Adverse effects of extradural and intrathecal opiates: report of a nationwide survey in Sweden

The Swedish Society of Anaesthetists conducted a nationwide retrospective survey of clinical experience with extradural and intrathecal opiates. Special interest was focused on the frequency and type of ventilatory depression. The questionnaire was answered by 84 of 93 departments (90%). Up to May 1981 extradural morphine had been given to approximately 6000-9150 patients, extradural pethidine to 220-450 and intrathecal morphine to 90-150 patients. Ventilatory depression requiring treatment with naloxone was reported in 23 patients treated with extradural morphine (0.25-0.40%) and in six given intrathecal morphine (4-7%). In 22 patients the administration of extradural morphine was considered as a major contributory factor for the occurrence of ventilatory depression. Only two of these 22 patients experienced ventilatory depression later than 6 h after the last dose of opiates (S.C., i.m., i.v. or extradural). Patients aged 70 yr or more, those receiving thoracic extradural puncture and those with reduced ventilatory capacity seemed to be overrepresented.

Mutations of the heat inducible 70 kilodalton genes of yeast confer temperature sensitive growth

S. cerevisiae contains a family of genes related to the major heat shock induced gene of Drosophila (Hsp70). Two members of this family, YG100 and YG102, are 97% identical to each other in their protein coding regions. RNA transcribed from YG100 increases markedly after a heat shock, while transcripts of YG102 increase minimally. Mutants of the two genes were constructed in vitro and substituted in the yeast genome in place of the wild-type alleles. No phenotypic effect of single mutations of either gene was detected. However, cells containing both the YG100 and YG102 mutations grew slowly at 30 degrees C and could not form colonies at 37 degrees C. The temperature sensitive phenotype can be overcome by inserting either an intact YG100 or YG102 gene into the genome. Pretreatment at 37 degrees C before shift to a normally lethal temperature of 51 degrees C protected the double mutant as well as the wild type, indicating that YG100 and YG102 gene products are not needed for resistance to high temperatures for short periods.

Receptor heteromerization in adenosine A2A receptor signaling: relevance for striatal function and Parkinson's disease

Recently evidence has been presented that adenosine A2A and dopamine D2 receptors form functional heteromeric receptor complexes as demonstrated in human neuroblastoma cells and mouse fibroblast Ltk- cells. These A2A/D2 heteromeric receptor complexes undergo coaggregation, cointernalization, and codesensitization on D2 or A2A receptor agonist treatments and especially after combined agonist treatment. It is hypothesized that the A2A/D2 receptor heteromer represents the molecular basis for the antagonistic A2A/D2 receptor interactions demonstrated at the biochemical and behavioral levels. Functional heteromeric complexes between A2A and metabotropic glutamate 5 receptors (mGluR5) have also recently been demonstrated in HEK-293 cells and rat striatal membrane preparations. The A2A/mGluR5 receptor heteromer may account for the synergism found after combined agonist treatments demonstrated in different in vitro and in vivo models. D2, A2A, and mGluR5 receptors are found together in the dendritic spines of the striatopallidal GABA neurons. Therefore, possible D2/A2A/mGluR5 multimeric receptor complexes and the receptor interactions within them may have a major role in controlling the dorsal and ventral striatopallidal GABA neurons involved in Parkinson's disease and in schizophrenia and drug addiction, respectively.

Osteoarthrosis following insufficiency of the cruciate ligaments in man. A clinical study

Based on a series of 48 patients with old untreated ruptures of one or both cruciate ligaments, the development of osteoarthrotic changes was demonstrated by radiography and at operation. The changes were similar to those seen in animal experiments and developed in the same sequence. Osteophytes occurred in knees with anterior cruciate insufficiency after about 2 years; significant osteoarthrotic changes occurred after longer periods, and particularly in knees with damage to both cruciate ligaments.

