Activation of PI3K and R-Ras signaling promotes the extension of sensory axons on inhibitory chondroitin sulfate proteoglycans

Chondroitin sulfate proteoglycans (CSPGs) are extracellular inhibitors of axon extension and plasticity, and cause growth cones to exhibit dystrophic behaviors. Phosphoinositide 3-kinase (PI3K) is a lipid kinase activated by axon growth promoting signals. In this study, we used embryonic chicken dorsal root ganglion neurons to determine if CSPGs impair signaling through PI3K. We report that CSPGs inhibit PI3K signaling in axons and growth cones, as evidenced by decreased levels of phosphorylated downstream kinases (Akt and S6). Direct activation of PI3K signaling, using a cell permeable phosphopeptide (PI3Kpep), countered the effects of CSPGs on growth cones and axon extension. Both overnight and acute treatment with PI3Kpep promoted axon extension on CSPG-coated substrates. The R-Ras GTPase is an upstream positive regulator of PI3K signaling. Expression of constitutively active R-Ras promoted axon extension and growth cone elaboration on CSPGs and permissive substrata. In contrast, an N-terminus-deleted constitutively active R-Ras, deficient in PI3K activation, promoted axon extension but not growth cone elaboration on CSPGs and permissive substrata. These data indicate that activation of R-Ras-PI3K signaling may be a viable approach for manipulating axon extension on CSPGs.

Regulation of actomyosin contractility by PI3K in sensory axons

Phosphatidylinositol 3-kinase (PI3K) activity is known to be required for the extension of embryonic sensory axons. Inhibition of PI3K has also been shown to mediate axon retraction and growth cone collapse in response to semaphorin 3A. However, the effects of inhibiting PI3K on the neuronal cytoskeleton are not well characterized. We have previously reported that semaphorin 3A-induced axon retraction involves activation of myosin II, the formation of an intra-axonal F-actin bundle cytoskeleton, and blocks the formation of F-actin patches that serve as precursors to filopodial formation in axons. We now report that inhibition of PI3K results in activation of myosin II in axons. Inhibition of myosin II activity, or its upstream regulatory kinase RhoA-kinase, blocked axon retraction induced by inhibition of PI3K. In addition, inhibition of PI3K also induced intra-axonal F-actin bundles, which likely serve as a substratum for myosin II-based force generation during axon retraction. In axons, filopodia are formed from axonal F-actin patch precursors. Analysis of axonal F-actin patch formation in eYFP-actin expressing neurons revealed that inhibition of PI3K blocked formation of axonal F-actin patches, and thus filopodial formation. These data provide insights into the regulation of the neuronal cytoskeleton by PI3K and are consistent with the notion that decreased levels of PI3K activity mediate axon retraction and growth cone collapse in response to semaphorin 3A.

Extracellular Muscle Myosin II Promotes Sensory Axon Formation

Myosin II is an intracellular force-generating enzyme with no known extracellular action. In the course of experiments involving trituration loading of skeletal myosin II into embryonic sensory neurons we observed that extracellular application of myosin II to neurons resulted in a robust increase in the number of axons initiated by each neuron, but did not alter the rate of axon extension. Substratum bound myosin II in the presence of laminin was sufficient to elicit increases in axon formation. However, in the absence of laminin, extracellular myosin II alone was not sufficient to promote axon formation, although it allowed neuron survival in the presence of neurotrophin. Myosin II promoted the attachment of neurons to the substratum in the absence or presence of laminin. In addition to promoting the initiation of axons, extracellular myosin II also increased the frequency of axon collateral branching. Finally, extracellular myosin II did not affect growth cone collapse in response to semaphorin-IIIA, but attenuated the inhibitory action of chondroitin sulfate proteoglycans on axon extension. Surprisingly, these results demonstrate that extracellular myosin II promotes attachment of neurons and increases axon formation and branching. The potential significance of these observations is discussed in the context of myosin II release from injured muscle and a previous demonstration of extracellular myosin II association with the extracellular matrix.

Bidirectional inhibitory interactions between the embryonic chicken metanephros and lumbosacral nerves in vitro

During chicken embryonic development the metanephros forms from the uretic duct at embryonic day (E) 7. As the metanephric tissue develops between E7 and E10, it comes into close apposition with lumbosacral nerves. Coculturing of metanephric and nerve explants demonstrated that the Schwann cells of the sciatic nerve inhibit the migration of metanephric cells in a contact-dependent manner. Conversely, metanephric cells inhibit dorsal root ganglion axon extension in a contact-dependent manner. However, metanephric cells are not inhibited by contact with growth cones or axons. Dorsal root ganglion growth cones become sensitive to the inhibitory signals on the surfaces of metanephric cells around E8, a time when the metanephros is expanding into the territory occupied by nerves in vivo. These observations demonstrate inhibitory bidirectional tissue-tissue interactions in vitro and provide a novel model system for the study of contact-based guidance of both neuronal and non-neuronal cell migration.

Travoprost compared with latanoprost and timolol in patients with open-angle glaucoma or ocular hypertension

PURPOSE

This study evaluated the safety and intraocular pressure-lowering efficacy of two concentrations of travoprost (0.0015% and 0.004%) compared with latanoprost 0.005% and timolol 0.5% in patients with open-angle glaucoma or ocular hypertension.

