Amlodipine accelerates bone healing in a stable closed femoral fracture model in mice

Calcium channel blockers (CCBs), which are widely used in the treatment of hypertension, have been shown to influence bone metabolism. However, there is little information on whether CCBs also influence the process of fracture healing. Therefore, the effect of the CCB amlodipine on bone healing was studied in a stable closed fracture model in mice using intramedullary screw fixation. Bone healing was investigated by radiology, biomechanics, histomorphometry and Western blot analysis 2 and 5 weeks after fracture healing. Animals were treated daily (post operatively) per os using a gavage with amlodipine low dose (1 mg/ kg body weight, n = 20), amlodipine high dose (3 mg/kg body weight, n = 20) or vehicle (NaCl) (control, n = 20) serving as a negative control. At 2 and 5 weeks, histomorphometric analysis revealed a significantly larger amount of bone tissue within the callus of amlodipine low-dose- and high-dose-treated animals when compared to controls. This was associated with a smaller amount of cartilaginous and fibrous tissue, indicating an acceleration of fracture healing. Biomechanics showed a slightly, but not significantly, higher bending stiffness in amlodipine low-dose- and high-dose-treated animals. Western blot analysis revealed a significantly increased expression of bone morphogenetic protein (BMP)-2 and vascular endothelial growth factor (VEGF). Moreover, the analysis showed a 5-fold higher expression of osteoprotegerin (OPG) and a 10-fold elevated expression of the receptor activator of NF-κB ligand (RANKL), indicating an increased bone turnover. These findings demonstrated that amlodipine accelerated fracture healing by stimulating bone formation, callus remodelling and osteoclast activity.

Leitlinie zur Diagnostik und Therapie der Krampfadererkrankung

Leitlinien sind systematisch erarbeitete Empfehlungen, um den Arzt in Klinik und Praxis bei Entscheidungen über eine angemessene Versorgung des Patienten im Rahmen spezi-fischer klinischer Umstände zu unterstützen. Leitlinien gelten für Standardsituationen und berücksichtigen die aktuellen, zu den entsprechenden Fragestellungen zur Verfügung stehenden wissenschaftlichen Erkenntnisse. Leitlinien bedürfen der ständigen Überprüfung und eventuell der Änderung auf dem Boden des wissenschaftlichen Erkenntnisstandes und der Praktikabilität in der täglichen Praxis. Durch die Leitlinien soll die Methodenfreiheit des Arztes nicht eingeschränkt werden. Ihre Beachtung garantiert nicht in jedem Fall den diagnostischen und therapeutischen Erfolg. Leitlinien erheben keinen Anspruch auf Vollständigkeit. Die Entscheidung über die Angemessenheit der zu ergreifenden Maßnahmen trifft der Arzt unter Berücksichtigung der individuellen Problematik.

Die Empfehlungsgrade entsprechen denen des American College of Chest Physicians (ACCP):

GRADE 1A: starke Empfehlung, hohe Qualität der Evidenz

GRADE 1B: starke Empfehlung, mittlere Qualität der Evidenz

GRADE 1C: starke Empfehlung, niedrige Qualität der Evidenz

GRADE 2A: schwache Empfehlung, hohe Qualität der Evidenz

GRADE 2B: schwache Empfehlung, mittlere Qualität der Evidenz

GRADE 2C: schwache Empfehlung, niedrige Qualität der Evidenz

Angaben der evidenzbasierten Level erfolgen entsprechend den Empfehlungen der DEGAM (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin):

A sehr gut fundiert

B mittelmäßig fundiert

C mäßige wissenschaftliche Grundlage

High ligation of the saphenofemoral junction is necessary!

