Replication competent retrovirus testing (RCR) in the National Gene Vector Biorepository: No evidence of RCR in 1,595 post-treatment peripheral blood samples obtained from 60 clinical trials

The clinical impact of any therapy requires the product be safe and effective. Gammaretroviral vectors pose several unique risks, including inadvertent exposure to replication competent retrovirus (RCR) that can arise during vector manufacture. The US FDA has required patient monitoring for RCR, and the National Gene Vector Biorepository is an NIH resource that has assisted eligible investigators in meeting this requirement. To date, we have found no evidence of RCR in 338 pre-treatment and 1,595 post-treatment blood samples from 737 patients associated with 60 clinical trials. Most samples (75%) were obtained within 1 year of treatment, and samples as far out as 9 years after treatment were analyzed. The majority of trials (93%) were cancer immunotherapy, and 90% of the trials used vector products produced with the PG13 packaging cell line. The data presented here provide further evidence that current manufacturing methods generate RCR-free products and support the overall safety profile of retroviral gene therapy.

NB housing study protocol: investigating the relationship between subsidized housing, mental health, physical health and healthcare use in New Brunswick, Canada

BACKGROUND

Income and housing are pervasive social determinants of health. Subsidized housing is a prominent affordability mechanism in Canada; however, waitlists are lengthy. Subsidized rents should provide greater access to residual income, which may theoretically improve health outcomes. However, little is known about the health of tenants who wait for and receive subsidized housing. This is especially problematic for New Brunswick, a Canadian province with low population density, whose inhabitants experience income inequality, social exclusion, and challenges with healthcare access.  METHODS: This study will use a longitudinal, prospective matched cohort design. All 4,750 households on New Brunswick's subsidized housing wait list will be approached to participate. The survey measures various demographic, social and health indicators at six-month intervals for up to 18 months as they wait for subsidized housing. Those who receive housing will join an intervention group and receive surveys for an additional 18 months post-move date. With consent, participants will have their data linked to a provincial administrative database of medical records.  DISCUSSION: Knowledge of housing and health is sparse in Canada. This study will provide stakeholders with a wealth of health information on a population that is historically under-researched and underserved.

Serious adverse events are uncommon with combination neonatal antiretroviral prophylaxis: a retrospective case review

Six weeks of zidovudine (ZDV) is recommended for postnatal prophylaxis of HIV-exposed infants, but combination antiretrovirals are indicated if HIV transmission risk is increased. We investigated the frequency and severity of adverse events (AE) in infants receiving multiple drug prophylaxis compared to ZDV alone. In this retrospective review of 148 HIV-exposed uninfected infants born between 1997–2009, we determined clinical and laboratory AE that occurred between days of life 8–42. Thirty-six infants received combination prophylaxis; among those, a three-drug regimen containing ZDV, lamivudine, and nevirapine was most common (53%). Rates of laboratory AE grade ≥1 were as follows for the combination prophylaxis and ZDV alone groups, respectively: neutropenia 55% and 39%; anemia 50% and 39%; thrombocytopenia 0 and 3%; elevated aspartate aminotransferase 3% and 3%; elevated alanine aminotransferase 0 and 1%; hyperbilirubinemia 19% and 42%. Anemia occurred more frequently in infants who received three-drug prophylaxis compared to infants who received ZDV alone (63% vs. 39%, p = 0.04); all anemia AE were grade 1 or 2 in the three-drug prophylaxis group. Overall, 75% of infants on combination prophylaxis and 66% of infants on ZDV alone developed grade ≥1 AE (p = 0.32), and 17% of infants in either group developed grade ≥3 AE. Stavudine was substituted for ZDV in 23 infants due to anemia or neutropenia. After this antiretroviral change, 50% of evaluable infants demonstrated improvement in AE grade, and 25% had no change. In conclusion, low grade anemia, neutropenia, and hyperbilirubinemia occurred frequently regardless of the prophylactic regimen, but serious AE were uncommon. Although most AE were typical of ZDV toxicity, the combination of ZDV with lamivudine and nevirapine resulted in an increased frequency of low-grade anemia. Further studies are needed to identify prophylactic regimens with less toxicity for infants born to HIV-infected mothers.