METHODS

Eight hundred one patients with open-angle glaucoma or ocular hypertension were randomly assigned to travoprost 0.0015%, travoprost 0.004%, latanoprost 0.005%, or timolol 0.5%. The efficacy and safety of travoprost (0.0015% and 0.004%) daily was compared with latanoprost daily and timolol twice daily for a period of 12 months.

RESULTS

Travoprost was equal or superior to latanoprost and superior to timolol with mean intraocular pressure over visits and time of day ranging from 17.9 to 19.1 mm Hg (travoprost 0.0015%), 17.7 to 19.1 mm Hg (travoprost 0.004%), 18.5 to 19.2 mm Hg (latanoprost), and 19.4 to 20.3 mm Hg (timolol). For all visits pooled, the mean intraocular pressure at 4 PM for travoprost was 0.7 mm Hg (0.0015%, P =.0502) and 0.8 mm Hg (0.004%, P =.0191) lower than for latanoprost. Travoprost 0.004% was more effective than latanoprost and timolol in reducing intraocular pressure in black patients by up to 2.4 mm Hg (versus latanoprost) and 4.6 mm Hg (versus timolol). Based on a criterion of 30% or greater intraocular pressure reduction from diurnal baseline or intraocular pressure 17 mm Hg or less, travoprost 0.0015% and 0.004% had an overall response to treatment of 49.3% and 54.7%, respectively, compared with 49.6% for latanoprost and 39.0% for timolol. Iris pigmentation change was observed in 10 of 201 of patients (5.0%) receiving travoprost 0.0015%, six of 196 of patients (3.1%) receiving travoprost 0.004%, 10 of 194 of patients (5.2%) receiving latanoprost, and none of the patients receiving timolol (0 of 196). The average ocular hyperemia score was less than 1 on a scale of 0 to 3, indicating that on average patients experienced between none/trace and mild for all treatment groups. There were no serious, unexpected, related adverse events reported for any therapy.

CONCLUSIONS

Travoprost (0.0015% and 0.004%), a highly selective, potent prostaglandin F (FP) receptor agonist, is equal or superior to latanoprost and superior to timolol in lowering intraocular pressure in patients with open-angle glaucoma or ocular hypertension. In addition, travoprost 0.004% is significantly better than either latanoprost or timolol in lowering intraocular pressure in black patients. Travoprost is safe and generally well tolerated in the studied patient population.

Necrotizing fasciitis: a plea for early diagnosis and treatment

INTRODUCTION

Necrotizing fasciitis is an uncommon infectious entity that poses difficult diagnostic and therapeutic management decisions.

PURPOSE

This paper addresses the presentation, evaluation and management of the patient with a necrotizing soft tissue infection.

CASE REPORT

A 54-year-old man presented to his physician with pain and swelling of the left anterior chest wall following a presumed insect bite several days prior. He was treated with oral antibiotics but returned to the office three days later with increased swelling, pain, and erythema in the axilla. Necrotizing fasciitis was diagnosed. He was hospitalized and taken to the operating room for debridement of the chest wall. Extensive necrosis of the skin, subcutaneous tissue and muscle was encountered. Muscle debridement extended from the pectoralis major and both obliques anteriorly to the latissimus dorsi and para-spinalis muscles posteriorly. Multiple operative debridements were performed over several days. The patient developed septic shock requiring blood pressure support, and multiple organ system failure requiring hemodialysis, prolonged ventilatory support and eventual tracheostomy. Split-thickness skin grafts were placed during the third operative debridement and concluded on the 15th day of hospitalization. The patient eventually recovered and on the 53rd hospital day was transferred to the rehabilitation service, where he spent the next four weeks recovering movement in the left arm.

CONCLUSION

Necrotizing fasciitis is an infectious entity that requires rapid diagnosis, surgical debridement, and tissue coverage if the patient is to survive.

Childhood longitudinal melanonychia: case reports and review of the literature

"Longitudinal melanonychia" refers to a brown or brown-black longitudinal band on a fingernail or toenail. A number of conditions can cause longitudinal melanonychia, but its main importance is that, in some patients, it may indicate the presence of a subungual malignant melanoma. Hyperpigmented nail bands are not uncommon in African-American, Latino and Asian patients, especially those over sixty years of age, and are often multiple in these groups. Longitudinal melanonychia is most worrisome when there is a solitary, dark, broad longitudinal band with pigment extending over the proximal nail fold (Hutchinson's sign). Such findings are considered to be a strong indication for biopsy of the nail matrix to rule out melanoma. Since nail matrix biopsy sometimes results in permanent nail deformity, and since the incidence of malignant melanoma is quite small in the pediatric age group, there is some controversy as to whether this procedure should routinely be performed in children. We report two cases of dramatic longitudinal melanonychia in toddlers and review the current literature on the management of this striking condition in the pediatric age group.

Assessing the dimensionality of the Singhapakdi, Vitell, and Kraft measure of moral intensity

In a sample of 105 students, the dimensionality of a moral intensity scale developed by Singhapakdi, Vitell, and Kraft in 1996 was assessed. Principal components analysis yielded a one-factor solution across 10 ethics scenarios, indicating that moral intensity may be treated as a unidimensional construct in some situations.