Stress radiographical measurement of the anteroposterior, medial and lateral stability of the knee joint

A hydraulically operated machine for applying well-defined forces to the knee joint is described. The measurement of anteroposterior as well as lateral and medial stability in the knee joint is based upon roentgenograms exposed while the forces are being exerted on the patient. The advantage of the radiological measuring method over methods using external measurements is the elimination of inaccuracies due to displacements of the soft tissues of the limb. The accuracy was evaluated by test/retest examination of 50 healthy subjects. The radiographs were measured at random after cessation of examinations in the gonylaxometer. The accuracy is +/- 1.2 nm for medial/lateral, +/- 2.4 nm for drawer sign. Diagnostically the difference between the two knees must exceed 2.0 nm (collateral instability) or 3.1 nm (drawer) to exceed standard values. The standard values for the different ligament laxities are given. The applied force to be used for evaluation of medial/lateral stability is recommended to be 9 kg, and for anteroposterior stability between 20 and 30 kg.

Diverse cellular architecture of atherosclerotic plaque derives from clonal expansion of a few medial SMCs

Fibrous cap smooth muscle cells (SMCs) protect atherosclerotic lesions from rupturing and causing thrombosis, while other plaque SMCs may have detrimental roles in plaque development. To gain insight into recruitment of different plaque SMCs, we mapped their clonal architecture in aggregation chimeras of eGFP+Apoe-/- and Apoe-/- mouse embryos and in mice with a mosaic expression of fluorescent proteins in medial SMCs that were rendered atherosclerotic by PCSK9-induced hypercholesterolemia. Fibrous caps in aggregation chimeras were found constructed from large, endothelial-aligned layers of either eGFP+ or nonfluorescent SMCs, indicating substantial clonal expansion of a few cells. Similarly, plaques in mice with SMC-restricted Confetti expression showed oligoclonal SMC populations with little intermixing between the progeny of different medial SMCs. Phenotypes comprised both ACTA2+ SMCs in the cap and heterogeneous ACTA2- SMCs in the plaque interior, including chondrocyte-like cells and cells with intracellular lipid and crystalline material. Fibrous cap SMCs were invariably arranged in endothelium-aligned clonal sheets, confirming results in the aggregation chimeras. Analysis of the clonal structure showed that a low number of local medial SMCs partake in atherosclerosis and that single medial SMCs can produce several different SMC phenotypes in plaque. The combined results show that few medial SMCs proliferate to form the entire phenotypically heterogeneous plaque SMC population in murine atherosclerosis.

Microenvironmental organization and stromal cell associations of B lymphocyte precursor cells in mouse bone marrow

B lymphocyte precursor cells expressing B220 glycoprotein have been examined in mouse bone marrow (BM) by the in vivo binding of monoclonal antibody (mAb) 14.8 visualized by light and electron microscope radio autography. Young mice were injected intravenously with 125I-labeled mAb 14.8 and then perfused to remove unbound antibody. Quantitative analysis of radioauto graphic sections of femoral BM revealed many labeled mAb 14.8-binding cells which were situated both singly and in groups throughout the extravascular BM parenchyma. Groups of large 14.8+ cells were located in patchy areas in the peripheral regions of the BM near the endosteum. These cells were shown to include proliferating precursor B cells by using mice given vincristine sulfate to stop cells in metaphase and mice treated from birth with anti-IgM antibodies to delete mature B lymphocytes. Electron microscopy revealed clusters of 14.8+ cells intimately associated with the processes of stromal reticular cells. Other 14.8+ cells were in close contact with macrophages; in some instances the intervening cell membranes were indistinct and the macrophages contained 14.8+ material in their cytoplasm. In addition, 14.8+ small lymphocytes were highly concentrated within the lumen of some sinusoids. The present method of detecting B lineage precursor cells in situ has led to a working model of the microenvironmental organization of primary B cell genesis in vivo. The model proposes (a) a centrally directed sequence of differentiation initiated by early precursor cells situated peripherally near the surrounding bone; (b) close associations between precursor B cells and stromal reticular cells; (c) deletion of ineffective B cells by macrophages, and (d) an intravascular maturation phase before B lymphocytes are finally delivered into the blood stream.

