In vivo activation of invariant natural killer T cells induces systemic and local alterations in T-cell subsets prior to preterm birth

Preterm birth, the leading cause of neonatal morbidity and mortality worldwide, is frequently preceded by spontaneous preterm labour, a syndrome of multiple aetiologies. Pathological inflammation is causally linked to spontaneous preterm labour. Indeed, direct activation of invariant natural killer T (iNKT) cells via α-galactosylceramide induces preterm labour/birth largely by initiating systemic and local (i.e. decidua and myometrium) innate immune responses. Herein, we investigated whether iNKT-cell activation altered local and systemic T-cell subsets. Administration of α-galactosylceramide induced an expansion of activated CD1d-restricted iNKT cells in the decidua and a reduction in the number of: (1) total T cells (conventional CD4⁺ and CD8⁺ T cells) through the down-regulation of the CD3ɛ molecule in the peripheral circulation, spleen, uterine-draining lymph nodes (ULNs), decidua and/or myometrium; (2) CD4⁺ regulatory T cells in the spleen, ULNs and decidua; (3) T helper type 17 (Th17) cells in the ULNs but an increase in the number of decidual Th17 cells; (4) CD8⁺ regulatory T cells in the spleen and ULNs; and (5) CD4⁺ and CD8⁺ forkhead box protein 3 negative (Foxp3^- ) responder T cells in the spleen and ULNs. As treatment with rosiglitazone prevents iNKT-cell activation-induced preterm labour/birth, we also explored whether the administration of this peroxisome proliferator-activated receptor gamma (PPARγ) agonist would restore the number of T cells. Treating α-galactosylceramide-injected mice with rosiglitazone partially restored the number of T cells in the spleen but not in the decidua. In summary, iNKT-cell activation altered the systemic and local T-cell subsets prior to preterm labour/birth; however, treatment with rosiglitazone partially reversed such effects.

Ulnar nerve palsy following rotational osteotomy of congenital radioulnar synostosis

Two successive cases of ulnar nerve palsy following rotational osteotomy through a congenital radioulnar synostosis are described. Entrapment of the ulnar nerve by the fascia connecting the two heads of the flexor carpi ulnaris was documented in one patient. Recommendations to avoid this complication include shortening of the forearm at the osteotomy site and the release of unyielding soft tissue restraints. Rotational osteotomy at the distal radial metaphysis may provide a safe, alternative approach in the surgical management of this difficult problem.

Preincubation with endothelial cell monolayers increases gene transfer efficiency into human bone marrow CD34(+)CD38(-) progenitor cells

Retroviral gene transfer studies targeting bone marrow CD34(+)CD38(-) stem cells have been disappointing because of the rarity of these cells, their G(0) cell cycle status, and their low or absent expression of surface retroviral receptors. In this study, we examined whether preincubation of bone marrow CD34(+)CD38(-) stem cells with a hematopoietically supportive porcine microvascular endothelial cell line (PMVECs) could impact the cell cycle status and expression of retroviral receptors in pluripotent CD34+CD38- cells and the efficiency of gene transfer into these primitive target cells. PMVEC coculture supplemented with GM-CSF + IL-3 + IL-6 + SCF + Flt-3 ligand induced >93% of the CD34(+)CD38(-) population to enter the G(1) or G(2)/S/M phase while increasing this population from 1.4% on day 0 to 6.5% of the total population by day 5. Liquid cultures supplemented with the identical cytokines induced 73% of the CD34(+)CD38(-) population into cell cycle but did not maintain cells with the CD34(+)CD38(-) phenotype over time. We found no significant increase in the levels of AmphoR or GaLVR mRNA in PMVEC-expanded CD34(+)CD38(-) cells after coculture. Despite this, the efficiency of gene transfer using either amphotropic vector (PA317) or GaLV vector (PG13) was significantly greater in PMVEC-expanded CD34(+)CD38(-) cells (11.4 +/- 5.6 and 10.9 +/- 5.2%, respectively) than in either steady state bone marrow CD34(+)CD38(-) cells (0.6 +/- 1.7 and 0.2 +/- 0.6%, respectively; p < 0.01 and p < 0.01) or liquid culture-expanded CD34(+)CD38(-) cells (1.4 +/- 3.5 and 0.0%, respectively; p < 0.01 and p < 0.01). Since PMVEC coculture induces a high level of cell cycling in human bone marrow CD34(+)CD38(-) cells and expands hematopoietic cells capable of in vivo repopulation, this system offers potential advantages for application in clinical gene therapy protocols.