Salvage of ear replantation using the temporoparietal fascia flap

The authors report a case involving a 46-year-old man who sustained a traumatic amputation of approximately 60% of his ear from a human bite. The ear was replanted microsurgically without the benefit of venous anastomosis. Blood transfusion was not required despite the use of leech therapy and systemic anticoagulation. The replantation appeared to be a success at the time of his discharge from the hospital, but during the late postoperative period the replanted ear became progressively necrotic. The failing ear replantation was rescued successfully with the use of temporoparietal fascia flap reconstruction.

Plastic surgical perspectives on vascular endothelial growth factor as gene therapy for angiogenesis

The practice of plastic surgery has always remained at the frontier of medical science. Over the past few decades, this frontier has been marked by significant developments in the field of gene therapy. Gene therapy serves to replace, supplement, or manipulate a patient's genetic makeup to restore function that has been lost or to correct function that is aberrant. Recent technology may allow surgeons to augment the processes of wound healing and angiogenesis by transfecting genes encoding desirable proteins, such as vascular endothelial factor (VEGF), into ischemic tissues. VEGF is a vital growth factor in the development of blood vessels. Although its mechanisms of action are numerous, its sole function seems to be the augmentation of angiogenesis. VEGF is active in growth and development, in wound healing, and in various pathologic conditions, such as psoriasis and rheumatoid arthritis. The role of VEGF in the field of plastic surgery is just beginning to be explored; it may someday prove to be very rewarding.

Accelerated flap prefabrication with vascular endothelial growth factor

Vascular endothelial growth factor (VEGF) is a potent promoter of angiogenesis that has been shown to enhance revascularization of ischemic tissues, including skin flaps. This study was designed to investigate the value of a single topical application of recombinant human VEGF to accelerate flap viability in a rat model of a non-ischemic prefabricated flap. Prefabricated flaps were created in 48 Sprague-Dawley rats. An autologous tail artery loop was anastomosed to the femoral artery and vein, and implanted subcutaneously in the lower abdomen. Flaps were divided into two groups of 24 each. At the time of loop implantation the control group received 0.9 percent NaCl or a 16 percent vol/wet polyvinyl alcohol (PVA) solution: the treatment group received VEGF in 0.9 percent NaCl or VEGF in PVA. The PVA gel was used to facilitate topical application In each group, 3- x 4-cm flaps nurtured by the tail artery pedicle were elevated and resutured into place after 3, 4, and 5 weeks. The percentage of surviving skin of each flap was determined by planimetry 7 days after flap elevation. Mean skin survival areas at 3, 4, and 5 weeks were control group 0 percent. 8 percent and 17.5 percent; and VEGIF-treated group, 6 percent, 40 percent, and 66.7 percent respectively VEGF significantly improved flap survival by 5 weeks (p = 0.02). These results suggest that VEGF can accelerate maturation of prefabricated flaps. This approach could expand the application of flap prefabrication as a resource for reconstructive surgery.

Staging arteriovenous fistula loops for lengthening of free-flap pedicles

The authors investigated the optimal period of maturation following the creation of arteriovenous (AV) loops using polyterafluoroethylene (PTFE) in a white rat model, which were subsequently used to support free-tissue transfer The AV loops in Group 1 (n = 17) were allowed to mature for 3 days prior to creation of the flap, while those from Group 2 (n = 14) were allowed to mature for 5 days. Results were compared to those from a previous study in which the authors reported an 80 percent initial patency rate (n = 30) and a 67 percent viability rate, based on 12 patent loops after 7 days. In the present study, patency rates were 59 percent for the 3-day group and 79 percent for the 5-day group; viability rates were 50 and 64 percent, respectively. Considering both patent and nonpatent loops, the overall viability rates were 29 and 50 percent respectively. Maturation periods longer than 3 days for AV loops constructed from PTFE micrografts were determined to be preferable for subsequent free-tissue transfer.

Reduced immunotoxicity and preservation of antibacterial activity in a releasable side-chain carbapenem antibiotic

A carbapenem antibiotic, L-786,392, was designed so that the side chain that provides high-affinity binding to the penicillin-binding proteins responsible for bacterial resistance was also the structural basis for ameliorating immunopathology. Expulsion of the side chain upon opening of the beta-lactam ring retained antibacterial activity while safely expelling the immunodominant epitope. L-786,392 was well tolerated in animal safety studies and had significant in vitro and in vivo activities against methicillin- and vancomycin-resistant Staphylococci and vancomycin-resistant Enterococci.

Locally administered vascular endothelial growth factor cDNA increases survival of ischemic experimental skin flaps

Microvascular surgery has emerged as an attractive area for recent advances in the field of gene therapy. The present study investigated the survival of ischemic, experimental skin flaps after treatment with the gene encoding vascular endothelial growth factor (VEGF). In 30 Sprague-Dawley rats, anterior abdominal skin flaps supplied by the epigastric artery and vein were created. Ten animals were treated with a mixture of liposomes and the cDNA encoding the 121-amino acid isoform of VEGF. Another 10 animals were treated with control plasmid DNA and liposome transfection medium; a third group of 10 animals was given physiologic saline. Each solution was injected directly into the femoral artery distal to the origin of the epigastric pedicle supplying the flap. Four days after injection, the pedicle was ligated and blood flow in the flap was approximated using dye fluorescence. Seven days later, the amount of viable tissue within the flap was measured by planimetry. After the animals were killed, specimens from both the operated and nonoperated sides of the abdomen were harvested for immunohistologic evidence of VEGF protein expression. Average dye fluorescence indices of the three groups (VEGF cDNA, control plasmid, and saline) 2 hours after pedicle ligation were 35.9, 23.9, and 53.9 percent, respectively (p < 0.05). Compared with the two control groups, flaps receiving VEGF cDNA had significantly greater tissue viability at the end of 7 days: 93.9 versus 28.1 percent for the control plasmid DNA group and 31.9 percent for the saline group (p < 0.05). Immunohistochemical staining documented increased deposition of VEGF protein in flaps that were infused with the VEGF cDNA versus saline alone (p < 0.05). The results indicated that the survival of ischemic tissues can be enhanced by administration of a cDNA encoding VEGF, a protein known to be important in the process of angiogenesis and wound healing.