Neovascularisation can compromise the success of high ligation and resection of the greater saphenous vein. Studies using duplexultrasound to classify recurrent groin veins have described rates of neovascularisation as high as 60% and raised the question whether high ligation is actually able to prevent groin recurrences. In the present study, recurrent groin veins were excised and examined histologically in order to prove whether neovascularisation is the main cause for sapheno-femoral recurrences. Patients, methods: 419 patients accounting for 458 legs with clinically symptomatic groin recurrences were included in a country-wide multicenter study. The recurrent groin veins were excised in a standardized fashion and subsequently divided into the different types of recurrence based on histopathological criteria. Results: 427 specimen (93%) were available for histopathological examination. In 69 cases (16.2%) a neovascularisation was found to be the cause of recurrence. 311 specimen (72.8%) contained a long residual stump of the greater saphenous vein, out of which 32 (7.5%) showed additional neovascularisation at the site of the ligation. In 29 cases (6.8%) a venous side branch was found to be the recurrent groin vein. 11 specimen (2.6%) did not contain any evidence of venous material and in another 7 cases (1.6%) it was not possible to clearly identify the cause of recurrence during the histo pathological workup. Conclusion: The high rates of neovascularisation described in several duplex ultrasound studies could not be confirmed in our investigation. Recurrences seem to be mainly caused by a technically incorrect initial operation which leaves a long residual stump of the saphenous vein in place. Following a technically correct high ligation, clinically relevant recurrences appear to be rare. This finding underlines the necessity of a high ligation of the saphenous vein according to current guidelines.

Der lang belassene Saphenastumpf

Ziel: Nach endovenöser Hitzeablation der V. saphena magna verbleibt im Bereich der Krosse nahezu regelhaft bis zu 5 cm langer Venenstumpf unverschlossen. Aufgrund fehlender Langzeiterfahrungen ist unklar, ob sich aus dem zurückgelassenen Stumpf im Spätverlauf ein Leistenrezidiv entwickelt. Um Anhaltspunkte für den potenziellen Zeitpunkt der Rezidiventwicklung zu gewinnen, sollte bei Pat. mit histologisch gesichertem Saphenastumpfrezidiv geklärt werden, wie lange es dauerte, bis nach dem Ersteingriff Rezidiv klinisch apperent wird. Methoden: Im Rahmen einer an sieben Zentren durchgeführten Multizenterstudie wurden operativ exstirpierte Leistenrezidive histologisch klassifiziert. Die Pat. mit eindeutigem Saphenastumpfrezidiv wurden anhand eines standardisierten Fragebogens nach den ersten Rezidivzeichen befragt. Anhand der Angaben wurde das beschwerdefreie Intervall ermittelt, das Zeitraum zwischen dem Ersteingriff und dem ersten Auftreten von Rezidivzeichen kennzeichnet. Ergebnisse: Bei 251 Pat. wurde an 278 Extremitäten ein lang belassener Saphenastumpf als Ursache des Leistenrezidivs ermittelt. den meisten Pat. bestand nach dem Ersteingriff ein beschwerdefreies Intervall, das im Durchschnitt 7,4 ± 5,70 Jahre betrug. Rezidivvarizen kündigten nach durchschnittlich 6,3 ± 5,68 Jahre und Stauungsbeschwerden nach durchschnittlich 8,5 ± 5,71 Jahre das Rezidiv an. Schlussfolgerungen: Überträgt man die Erfahrungen aus operativen Therapie auf die unverschlossenen Krossestümpfe nach endovenöser Therapie, so ist frühestens nach 7–8 Jahren mit den klinischen Zeichen eines Leistenrezidivs zu rechnen. Die gegenwärtig vorhandenen Nachbeobachtungszeiten reichen nicht aus, um den Langzeitverlauf nach endovenöser Therapie beurteilen zu können.

Saphenofemoraler Neoreflux nach Lasertherapie, Crossektomie/ Stripping oder Crossektomie/ Lasertherapie

Einleitung: In der vorliegenden Arbeit gilt es, mittelfristige Refluxbefunde nach 2 und 6 Monaten sowie die klinischen und sonografischen Befunde im Bereich der Magnacrosse zu beschreiben, die für eine langfristige Entwicklung von Bedeutung sein könnten.

Material und Methode: Die offene multizentrisch prospektiv randomisierte kontrollierte 3-armige Vergleichsstudie zwischen der endoluminalen Lasertherapie und der invaginierend durchgeführten modifizierten offen operativen Therapie der Stammvarikosis der Vena saphena magna (VSM) hat den primären Endpunkt der Beobachtung der mittelund langfristigen Rezidiventwicklung mit einem Ausgangspunkt im Inguinalbereich. (Laserprozedur mit 980 nm Laser (Biolitec), Continous-Mode-Verfahren mit 30 Watt). Um die Bedeutung der Crossektomie in Bezug zur Entstehung eines Crosserezidivs herauszuarbeiten wurde eine dritte Gruppe gebildet, in der die Lasertherapie des Stammvenenabschnitts mit einer Crossektomie der Vena saphena magna kombiniert wurde.