Feeding difficulties and foregut dysmotility in Noonan's syndrome

PURPOSE

Noonan's syndrome is a common dysmorphic syndrome in which failure to thrive and gastrointestinal symptoms are frequent but poorly understood.

DESIGN

Twenty five children with Noonan's syndrome were investigated by contrast radiology, pH monitoring, surface electrogastrography (EGG), and antroduodenal manometry (ADM).

RESULTS

Sixteen had poor feeding and symptoms of gastrointestinal dysfunction. All 16 required tube feeding. Seven of 25 had symptoms of foregut dysmotility and gastro-oesophageal reflux. In the most symptomatic children (four of seven) EGG showed fasting frequency gradient loss along the stomach fundus and pylorus with antral postprandial frequency loss. ADM showed shortened fasting cycle length, with abnormal phase III and shortened postprandial activity containing phasic contractions.

IMPLICATIONS

Gastroduodenal motor activity was reminiscent of 32-35 week preterm patterns. The feeding difficulties appear to resolve as gut motility matures. In Noonan's syndrome, feeding problems appear to be the result of delayed gastrointestinal motor development.

Mimickers of hand infections

A variety of local or systemic conditions may mimic an infectious process in the hand and upper extremities. Familiarity with these conditions is important so that appropriate diagnosis and management may ensue. Most of the conditions presented in this article may be successfully managed nonsurgically; however, certain conditions such as the extravasation of a chemotherapy agent or retained foreign body require surgical intervention.

The evolution of the distal radio-ulnar joint

The pectoral girdle and the distal radio-ulnar joint have evolved over a period of 400 million years. Clinical circumstances exist that may represent atavistic development in modern man. Current understanding of this complex area does not explain all clinical situations.

A comprehensive approach to surgical management of the type IIIA hypoplastic thumb

In order to adequately identify pathologic anatomy and effectively reconstruct 14 type IIIA hypoplastic thumbs, a comprehensive clinical evaluation and surgical approach was employed. Eleven patients had congenital differences in the forearm, while all patients had anomalies in the wrist, hand, and digits. In addition to well-described interconnections between the flexor pollicis longus and the extensor pollicis longus, and thenar muscle hypoplasia, the authors observed duplication of musculotendinous units, anomalous muscles between the thumb and index rays, and abnormal insertions or dense adhesions along tendons as proximal as the forearm level. Successful reconstruction required an extended approach from the digit to the forearm, through which division of abnormal connections, reorientation of tendons, and lysis of adhesions was performed. Opposition transfer was needed in only 8 of the patients after the other pathologies were treated. Web-space deepening and ulnar collateral ligament reconstruction was performed when indicated. Improvement in function and appearance was achieved.

Fibrous hamartoma of infancy in the hand: a case report

Fibrous hamartoma of infancy (FHI) is a rare, benign tumor. The proximal upper extremity is most commonly involved. A previously unreported case of FHI in the hand is presented.

Intra-articular fractures of the distal end of the radius treated with an adjustable fixator system

Twenty-five wrists with comminuted, displaced, intra-articular fractures of the distal radius were prospectively treated with an adjustable external fixator for an average of 51 days. Twenty fractures (80% [20 of 25] were available for follow-up) in 16 adults (mean age, 34 years) were treated with the Wrist Jack external fixator system (Hand Biomechanics Lab, Sacramento, CA) and evaluated at a mean follow-up period of 25 months. Ten patients (12 fractures) sustained high-energy trauma with multiple injuries, while 6 patients (8 fractures) sustained isolated distal radius fractures. Percutaneous pins supplemented the fixation in 6 fractures. All fractures were reduced to restore articular congruity to within 1 mm. At follow-up, 5% were excellent, 75% good, 20% fair, and none as poor using the demerit point system of Gartland and Werley as modified by Sarmiento. Grip strength averaged 80% of the unaffected limb. Seventeen of the 20 fractures showed some evidence of articular incongruity at follow-up evaluation. Restoration of palmar tilt, radial inclination, radial length, and range of motion were at acceptable values. Subjective analysis confirmed 85% of the patients to have only occasional pain or none at all and 15% to have some pain with weakness or limitation of motion. Two patients required additional surgery: 1 underwent a Darrach procedure and the other a tendon transfer for a rupture of the extensor pollicis longus tendon. Results suggest that an external fixator system provides an additional alternative to the surgical armamentarium for an otherwise difficult fracture fixation problem.