Effect of time on the viability of ischemic skin flaps treated with vascular endothelial growth factor (VEGF) cDNA

This study examined the efficacy of gene therapy on wound healing. The authors investigated whether delivery of the gene encoding a particular cytokine, known to be important in angiogenesis, could affect ischemic skin flaps. Anterior abdominal skin flaps, based solely on the epigastric artery and vein, were created in the Sprague-Dawley rat model. At the time of elevation, the arterial pedicle supplying each flap was infused either with the gene for vascular endothelial growth factor (VEGF) or physiologic saline alone. The flaps were resutured into place and observed for a period of either 4 or 3 days, at which time the pedicle was ligated. Twenty minutes following ligation, blood flow in the flaps was measured by dye fluorescence. Tissue viability of the flaps was subsequently measured by planimetry after a period of 7 days. Flaps that received the VEGF gene and were ligated at 4 days had an average dye fluorescence index (DFI) of 31.1 following ligation, and 93.9 percent viable tissue after 7 days. Flaps that received saline alone, and were ligated following a similar interval, had an average DFI of 14.0 and 31.9 percent viable tissue. Among the subjects that were ligated at 3 days, only a single, gene-infused flap had any noticeable viable tissue after 7 days. The DFI of these groups was 11.0 for the gene-infused group and 22.1 for the saline-infused group. The results suggest that delivery of the gene for VEGF can improve the survival of ischemic skin flaps, but that the effect of gene therapy is not limitless.

Erythropoietin-receptor expression and function during the initiation of murine yolk sac erythropoiesis

Although erythropoietin is necessary for definitive (fetal liver and bone marrow) erythropoiesis, the role of erythropoietin signaling in primitive (yolk sac) hematopoiesis has not been well defined. In situ hybridization studies have revealed that erythropoietin-receptor (EPOR) mRNA accumulation begins in mesoderm cell masses of the developing yolk sac of the neural plate stage embryo (E7.5) before the development of morphologically recognizable erythroblasts. EPOR mRNA is also present in yolk sac blood islands at early somite stages (E8.5). These findings suggest that EPOR functions during early stages of yolk sac erythropoiesis. We have used a serum-free murine yolk sac explant system (Palis et al., Blood 86:156, 1995) to investigate the initial differentiation of primitive erythroblasts from extraembryonic mesoderm cells. Exogenous erythropoietin increased both erythroblast numbers and betaH1-globin accumulation in yolk sac explants, suggesting that primary yolk sac erythroblasts are directly responsive to erythropoietin. An antisense oligodeoxynucleotide (ODN) experimental approach was used to examine the functional role of erythropoietin signaling during the initiation of yolk sac hematopoiesis in yolk sac explants. Antisense EPOR ODN produced a >50% reduction (p < 0.005) in the number of differentiating primitive erythroblasts, >95% reduction in betaH1-globin accumulation (p < 0.001), and a >50% reduction (p < 0.01) in the number of CFU-E and BFU-E compared with missense EPOR ODN-treated and untreated control explants. Antisense EPOR ODN also blocked the increase in primitive erythroblast number induced by exogenous erythropoietin. We conclude that erythropoietin/EPOR signaling is functionally active during the initial proliferation and differentiation of primary yolk sac erythroblasts. These results also suggest that other growth factor signaling cascades are active during the onset of mammalian erythropoiesis.

Isolation and characterization of a gene from the DiGeorge chromosomal region homologous to the mouse Tbx1 gene

DiGeorge syndrome, velocardiofacial syndrome, conotruncal anomaly face syndrome, and isolated and familial forms of conotruncal cardiac defects have been associated with deletions of chromosomal region 22q11.2. This report describes the identification, cloning, and characterization of the human TBX1 gene, which maps to the center of the DiGeorge chromosomal region. Further, we have extended the mouse cDNA sequence to permit comparisons between human and mouse Tbx1. TBX1 is a member of a phylogenetically conserved family of genes that share a common DNA-binding domain, the T-box. T-box genes are transcription factors involved in the regulation of developmental processes. There is 98% amino acid identity between human and mouse TBX1 proteins overall, and within the T-box domain, the proteins are identical except for two amino acids. Expression of human TBX1 in adult and fetal tissues, as determined by Northern blot analysis, is similar to that found in the mouse. Additionally, using 3 'RACE, we obtained a differentially spliced message in adult skeletal muscle. Mouse Tbx1 has been previously shown to be expressed during early embryogenesis in the pharyngeal arches, pouches, and otic vesicle. Later in development, expression is seen in the vertebral column and tooth bud. Thus, human TBX1 is a candidate for some of the features seen in the 22q11 deletion syndrome.