Real-time correction of heart interbeat intervals

Heart rate variability (HRV) is traditionally analyzed while a subject is in a controlled environment, such as at rest in a clinic, where it can be used as a medical indicator. This paper concerns analyzing HRV outside of controlled environments, such as on an actively moving person. We describe automated methods for inter-heartbeat interval (IBI) error detection and correction. We collected 124,998 IBIs from 18 subjects, undergoing a variety of active motions, for use in evaluating our methods. Two human graders manually labeled each IBI, evaluating 10% of the IBIs as having an error, which is a far greater error percentage than has been examined in any previous study. Our automated method had a 96% agreement rate with the two human graders when they themselves agreed, with a 49% rate of matching specific error corrections and a 0.01% false alarm rate.

Biexponential T2 relaxation time analysis of the brain: correlation with magnetization transfer ratio

RATIONALE AND OBJECTIVES

To measure T2 relaxation times of normal white and gray matter using a novel CPMG sequence and investigate if any correlation exists between magnetization transfer ratio (MTR) and T2 relaxation-related parameters.

MATERIALS AND METHODS

Seventeen normal volunteers participated on this study. A single-slice 32-echo sequence was used to calculate the T2 relaxation time of frontal and occipital white matter and cortical gray matter. T2 relaxation analysis included monoexponential and biexponential fitting whereas an F test was used to determine if biexponential fitting was statistically more accurate than monoexponential fitting. Short and long T2 constants were calculated as well as the signal fractions of each pool. MTR calculations were based on a three-dimensional gradient echo (3D FFE) proton density weighted sequence with and without an on-resonance composite prepulse. MTR and T2 relaxation times were calculated and linear regression analysis was applied.

RESULTS

Biexponential fitting was more accurate comparing with monoexponential fitting in all WM and GM regions (F > 2.47, P < 0.01). Mean values of short T2 constant for frontal white matter (fWM), occipital white matter (oWM) and gray matter (GM) were 8.10, 9.36, and 22.23 milliseconds, respectively, whereas the mean values of long T2 constant were 85.1, 93.02, and 118.72 milliseconds, respectively. Mean restricted water percentages (RWP)-corresponding to the signal fraction of the protons with short T2-for the fWM, oWM, and GM were 22.01%, 23.36%, and 18.7%. Mean free water percentages (FWP)-corresponding to the signal fraction of the protons with long T2-for the fWM, oWM and GM were 77.99%, 76.64%, and 81.3%. Mean MTR values for fWM, oWM and GM were 68.4%, 68.2%, and 61.3%, respectively. No significant correlation was found in fWM and oWM between MTR and RWP, short and long T2 components while a moderate correlation existed in GM between MTR and RWP (r = 0.57; P = 0.02), MTR and short T2 component (r = -0.69; P = 0.004) and MTR and long T2 component (r = -0.62; P = 0.012).

CONCLUSIONS

Two proton pools with different T2 decay characteristics can be separated in normal gray and white matter when using a multiecho sequence with short echo spacing. MTR and T2 relaxation times were significantly correlated in gray matter and the combination of both types of measurements may be helpful in studying myelin related disorders.

Tumor necrosis factor-alpha, interleukin-6, and nitric oxide in sterile ascitic fluid and serum from patients with cirrhosis who subsequently develop ascitic fluid infection

Ascitic fluid infection probably results from repeated episodes of bacteremia and seeding of ascitic fluid. The outcome of these episodes of colonization is probably a function of serum and ascitic fluid defense mechanisms and the virulence of the organism. Patients who develop spontaneous bacterial peritonitis may have serum and ascitic fluid characteristics that are different from those who do not develop infection. We prospectively collected serum and ascitic fluid specimens at the time of admission from patients with sterile cirrhotic ascites, and tested these specimens for interleukin-6, tumor necrosis factor-alpha, and nitric oxide and compared these results as well as other characteristics of patients who did not develop infection to those who did. An elevated baseline serum tumor necrosis factor-alpha as well as an increased proportion of polymorphonuclear leukocytes in sterile ascitic fluid from patients who subsequently developed infection probably represent a subclinical activation of defense mechanisms from prior silent colonizations with bacteria.

Composite effects of group drumming music therapy on modulation of neuroendocrine-immune parameters in normal subjects

CONTEXT

Drum circles have been part of healing rituals in many cultures throughout the world since antiquity. Although drum circles are gaining increased interest as a complementary therapeutic strategy in the traditional medical arena, limited scientific data documenting biological benefits associated with percussion activities exist.

OBJECTIVE

To determine the role of group-drumming music therapy as a composite activity with potential for alteration of stress-related hormones and enhancement of specific immunologic measures associated with natural killer cell activity and cell-mediated immunity.