Non-infective colitis in infancy: evidence in favour of minor immunodeficiency in its pathogenesis

Forty two infants below the age of 2 years presenting with chronic non-infective diarrhoea and shown to have histologically proved colitis were investigated over a five year period. Allergic colitis was the most common cause of colitis, accounting for 62% of the cases. Other colitides diagnosed included: non-specific colitis, autoimmune enterocolitis, and ulcerative colitis accounting for 10% each; severe combined immunodeficiency 7%, and Crohn's disease 3%. A positive family history and a personal history of atopy were obtained in 48% and 29% of the cases respectively. Serum immunoglobulin A, IgG2, and IgG4 were very low in over 50% of the entire cohort of infants with colitis; 66% of those with severe combined immunodeficiency, autoimmune enterocolitis, and ulcerative colitis (n = 11) had low CD3 and CD4 T lymphocytes with an accompanying increase in CD8 in two thirds of those with severe combined immunodeficiency. T lymphocytes were normal in those with allergic colitis. Thus infants with proved non-infective colitis as a group show a high prevalence of IgA, IgG2, and IgG4 deficiency. It is likely that this minor deficiency of mucosa associated immunoglobulin production has a role in the pathogenesis of the colitic process.

Major vascular malformations of the upper extremity: long-term observation

Vascular malformations of the upper extremity continue to be a therapeutic challenge to the hand surgeon. In the past 22 years, the authors treated 17 patients with major vascular malformations of the upper extremity. The lesions were evaluated with the aid of plain radiographs, angiography, and histology. Thirteen of the patients were female and 4 were male. The average age at treatment was 18 years, ranging from birth to 64 years. The average follow-up period was 12 years, ranging from 4 months to 36 years. The main indications for surgery were pain, progressive enlargement, neurologic compromise, diminished function, or a combination of these. The progression of these lesions under observation led to surgical management in all cases. A total of 36 excisions, 3 embolizations, and 4 amputations were done. Postoperative angiograms were obtained in selected individuals. Diffuse lesions defied total surgical removal. Recurrence and persistence was evident in 12 of the 17 patients. A knowledge of the progressive nature of these lesions and the need for long-term observation are the keystones to the successful management of these challenging yet unresolved problems.

Measurement of CD69 induction in the assessment of immune function in asymptomatic HIV-infected individuals

Peripheral blood mononuclear cells from many asymptomatic HIV-infected patients exhibit defects in cytokine production and impaired proliferative responses in vitro but the mechanisms underlying this subclinical immune deficiency are controversial. To determine whether abnormalities in the earliest events following receptor engagement may help to explain the in vitro immune dysfunction, we measured the inducibility of the early activation marker CD69 in T cells from asymptomatic HIV-infected individuals in response to stimulation with anti-CD2 or anti-CD3 mAb. In a whole blood assay, we found that induction of CD69 was markedly impaired in CD4+ T cells from later-stage HIV-infected patients (CD4 counts 200-400/mm3) compared to uninfected controls. Among early stage patients (CD4 > 400/mm3), a subset (29%) had impaired CD69 induction. CD69 responses were equally depressed after stimulation through the CD3 or CD2 receptor pathways. Survey of a panel of immunophenotypic markers and propensity for apoptosis demonstrated a significant association between depressed induction of CD69 and decreased percentages of CD4+CD26+ and CD4+CD95+ cells but no association with the level of apoptosis. These data indicate that defects in T lymphocyte activation through CD3 and CD2 can be measured within hours of receptor stimulation in asymptomatic HIV-infected individuals and might be useful to monitor as an indicator of immune function in these patients.