Evaluation of experimental therapeutics in a new mouse model of Helicobacter felis utilizing 16S rRNA polymerase chain reaction for detection

BACKGROUND

A new mouse model of Helicobacter felis infection, which mimics the human infection observed with H. pylori, has recently been developed utilizing polymerase chain reaction (PCR) based on the 16S rRNA gene sequence for detection of infection.

METHODS

We tested several therapeutic regimens in this model, including some currently utilized in the clinic and some shown ineffective in the clinic.

RESULTS

The therapeutic results obtained by PCR with this model are consistent with results observed in the published human H. pylori clinical trials and also with results obtained in another H. felis mouse model utilizing culture and histology.

CONCLUSIONS

These results support further use of this new model in screening for new therapeutic regimens for the management of Helicobacter disease.

Documenting wife abuse: a guide for physicians

An estimated 12% to 30% of women are assaulted by their male partners at least once during the relationship. Therefore, in their everyday practice, physicians are likely to encounter women who have suffered domestic abuse. The authors define wife abuse, outline epidemiologic aspects and discuss common signs and symptoms. In cases of suspected or confirmed abuse, it is very important for physicians to document the details of the injuries, the patient visit, any treatment and follow-up as well as to screen for associated conditions and ensure that any samples taken are not tampered with. When asked to disclose information by police or courts, physicians need to know when they are obliged to submit copies of their patients' medical records, when patient consent is required, what information should be divulged and how to defend this information in court. The authors present information about the necessary, relevant and appropriate evidence to be collected and documented for both medical and legal purposes. They also discuss the criminal justice system and the role of physicians in legal proceedings concerning wife abuse.

Continuous tissue oxygen tension measurement as a monitor of free-flap viability

Early recognition of vascular compromise within microvascular free-tissue transfers is essential if reexploration is to prove successful. Tissue oxygen tension is increasingly recognized to be a sensitive and reliable index of tissue perfusion, and preliminary studies suggest that it may be of value in the assessment of free-flap viability. We describe our investigation into the application of an implantable microcatheter oxygen sensor in the monitoring of free flaps used in head and neck and extremity reconstruction. In a preliminary study using the rabbit model, we sought to evaluate the response of oxygen tension as an index of tissue perfusion in myocutaneous (n = 20) and osteomyocutaneous flaps (n = 5) under conditions of arterial and venous occlusion. A clinical study was then undertaken to evaluate the role of this method in the monitoring of surface and buried free flaps. In 30 heterogeneous free-tissue transfers, sensors placed intraoperatively were used to provide continuous information about flap oxygen tension (mean monitoring period 3.2 +/- 0.8 days). The data generated were correlated with changes in clinical parameters and routine flap observations. Results for experimental and clinical data have confirmed the efficacy of continuous tissue oxygen measurements using this device as a method that provides an objective, recordable index of free-tissue transfer viability in a variety of circumstances and vascular events. Tissue oxygen tension is a suitable index by which to evaluate flap viability with the probe placed in muscle or bone but is unreliable when used for the monitoring of revascularized cutaneous flaps.

Initiation of murine embryonic erythropoiesis: a spatial analysis

Hematopoiesis in the mouse conceptus begins in the visceral yolk (VYS), with primitive erythroblasts first evident in blood islands at the headfold stage (E8.0). VYS erythropoiesis is decreased or abrogated by targeted disruption of the hematopoietic transcription factors tal-1, rbtn2, GATA-1, and GATA-2. To better understand the potential roles of these genes, and to trace the initial temporal and spatial development of mammalian embryonic hematopoiesis, we examined their expression patterns, and that of betaH1-globin, in normal mouse conceptuses by means of in situ hybridization. Attention was focused on the 36-hour period from mid-primitive streak to early somite stages (E7.25 to E8.5), when the conceptus undergoes rapid morphologic changes with formation of the yolk sac and blood islands. Each of these genes was expressed in extraembryonic mesoderm, from which blood islands are derived. This VYS expression occurred in a defined temporal sequence: tal-1 and rbtn2 transcripts were detected earlier than the others, followed by GATA-2 and GATA-1, and then by betaH1-globin. Transcripts for all of these genes were present in VYS mesoderm cell masses at the neural plate stage (E7.5), indicating commitment of these cells to the erythroid lineage before the appearance of morphologically recognizable erythroblasts. By early somite stages (E8.5), GATA-2 mRNA expression is downregulated in VYS blood islands as terminal primitive erythroid differentiation proceeds. We conclude that primitive mammalian erythropoiesis arises during gastrulation through the ordered temporal expression of tal-1, rbtn2, GATA2, and GATA-1 in a subset of extraembryonic mesoderm cells. During the stages analyzed, tal-1 and rbtn2 expression was also present in posterior embryonic mesoderm, while GATA-1 and GATA-2 expression was evident in extraembryonic tissues of ectodermal origin.