Ergebnisse: 449 Patienten wurden perioperativ und nach 2 Monaten untersucht. 388 Patienten konnten nach 6 Monaten nachuntersucht werden. Nach 2 und 6 Monaten zeigten sich signifikant mehr inguinale Refluxe und Seitenäste in den Lasergruppen.

Ausblick: Die Befunde werden in einer derzeit laufenden Nachuntersuchung überprüft und auf ihre klinische Relevanz für das Langzeitergebnis getestet.

Obesity does not affect the healing of femur fractures in mice

Obesity is reported to be both protective and deleterious to bone. Lipotoxicity and inflammation might be responsible for bone loss through inhibition of osteoblasts and activation of osteoclasts. However, little is known whether obesity affects the process of fracture healing. Therefore, we studied the effect of high fat diet-induced (HFD) obesity on callus formation and bone remodelling in a closed femur fracture model in mice. Thirty-one mice were fed a diet containing 60kJ% fat (HFD) for a total of 20 weeks before fracture and during the entire postoperative observation period. Control mice (n=31) received a standard diet containing 10kJ% fat. Healing was analyzed using micro-CT, biomechanical, histomorphometrical, immunohistochemical, serum and protein biochemical analysis at 2 and 4 weeks after fracture. HFD-fed mice showed a higher body weight and increased serum concentrations of leptin and interleukin-6 compared to controls. Within the callus tissue Western blot analyses revealed a higher expression of transcription factor peroxisome proliferator-activated receptor y (PPARy) and a reduced expression of runt-related transcription factor 2 (RUNX2) and bone morphogenetic protein (BMP)-4. However, obesity did not affect the expression of BMP-2 and did not influence the receptor activator of nuclear factor κB (RANK)/RANK ligand/osteoprotegerin (OPG) pathway during fracture healing. Although the bones of HFD-fed animals showed an increased number of adipocytes within the bone marrow, HFD did not increase callus adiposity. In addition, radiological and histomorphometric analysis could also not detect significant differences in bone formation between HFD-fed animals and controls. Accordingly, HFD did not affect bending stiffness after 2 and 4 weeks of healing. These findings indicate that obesity does not affect femur fracture healing in mice.

Effect of Stabilization on the Healing Process of Femur Fractures in Aged Mice

BACKGROUND

The influence of mechanical stability on fracture healing has previously been studied in adult mice, but is poorly understood in aged animals. Therefore, we herein studied the effect of stabilization on the healing process of femur fractures in aged mice.

METHODS

Twenty-four 18-month-old CD-1 mice were stabilized after midshaft fracture of the femur with an intramedullary screw. In another 24 18-month-old mice, the femur fractures were left unstabilized. Bone healing was studied by radiological, biomechanical, histomorphometric, and protein expression analyses.

RESULTS

After 2 and 5 weeks of healing, the callus of nonstabilized fractures compared to stabilized fractures was significantly larger, containing a significantly smaller amount of osseous tissue and a higher amount of cartilaginous tissue. This was associated with a significantly lower biomechanical stiffness during the early phase of healing. However, during the late phase of fracture healing both nonstabilized and stabilized fractures showed a biomechanical stiffness of ∼40%. Of interest, Western blot analyses of callus tissue demonstrated that the expression of proteins related to angiogenesis, bone formation and remodeling, i.e. VEGF, CYR61, BMP-2, BMP-4, Col-2, Col-10, RANKL, OPG, did not differ between nonstabilized and stabilized fractures.

CONCLUSION

Nonstabilized fractures in aged mice show delayed healing and remodeling. This is not caused by an altered protein expression in the callus but rather by the excessive interfragmentary movements.

Characterization of the healing process in non-stabilized and stabilized femur fractures in mice

BACKGROUND

Although a variety of suitable fracture models for mice exist, in many studies bone healing was still analyzed without fracture stabilization. Because there is little information whether the healing of non-stabilized fractures differs from that of stabilized fractures, we herein studied the healing process of non-stabilized compared to stabilized femur fractures.

MATERIALS AND METHODS

Twenty-one CD-1 mice were stabilized after midshaft fracture of the femur with an intramedullary screw allowing micromovements and endochondral healing. In another 22 mice the femur fractures were left unstabilized. Bone healing was studied by radiological, biomechanical, histomorphometric and protein expression analyses.