Hereditary disorders with maladies of the wrist and elbow

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Full-length sequence and mosaic structure of a human immunodeficiency virus type 1 isolate from Thailand

Human immunodeficiency virus type 1 isolates of envelope genotype E are contributing substantially to the global pandemic. These strains appear to be mosaics, with the gag gene from clade A and the envelope from clade E; the parental clade E strain has not been found. Here we report the first full genomic sequence of one such mosaic virus, isolate CM240 from Thailand. Multiple breakpoints between the two parental genotypes have been found in a CM240 virus. The entire gag-pol region and most, if not all, of the accessory genes vif, vpr, tat, rev, and vpu appear to derive from clade A. The genotype switches to E shortly after the signal peptide of the envelope and back to clade A near the middle of gp41; thus, the portion of the envelope that lies on the cytoplasmic side of the membrane appears to be principally derived not from clade E, as previously thought, but from clade A. Another small segment not belonging to any recognized clade and presumably also contributed by the parental E strain has been found in the long terminal repeat. It may be significant that the implied virion structure resembles a pseudotype virus with the matrix and core from one clade and the outer envelope from another. In the long terminal repeat, differences were observed between CM240 and other clades in the number of NF-kappa B binding sites, the sequence of the TATA box, and the putative secondary structure of the transactivation response region stem-loop. The mosaic structure of a CM240 virion is suggestive of phenotypic differences which might have contributed to the emergence of this variant.

Open reduction and internal fixation of forearm fractures in children

We retrospectively reviewed 16 children younger than 13 years with 17 fractures of the shafts of the radius or ulna or both who had undergone an open reduction-internal fixation (ORIF). ORIF was performed when a closed reduction was deemed unacceptable in 14 radius fractures and for three unstable open fractures of the radius. The average age was 9.4 +/- 2.3 years (range, 5.0-12.5). Of the 14 fractures with an unacceptable closed reduction, soft-tissue interposition was encountered in seven. Fixation was secured by plates and screws, percutaneous Steinmann pins, or intramedullary Steinmann pins. There were no delayed unions or nonunions, no infections, and no neurovascular injuries. The average follow-up was 12.3 months; all 17 fractures had excellent results (forearm rotation loss of < 10 degrees). Our study indicates that excellent results can be expected with no increased risk of complications if the treating physician elects to proceed with an ORIF in a pediatric forearm fracture with proper indications.

Carpal tunnel syndrome: a case of median nerve injection injury and a safe and effective method for injecting the carpal tunnel

The carpal tunnel syndrome is a compressive neuropathy of the median nerve at the wrist. The local injection of corticosteroid is an effective treatment modality in properly selected cases; however, this usually efficacious and safe procedure may result in serious complications if insufficient attention is paid to technique. A recent case of severe median nerve injury secondary to local steroid injection at the wrist prompted this report. We present a safe and effective method for injection of the carpal tunnel syndrome.

Exposure of human CD34+ cells to human immunodeficiency virus type 1 does not influence their expansion and proliferation of hematopoietic progenitors in vitro

The susceptibility of highly purified human CD34+ cells to monocytotropic (Ba-L) and lymphotropic (A018-post) strains of human immunodeficiency virus-1 (HIV-1) was examined. Liquid cultures initiated with fresh immunomagnetically purified CD34+ cells using the K6.1 CD34 monoclonal antibody (MoAb) (K6.1/CD34+) were positive for HIV expression 2 weeks after exposure to HIV-1 Ba-L. These cells were initially greater than 90% CD34+ and had undetectable monocyte contamination by flow-cytometric staining and side-scatter analyses, respectively, and undetectable T-cell contamination by CD3 polymerase chain reaction (PCR) analysis. However, secondary CD34+ liquid cultures reselected from the primary liquid cultures 24 hours after HIV exposure by panning with the ICH3 CD34 MoAb (ICH3/CD34+) and maintained for an additional 14 days were negative for HIV expression. The ICH3-unbound cells were positive for both spliced and unspliced HIV RNA when exposed to HIV-1 Ba-L, and were DNA PCR positive when exposed to either monocytotropic or lymphotropic HIV-1. To further test that CD34+ cells were not infectible by HIV-1, we exposed K6.1/CD34+ cells continuously to HIV-1 in a culture system capable of maintaining and expanding primitive CD34+ cells. HIV-exposed K6.1/CD34+ cells proliferated and expanded as efficiently as uninfected cultures. However, when reselected magnetically using the K6.1 CD34 MoAb after expansion for 7 days, bound K6.1/CD34+ cells were again negative for HIV-1 expression, whereas unbound cells were positive for HIV-1 expression. These findings suggest that a sequential CD34+ cell-selection process, in which the two selections are separated by a brief culture period, can yield a population of CD34+ cells that are not infected with HIV-1. This process may be useful in the design of stem or progenitor cell-based transplantation therapies for HIV infection.