Clinical and histologic behavior of exposed porous high-density polyethylene implants

Reconstruction in the head and neck is difficult and often requires complex solutions to restore functional and aesthetic form. While autogenous tissue is preferred, many alloplasts have been investigated. These materials, however, are foreign bodies, and most alloplasts tolerate exposure and infection poorly. An alloplast's in vivo behavior is a function not only of its composition but also of its form and macrostructure, as well as the interaction at the host-implant interface. Porous high-density polyethylene is well tolerated by surrounding tissue, and its porous core is rapidly infiltrated by host tissue. In order to further investigate the response of porous high-density polyethylene under adverse conditions, we implanted three porous high-density polyethylene disks and one silicone disk underneath the dorsal skin in each of 12 rats. The implants were exposed at differing times after implantation. After 7 days, the exposed areas were either skin grafted or allowed to close by secondary intention. Silicone implants all tolerated exposure poorly. Porous high-density polyethylene implants exposed soon after implantation also tolerated exposure poorly; however, none of these extruded. Porous high-density polyethylene implants exposed after the host tissue had invaded the pores tolerated exposure well, healing either by secondary intention or by skin grafting. Porous high-density polyethylene is a safe and reliable material for use in aesthetic and functional reconstruction of the head and neck. Porous high-density polyethylene and possibly other porous alloplasts tolerate exposure well once host fibrovascular tissue has invaded the implant pores. Further investigation of differing clinical settings and implant behavior is currently in progress.

Increased patency of artificial microvascular grafts using arteriovenous fistula loops: a two-stage procedure for lengthening the pedicle of free-tissue transfer

The effect of a high-flow system on the patency of artificial microvascular grafts (AMG) was investigated using arteriovenous (A-V) fistula loops made of polytetrafluoroethylene (PTFE) in a clinically useful longer length. At a second stage, the A-V loops, matured for 7 days, were used as recipient conduits for free-tissue transfer. The patency rates of 5-cm long PTFE A-V fistula loops were compared with 5-cm and 1-cm long interpositional micrografts in a rat model. The patency rate of the loops at 7 days was 80 percent, compared to 0 percent for both the 5-cm and 1-cm interpositional grafts. A-V fistula loops matured for 7 days in vivo were divided in their midsections and used as arterial and venous conduits (each 2.5 cm long) for free epigastric flaps (3 x 6 cm) raised from the contralateral groin. Sixty-seven percent (8/12) of the free flaps were viable at 7 days. The A-V fistula loop in a high-flow system has a beneficial effect in maintaining patency of AMGs. PTFE fistula loops matured for 7 days can be used as arterial and venous conduits for microsurgical tissue transfer in rats.

A sensitive and specific PCR method to detect Helicobacter felis in a conventional mouse model

Although many detection methods have been used to determine Helicobacter colonization in small animal models, the sensitivity and specificity of these detection methods are limited. To improve the Helicobacter felis conventional mouse model for accurate evaluation of therapeutic regimens, we developed a PCR for detection of, and a competitive PCR for quantitation of, H. felis in viral antibody-free (VAF) mice. The PCR was based on the H. felis 16S rRNA gene. An internal control DNA was used for competitive quantitation of the PCR. VAF conventional Swiss-Webster mice were infected with an H. felis culture by oral gavage. At various times after H. felis challenge and therapy, stomach mucosa was collected and evaluated by PCR. PCR detected approximately 50 to 100 H. felis cells per mouse stomach and showed no cross-reaction with other bacteria commonly found in mouse stomachs. Colonization of H. felis in the mouse stomach was confirmed by culture isolation from germfree mice and histological examination of VAF mice. Response to therapy in this H. felis model correlated well with results seen in human clinical trials with H. pylori. A model utilizing PCR detection which may be useful for discovering new antibiotics and/or vaccines against Helicobacter ulcer disease has been developed.

Interaction of disintegrins with the alpha IIb beta 3 receptor on resting and activated human platelets

Viper venom disintegrins contain the RGD/KGD motif. They inhibit platelet aggregation and cell adhesion, but show structural and functional heterogeneity. We investigated the interaction of four prototypic disintegrins with alpha IIb beta 3 expressed on the surface of resting and activated platelets. The binding affinity (Kd) of 125I-albolabrin, 125I-echistatin, 125I-bitistatin and 125I-eristostatin toward resting platelets was 294, 153, 48 and 18 nM respectively. The Kd value for albolabrin decreased 3-fold and 6-fold after ADP- or thrombin-induced activation. The Kd values for bitistatin and echistatin also decreased with ADP, but there was no further decrease with thrombin. In contrast, eristostatin bound with the same high affinity to resting and activated platelets. The pattern of fluorescein isothiocyanate (FITC)-eristostatin and FITC-albolabrin binding to resting and activated platelets was consistent with observations using radiolabelled material. Eristostatin showed faster and more irreversible binding to platelets, and greater potency compared with albolabrin in inducing conformational neo-epitopes in beta 3. The anti-alpha IIb beta 3 monoclonal antibody OP-G2 that is RGD-dependent inhibited disintegrin binding to activated platelets more strongly than binding to resting platelets and it inhibited the binding to platelets of albolabrin more strongly than eristostatin. The specificity of disintegrin interaction with alpha IIb beta 3 was confirmed by demonstrating cross-linking of these peptides to alpha IIb beta 3 on normal platelets, but not to thrombasthenic platelets deficient in alpha IIb beta 3.