DESIGN

A single trial experimental intervention with control groups.

SETTING

The Mind-Body Wellness Center, an outpatient medical facility in Meadville, Pa.

PARTICIPANTS

A total of 111 age- and sex-matched volunteer subjects (55 men and 56 women, with a mean age of 30.4 years) were recruited.

INTERVENTION

Six preliminary supervised groups were studied using various control and experimental paradigms designed to separate drumming components for the ultimate determination of a single experimental model, including 2 control groups (resting and listening) as well as 4 group-drumming experimental models (basic, impact, shamanic, and composite). The composite drumming group using a music therapy protocol was selected based on preliminary statistical analysis, which demonstrated immune modulation in a direction opposite to that expected with the classical stress response. The final experimental design included the original composite drumming group plus 50 additional age- and sex-matched volunteer subjects who were randomly assigned to participate in group drumming or control sessions.

MAIN OUTCOME MEASURES

Pre- and postintervention measurements of plasma cortisol, plasma dehydroepiandrosterone, plasma dehydroepiandrosterone-to-cortisol ratio, natural killer cell activity, lymphokine-activated killer cell activity, plasma interleukin-2, plasma interferon-gamma, the Beck Anxiety Inventory, and the Beck Depression Inventory II.

RESULTS

Group drumming resulted in increased dehydroepiandrosterone-to-cortisol ratios, increased natural killer cell activity, and increased lymphokine-activated killer cell activity without alteration in plasma interleukin 2 or interferon-gamma, or in the Beck Anxiety Inventory and the Beck Depression Inventory II.

CONCLUSIONS

Drumming is a complex composite intervention with the potential to modulate specific neuroendocrine and neuroimmune parameters in a direction opposite to that expected with the classic stress response.

Amplification of T-cell receptor alpha- and beta-chain transcripts from mouse spleen lymphocytes by the nonpalindromic adaptor-polymerase chain reaction

We employed the nonpalindromic adaptor-PCR (NPA-PCR) method to amplify T-cell receptor (TCR) alpha- and beta-chain transcripts from the spleen of normal SJL mice. The NPA-PCR method has been specifically designed for the amplification of transcripts with variable or unknown 5' ends, such as TCRs and immunoglobulins (Ig). This method has certain distinct advantages over existing two-sided PCR methods for the amplification of TCR transcripts. Two NPA-PCR amplifications are sufficient to amplify all the TCR transcripts (one for the alpha-chain and another one for the beta-chain). Amplification of TCR transcripts by classical two-sided PCR requires a minimum of 45 amplification reactions for the murine TCR (20 for the V alpha families and 25 for the V beta families), using 45 different V-family-specific amplification primers. cDNA was synthesized from spleen RNA, using oligonucleotides complementary to sequences of either the murine TCR C alpha or C beta regions. The NotI restriction site was conjugated to these primers and therefore, a NotI restriction site was incorporated at the 3' end of the cDNA. A double-stranded nonpalindromic adaptor (EcoRI-XmnI strand and XmnI G strand, which are complementary to each other) was ligated onto both ends of the double-stranded cDNA. The adaptor was removed from the 3' end by NotI nuclease digestion whereas the adaptor was retained at the 5' end. Two rounds of PCR amplification were carried out. In the first, the EcoRI-XmnI adaptor was used as 5' end amplification primer; an antisense C region primer, designated mC alpha 2 or mC beta 2 (for the alpha- and beta-chain, respectively), was used as 3' amplification primer. In the second round of PCR amplification the same 5' end primer and a 3' end antisense primer, designated mC alpha 1 or mC beta 1, were used. These mC alpha 1 and mC beta 1 primers are located 5' to the mC alpha 2/mC beta 2 primers that were used for the first amplification. The amplified transcripts were cloned. Colonies were screened using a 32P-labeled probe, either C alpha or C beta, located 5' to those used for the last amplification and many positive clones were isolated and sequenced. All clones were unique when compared to each other, as anticipated for polyclonal T-cell populations. Comparison of the sequences obtained to those in the GENBANK/EMBL database revealed that they were typical of mouse alpha- or beta-chain TCR. With the exception of two beta-chain TCR transcripts, all the sequences shown here (36 alpha-chain and 20 beta-beta chain) have not been previously reported to the GENBANK/EMBL database.