RESULTS

Non-stabilized femur fractures revealed a significantly lower biomechanical stiffness compared to stabilized fractures. During the early phase of fracture healing non-stabilized fractures demonstrated a significantly lower amount of osseous tissue and a higher amount of cartilage tissue. During the late phase of fracture healing both non-stabilized and stabilized fractures showed almost 100 % osseous callus tissue. However, in stabilized fractures remodeling was almost completed with lamellar bone while non-stabilized fractures still showed large callus with great amounts of woven bone, indicating a delay in bone remodeling. Of interest, western blot analyses of callus tissue demonstrated in non-stabilized fractures a significantly reduced expression of vascular endothelial growth factor and a slightly lowered expression of bone morphogenetic protein-2 and collagen-10.

CONCLUSION

Non-stabilized femur fractures in mice show a marked delay in bone healing compared to stabilized fractures. Therefore, non-stabilized fracture models may not be used to analyze the mechanisms of normal bone healing.

Endovenous laser ablation with and without high ligation compared to high ligation and stripping for treatment of great saphenous varicose veins: Results of a multicentre randomised controlled trial with up to 6 years follow-up

Objectives

High ligation and stripping was compared to endovenous laser ablation for the therapy of great saphenous vein varicosity. Long-term efficacy was assessed in terms of avoidance of inguinal reflux and mechanisms of recurrence were investigated.

Design

Multicentre, randomised, three-arm, parallel trial.

Materials and methods

A total of 449 patients were randomised into three different treatment groups: high ligation and stripping group ( n = 159), endovenous laser ablation group ( n = 142; 980 nm, 30 W continuous mode, bare fibre) or a combination of laser ablation with high ligation (endovenous laser ablation group/ high ligation group, n = 148). Patients were examined clinically and by duplex ultrasound once a year. The primary end point of this study is inguinal reflux at the saphenofemoral junction after 2 years. This paper presents secondary data on sonographically determined inguinal reflux and clinical recurrences in the treated area after up to 6 years of follow-up.

Results

Median time to follow-up was 4.0 years; the mean time follow-up 3.6 years. Follow-up rates were: 2 years 74%, 3 years 47%, 4 years 39%, 5 years 36% and 6 years 31%. Most reflux into the great saphenous vein appeared in the endovenous laser ablation group (after 6 years: high ligation/stripping versus endovenous laser ablation p = 0.0102; high ligation/endovenous laser ablation vs. endovenous laser ablation p < 0.0002). Furthermore, more refluxive side branches were also observed in the endovenous laser ablation group (after 6 years high ligation/stripping vs. endovenous laser ablation p = 0.0569; high ligation/endovenous laser ablation vs. endovenous laser ablation p = 0.0111). In terms of clinical recurrence during the 6 years post therapy, no significant differences between the three treatment groups were observed ( p values from log-rank test: high ligation/stripping vs. endovenous laser ablation p = 0.5479; high ligation/stripping vs. high ligation/endovenous laser ablation p = 0.2324; high ligation/endovenous laser ablation vs. endovenous laser ablation p = 0.0848). The postoperative decline and later development in Class C (clinical etiological anatomical pathological) went parallel in all groups.

Conclusions

Clinical recurrence appears with the same frequency in all three treatment groups, but the responsible pathological mechanisms seem to differ. Most reflux into the great saphenous vein and side branches appears after endovenous laser ablation, whereas more saphenofemoral junction-independent recurrences are seen after high ligation/stripping.

[Two-year results of a prospective randomised controlled multicenter trial to compare open operative therapy vs. endoluminal venous laser therapy with and without high ligation for the therapy of varicose greater saphenous veins]

INTRODUCTION

Therapeutic options for the treatment of varicosis of the great saphenous vein (gsv) include endoluminal laser therapy, crossectomy/stripping and a combination of both. In this paper we present data for clinical and sonographic inguinal recurrencies up to two years post operation.

MATERIAL AND METHODS

In an open multicentre, randomised three-arm trial, sonographic and clinical parameters were compared perioperatively, after 2, 6, 12 and 24 months between endoluminal venous laser therapy, high ligation and invaginating stripping and a combination of both (laser: 980 nm, continuous mode, 30 W, Biolitec®, Jena, Germany). Data of 449 patients were available for the perioperative and 2 months examination. 388 patients were followed up until 6, 380 patients for 12 and 332 patients for 24 months. We compared clinical recurrences, sonographic reflux findings, and reflux side branches in the inguinal region at the saphenofemoral junction.