Effect of hypertonic sodium bicarbonate in the treatment of moderate-to-severe cyclic antidepressant overdose

The objective of this study was to characterize the effect of intravenous hypertonic sodium bicarbonate (NaHCO3) administration in patients with moderate-to-severe cyclic antidepressant (CA) overdose. We reviewed charts of all 91 patients given the diagnosis of CA overdose in the University of California Los Angeles (UCLA) Emergency Medicine Center (EMC), who either died in the EMC or were admitted to the medical intensive care unit (MICU), and who received NaHCO3 in the EMC between 1980 and 1988. Twenty-four other patients with the same EMC diagnosis were admitted to the MICU during this period but did not receive NaHCO3. The response of blood pressure, electrocardiographic parameters, and mental status to serum alkalinization with NaHCO3 were evaluated. Major morbidity and mortality were recorded for all patients. Hypotension was corrected within 1 hour in 20 of 21 (96%) patients, QRS prolongation corrected in 39 of 49 (80%), and mental status improved in 40 of 85 (47%). There was one death, in a patient who was moribund on arrival to the EMC. No complications were attributable to the administration of NaHCO3. NaHCO3 seems to improve hypotension and normalize QRS duration rapidly in most patients treated, and improve mental status changes in almost one half. Serum alkalinization with NaHCO3, in conjunction with appropriate supportive care, seems to limit major morbidity and mortality effectively in patients with serious CA overdose.

Is human papillomavirus-related disease an independent risk factor for human immunodeficiency virus infection?

We sought to determine the prevalence of human immunodeficiency virus (HIV) infection in a population of women with human papillomavirus (HPV)-related diseases attending a colposcopy clinic who had no other CDC-defined risk factors for HIV. Study patients included all new patients attending our colposcopy clinic who were found to have histologic evidence of condyloma or cervical intraepithelial neoplasia. Those patients not already known to be HIV-positive were offered testing for HIV. Demographic information was obtained on all patients. Results were compared to data from anonymous testing of our own obstetrical population. One hundred forty of 208 women (67.3%) were either previously known to be HIV-positive or agreed to be tested. Sixteen (11.4%) were HIV-positive. Eight of the HIV-positive women were not previously known to be HIV-positive and 6 of the 8 had no definable risk factors for HIV infection. This is 4.6% of the women not already known to have a CDC-defined risk factor for HIV. The rate of HIV infection in our obstetrical population is 1.6%. In women without other definable risks for HIV infection and who had HPV-related disease the relative risk of HIV infection in our population was 2.94 (95% confidence interval 1.21-6.94; P < 0.031). In areas where HIV is endemic there is a high prevalence of HIV infection in women with HPV-related disease. Even in women without another definable risk factor for HIV, HPV-related disease may serve as a marker for an increased risk of HIV infection in this population.

Exposure of platelet fibrinogen receptors by zinc ions: role of protein kinase C

Previous studies demonstrated that Zn2+ at a concentration of 50 microM increases the number of fibrinogen receptors exposed on ADP-stimulated platelets and that higher concentrations of Zn2+ induce platelet aggregation that appears to be mediated by receptors associated with the glycoprotein IIb/IIIa complex. The purpose of this study was to identify the mechanism by which Zn2+ modulates exposure of fibrinogen receptors on the surface of human washed platelets. We determined that Zn2+ (300-800 microM)-induced platelet aggregation that was not accompanied by the release of [14C]serotonin was not blocked by ADP scavenging enzymes and 5'-p-fluorosulfonylbenzoyl-adenosine, an affinity label for ADP binding sites, but it was inhibited by disintegrins, staurosporine, and EDTA. Zn2+ (50-200 microM) showed a synergistic effect on platelet aggregation and platelet release caused by ADP and N,N,N',N'-tetrakis(2-pyridylmethyl)ethylenediamine, a Zn2+ chelator, and inhibited ADP-induced platelet aggregation that was reversed by Zn2+ (50 microM). Zn2+ (200 microM) increased the number of fibrinogen binding sites and the affinity of albolabrin (a disintegrin isolated from Trimeresurus albolabris snake venom that has been shown to bind to the fibrinogen receptor) on ADP-activated platelets. On the other hand, Zn2+ (100-800 microM) did not increase fibrinogen binding to the purified receptor. Incubation of platelets with Zn2+ (200 microM) resulted in the phosphorylation of a 47-kDa protein that was blocked by staurosporine, an inhibitor of protein kinase C. In conclusion, Zn2+ ions activate protein kinase C and enhance fibrinogen receptor exposure on the surface of platelets stimulated by ADP.

Use of tissue expansion in clubfoot surgery

Tissue expansion was used successfully to prepare adequate soft tissue for closure following a difficult clubfoot correction. The gradual expansion was done weekly at the outpatient clinics (average 3-4 months). The procedure proved to be useful in severe cases of clubfoot.

Posttraumatic tibial osteomyelitis: a comparison of three treatment approaches

The treatment of 25 tibias in 25 patients with posttraumatic chronic osteomyelitis was reviewed. The approaches to soft tissue management fell into three groups: 1) muscle flap coverage; 2) primary closure with suction irrigation; and 3) open cancellous bone grafting. Treatment success was judged by the presence or absence of drainage and the local signs or symptoms of infection, and by the status of the tibial nonunion. Overall, 19 of 25 tibias (76%) had successful treatment. We found flap coverage to have a higher success rate (80%) than either primary closure with suction irrigation (45.5%) or open cancellous bone grafting (40%). These results further attest to the refractory nature of chronic osteomyelitis.