HMG I-like proteins from leaf and nodule nuclei interact with different AT motifs in soybean nodulin promoters

Three different nuclear factors recognizing short AT-rich DNA sequences were identified in different organs of soybean. One factor (NAT2) was found to be present in mature nodules, another factor (NAT1) was detected in roots and nodules, and a third one (LAT1) was only observed in leaves. All three factors recognized several DNA sequences in the promoter region of the soybean nodulin N23 gene. Footprinting, deletion, and point mutation analyses revealed different binding properties for all three factors and further showed that even single base pair substitutions had a dramatic effect on binding affinity. The LAT1 and NAT1 factors were released from chromatin by extraction with a low-salt buffer and were soluble in 2% trichloroacetic acid, implying a relationship to high-mobility group (HMG) proteins. DNA binding studies further indicated a functional relationship of these factors to the human HMG I protein. Purification of the LAT1 factor from leaf nuclei revealed the presence of two polypeptides with molecular masses of 21 kilodaltons and 23 kilodaltons, respectively, binding the same DNA sequence with equal affinity.

Apoptosis and macrophage-mediated cell deletion in the regulation of B lymphopoiesis in mouse bone marrow

Studies of cell population dynamics and microenvironmental organization of B lymphopoiesis in the bone marrow of normal mice and in various genetically modified states have shown that cell loss, involving processes of apoptosis and macrophage-mediated cell deletion, is a prominent feature of the primary genesis of B lymphocytes. Balanced against the influence of proliferative stimulants, the programmed death of precursor B cells provides a quantitative control, determining the magnitude of the final output of functional B lymphocytes to the peripheral immune system. The cell loss mechanisms can be readily set in motion by external or systemic influences, making the B-cell output particularly vulnerable to suppression by ionizing irradiation, stress or other systemic mediators. In addition, however, cell loss exerts an important quality control in the formation of the primary B-cell repertoire. The combination of apoptosis and macrophage-mediated deletion, acting at successive stages of B-cell differentiation, efficiently eliminates many precursors having non-productive Ig gene rearrangements, cell cycle dysregulations, and certain autoreactive Ig specificities. Outstanding areas of further work abound. Important questions concern the nature of mechanisms which underlie the processes of B-cell apoptosis and macrophage deletion in bone marrow, the microenvironmental signals involved in B-cell life or death decisions and genetic factors which may override these B-cell culling mechanisms. The answers will be relevant to problems of autoimmune disease, humoral immunodeficiency and B-cell neoplasia.

Mutations in cognate genes of Saccharomyces cerevisiae hsp70 result in reduced growth rates at low temperatures

Expression of two Saccharomyces cerevisiae genes (YG101 and YG103) that are related to the gene encoding inducible 70K protein (hsp70) is repressed upon heat shock. Mutations of the two genes were constructed in vitro and substituted into the yeast genome in place of the wild-type alleles. No phenotypic effect of single mutations of either gene was detected. However, cells containing both YG101 and YG103 mutations showed altered growth properties; double-mutation cells possess an optimal growth temperature of 37 degrees C rather than 30 degrees C and grow increasingly poorly as the temperature is lowered. Mutations of two other members of this hsp70-related multigene family, YG100 and YG102, have been analyzed (E. A. Craig and K. Jacobsen, Cell 38:841-849, 1984). Cells containing both YG100 and YG102 mutations cannot form colonies at 37 degrees C. Fusions between the YG101 and YG102 promoter regions and the YG100 and YG101 structural genes, respectively, were constructed. The YG101 promoter-YG100 structural gene fusion was not able to restore normal growth properties to the yg101- yg103- mutant. Also, yg100- yg102- cells containing the YG102 promoter-YG101 structural gene fusion were unable to grow at 37 degrees C. Failure of the protein products of related genes to rescue the relative cold sensitivity of growth suggests that members of the hsp70 multigene family are functionally distinct.