Carpal tunnel syndrome in the work place

The management of patients with the CTS that appears to be related to occupational tasks is a complex issue. At this time, there is no definite evidence to show that any job is the sole cause of an individual worker's symptom complex. Management of patients in this situation requires surgical restraint coupled with an understanding of the worker's overall lifestyle. The most effective outcomes for all concerned appear to occur when there is cooperation among the patient, the physician, and the employer or his or her representatives. The recent prospective study by MacDougal that attempted to correlate job classifications with surgical outcome may be a very positive step in this direction.

Congenital hand and forearm anomalies

Congenital anomalies of the hand and forearm remain a continuing challenge for the patient and the patient's family. Health care professionals, including the pediatrician, the orthopedic surgeon, and the hand surgeon, all have roles to play in the treatment of these patients. This article reviews the literature for the past year with special emphasis on recent developments in the genetic transmission of some of these interesting congenital differences.

Immunogenic determinants of a neuropathogenic murine leukemia virus

Previous studies of Cas-Br-M murine leukemia virus (MuLV) (Cas-MuLV) infection demonstrated that cytotoxic T cells (CTL) of the CD8+ phenotype play a role in resistance to the neuropathogenic effects of the virus in NFS/N mice. In the current study, we sought to identify the Cas-MuLV epitopes that are immunogenic for the CTL response. Infection of adult NFS/N mice with a well-characterized neuropathogenic variant of Friend MuLV, PVC-211 MuLV (PVC-MuLV), was not immunogenic for MuLV-specific CTL. Therefore, we constructed chimeric viruses between Cas-MuLV and PVC-MuLV. Infectious chimeras contained the Cas-MuLV env gene on a PVC-MuLV background (PVC-CasenvMuLV) and the PVC-MuLV env gene on a Cas-MuLV background (Cas-PVCenvMuLV). Cas-MuLV-specific CTL were found following inoculation of both the chimeric viruses and the parental Cas-MuLV but not the parental PVC-MuLV, despite evidence of antibody responses to both parental and chimeric MuLV. CTL generated in response to infection with PVC-CasenvMuLV and Cas-PVCenvMuLV were exclusively of the CD8+ phenotype. These results indicate that both the env and gag-pol regions of Cas-MuLV express epitopes that are immunogenic for CTL.

Divergent single-column fractures of the distal part of the humerus

We report an unusual intra-articular fracture of the distal part of the humerus that was seen in five patients, including one who had the fracture bilaterally. The fractures were characterized by three features. First, the fractures were initiated in the trochlear groove as a result of a direct impact on the olecranon, which divided the trochlea and then split the two columns of the humerus divergently. Second, the fractures occurred exclusively in adolescents and young adults (average age, fifteen years old; range, thirteen to twenty years old). Third, all of the fractures were seen in patients who had a large fossa or septal aperture between the coronoid and olecranon fossae. Four of the fractures involved the right side and two, the left. There were three fractures of the lateral column and three of the medial column. Because the periosteum, the capsule, and the ligaments remained intact despite intra-articular displacement of the distal part of the humerus, these fractures were also characterized by inherent proximal stability. The fractures were treated with closed reduction and percutaneous internal fixation to reduce the displacement between the two halves of the trochlea. All of the fractures united. Four patients (five elbows) regained full motion by eight months; one patient was lost to follow-up. Current classification systems that describe single-column fractures of the distal part of the humerus should be modified to include this unusual fracture pattern.