Implementation and evaluation of Nursing Interventions Classification and Nursing Outcomes Classification in a patient education plan

Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) are recognized examples of standardized nursing languages used to describe the contribution nursing makes to patient care. Columbus Regional Hospital nursing leadership recognized the need to use standardized nursing interventions and nursing-sensitive patient outcomes to describe the unique contribution nursing makes to patient education. In collaboration with the University of Iowa, NIC/NOC languages were implemented in the development of a patient education plan for a clinical pathway population.

Differential expression of Met/hepatocyte growth factor receptor in subtypes of non-small cell lung cancers

Hepatocyte growth factor (HGF)/scatter factor (SF) is a multifunctional factor that stimulates epithelial cell motility, invasion and morphogenesis. Its receptor is a transmembrane tyrosine kinase encoded by the Met proto-oncogene. Several studies have suggested a possible role for HGF/Met in tumor development and progression. To investigate the potential roles of Met in human lung cancer biology, we have studied the mRNA and protein expression of Met in normal lung tissue, primary non-small cell lung carcinoma (NSCLC), and NSCLC cell lines. The results indicated a differential pattern of Met expression among various subtypes of NSCLC. The majority of squamous cell carcinoma (SQCC), either in vivo or in vitro, expressed Met mRNA and its protein product at levels much lower than or similar to normal lung tissue or bronchial epithelium. Moreover, SQCC characteristically over-expressed a variant Met mRNA which corresponds to a 5' partially deleted transcript produced by alternative splicing. In contrast, the expression of Met mRNA and its protein product in adenocarcinoma (ADC) and large cell undifferentiated carcinoma were more heterogeneous. Overexpression was demonstrated in approximately 35% and 20% of these subtypes of NSCLC, respectively. Among ADC, intermediate to high levels of Met immunoreactivity correlated with greater degree of tumor differentiation. Furthermore, an accentuation of Met immunoreactivity was often noted in cancer cells at the advancing edge of tumors. These findings support a role for Met in lung cancer cell invasion and differentiation in vivo, but its expression and functions may be modified by the differentiation phenotype of the tumor cells.

Peritoneal metastases from transitional cell carcinoma of the urinary tract: CT and MR imaging

We present three patients with peritoneal metastases from transitional cell carcinoma of the urinary tract. CT scan in one patient showed massive ascites with subtle peritoneal thickening and infiltration of omental fat. We had the opportunity to study the other patients with both CT and MR. Both examinations showed numerous large and small peritoneal implants in the abdomen and pelvis, mostly in the greater omentum.

A software architecture to support a large-scale, multi-tier clinical information system

A robust software architecture is necessary to support a large-scale multi-tier clinical information system. This paper describes our mechanism for enterprise distribution of applications and support files, the consolidation of data-access functions and system utilities stored on the data access tier, and an application framework which implements a coherent clinical computing environment. The software architecture and systems described in this paper have been robust through pilot testing of our applications at Massachusetts General Hospital.

MR cholangiopancreatography at 0.5 T with a 3D inversion recovery turbo-spin-echo sequence

The objective of this study was to assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) at 0.5 T. The MRCP technique was performed in 28 patients with symptomatology referrable to the biliary system. A three-dimensional (3D) inversion recovery turbo-spin-echo (TSE) sequence was used to create 3D reconstructions of the bile ducts. Dilation of the biliary tree or pancreatic duct in 23 patients due to tumor, calculi, or strictures was depicted with excellent contrast resolution. The approximate level of obstruction and all calculi were accurately predicted by MRCP. In another 3 patients no cause was found for the biliary dilatation. In the last 2 cases no abnormalities were found by either MRCP or endoscopic retrograde cholangiopancreatography (ERCP). The MRCP technique at 0.5 T is an accurate method for the assessment of pathology of the biliary tree.

Acquired CD40-ligand deficiency in chronic lymphocytic leukemia

Patients with B-cell chronic lymphocytic leukemia (CLL) acquire an immunodeficiency with many characteristics similar to those of persons with inherited defects in the gene encoding the CD40-ligand (CD154). We found that the blood and splenic CD4+ T cells of patients with CLL failed to express surface CD154 after CD3 ligation. However, using an enzyme-linked immunosorbent assay (ELISA)-based quantitative competitive polymerase chain reaction (PCR), we noted that CD3 ligation could induce such T cells to express CD154 messenger RNA at levels similar to that of CD3-activated T cells from normal donors. Moreover, addition of increasing numbers of CLL B cells to activated normal donor T cells rapidly resulted in progressively greater down-modulation of CD154. Such down-modulation of CD154 could be blocked by addition of CD40 monoclonal antibody to cultures in vitro. We propose that leukemia cell-mediated down-modulation of CD154 on activated T cells accounts for some of the acquired immune defects of patients with CLL.