Congenital dislocation of the knee

Congenital dislocation of the knee is a very rare condition, the incidence in Scandinavia hitherto not being known with certainty. Thirteen patients treated during the years 1960 to 1983 with 19 affected knees were reviewed and followed up. Findings of muscular imbalances in nine of these cases and of spinal abnormalities in four cases strongly indicate neuromuscular imbalance as an aetiological factor. The minimum incidence was estimated to be 0.017 per mille or approximately 1 per cent of the incidence of congenital dislocation of the hip. Recommendations for treatment are that manipulation should be carried out gently, and if not successful within 2-3 months and in all cases of Grade III, an operation is indicated. Too many newborn children in this series had manipulation fractures or slipped epiphyses. However, signs of fracture had disappeared at follow-up in most cases.

Immunohistochemical detection of metallothionein in primary breast carcinomas and their axillary lymph node metastases

Metallothioneins (MTs) are low-molecular-weight proteins with specific binding for group II metal ions. MTs are involved in the detoxification of metals, but can also play a role in protection of the cell against certain anticancer agents and from damage of irradiation. High expression of MTs in primary breast carcinomas has been found to be associated with poorer prognosis. Expression of MT (MT) was examined immunohistochemically in 160 breast carcinomas and their concomitant lymph node metastases. The immunoreactivity appeared to be independent of the length of fixation when the section was microwaved before incubation with the primary antibody, a monoclonal antibody E-9. The findings were correlated with various histopathological factors, disease-free survival and over-all survival. Patients were divided into two groups, those with MT over-expression (above 10% of positive tumour cells), and those with low MT expression (below 10% positive). MT over-expression was found to be correlated with postmenopausal status and inversely with positive progesterone receptor status (PgR). MT over-expression showed statistically significant correlation with poor over-all survival. No differences in survival were seen between pre- and postmenopausal patients. PgR was in univariate analysis a poor prognostic parameter. In one fourth of the patients, the lymph node metastases showed increased MT expression compared with the primary tumour. These patients had a poorer, but not statistically significant different survival. MT expression was not correlated to chemo- or radiation therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Electroacupuncture in anaesthesia for hysterectomy

We have studied the effects of electroacupuncture at classical acupuncture points, applied before and during surgery in patients undergoing hysterectomy, on postoperative pain and metabolic stress responses in a prospective, randomized and patient-blinded manner. Fifty otherwise healthy women were allocated randomly to receive or not receive electroacupuncture. Electroacupuncture was begun 20 min before skin incision and continued to the end of surgery. All patients received similar general anaesthesia and all received patient-controlled analgesia (PCA) after operation. Postoperative pain in the two groups was evaluated by recording analgesic requirements by PCA and by pain-rating performed by patients and nursing staff. There were no significant differences between the two groups in postoperative analgesic requirements, pain-rating or metabolic stress responses.

Acute and habitual caffeine ingestion and metabolic responses to steady-state exercise

This study compared the exercise catecholamine and metabolic responses to a caffeine challenge in trained subjects before and after a 6-wk period of increased caffeine ingestion. Trained subjects (n = 6) were challenged with 500 mg of caffeine followed by prolonged exercise before and after 6 wk of increased caffeine ingestion (500 mg ingested before each daily run). A control group (n = 6) of trained subjects followed the same protocol except for caffeine ingestion. Acute caffeine ingestion resulted in increased plasma epinephrine and decreased respiratory exchange ratio (RER) during exercise. After 6 wk of caffeine supplementation, the epinephrine response to exercise or caffeine plus exercise was decreased, although the latter still resulted in a lower RER value compared with exercise without caffeine ingestion. Activity of key metabolic enzymes (hexokinase, citrate synthase, phosphorylase, and 3-hydroxyacyl-coenzyme A dehydrogenase) from biopsies of the gastrocnemius showed no response to 6 wk of this increased adrenergic receptor stimulation and, on the basis of the lower RER, enhanced fat metabolism. This study suggests that caffeine ingestion by trained subjects causes increases in plasma epinephrine and reduces the RER during exercise. However, habitual stimulation results in a general dampening of the epinephrine response to caffeine or exercise. There was no indication that increased adrenergic stimulation and fat oxidation caused any adaptation in the activity of metabolic enzymes.

