Evaluation of candidate control genes for diagnosis and residual disease detection in leukemic patients using 'real-time' quantitative reverse-transcriptase polymerase chain reaction (RQ-PCR) - a Europe against cancer program

Real-time quantitative RT-PCR (RQ-PCR) is a sensitive tool to monitor minimal residual disease (MRD) in leukemic patients through the amplification of a fusion gene (FG) transcript. In order to correct variations in RNA quality and quantity and to calculate the sensitivity of each measurement, a control gene (CG) transcript should be amplified in parallel to the FG transcript. To identify suitable CGs, a study group within the Europe Against Cancer (EAC) program initially focused on 14 potential CGs using a standardized RQ-PCR protocol. Based on the absence of pseudogenes and the level and stability of the CG expression, three genes were finally selected: Abelson (ABL), beta-2-microglobulin (B2M), and beta-glucuronidase (GUS). A multicenter prospective study on normal (n=126) and diagnostic leukemic (n=184) samples processed the same day has established reference values for the CG expression. A multicenter retrospective study on over 250 acute and chronic leukemia samples obtained at diagnosis and with an identified FG transcript confirmed that the three CGs had a stable expression in the different types of samples. However, only ABL gene transcript expression did not differ significantly between normal and leukemic samples at diagnosis. We therefore propose to use the ABL gene as CG for RQ-PCR-based diagnosis and MRD detection in leukemic patients. Overall, these data are not only eligible for quantification of fusion gene transcripts, but also for the quantification of aberrantly expressed genes.

The TEL-AML1 real-time quantitative polymerase chain reaction (PCR) might replace the antigen receptor-based genomic PCR in clinical minimal residual disease studies in children with acute lymphoblastic leukaemia

Prospective studies in children with B-precursor acute lymphoblastic leukaemia (ALL) have shown that polymerase chain reaction (PCR)-based detection of minimal residual disease (MRD) using immunoglobin (Ig) and T-cell receptor (TCR) gene rearrangements as targets can be used to identify patients with a high relapse risk. The disadvantage of this approach is that for each patient preferably two different targets have to be identified. The t(12;21)(p13;q22) with the TEL-AML1 fusion gene is present in approximately 25% of children with B-precursor ALL. In these patients, sensitive reverse transcription (RT)-PCR analysis of the TEL-AML1 fusion transcript might be a more simple and less laborious alternative approach. However, it is unknown how stable the mRNA is and whether the number of transcripts per leukaemic cell remains constant during follow-up. We investigated whether the MRD results obtained using RT-PCR of TEL-AML1 transcripts correlated with the clinically validated genomic PCR for Ig and TCR gene rearrangements. Therefore, we used real-time quantitative (RQ)-PCR analysis for both types of targets and assessed the MRD levels in 36 follow-up bone marrow samples (obtained during the first 1.5 years after diagnosis) from 13 patients with B-precursor ALL. In 34/36 bone marrow samples the Ig/TCR RQ-PCR and TEL-AML1 RQ-PCR revealed equal levels of MRD and these results had a strong correlation (P < 0.0001, R2 = 0.84). Therefore, we conclude that the TEL-AML1 RQ-PCR can, in principle, replace Ig/TCR RQ-PCR in B-precursor ALL with t(12;21).

Minimal residual disease studies are beneficial in the follow-up of TEL/AML1 patients with B-precursor acute lymphoblastic leukaemia

The t(12;21)(p13;q22) translocation has been identified as the most common chromosomal abnormality in childhood acute lymphoblastic leukaemia (ALL). Initially, several investigators reported an excellent prognosis in paediatric leukaemias with this translocation, but other studies showed a 20% incidence in relapsed ALL. We performed an extensive analysis of 90 ALL patients. In 17 (19%) cases a TEL/AML1 fusion was found. However, this group was not representative as it included a high number of relapsed patients compared with the normal incidence in B-precursor ALL [54 in continuous complete remission (CCR) and 36 relapsed patients] and only a slightly better prognosis for TEL/AML1-positive patients was found (not significant) (four relapses in 17 TEL/AML1-positive patients vs. 32 relapses in 73 TEL/AML1-negative patients). Comparison of known prognostic factors (age, sex, ploidy, white blood cell count and immunophenotype) between relapsed TEL/AML1-positive and TEL/AML1-positive patients in CCR did not reveal differences, except that the white blood cell count was significantly higher in the relapsed group (P = 0.001). Time between diagnosis and relapse was not different for the relapsed TEL/AML1-positive group vs. the relapsed TEL/AML1-negative group. In 11 TEL/AML1-positive patients, the minimal residual disease (MRD) level at the end of induction therapy was quantified in a limiting dilution assay using IGH or TCRD junctional regions as polymerase chain reaction (PCR) targets. In all four relapsed patients, the level of MRD at the end of induction therapy was high (range 0.24-1.2%), whereas in all seven CCR patients, the MRD level was extremely low (0.02 to < 0.001%). In agreement with previous studies in which MRD levels at the end of induction therapy were found to be the strongest risk factor independent of other risk factors, in the present study we show that the MRD level remains a risk factor independent of the presence of a TEL/AML1 fusion gene.