Proteus syndrome

Proteus syndrome is a rare congenital disorder that is characterized by a wide variety of deformities including macrodactyly. Skin and soft tissue lesions are common; they may increase in size as the child develops and may assume tremendous proportions. The syndrome is often mistaken for other more commonly recognized conditions such as neurofibromatosis. Unlike neurofibromatosis, the soft tissue masses in Proteus syndrome are not nerve tumors but, rather, are hamartomas composed primarily of lipomatous tissue. The hand surgeon should be aware of this condition when evaluating a child with macrodactyly.

Lymphoma models for B-cell activation and tolerance. IX. Efficient reversal of anti-Ig-mediated growth inhibition by an activated TH2 clone

We have utilized several B-cell lymphomas that are growth inhibited by anti-Ig reagents as models for tolerance induction. In a previous communication, we demonstrated that the growth inhibition by anti-Ig can be partially prevented by the recombinant lymphokine, IL-4. In this paper, we report that complete protection of B lymphomas from anti-Ig was provided by a type 2 helper cell clone, D10.G4, when these T cells were activated by monoclonal anti-CD3. Conditioned medium from anti-CD3-stimulated D10.G4 cells also provided protection from anti-Ig. In contrast, little protection was observed with activated cells from a type 1 T-cell clone, A.E7. Furthermore, we show that combinations of IL-4 and tumor necrosis factors (both TNF alpha and TNF beta), as well as IL-4, effected partial protection by themselves and enhanced the activity of the other lymphokine if used in a pretreatment protocol. However, anti-cytokine antibodies were ineffective at reversing the T-cell-mediated protection. The possibility that direct T:B-cell contact mediates part of the protective signal is discussed.

[The development of diagnosis-related groups--DRG's. Methodology for classifying hospital patients]

The history of Diagnosis Related Groups (DRG's), a system for classifying patients in acute care hospitals, developed by researchers at Yale University, USA, is reviewed. DRGs are an instrument for measuring the hospital product, primarily from a management viewpoint. Starting with a review of the definitions of hospital product, the article follows the course from the first DRGs through the most recent revision, providing a summary of potential and current applications of the system in several countries, which range from payment mechanism to uses in quality control.

Rhegmatogenous retinal detachments in patients with AIDS and necrotizing retinal infections

Rhegmatogenous retinal detachments can occur in patients with acquired immune deficiency syndrome (AIDS) and necrotizing retinal infections. Of 68 patients with AIDS and necrotizing retinal infections seen between 1983 and 1987, rhegmatogenous retinal detachments developed in 16 patients (27 eyes). In this group, cytomegalovirus retinopathy was present in 75% (12 of 16) of patients, 18.8% (3 of 16) had probable herpes simplex virus retinopathy, and 6.2% (1 of 16) had toxoplasmic retinochoroiditis. Retinal detachment was bilateral in 68.8% (11 of 16) of patients. The retina was reattached successfully in 91% (10 of 11) of operated eyes. Proliferative vitreoretinopathy was present preoperatively in 95% of these eyes. Seven of 11 operated eyes had initial improvement in visual acuity. However, 5 of 11 continued to lose vision despite successful reattachment. Techniques included pneumatic reattachment, scleral buckle, vitrectomy, and silicone oil injection. Complicated retinal detachments in AIDS patients with rhegmatogenous retinal detachments and necrotizing retinal infections are common and can be repaired, but the prognosis is guarded in many patients.

Does paramedic-base hospital contact result in beneficial deviations from standard prehospital protocols?

We reviewed written and audio records of paramedic-base hospital radio contact to determine whether care differed from that suggested in standard prehospital care protocols. Records of all 659 contacts for seizure, syncope, abdominal pain, or altered mental state during 1987 (28.4% of all contacts) were scored for the use of standard therapies (such as intravenous access, oxygen, naloxone hydrochloride) and unanticipated therapies (intubation, nitroglycerin). Cases that involved unanticipated treatments were reviewed to determine whether they could have been prospectively identified by simple clinical findings. Standard therapies were used in the majority of patients. Unanticipated therapies were administered to 13 patients, all of whom had abnormal vital signs, diaphoresis, respiratory distress, or a second prominent symptom. Data suggest that protocols could replace radio contact for most patients and that the few who might benefit from radio contact can be easily identified. A 90% reduction in radio contacts in Los Angeles county could save $3 million each year.

Tropical pyomyositis. Demonstration of extent and distribution of disease by gallium scintigraphy

Pyomyositis is a Staphylococcus aureus infection of muscles reported primarily in tropical countries but seen with increasing frequency in temperate climates. Because of its rarity in the United States, the diagnosis may not be considered immediately, and involved muscles may break down and become abscessed. Diagnosis is most reliably made by the recovery of pus from a muscle aspirate. Ga-67 scan findings of an interesting case of pyomyositis involving many muscle groups in both upper and lower extremities is reported. Despite arthralgias and complicating adult respiratory distress syndrome, Ga-67 correctly localized the infection to muscles in the shoulders, upper thorax, buttocks, and thighs. A bone scan was negative, excluding the possibility of extension of the infection to bone.

The use of a tissue expander in club-foot surgery. A case report and review

Primary skin closure after the surgical correction of severe club-foot may be difficult. We describe the use of a tissue expander to provide sufficient skin, and review some aspects of the use of the method.