Carpal tunnel syndrome: a clinicopathologic study

We evaluated 44 patients with carpal tunnel syndrome and performed histological evaluations of tenosynovium taken at the time of carpal tunnel release. Age, disease and work history, radiographs, and outcome were assessed. The clinical parameters were then compared with the histologic features to determine if the histology was predictive of the clinical course of carpal tunnel syndrome. We found no significance in the histologic changes in patients with carpal tunnel syndrome when age, duration of symptoms, work history, radiographs, and outcome were evaluated.

Consequences of stable transduction and antigen-inducible expression of the human interleukin-7 gene on tetanus-toxoid-specific T cells

Interleukin-7 (IL-7) has previously been shown to increase antigen-specific immune responses; the effect of IL-7 on human antigen-specific T cell lines has not directly been addressed. A tetanus-toxoid (TT)-specific T cell line exhibited increased proliferation in the presence of exogenous IL-7, suggesting that IL-7 may be useful in the potentiation of immune responses to defined microbial antigens. Murine retroviral vectors encoding the human IL-7 gene and the neomycin phosphotransferase gene (neoR) were packaged into murine retroviral particles, and supernatants containing these retroviral vectors were used to infect a CD4+ lymphoblastoid cell line. Stable integration of the retroviral vector and constitutive expression of the IL-7 gene were observed. Successful IL-7 gene transduction into TT-specific T cells was also accomplished. Detection of neoR DNA sequences and expression of IL-7-specific mRNA increased with selection in geneticin. Production of IL-7 in these cells was induced by exposure to TT. Production of IL-4, IL-6, and interferon-gamma (IFN-gamma) was detected after antigenic stimulation; there was, however, no effect of IL-7 on the pattern or kinetics of cytokine production by these cells. Human IL-7 transduced cells showed greater proliferation to TT than control T cells, particularly at subthreshold TT concentrations. These dta imply that genetic modification of antigen-specific T cells may be a plausible strategy for the study and manipulation of the immune responses to microbial pathogens.

Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis

A series of 19 consecutive patients who underwent scaphoid-trapezium-trapezoid arthrodesis for chronic scapholunate instability or isolated arthrosis was reviewed. The average follow-up of 14 patients was 62 months. Eight of these 14 patients had significant residual symptoms and/or functional limitations at follow-up, and 11 had complications, including radiocarpal arthrosis (six patients), trapeziometacarpal arthrosis (four patients), and nonunion (three patients). Fusion without reduction of the scaphoid to a normal orientation was predictive of a poor result, but normal scaphoid positioning did not preclude development of arthrosis. Development of a painful degenerative thumb carpal-metacarpal joint may occur as an isolated phenomenon after scaphoid-trapezium-trapezoid arthrodesis.

Recognizable dysfunction syndromes

Many presentations of dysfunctional postures of the upper extremity have been described in the literature. Attempts have been made to differentiate these situations by describing their physical and pathophysiologic circumstances. Unfortunately, these attempts to define and differentiate the various conditions that are recognizable patterns of upper-extremity dysfunction syndromes have not been entirely successful. This failure is perhaps because hard and firm diagnostic criteria that would specifically delineate each of these circumstances are wanting. At best, it can be said that there are patients who will present with pain as their primary complaint and who present with physical findings that would best support a diagnosis of reflex sympathetic dystrophy. There are others who present with dysfunctional postures in which pain is not a primary presenting complaint. In addition, are those in an intermediate zone, where pain and dysfunction are intermixed, and where prolonged observation may help to place them in one category or the other. Recent evidence has suggested that patients with painless dysfunctional syndrome benefit from the attentions of psychically oriented providers. The timing and appropriateness of such interventions require further study. The literature of the behavioral scientists and that of the practitioners of the medical arts is bereft of concrete explanations for causation and specific definitive solutions.