RESULTS

We found significantly more inguinal reflux and reflux side branches in the laser groups (p < 0.0001), however, there was no statistically significant relation between clinical recurrences and sonographic reflux. Over time, there were no intraindividual constant refluxes. Regarding the secondary endpoints oedema, lymphatic oedema, local disturbances of sensibility and irritations of the saphenous nerve, lymphatic oedema and irritations of the saphenous nerve were significantly more present in the two laser groups. After two years pain and restrictions in professional life were no longer relevant in all groups.

DISCUSSION

Clinical recurrences developed both in the C/S and in the laser group but reflux into the gsv and into proximal side branches developed significantly more often in the laser group. In a long-term follow-up we have to investigate the importance of reflux side branches for the development of clinical recurrences to reveal differences between the three therapeutic strategies.

[High ligation and vein stripping. The classic procedure]

The guidelines of the Society for Vascular Surgery and the American Venous Forum for management of patients with varicose veins recommend at level 1B endovenous thermal ablation for treatment of saphenous incompetence. High ligation and stripping is recommended only at level 2B. Consequently today most of the surgical procedures in the US are done endoluminally. The situation in Germany is different. The vast majority of the over 300,000 procedures done annually for varicose veins are surgical. In specialized centers in Germany, post-operative failures after high ligation are uncommon. Improper operative approaches seem likely in many of the randomized controlled trials (RCT). After proper high ligation, the results are very good.

Pantoprazole, a proton pump inhibitor, delays fracture healing in mice

Proton pump inhibitors (PPIs), which are widely used in the treatment of dyspeptic problems, have been shown to reduce osteoclast activity. There is no information, however, on whether PPIs affect fracture healing. We therefore studied the effect of the PPI pantoprazole on callus formation and biomechanics during fracture repair. Bone healing was analyzed in a murine fracture model using radiological, biomechanical, histomorphometric, and protein biochemical analyses at 2 and 5 weeks after fracture. Twenty-one mice received 100 mg/kg body weight pantoprazole i.p. daily. Controls (n = 21) received equivalent amounts of vehicle. In pantoprazole-treated animals biomechanical analysis revealed a significantly reduced bending stiffness at 5 weeks after fracture compared to controls. This was associated with a significantly lower amount of bony tissue within the callus and higher amounts of cartilaginous and fibrous tissue. Western blot analysis showed reduced expression of the bone formation markers bone morphogenetic protein (BMP)-2, BMP-4, and cysteine-rich protein (CYR61). In addition, significantly lower expression of proliferating cell nuclear antigen indicated reduced cell proliferation after pantoprazole treatment. Of interest, the reduced expression of bone formation markers was associated with a significantly diminished expression of RANKL, indicating osteoclast inhibition. Pantoprazole delays fracture healing by affecting both bone formation and bone remodeling.

Endovenous laser ablation with and without high ligation compared with high ligation and stripping in the treatment of great saphenous varicose veins: initial results of a multicentre randomized controlled trial

OBJECTIVES

To compare reflux recurrences at the saphenofemoral junction after endovenous laser ablation (EVLA) with or without high ligation with high ligation and stripping (HL/ST) of the great saphenous vein (GSV) in patients with varicosity of the GSV. Design Multicentre, randomized, three-arm, parallel trial. Material and Methods Patients with varicosity of the GSV were randomized to one of three groups: HL/ST, laser ablation (980 nm) or a combination of laser ablation with high ligation (EVLA/HL). Patients were examined clinically and by ultrasound pre- and postoperatively and after two months. The primary endpoint of this ongoing study is the inguinal venous reflux (IVR) in the proximal section of the GSV after two years. We present data after two months. Secondary endpoints include postoperative ecchymosis, pain or discomfort, saphenous syndrome. Groups were compared by chi-squared test.

RESULTS

A total of 449 patients were randomized; mean age 48 years and 71.2% were women. Postoperative ecchymosis developed among 69.2% in the HL/ST group, in 50.4% of the EVLA group and in 50.3% of the EVLA/HL group (P = 0.0007). Postoperative pain after one day occurred in 32.7% in the HL/ST group. Discomfort occurred after surgery in 37.3% in the EVLA group, and in 50.0% in the EVLA/HL group (P = 0.0069). Early postoperative nervus saphenous syndrome developed in 0.6% in the HL/ST group, in 3.7% in the EVLA group and in 6.1% in the EVLA/HL group (P = 0.0341). After two months, IVR persisted in 38 cases (8.5%) in the laser group, in 10 (2.2%) in the EVLA/HL group and none in the HL/ST group (P = 0.6800).