A logical approach to the injection treatment of varicose and "spider" veins

The incurable nature of varicose veins mandates a re-evaluation of excisional surgery both as appropriate therapy and as the gold standard against which to judge alternative treatments. An injection techniques has been developed which enables synchronous in situ obliteration of all varicose veins and superficial venous ectasia, regardless of their size or extent, and eliminates the need to identify incompetent perforators. The results of 742 patients (1,425 legs) were evaluated retrospectively from two to 12 years following initial therapy. All patients experienced total relief of painful symptoms and 95% were very pleased with the final appearance. Some residual brown pigmentation or a scar from an injection ulcer were the reasons for less than total satisfaction in the remaining 5%. None regretted having undergone the procedure. Because of the difficulty in sustaining compression in the inguinal area, 6% of patients required a concomitant sapheno-femoral disconnection under local anesthesia immediately prior to injection therapy, but none required stripping. The results repudiate the generally held belief that injection therapy is only of value for treating postsurgical recurrences, or for eliminating small varicosities and superficial capillary ectasia (spider veins) for cosmetic improvement.

Downregulation of HLA class I expression by c-myc in human melanoma is independent of enhancer A

High constitutive expression of the c-myc oncogene in human melanoma leads to downregulation of expression of HLA Class I genes. The genes at the HLA-B locus are preferentially affected. To investigate the mechanism of downregulation, the activity of the main HLA Class I enhancer, enhancer A-region I, was compared in a panel of c-myc transfectants with increasing myc expression. Gel retardation experiments demonstrated in all tested cell lines binding of the transcription factors KBF1 and NF-kappa B to the enhancer. However, no correlation between the levels of HLA Class I expression and binding to the enhancer could be established. Strikingly, the cell line with the highest c-myc expression showed more binding of KBF1 and NF-kappa B than the parental cell line. By using CAT reporter plasmids in transient transfection assays we investigated the in vivo function of enhancer A-region I in the c-myc transfectant panel. Again, c-myc expression had no effect at all on the activity of enhancer A. This study shows that HLA Class I expression is regulated by the c-myc oncogene at the level of transcription, but that the main HLA Class I enhancer is not involved in this process.

"Ratchet-type" marginal fracture of the radial head with locked anterior dislocation. A case report

Locked anterior dislocation of the superior radioulnar joint occurred in a 26-year-old man. The configuration of the associated radial head fracture maintained the locked position and predisposed to recurrence after open reduction. Radial head excision was necessary to resolve the problem. Both medial ligament repair and a radial head prosthesis were necessary to stabilize the elbow.

Normal pelvic strain pattern in vitro

Four cadaver pelves were dissected of soft tissue and each of the eight hemipelves instrumented with ten rosette strain gauges. Static loading was conducted to simulate single leg stance, and applied through the intact hip joint. The medial portion of the pelvis was under tension directed vertically and the lateral ilium was in compression. This strain pattern is consistent with bending applied to the ilium from the action of the abductor and joint reaction forces.

Cortical pelvic strains with varying size hemiarthroplasty in vitro

Four human pelves were dissected of soft tissues and instrumented with rosette strain gages. The pelves were left intact (not separated at the pubic symphysis or sacroiliac joints) although each of the eight hemipelves was tested separately. The pelves were loaded to simulate single leg stance with use of a wire mesh cemented to the wing of the ilium, representing the abductor muscles. Loading was carried out with the intact hip joint and 1 mm undersized, correct sized, and 1 mm oversized hemiarthroplasty. The correct sized component produced a strain pattern closet to normal. The oversized component was associated with an increase in strain at the medial acetabular dome.