Infarction of the corpus callosum: computed tomography and magnetic resonance imaging

OBJECTIVE

To describe the computed tomography (CT) and magnetic resonance (MR) features of corpus callosum (CC) infarctions.

METHODS

We reviewed retrospectively 352 consecutive cranial CT and MR scans showing cerebral infarcts. Involvement of the CC was identified in 28 patients.

RESULTS

Infarctions of the CC were diffuse (n = 3) or focal (n = 25). The former were seen in the setting of diffuse cerebral ischemia secondary to cardiopulmonary arrest or status epilepticus. The latter were divided into those affecting predominantly the genu, body or splenium. The most common location of the insult was the splenium (n = 13), followed by the body (n = 6) and genu (n = 3). In the remaining three patients combined genu/body infarctions were seen.

CONCLUSION

Infarction of the CC may be more common than previously thought and is most often the result of cerebral embolism. MR is better suited than CT for the detection of vascular lesions of the CC.

Cholera toxin triggers apoptosis in human lung cancer cell lines

Cholera toxin (ChT) inhibits signals generated by multiple growth factors in human lung cancer cells, resulting in cell growth inhibition. We now report that ChT triggers apoptosis as shown by DNA fragmentation and activation of caspases cleaving poly(ADP-ribose) polymerase and lamin B. Apoptosis induced by ChT in a small cell lung cancer cell line is not affected by manipulations of intracellular cAMP through preincubation with isobutylmethylxanthine but can be modestly increased through inhibition of protein kinase C with chelerythrine. Thus, apoptosis is actively suppressed in lung cancer cells by a ChT-sensitive-growth regulatory pathway, and these observations may have significant implications in the development of novel strategies for lung cancer treatment.

Bone marrow lesions: evaluation with fat-suppression turbo spin echo MR imaging at 0.5 T

The purpose of this study was the assessment of the diagnostic value of fat-suppression T2-weighted images for a variety of bone marrow lesions. We performed 40 studies of the axial or appendicular skeleton in 33 patients (age range 4-80 years) with neoplastic, inflammatory or traumatic lesions with a 0.5 T system (Gyroscan T5, Philips Medical Systems, Best, The Netherlands). Fat-suppression T2-weighted images [turbo spin echo (TSE) with spectral presaturation with inversion recovery (SPIR)] were obtained in addition to the routine T1-weighted SE and T2-weighted TSE sequences. Fat-suppression TSE T2-weighted images were better than standard TSE T2-weighted images in 25 studies. In 11 of them demonstration and characterization of the lesions (known from T1-weighted images) was possible only after fat suppression. In the other 14 patients demonstration of the full extent of the lesion especially to the nearby soft tissues was possible only after fat suppression. In 13 studies no advantage was conferred by SPIR, whereas in two instances T2-weighted images were better. Fat-suppression T2-weighted images are diagnostically useful in a variety of lesions of the musculoskeletal system, but their limitations should be known.

Growth factor expression and effects of amrinone in monocrotaline-induced pulmonary hypertension in rats

Platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) have been implicated in myointimal proliferative arteriopathy, a lesion seen in monocrotaline-induced pulmonary hypertension (MIPH). The purpose of this study was to examine the expression of PDGF and bFGF in the lungs of rats given monocrotaline and to examine the effects of amrinone on the hearts and lungs of these rats. Twenty-four 26-day-old rats were randomized to receive either monocrotaline (approximately 3.6 mg/kg/d) or no monocrotaline and concomitantly to receive either amrinone (100 mg/kg/d) or no amrinone for 21 days. Lungs were examined for immunohistochemical evidence of PDGF and bFGF, and hearts were examined for effects of pulmonary hypertension and amrinone. Immunohistochemical staining of lungs showed no evidence of PDGF except in bronchioles. bFGF staining was similar between groups (no monocrotaline 25%, monocrotaline 27%, monocrotaline and amrinone 22%), and the staining was confined to the arterial walls. Rats given monocrotaline showed significantly greater right ventricular (RV) weight (0.13 +/- 0.02 g versus 0.23 +/- 0.04 g [mean +/- SD], P < 0.001), right ventricular/left ventricular (RV/LV) weight ratio (0.29 +/- 0.06 versus 0.59 +/- 0.1, P < 0.001), and lung/body weight ratio (0.006 +/- 0.001 versus 0.01 +/- 0.003, P < 0.05) than controls. Rats given monocrotaline and amrinone were not significantly different from rats given only monocrotaline with regard to RV weight, RV/LV weight ratio, or lung/body weight ratio. We conclude that the vasculopathy seen in MIPH is not associated with the presence of PDGF or bFGF, suggesting that other growth factors may mediate this process. The course of MIPH is not altered by amrinone.