CONCLUSIONS

After two months IVR was more often seen in both EVLA groups compared with the HL/ST group. There were significantly more postoperative ecchymosis in the HL/ST. Postoperative pain occurred significantly more often in the EVLA/HL group. Peri- and postoperative data showed significant differences between the three groups. For definitive results concerning the primary endpoint of IVR the later follow-up has to be waited for.

Leitlinie Medizinischer Kompressionsstrumpf (MKS)

Leitlinien sind systematisch erarbeitete Empfehlungen, um den Arzt in Klinik und Praxis bei Entscheidungen über eine angemessene Versorgung des Patienten im Rahmen spezifischer klinischer Umstände zu unterstützen. Leitlinien gelten für Standardsituationen und berücksichtigen die aktuellen, zu den entsprechenden Fragestellungen zur Verfügung stehenden wissenschaftlichen Erkenntnisse. Leitlinien bedürfen der ständigen Überprüfung und eventuell der Änderung auf dem Boden des wissenschaftlichen Erkenntnisstandes und der Praktikabilität in der täglichen Praxis. Durch die Leitlinien soll die Methodenfreiheit des Arztes nicht eingeschränkt werden. Ihre Beachtung garantiert nicht in jedem Fall den diagnostischen und therapeutischen Erfolg. Leitlinien erheben keinen Anspruch auf Vollständigkeit. Die Entscheidung über die Angemessenheit der zu ergreifenden Maßnahmen trifft der Arzt unter Berücksichtigung der individuellen Problematik.

Die Empfehlungsgrade (EM-GR) wurden gemäß DEGAM (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin) festgelegt:

A sehr gutfundiert (EV-GR I)

B mittelmäßig fundiert (EV-GR II)

C mäßige wissenschaftliche Grundlage (EV-GR III, IV)

Combined use of autoantibodies (IA-2 autoantibody, GAD autoantibody, insulin autoantibody, cytoplasmic islet cell antibodies) in type 1 diabetes: Combinatorial Islet Autoantibody Workshop

The aim of this workshop was to assess the ability of individual autoantibody (ab) assays and their use in combination to discriminate between type 1 diabetic and control sera. Coded aliquots of sera were measured in a total of 119 assays by 49 participating laboratories in 17 countries. The sera were from 51 patients with new onset type 1 diabetes and 101 healthy control subjects with no family history of diabetes. In the final analysis, data on diabetic sera were restricted to 43 subjects younger than age 30 years. The laboratories were asked to report results for these sera using their currently available anti-islet autoantibody assays. In addition, they were asked to combine information from their assays to classify sera as having high, moderate, or low probability of originating from a patient with type 1 diabetes. Actual strategies for combining assays were determined by each laboratory. There were no significant differences in sensitivity among 19 radioimmunoassays (RIAs) for IA-2 autoantibodies (cytoplasmic islet cell antibody [ICA] 512) using different constructs that included the intracellular portion of the molecule (mean sensitivity 73%). However, an enzyme-linked immunosorbent assay (ELISA) using the extracellular portion of the IA-2 molecule did not discriminate between diabetic and control sera. Among GAD autoantibody assays that achieved sensitivity >70%, 26 were RIAs and one was an ELISA. When the sera were ranked according to their autoantibody levels, the concordance for insulin autoantibodies (IAAs) in different laboratories was markedly less than for IA-2ab and GADab. Using a combination of autoantibody assays, several laboratories achieved excellent discrimination between diabetic and control sera (sensitivity up to 80% with false-positive rate of 0%). A variety of strategies for combining information from different assays were successful (e.g., those including and excluding ICA), and no one strategy emerged as clearly superior. In conclusion, IA-2/ICA512 autoantibodies are a marker of type 1 diabetes and can be measured consistently by most assays. Several different strategies for combining assays achieved high sensitivity with a low false-positive rate.

The diabetic BB rat. Neither Th1 nor Th2?