The survival of cytochalasin-induced polykaryons following exposure to cytotoxic agents

Using CHO-K1, HeLa S3 and two Walker lines (WR and WS) differentially sensitive to cis-diamminedichloroplatinum(II) (cisplatin), the survival after exposure to cisplatin, mitomycin C, vinblastine, vincristine or cytosine arabinoside has been determined either of clonogens or of cells rendered polyploid by post-exposure incubation in the presence of cytochalasin B (CB). It is suggested that the inhibition of cytokinesis by CB permits an assessment to be made of the fraction of damage whose expression is cell division-related, possibly including that resulting from a loss or malsegregation of genetic material. It was found that the response of polykaryons in comparison to clonogens was both agent- and cell line-dependent. After cisplatin exposure, polykaryon survival (defined as the ability to accumulate at least 16C DNA) declined exponentially with dose and was qualitatively, and to some extent quantitatively, similar to that observed previously after irradiation. In HeLa S3, giant cells induced by 10-20Gy irradiation in the absence of CB exhibited a radiation dose-dependent reduction in the relative frequency of highly polyploid cells which was similar to that observed in CB-induced polykaryons.

Hand manifestations of oxalosis

Oxalosis is an unusual metabolic disease that results either from an inherited hepatic enzyme deficiency or as the result of poor oxalate clearance during chronic hemodialysis. We present two cases of oxalosis and describe the hand manifestations of this condition and their treatment. One patient had painful, progressive gangrene, whereas in the other the disease took an indolent course with small palmar crystalline deposits.

Embryologic development and variations in the anatomy of the ulnocarpal ligamentous complex

Eighteen fetal hand specimens were reviewed in an effort to clarify variations in reports of the ligamentous anatomy of the ulnar side of the wrist. Sizes ranged from 45 mm crown-rump length (CRL) to 325 mm CRL. Representative coronal sections from the 2779 sections available were reviewed. Significant variations in size of triquetral attachment and thickness and consistency of the ulnocarpal ligamentous complex (UCLC) were observed. Each of the specimens exhibited one of four UCLC variations: (1) 5 of 18 (28%) with an average CRL of 187 mm had a dense, thin UCLC, with a focal triquetral attachment; (2) 7 of 18 (39%) with an average CRL of 209 mm had a focal, dense attachment of a thick UCLC to the triquetrum; (3) 5 of 18 (28%) with an average CRL of 220 mm exhibited a thick, dense UCLC with a broad attachment to the triquetrum; and (4) 1 of 18 (5%) with a CRL of 166 mm was unique, with a loose, areolar UCLC broadly attached to the triquetrum.

Perineural hemangiomas of the upper extremity: report of four cases

Perineural hemangiomas in the upper extremity have been the subject of few reports. We found only eight such cases reported in the literature. We report four additional cases in which there were neurologic symptoms. The specific diagnosis of cavernous hemangioma was not made preoperatively in any of the patients. The greater the extent of intrafascicular involvement, the more difficult is total eradication of the hemangioma.

Neurofibrosarcomas of the upper extremity

A retrospective review of all malignant hand tumors seen at the University of Michigan from 1950 to 1987 demonstrated six biopsy-proven cases of neurofibrosarcoma involving the upper extremity. There were four male and two female patients; average age at presentation was 37 years and ages ranged from 15 to 63 years. All patients had a history of von Recklinghausen's disease. Three patients were seen initially with painful enlarging masses, one with a painful mass with a neurological deficit, and two with painless enlarging masses. Three patients had radical excisions requiring upper extremity or forequarter amputation, and three patients received limited or no surgical treatment. Five patients died of metastases an average of 3 years after diagnosis. One patient remains alive 18 years after upper extremity amputation despite an early local recurrence. Early diagnosis and radical surgical excision offer the best chance of long-term survival from this highly lethal cancer.