Acute subarachnoid haemorrhage: detection with magnetic resonance imaging

The purpose of this study was the evaluation of fluid attenuated turbo inversion recovery (FLAT TIRE) MR pulse sequence for detecting acute subarachnoid hemorrhage (SAH). Seven patients with SAH were studied within 6 days of ictus. Six of them underwent both CT and MRI and one MRI only. Pulse sequences included T1 spin echo (SE), PD and T2 turbo spin echo (TSE) and FLAT TIRE (TR/TI/TE = 6500/1800/140-180). All studies were performed on a 0.5 T system (Gyroscan T5, Philips Medical Systems). Simulated acute SAH was also studied with MRI. The FLAT TIRE sequence was better than the SE and TSE in all seven cases and better than CT in two cases. In two cases MRI was equivalent to CT, and in another two MRI underestimated the extent of SAH. The simulated acute SAH could be detected easily with the FLAT TIRE sequence, with difficulty on the T1 weighted images and not at all on the PD/T2 weighted images. The specific FLAT TIRE sequence used seems promising for the detection of acute SAH.

The third component of Xenopus complement: cDNA cloning, structural and functional analysis, and evidence for an alternate C3 transcript

Although the third component of complement has been purified from two amphibian species, Xenopus laevis and the axolotl, only limited information is available about its primary structure in these species. We now present (a) 95% of the cDNA sequence encoding C3 from a Xenopus laevis/Xenopus gilli (Xenopus LG) hybrid (b) an analysis of the C3 convertase and factor I cleavage sites in Xenopus C3, and (c) evidence for an alternative form of C3. The Xenopus LG sequence has a 57% nucleotide and 52% amino acid sequence identity to human C3 and contains one potential N-glycosylation site in the beta-chain. The deduced amino acid sequence showed that the C3 convertase and factor I cleavage sites (Arg-Ser) are conserved in Xenopus C3 and protein sequencing of Xenopus C3 fragments fixed on zymosan during complement activation demonstrated that Xenopus C3 is indeed cleaved by C3 convertase and factor I at these sites. Our screening of a liver cDNA library identified an unusual C3 clone with a deletion of 2502 bp, suggesting the presence of a novel C3 transcript in Xenopus LG liver. The presence of this C3 transcript was confirmed by reverse transcription polymerase chain reaction using Xenopus LG liver mRNA and specific oligonucleotide probes. This transcript encoded a putative 102-kDa protein comprising the beta-chain of C3, together with the first 59 residues and the last 103 residues of the alpha-chain; it would therefore lack many of the ligand binding sites found in the intact alpha-chain. However, the molecule may be an analog of a truncated C3 molecule that is found in the serum of allergic dermatitis patients and acts as an inhibitor of eosinophil cytotoxicity and neutrophil adherence.

Intraarticular "pilon" fracture of the tibia

Classification and treatment options for the management of tibial pilon fractures are reviewed. For comminuted and/or displaced fractures that require open reduction and internal fixation, a detailed description of the surgical technique, including indirect reduction techniques, is provided. Thirty-four pilon fractures (32 patients) treated during a period of five years (1984-1989) were reviewed. All were high-energy injuries (15 patients with multiple trauma) with Rüedi-Allgöwer Type II in 26 and Type III in eight. Eighteen (56%) were open fractures. Six fractures were treated with external fixation and the remaining 28 with open reduction and internal fixation. The patient follow-up examination period averaged 16.2 months (range, six to 38 months). Thirty (88%) fractures had united by 16 weeks (two delayed unions, one below knee amputation, and one plate breakage). In the 26 Type II fractures, functional grading found 17 excellent (65%) and six (23%) poor results. In the eight Type III fractures, there were four (50%) excellent and three (37%) poor results. Complications included one superficial pin-tract infection and two deep wound infections, both in Grade II open fractures.