Mechanical stimulation of dorsal root ganglia induces increased production of substance P: a mechanism for pain following nerve root compromise?

The undecapeptide, substance P, is known to be synthesized in cell bodies of dorsal root ganglia. This neuropeptide is also known to modulate sensory, nociceptive transmission postsynaptically on dorsal horn interneurons. In the animal model used in the current study, experimental mechanical stimulation of dorsal root ganglia and nerve roots increased the amounts of substance P, as well as substance P immunoreactivity in cell bodies of the dorsal root ganglia and in the substantia gelatinosa of the spinal dorsal horn that the cell bodies innervated. These results were determined by using both immunohistochemistry and radioimmunoassay. This study suggests that substance P may modulate nociception when lumbar nerve roots are stimulated mechanically.

Effects of low-modulus coatings on pin-bone contact stresses in external fixation

The intent of this study was to investigate the stress distribution in cortical bone around fracture fixation pins and around pins coated with various polymeric and elastomeric materials. Since these interface stresses cannot be measured directly, a photoelastic technique was employed and stresses were measured in two-dimensional bone models fabricated from sheets of epoxy resin. Our results showed that when a fixation pin was loaded in compression, the compressive stress measured in the model was greatest at the pin-model interface. The magnitude of the compressive stress was found to diminish steeply away from the hole in a log decrement distribution which was asymptotic to the value of the average stress in the model. When polymeric and elastomeric materials were applied as pin coatings and the performance of the coated pins was compared to that of uncoated pins of the same overall diameter, a reduction of the maximum stress in the bone model was demonstrated. Among the coatings tested, we found that of the polymeric materials ultrahigh molecular weight polyethylene (UHMWPE) was most effective at reducing the peak cortical stress magnitude. The most effective coating material overall was found to be silicon elastomer. Computation of stress values in models loaded through stainless-steel pins and through pins coated with 1-mm silicon elastomer showed that the presence of the elastomer layer caused a reduction of about 50% in the maximum compressive stress in the model.

Ultrastructure of sensory nerve endings in monkey (Macaca fascicularis) knee joint capsule

Ultrastructural studies of sensory endings in monkey posterior medial knee joint capsule were undertaken. Three distinct sensory nerve endings have been identified: free nerve endings, Ruffini corpuscles, and Pacinian corpuscles. The free nerve endings are present in all layers of the joint capsule excluding the synovium. Two types of Ruffini corpuscles have been found in the fibrous layer. The first type is characterized by a thin perineurial capsule, the second type by a thicker perineurial capsule and extensive intra-capsular space. Both types of Ruffini corpuscles are innervated by approximately one to four myelinated axons which lose their sheaths as they course through the corpuscle. They terminate on collagen fiber bundles as distinct swellings with spiny membrane projections that are covered by a thin basal lamina. These terminals contain abundant mitochondria, agranular vesicles, and irregularly arranged neurofilaments and neurotubules. Two types of Pacinian corpuscles were occasionally observed. The first was a small, typically laminated structure with an inner core at the layer between the synovium and the fibrous layer and between the fibrous layer and muscle/ligament; larger Vater-Pacinian corpuscles were noted only at the boundary between the fibrous layer and the muscle/ligament layer.

Reconstructive surgery following total elbow endoprosthesis

Elbow arthroplasty should only be undertaken by surgeons who have considerable experience in total arthroplasty and special training in upper-extremity surgery. The failed total prosthesis presents a formidable challenge. The recognition of this fact fortunately has had an impact on prosthetic design, so that less bone stock is removed at surgery. In addition, second- and third-generation arthroplasties are becoming available that biomechanically are more suitable and that may be expected to be somewhat more durable than those of the first generation. Early and decisive action is recommended in the case of the loose elbow joint prosthesis before the cement mantle causes further abrasive wear to the cortex, which eventually may be broken through, rendering revision much more difficult. If there is any doubt about the adequacy of the bone stock to receive a further prosthesis after removal of the failed joint, a nonprosthetic salvage procedure, or, alternatively, revision as a two-stage procedure is recommended. In the case of the failed surface implant, nonprosthetic interposition arthroplasty will usually give a satisfactory result.

Total replacement arthroplasty of the elbow joint for rheumatoid arthritis: two cases

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Structure and function of hip joint innervation

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Elbow arthroplasty

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Separate dens with subluxation and paraplegia treated by occipitocervical fusion

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Signal metastasis in the radius treated by excision and bone graft

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