A long term objective of our work has been to identify and characterize the T cells responsible for causing autoimmune type I diabetes in the spontaneously diabetic BB rat. Based on the Th1/Th2 paradigm encompassing "regulated" and "regulatory" T cells, our analyses show that there are very few "regulatory" peripheral Th2 cells. The "regulated" T cells that remain express an unusual, immature phenotype that is neither Th1 nor Th2. Our data also indicate that transcript expression for p56lck, an enzyme required for T cell development, is abnormal in BB peripheral T cells. We discuss the role abnormal transcript expression of p56lck might play in retarding the development of mature regulatory Th2 cells while simultaneously influencing the escape of autoreactive T cells from the thymus.

Heterogeneity of islet pathology in two infants with recent onset diabetes mellitus

The mechanisms by which the beta cells of pancreatic islets are destroyed in insulin-dependent diabetes mellitus (IDDM) are poorly understood. In this report the pancreatic histo- and immunopathology of two children, both HLA-DR 3/4, DQ 2/8 positive and who both died from cerebral oedema within a day of clinical diagnosis of IDDM, were investigated. Patient 1, a 14-month-old girl, had a 4-week history of polydipsia and polyuria. Patient 2, a 3-year-old boy, had 2 days of illness. Both patients had a similarly severe loss of insulin cells but differed markedly as to the extent of lymphocytic islet infiltration (insulitis). Apart from insulitis, marked islet macrophage infiltration was demonstrated in both patients with the HAM-56 monoclonal antibody. Neither patient showed aberrant expression of HLA class II antigens on insulin-immunoreactive cells, but allele-specific HLA-DQ8 expression was evident on endothelial cells. Glutamic acid decarboxylase immunoreactivity was detected in both insulin- and glucagon-immunoreactive cells. It is concluded that the heterogeneity of islet pathology, especially insulitis, may reflect different dynamics and extent rather than different pathomechanisms of immune destruction of islets in IDDM.

Polymorphic amino acid variations in HLA-DQ are associated with systematic physical property changes and occurrence of IDDM. Members of the Swedish Childhood Diabetes Study

The association between human leukocyte antigen (HLA) and insulin-dependent diabetes was studied in a large population-based investigation using genotyping of 425 new-onset patients, 0-14 years of age, and 367 matched control subjects. As many as 97% of patients compared with 75% of control subjects were positive for one or several of DQA1*0301, DQA1*0501, DQB1*0302, or DQB1*0201. Asp-57 DQB was present among 28% of patients, indicating that this residue alone does not confer protection. Combining Asp-57 DQB1 with either Arg-52 DQA1 or Leu-69 DQA1 did not explain susceptibility or protection either. DQA1*0301-DQB1*0302 (DQ8) and DQA1*0301-DQB1*0301 (DQ7) are identical except for four amino acid substitutions in the beta-chain, but DQ8 was positively (odds ratio 8.07; P < 0.001) and DQ7 negatively (odds ratio 0.38; P < 0.001) associated with the disease. Molecular modeling was used to determine whether physiochemical properties such as steric factors and surface electrostatic potentials also differ in a systematic way for various DQ molecules. Amino acids were substituted systematically at the four polymorphic sites, and the solvent-accessible surfaces and electrostatic potentials were computed for each molecule. Dramatic alterations in electrostatic potential were seen for double substitutions at position 45 (G45E) and 57 (A57D) of DQB1. The variation of physicochemical properties due to polymorphic substitutions may be significant to the mechanism of HLA-DQ association with insulin-dependent diabetes, via the effect these property variations have on peptide antigen binding selectivity and subsequent interactions with specific T-cell receptors.

Effect of IgG subclasses on in vivo bioavailability and metabolic fate of immune-complexed insulin in Lewis rats