Thecoperitoneal shunt for syringomyelia: report of three cases

During 8 months, three consecutive cases of syringomyelia were treated by the placement of thecoperitoneal shunts. In the first two patients, the cord cavitation was idiopathic in one and thought to be related to spinal trauma in the other. In the third case, there was associated anomaly of the craniocervical junction of the Chiari I type. Surgery was followed by clinical improvement in all patients. Postoperative magnetic resonance images showed definite diminution of the syringomyelic cavity. The results of treatment seem to support the use of the technique as a primary treatment of syringomyelia associated with progressive myelopathy.

Variants of alpha 1-antitrypsin in Puerto Rican children with asthma

A survey of 393 Puerto Rican and 354 non-Hispanic pediatric patients at Beth Israel Hospital, New York, revealed a significantly larger percentage of asthmatic subjects among Puerto Ricans, confirming findings of a study of Puerto Rican adults in New York. Assays of alpha 1-antitrypsin (AAT) concentration and phenotypes in 61 Puerto Rican asthmatic children revealed a significantly larger number with an S or Z variant in AAT phenotype. The AAT concentration was not a significant variable in this relationship, since four of five subjects with intermediate deficient AAT concentrations and a PiM phenotype were among control nonasthmatic Puerto Rican subjects. A family history of asthma was more common among asthmatic than control subjects and was most common for variant AAT phenotypes in either asthmatic or control subjects. We speculate that the S or Z variant of AAT affects the inflammatory response in such a way as to predispose to asthma.

The salvage of open grade IIIB ankle and talus fractures

Between 1983 and 1989, 11 open grade IIIB ankle or talus fractures were treated according to protocol including debridement, temporary placement of antibiotic beads, soft tissue coverage (including seven free vascular tissue transfers), intravenous antibiotics and fusion using an anterior plate, and bone graft. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2/patient (range: 5-12). The total in-patient hospital stay averaged 61.6 days (20-107 days) and in patient costs averaged $62,174.43/patient (range: $33,535.06-$143,847.45). Overall hospital cost averaged $1,009.32/day. Follow-up averaged 47.8 months (range 32-85 months), with an average time to union of 4.4 months. Fusion rate and muscle flap success was 100%. Although fusion and eradication of infection in this specific group of patients was possible, significant functional and psychosocial disability remained. Eight of eleven patients had significant pain, difficulty with stairs, and limited ambulation. All changed jobs or were unemployed. Patients with open grade IIIB tibiotalar injuries with significant bone loss may therefore benefit from early amputation. A multicenter randomized clinical outcome study is needed.

Molecular characterization of strains of enteroinvasive Escherichia coli O143, including isolates from a large outbreak in Houston, Texas

A large diarrhea outbreak due to enteroinvasive Escherichia coli (EIEC) serogroup O143 occurring in Houston, Tex., provided the opportunity to investigate aspects of the molecular epidemiology of this and related organisms. This was done by comparing the plasmid patterns and the chromosomal restriction endonuclease digestion patterns by pulsed-field gel electrophoresis (PFGE) of EIEC from the outbreak, other E. coli from the same serogoup (O143), and EIEC isolated from other patients with diarrhea. Among the isolates studied, there was marked restriction fragment length polymorphism. All 3 non-O143 EIEC isolates had very different restriction endonuclease digestion patterns, as did 5 of 5 O143 non-EIEC isolates and 6 of 15 O143 EIEC isolates. Four Houston outbreak O143 EIEC isolates had the same restriction pattern as an O143 EIEC strain isolated 2 months before in Mexico and was nearly identical to another two O143 EIEC Mexican isolates. These related strains also had the same plasmid pattern; however, the presence of only a few plasmid bands, versus the 21 to 30 chromosomal bands seen with PFGE, suggests that plasmid patterns could be a less specific way to distinguish different strains. These results demonstrate that PFGE can distinguish between different E. coli strains of the same serogroup and phenotype. This technique can also identify relatedness within O143 EIEC, and our data suggest the spread of a strain of EIEC from Mexico to Houston, where it caused a large outbreak. PFGE may be useful to study the epidemiology of EIEC.