Induction of HIV-specific CTL and antibody responses in mice using retroviral vector-transduced cells

Recombinant retroviral vectors can efficiently transduce and express foreign genes in mammalian cells. We have examined the utility of retroviral vector-mediated gene transfer to deliver genes which encode human immunodeficiency virus type I (HIV) antigens capable of stimulating specific immune responses. Murine fibroblast cell lines were transduced with a nonreplicating murine retroviral vector carrying the gene encoding the HIV-IIIB envelope protein and were shown to express the gp160/120 protein. Mice immunized with syngeneic vector-transduced cells developed CD8+, class I major histocompatibility complex (MHC)-restricted cytotoxic T lymphocytes (CTL) specific for targets expressing the HIV envelope protein. The CTL also exhibited lytic activity on target cells coated with synthetic peptides derived from the gp120 V3 hypervariable region of both the HIV-IIIB and HIV(MN) isolates. Following adoptive transfer in a murine tumor model, these CTL were shown to be effective in vivo by their ability to eliminate established tumor cells expressing the HIV protein. Vector-transduced syngeneic cells were also capable of eliciting HIV envelope-specific antibody responses in immunized mice. Sera obtained from these mice were found to bind to the HIV-IIIB gp160 protein as well as a peptide-defined neutralizing antibody epitope contained within the V3 domain of gp120. These sera exhibited virus-neutralizing activity in that they markedly reduced the ability of HIV to infect and form syncytia of a human T-cell line. This is the first demonstration that cells transduced with a retroviral vector encoding the HIV-IIIB envelope protein are capable of inducing effective HIV-specific cellular and humoral immune responses in mice.

Evolving concerns relating to occupational disorders of the upper extremity

Occupational disorders of the upper extremity have become a problem of increasing concern around the world. The management of these problems must be understood in light of current social trends that influence patient management. Workers' compensation is one of these continually developing trends. This article describes the historical aspects of compensation and bodily injury or loss occurring in the work place. Changes in workers' attitudes during the development of workers' compensation have been observed since the turn of the century. The influence of the legal system in this regard is also noteworthy. The modern surgeon is faced with these confounding influences when treating a patient with a work-related injury or cumulative trauma disorder.

Ischemia-reperfusion in humans. Appearance of xanthine oxidase activity

We evaluated effluent blood from extremities of human patients undergoing reconstructive surgical treatment, which is routinely accompanied by upper-extremity exsanguination and application of a tourniquet, resulting in total interruption of arterial blood flow to one upper extremity. After tourniquet release (reperfusion), there were immediate increases in the plasma levels of xanthine oxidase activity, uric acid, and histamine in the ipsilateral limb and much smaller increases, if any, in levels of the same materials in plasma obtained from the contralateral extremity. There was no detectable xanthine dehydrogenase activity in plasma from either limb. Plasma also contained evidence of products consistent with the formation of oxygen-derived free radicals, namely, the appearance predominantly in the reperfused limb of hemoglobin and fluorescent compounds. These data indicate for the first time in humans that ischemia-reperfusion events are associated with the appearance of xanthine oxidase activity and its products in the plasma effluent.

Rehabilitation of the injured hand

The gradual development of hand surgery as an area of specialization has led to the development of rehabilitative efforts that have complemented this trend. This had led to further specialization in hand therapy as a primary endeavor. Specific efforts in the areas of rehabilitation for soft tissue, bone, tendon, and nerve injuries have facilitated functional restoration of the injured hand.

Diagnosis and treatment of obscure ulnar-sided wrist pain

Thirty-seven patients were followed for symptoms of chronic ulnar-sided wrist pain in which specific physical examination and standard radiographs were unrevealing. Initial conservative treatment did not relieve the pain. The patients underwent further diagnostic studies including dynamic cineroentgenographic evaluation and radiocarpal arthrography. Nineteen of the 37 patients were demonstrated to have a triangular fibrocartilage complex (TFCC) tear on arthrography; 18 had a normal examination. The average follow up was 23 months. Seven of the 19 patients with TFCC tears have undergone operative treatment, and 5 (71%) remain symptomatic. Of the remaining 12 patients with TFCC tears treated nonoperatively, eight (67%) have persistent symptoms. Of the 18 patients whose arthrograms were normal, five eventually underwent surgical exploration, four of which remain symptomatic. Of the 13 patients without TFCC tears treated nonoperatively, seven (54%) continue to have symptoms. In our experience, both surgical exploration and nonoperative treatment have been less than satisfying. In addition, treatment results could not be correlated with arthrographic findings.