The bioavailability, distribution, and metabolic fate of 125I-labeled insulin complexed to antibodies in guinea pig antiserum, purified guinea pig IgG1, IgG2, a mixture of IgG1 and IgG2, and homologous Lou/m rat antiserum were studied in inbred Lewis rats. 125I-insulin complexed to purified guinea pig IgG2 antibodies was rapidly cleared from the blood and sequestered in increasing amounts with time in the liver. Large amounts of the 125I-insulin complexed to guinea pig IgG1 antibodies remained in the blood for at least 30 min. The bioavailability of 125I-insulin bound to IgG1 and IgG2 antibodies was inhibited for at least 30 min because significantly less was available for rapid binding to insulin receptors on hepatocytes and renal tubular cells and its subsequent rapid degradation. The bioavailability of 125I-insulin was further decreased when bound to antibodies in native guinea pig antiserum or a mixture of IgG1 and IgG2 antibodies compared with the 125I-insulin complexed to either purified IgG1 or IgG2 antibodies alone. The 125I-insulin bound to antibodies in native guinea pig antiserum or a mixture of IgG1 and IgG2 antibodies was distributed in vivo in a manner reflecting the relative concentrations of the IgG1 and IgG2 antibodies present. The bioavailability, distribution, and metabolic fate of 125I-insulin in immune complexes prepared with homologous Lou/m rat insulin antiserum was qualitatively similar to that observed with immune complexes prepared with guinea pig insulin antiserum. It appears that the Lewis rat can be used as an in vivo model to study the bioavailability,distribution,and metabolic fate of insulin bound to xenogenic or homologous insulin antibodies.

[Brachyonychia of different types in a mother and daughter]

Different types of brachyonychia were observed in a mother and her daughter. The mother presented a unilateral racket thumb-nail (localized brachyonychia "en raquette" of Basset). In the case of the daughter the thumbs and three middle fingers of both hands were involved, the nails of the little fingers being normal (generalized brachyonychia "en raquette" of Basset). Also, the daughter's toe-nails were short and wide. There was a family history of short nails "on all fingers" occurring in the two sisters of the mother's father. We believe that localized and generalized types of racket nails are variants of the same inherited anomaly. As far as we know, this is the first report of brachyonychia of the toe-nails.

[Superficial cutaneous lipomatous nevus (Hoffmann-Zurhelle)]

Nevus lipomatosus of Hoffmann-Zurhelle is a rare condition characterized by ectopic accumulation of adipose tissue which is located almost always on the lower trunk. We present a typical case and give a detailed survey on the pertinent literature.

Penicillamine-induced pemphigus foliaceus-like dermatosis. A case with unusual features, successfully treated by plasmapheresis

A case of a severe, widespread bullous dermatosis clinically resembling pemphigus foliaceus occurred during treatment with penicillamine hydrochloride in a patient with rheumatoid arthritis. Histologically, the disease showed changes compatible with pemphigus vulgaris as well as with a bullous drug eruption. Treatment by plasmapheresis proved to be effective in controlling the disease.

[The long-eyelash syndrome (trichomegaly syndrome, Oliver-McFarlane)]

Two children with abnormally long eyelashes and bushy brows ("trichomegaly") present at birth and associated with pigmentary degeneration of the retina and general growth retardation are described. This combination of findings has been observed previously in three cases. Mental retardation, sparse scalp hair, endocrinologic deficiencies and (in one of our cases) koilonychia may be found in addition, but not necessarily.

[Standardized recall antigen testing in patients with malignant melanoma, endogenous eczema patients and healthy humans]

By means of a new test kit (Multitest), intracutaneous tests have been performed on several groups of patients in order to evaluate the degree of cellular immunity. This test system affords the simultaneous application of seven quantitatively and qualitatively standardized antigens. In comparison to healthy people, patients suffering from malignant melanoma showed a slightly higher immunity reaction whereas patients with atopic dermatitis revealed a significantly lesser degree of reactivity to the recall-antigens. Chemotherapy with Dacarbazine did not change the amount of reactivity to the Multitest. This paper discusses the advantages of the new test kit as well as the difficulties of recall-antigen testing with regard to the evaluation of cellular immunity.

Effects of cyproterone acetate and oestradiol benzoate on the rat testis. Morphometric study after treatment over 35 days

The testes of juvenile and adult rats were subjected to a histomorphometric and ultramorphometric examination after a 5-week cyproterone acetate and oestradiol benzoate treatment respectively. In the cyproterone acetate animals only minor changes of spermatogenesis are found in contrast to the oestradiol benzoate ones. The juvenile rats were not differing from those in the control group. In the older rats a reduction of the spermatocytes area portion in the basal zone of seminiferous epithelium can be proven. Oestradiol benzoate leads to an arrest of spermatogenesis at the stage of spermatocytes or the early spermatids respectively. At the same time the median diameter of seminiferous tubulus and the total area of seminiferous epithelium has considerably decreased in comparison to the treatment with anti-androgen. By the applied method an influence of the two substances on the spermatogonia was not recognizable.