Highly restricted expression of a stromal cell determinant in mouse bone marrow in vivo

B lymphocyte precursor cells in mouse bone marrow develop in close association with stromal cells which provide essential growth signals. To identify molecules that may normally play a role in this interaction we have examined the in vivo binding of a new monoclonal antibody (mAb) (KMI6) that recognizes a determinant on a bone marrow stromal cell line (BMS2) in vitro. Flow cytometric and radioautographic evaluations revealed that the antigen recognized by KMI6 is represented on the surface of an extremely small number of cells in bone marrow cell suspensions from adult mice. An apparent molecular mass of 110 kD was obtained by surface labeling of a stromal cell clone and immunoprecipitation. Purified mAb KMI6 labeled with 125I was then given intravenously to young C3H/HeJ mice. Unbound mAb was washed out by cardiac perfusion and femoral bone marrow was examined by light and electron microscope radioautography. KMI6 labeling was heavy on the plasma membrane of many stromal cells, especially those located towards the outer subosteal region. The KMI6-labeled stromal cells were usually associated with cells of lymphoid morphology which they often completely surrounded. The labeling was restricted to areas of stromal cell plasma membranes in contact with lymphoid cells. The lymphoid cells themselves, as well as macrophages and other hemopoietic cells, failed to bind mAb KMI6 significantly. Stromal cells in bone marrow depleted of hemopoietic cells by gamma-irradiation (9,5 Gy) bound mAb KMI6 at reduced intensity. The results demonstrate that the KMI6 determinant, a 110-kD protein, is expressed on bone marrow stromal cells in vivo. Its restriction to areas of interaction with lymphoid cells suggests a role in forming microenvironmental niches of B lymphopoiesis. The surface membrane of individual stromal cells may thus be functionally polarized towards interacting B cell precursors and other hemopoietic cells.

Correlation of abdominal ultrasound and computed tomography scans with second- or third-look laparotomy in patients with ovarian carcinoma

To determine the best noninvasive means of evaluating response in patients with advanced ovarian carcinoma, 50 abdominal ultrasound (US) and computed tomography (CT) scans were performed in clinically disease-free ovarian cancer patients. The scans were correlated with the results obtained at a subsequent second- or third-look laparotomy. CT and US were not complementary, and only metastases larger than 2 cm were detected. The overall positive predictive value of nonconcordant scans was 57% compared with 100% for concordant CT and US (95% confidence limits: 18.4-90.1 and 29.2-100%, respectively). The corresponding negative predictive values were 45 and 47% (30.2-59.9 and 30.4-61.2%, respectively), if undetected microscopic disease was classified as a false-negative result. The negative predictive value of US and CT increased only to 60% in both cases, if undetected microscopic disease was registered as a true-negative result. Compared with the pelvic examination CT and US added positive information for 4 of 22 (18%) patients with macroscopic residual disease. In this study neither CT nor US was sensitive enough to preclude second-look laparotomy.

Rett syndrome and ageing: a case study

PURPOSE

This case study of an elderly women with Rett syndrome is used to consider whether observed changes may be related to physiological processes involved in ageing or environmental adaptations, which is important for delivery of rehabilitation.

METHOD

The life story of a woman with Rett syndrome who lived to the age of 60 is presented. It is based on medical records, older and more recent videotapes, and interviews with her sister and care staff.

RESULTS

After 21 years without walking, following intensive physiotherapy, she regained the ability to walk without support. She also showed improvement in hand use a few years before she died. During the early regression she appeared to lose social interest. The interest improved after some time, but she remained wary of people she did not know.

CONCLUSION

The walking and hand use indicate that these functions may have been present to a greater extent than assumed by people in the environment and that her poor function reflects dyspraxia and lack of opportunity and training rather than lack of ability. Although more studies of elderly women with Rett syndrome is needed to answer whether the observed changes were due to physiological processes involved in ageing or environmental adaptations, the present case story demonstrates that identification of females with Rett syndrome is important at all age levels.