[Role of three dimensional computed tomography in the decision of the therapeutic plan in craniomaxillofacial surgery]

The three-dimensional computerized tomography (3D-CT) gives the possibility of recomposing the 3D features, using the data pictures of successive slices of ordinary computerized tomography. In this paper we present the 3D-CT technique, as well as representative cases of patients with fractures and residual deformities in the craniomaxillofacial area. We also discuss the way the 3D-CT helped in the therapeutic evaluation. Moreover the pictures taken with this technique are compared with other diagnostic methods used in this area. In conclusion the present paper shows the significance of the 3D-CT both in the accurate diagnosis and in the pre-operative evaluation of severe maxillofacial problems.

An outbreak of shigellosis associated with the consumption of raw oysters

We describe an outbreak of Shigella sonnei infection among 24 persons who had eaten raw oysters in restaurants in southeastern Texas within five days before the onset of symptoms. The oysters in all eight restaurants were supplied by the same dealer, but examination of a routine water sample collected six days before the probable time of contamination showed the waters where the oysters were harvested to be free of fecal contamination, making widespread sewage contamination unlikely. The suspect oysters were traced to a single boat. Stool swabs from that boat's oyster harvesters allowed the identification of one asymptomatic carrier who had a strain of S. sonnei (determined by colicin typing, plasmid analysis, and testing for susceptibility to antibiotics) that was similar to or the same as that infecting the patients. Although the source of this man's infection was unknown, he reported having eaten no oysters. Investigation revealed that 5-gallon (19-liter) pails were used as toilets aboard the oyster boats. Sewage collected in these pails was often dumped overboard into the harvesting area. We conclude that this outbreak of S. sonnei resulted from poor sanitary procedures that probably allowed stool from a carrier to contaminate oysters either just before or after they were taken aboard the boat.

Action of intermediate doses of methotrexate on dihydrofolate reductase in malignant diseases

This report describes the effect of intermediate methotrexate (MTX) doses on dihydrofolate reductase (DHFR) activity in vivo in the leukocytes of 16 children with malignant diseases. The authors used a cytochemical technique, and the enzyme was studied in intact cells. The treatment protocols included MTX 500 mg-2 g/m2 weekly with leucovorin rescue. The above doses of MTX partially inhibit DHFR. The reduction of enzyme activity was observed in leukocytes within 24 h after MTX infusion, and it was more obvious in the polymorphonucleas and the monocytes. Complete inhibition of enzyme activity was not observed. These results do not agree with those of previous reports using biochemical techniques, which showed that small amounts of MTX inhibit DHFR activity. Even the large doses of MTX used in this study do not completely inhibit enzyme activity. It would be worthwhile to test the effect of even larger doses of MTX to find out if DHFR activity is inhibited.

In vitro antimicrobial activity of six pulp-capping agents

The antimicrobial activity of six commonly used pulp-capping agents was compared to reagent Ca(OH)2 by means of an in vitro microbiologic assay. Microbial samples were collected from deep carious lesions in each of twelve teeth and plated onto T-soy blood agar. Uniform disks of each pulp-capping agent were pressed slightly below the surface of each agar dish, and zones of bacterial inhibition were measured at 24 hours to the nearest 0.1 mm. All agents, including IRM, demonstrated significantly more antimicrobial activity than reagent Ca(OH)2 with the exception of Pulpdent. This tends to indicate that the antibacterial properties associated with these capping compounds are not entirely due to the high pH associated with Ca(OH)2.

Treatment of bladder carcinoma with irradiation combined with misonidazole

One hundred patients suffering from cancer of the bladder were treated by external beam irradiation, 400 cGy twice a week to a total dose of 4800 cGy. One half of the patients were randomized to receive the electron affinic sensitizer agent, misonidazole, at a dose of 1 gr/m2 and a total dose of 12 gr/m2. There was no statistically significant difference in tumor responses and in recurrence--free survival time between the patients who received irradiation and misonidazole as compared to those who received irradiation and placebos.

Nasopharyngeal cancer in patients under the age of thirty years

There is evidence that patients under 30 years of age with nasopharyngeal cancer present a somewhat different form of disease than patients of the older age group. Serum immunologic reactivity in the former was quantitatively different. Histologically, tumors in the younger age group are always of the undifferentiated type, and clinically, the disease is aggressive, characterized by frequent bone and lung metastases. The lymphatic spread into the mediastinum is accompanied by a paraneoplastic syndrome consisting of finger clubbing and hypertrophic osteoarthropathy, which is reversible after successful therapy. High rates of recovery have been obtained, even in the presence of advanced disease or metastases. This warrants a radical and persistent radiotherapeutic and or chemotherapeutic approach.