than the methods previously used. The treatment decreased the bleeding frequency and stopped the progress of the arthropathy if applied at an early stage when the arthropathy was still reversible. If the treatment was begun at a later stage, the arthropathy seemed to progress independently of the effect on the bleeding frequency. No negative effect of the radioactive gold was observed on the joint or the growing zone.

Hematogenous infection in total joint replacement

Hematogenous infections may appear at any time after joint replacement operations. As distinguished from delayed infections where general symptoms of infection are absent, hematogenous infections cause malaise, chills and fever, usually of the septic type. Roentgenograms of the joint at an early stage of hematogenous infection do not show any sign of infection as these take time to develop. Nor is the scintigram positive at an early stage. The diagnosis is beyond doubt only when the same strain of bacteria is cultured from the joint, a primary focus and blood.

Arthroplasty of the knee in osteoarthritis and rheumatoid arthritis

147 cases of arthroplasty of the knee were reviewed. Three types of prostheses were used, viz., St. Georg, Geomedic and hinge (Shier and Guépar). Pain was the most common indication for the operation which produced complete or almost complete relief in 90% of the cases. In half of the joints with a mobility of less than 80 degrees preoperatively, the range of movement was increased to more than 80 degrees by the operation. Lack of extension, deformity and instability could be largely corrected. Two cases of deep infection were observed, both in patients treated with a hinge prosthesis. In one of them the complication led to amputation above the knee and in the other to arthrodesis.

Surgery of hemophiliacs--20 years' experience

Seventy-seven hemophilic patients of type A or type B were subjected to a total of 108 major surgical procedures mainly in the field of general surgery, orthopedic surgery, or neurosurgery. The principles for the substitution therapy in the different types of procedures and different types of hemophilic diseases are described, as well as the indications for surgery and the surgical technique. The importance of prolonged substitution therapy postoperatively to avoid late hematoma, particularly in patients with severe hemophilia undergoing major surgery, is stressed. With this type of management there has been no increased intraoperative hemorrhage, and very few cases of late hematoma formation. By combining the substitution therapy with immunosuppression, it has been possible to operate also on patients with inhibitors against factor VIII or IX. The rate of complications, particularly the incidence of hepatitis, has been low with the type of substitution given in this series of patients. It is concluded that major surgery can be carried out even in severe hemophilia without significantly increased risk. The handling of the substitution therapy, and the surgical judgment and technique, offers however, special problems, necessitating centralization of elective cases.

[Synoviorthesis with radioactive gold in hemophilia]

Intra-articular haemorrhage in haemophiliacs often provokes chronic synovitis which leads to further repeated haemorrhages. This conditions has been treated by means of intra-articular injection of 198Au in colloidal solution and this treatment has cured the synovitis in 50 per cent of cases and given a notable improvement in about another 40 percent. Because of this, in this group of patients it was possible to reduce replacement therapy to less than 1/4 and the effect persisted over at least 3 years. This treatment even means that surgical synovectomy may be avoided in many cases. No unfavourable effects were seen on joint mobility or on bone growth but an undesirable effect of the radioactivity has been described in the form of chromosome changes in the circulating lymphocytes, and the importance of these pathological transformations is the subject of new experiments.

The radiolucent zone in arthroplasty of the knee

Roentgenograms of 138 knee joint arthroplasties were examined for the presence and extent of a radiolucent zone at the bone-cement interface. Such a zone was significantly more common around the plastic tibial part than around the metallic femoral part of non-hinged prostheses. This observation argues for the theory that the development of heat plays a part in the causation of the zone. In some cases a zone was demonstrable within 1 month of the operation. The frequency and the sizes of such zones increased during the first 6 months after the operation. There was no definite correlation between the development of a radiolucent zone and the clinical symptoms.

Diffusion of tranexamic acid to the joint

Tranexamic acid (Cyklokapron, Kabi, Stockholm) in a dose of 10 mg per kg body weight was given i.v. to 17 patients at various intervals before operation on the knee joint, in order to elucidate the diffusion of the drug to the joint fluid and the synovial membrane. The acid diffused rapidly to both the above tissues, and in the joint fluid it reached the same concentration as in the serum. The biologic half-time in the joint fluid was about 3 hours. In the treatment of joint bleedings in hemophiliacs and in association with intra-articular operations on such patients tranexamic acid is a suitable supplement to conventional substitution therapy.

Haemophilia prophylaxis in Sweden

29 boys (4-18 years old) with severe haemophilia A were given prophylactic infusions of AHF concentrate (human fraction I-0) for 2 to 13 years in an attempt to change the haemophilia from a severe to a moderate form and thereby prevent arthropathy and severe bleeding episodes. The sizes of the doses and the intervals at which the doses were given were titrated by AHF survival studies. As a rule, the patients received AHF in amounts sufficient to raise the AHF level to 30-45% at 5-12 day intervals. In about 50% of the infusions the AHF content was not below 1% before the next infusion. During such prophylaxis all patients except one have been in a good general condition. They have had bleeding episodes, which have, however, been much less severe and less frequent. The children have been able to live an almost normal life. The number and duration of stays in hospital have been markedly reduced. 17 of the patients had only minor or no joint defects before the start of the treatment. In this group the joint function was identical with that found in moderate haemophilia in the same age groups. Two patients developed anticoagulants. No other side effects were seen. The prophylactic regimen in Sweden thus reduced severe haemophilia to moderate.