Stress radiographical measurements of post-traumatic knee instability. A clinical study

In a prospective, consecutive, clinical and stress radiographical study, comprising 153 traumatic knee injuries, the value of stress radiographical measurements, gonylaxometry, was studied. Clinical evaluation, gonylaxometry and preoperative evaluation under general anaesthesia were carried out in that order. Then the operative findings were recorded as drawings on standard diagrams. These were used as a basis for evaluation of the preoperative tests. Of all the methods evaluated, gonylaxometry was found to provide the most accurate information regarding the knee injury. Very close to this result were the findings under general anaesthesia. Anterior drawer sign was measured gonylaxometrically when damage to the anterior cruciate ligament was present; posterior drawer meant damage to the posterior cruciate ligament. Partial ruptures of cruciate ligaments did not allow antero-posterior displacements exceeding the critical levels of the test. Small positive medial instability was found with ruptures of profound medial structures, higher values with total rupture of the long superficial collateral band, and still higher values when cruciate ligament ruptures were also present. The predictive values of a positive radiographical test were 100 per cent as regards medial instability and 98 per cent for drawer looseness. The predictive values of a negative test were 96 per cent for drawer and 92 per cent for medial instability. These figures are based on the total material. 95 per cent confidence limits are given.

Implications of muscular defense in testing for the anterior drawer sign in the knee. A stress radiographic investigation

This study was performed with the aim of shedding some light on the effect of muscular guarding during clinical testing of the knee for anteroposterior laxity. Twenty physicians were tested on a knee phantom, for force used during testing for the anterior drawer sign. The force used averaged 109 N (range, 70 to 180 N). Fifteen patients were examined by stress radiography. Radiographs were taken with the knee flexed to 90 degrees (the drawer test position) and with the knee flexed to 15 degrees (the Lachman position). A comparison was made between the laxity measured on forward traction in the relaxed knee, and during traction while the patient was instructed to counteract the forward displacement of the tibia by tensing the hamstrings, thus simulating muscular defense. The test procedure was executed first with 80 N and then with 160 N applied. The opposing effect of tensing the hamstrings on the anterior shift of the tibia was significantly less at 15 degrees of knee flexion (with 80 N, P less than 0.02; with 160 N, P less than 0.05) than at 90 degrees. With the hamstrings tensed and the knee flexed to 90 degrees, no statistically significant gain in drawer sign was achieved by increasing the force from 80 to 160 N. With the knee in the Lachman position, increasing the force produced a significantly greater anterior drawer sign (P less than 0.01).

Normal ICOS, ICOSL and AID Alleles in Danish Patients with Common Variable Immunodeficiency

Common variable immunodeficiency, CVID, is a primary antibody deficiency characterized by decreased levels of serum immunoglobulin G (IgG), decreased IgA and/or IgM and recurrent infections. It is assumed to be heterogeneous group of disorders caused by different genetic defects. Some patients have decreased levels of class switched memory B cells and/or decreased levels of somatic hypermutation which points to defects in the germinal centre (GC) reactions as cause of the disease in these patients. The inducible costimulator, ICOS, and its' ligand, ICOSL, are both involved in and necessary for the GC reaction and so is activation-induced cytidine deaminase, AID. Therefore, we sequenced the ICOS, ICOSL and AID genes in a cohort of 34 Danish CVID patients. We found 13 new single nucleotide polymorphisms (SNP) in the intron regions of the ICOSL gene as well as one SNP in exon 3. However, none of these polymorphisms were associated with CVID. We did not find a previously reported CVID-causing ICOS gene deletion or any other unique mutations in the ICOS or AID genes.

A modified McCash operation for Dupuytren's contracture

The open palm technique for Dupuytren's contracture in connection with a midlateral ulnar incision on the fifth finger was used in selected cases of severe contracture with skin shrinkage (13% of all cases during a 2 1/2 year period). Special attention was drawn to the "cornerflap" of the incision, but no vascular problems were found. All wounds closed spontaneously in 3--6 weeks. The finger release was as good as in other series of patients with similar severity of the disease. We propose this technique only in cases with severe contracture and in good physical and mental condition.