Residual hydrogen peroxide as a function of platinum disc age. Recently there has been considerable attention given to the possible deleterious effects of residual hydrogen peroxide on both the cornea and the crystalline lens of the eye. We measured residual hydrogen peroxide levels of the AOSept disinfection system at regular intervals over a 4 month period. By 1 month the residual hydrogen peroxide level was 21 ppm +/- 9.4 (mean +/- standard deviation); at the end of 2 months it was 36 ppm +/- 17.6. At 3 months, when disc replacement is recommended, the residual hydrogen peroxide level was 43 ppm +/- 4.7 (range: 17-98 ppm). At 4 months the residual hydrogen peroxide level rose to a mean of 48 ppm +/- 18.2. The increase in measured residual hydrogen peroxide between month 1 and each successive month was found to be statistically significant. However, these levels failed to induce an increase in symptomatology or slit lamp findings. As determined by scanning electron microscopy there was an erosion of the platinum coating with time that appeared to coincide with the measured residual peroxide level. Cultures of randomly selected platinum discs at the end of 4 months failed to reveal more than isolated positive findings of Staphylococcus epidermidis. While an increase in residual peroxide with time may lead to greater disinfecting capabilities of this system, the possibility of corneal damage as a direct result of high peroxide levels is of concern.


A critical evaluation of the Multi-item Microbial Challenge Test in ophthalmic disinfectant testing. The Multi-item Microbial Challenge Test (MIMCT) is a stringent, carrier assay of the disinfecting efficacy of a contact lens care regimen. The test involves four steps: 1) in vitro contamination of contact lenses in the presence of organic load; 2) cleansing the contact lens by mechanical rubbing and subsequent rinsing; 3) disinfection of the cleansed lens; and 4) assaying the contact lens and the disinfecting solution for viable microorganisms. The variability of the individual steps was evaluated in this study by the Contributions of Elements protocol. The efficacy of the cleansing step, while reputed to be highly variable, was found to be reproducible and dependent upon the formulation under test. A contact lens disinfecting regimen must reduce the level of contaminants to approximately 10(-4) CFU/lens to enjoy a 95% chance of passing the MIMCT. This reflects a 10-log unit reduction from the initial inoculum of approximately 10(6) CFU/lens. The stringency of the MIMCT depends on the ability of the recovery system to allow the growth of low numbers of residual challenge microorganisms in the presence of the disinfecting solution. Neutralizers included in the recovery system to inhibit the disinfectant are therefore critically important to the stringency of the assay. The design of experiments to evaluate neutralizers specifically for the MIMCT is discussed with suggestions for an improved procedure.


Contrast sensitivity measurements with the Echelon diffractive bifocal contact lens as compared to bifocal spectacles. We examined the contrast sensitivity function of presbyopic subjects wearing the Hydron Echelon diffractive bifocal contact lens. Contrast sensitivity with the Echelon lens was compared to contrast sensitivity with bifocal spectacle correction. Each eye was tested for near and distance vision with the Echelon contact lens and with spectacle correction. Most subjects achieved a visual acuity of 20/20 with the Echelon lens; however, on average, contrast sensitivity was found to be significantly decreased with the contact lens as compared to spectacles for both distance and near vision. The largest decrease in contrast sensitivity was seen for mid-range spatial frequencies (4 to 16 cycles/degree). Although most subjects experienced a significant decrease in contrast sensitivity, two experienced only small decreases with the Echelon lens. Only one subject who met entry criteria reported that vision was as good with the Echelon lens as with spectacles. The decreased contrast sensitivity may result from contact lens decentration as well as inherent optical characteristics of the Echelon lens.


Giant papillary conjunctivitis and meibomian gland dysfunction blepharitis. In this prospective pilot study we saw 42 consecutive giant papillary conjunctivitis (GPC) patients (80 eyes), all of whom were found to have some meibomian gland dysfunction blepharitis. Severity of GPC at presentation correlated with severity of meibomian gland dysfunction blepharitis (Kendall's tau b averaged 0.246 across the adjusted statistical analyses). Thirty-two patients (63 eyes) were refit after treating meibomian gland dysfunction blepharitis. Twenty-eight of these patients (55 eyes; 87%) continue to wear contact lenses, maintaining an improvement in GPC (mean follow-up 21 months; range 11-36 months). We hypothesize that meibomian gland dysfunction blepharitis may play a role in the pathogenesis of GPC and suggest that a large, controlled, multi-observer study be performed to further investigate this possible association.


Fitting the SoftPerm contact lens after keratoplasty. We fit 22 eyes (20 patients) with the SoftPerm lens following keratoplasty when the potential acuity meter test exceeded the best corrected spectacle refraction. Fourteen eyes had more than 4 D of astigmatism. Fourteen of the 22 lenses were worn successfully for more than 3 months. Nineteen of 22 eyes achieved better acuity than with spectacles alone. Separation of the lens at the bonded junction and an inability to insert and remove the lens accounted for the majority of failures. We consider the SoftPerm lens whenever we encounter high astigmatism cases that have better potential acuity readings than best corrected spectacle acuity.


The use of the SoftPerm lens for the correction of irregular astigmatism. We evaluated the performance of the SoftPerm combined rigid gas permeable (RGP) and hydrogel lens for the visual correction of 49 eyes (30 patients) with irregular astigmatism. Follow-up was up to 15 months. An attempt was also made to compare the SoftPerm lens to its predecessor, the Saturn II lens. The most common etiology for irregular astigmatism was keratoconus. Others etiologies were penetrating keratoplasty and refractive surgery. Visual acuity improved significantly. Only two eyes were best corrected to 20/20 before fitting whereas, 13 eyes saw 20/20 after fitting. The rate of lens replacement was 0.22 lenses per eye per month. A variety of complications occurred, including corneal staining, abrasions, and edema. Complications also reflected the relative difficulty of handling of the lens, yet no vision threatening complications occurred. Overall, the SoftPerm lens is a vast improvement over the Saturn II and is a reasonable means of correction of irregular astigmatism.


Contact lens manipulation of corneal topography after penetrating keratoplasty: a preliminary study. We conducted a preliminary retrospective study of five eyes that had undergone penetrating keratoplasty (PK) to determine if rigid gas permeable (RGP) contact lenses could be used as splints or molds to improve postoperative corneal topography. RGP lenses were fit 3-6 months (mean: 4.1 months) after PK and 3-4 months (mean: 1.8 months) after removal of the 10-0 nylon suture. Lenses were fit to attain a contact lens resting position centered on the corneal graft. After 4 to 8 months (mean: 6.2 months) of contact lens wear, analysis of corneal topography showed a decrease in simulated keratometry cylinder from 4.7 +/- 0.6 D (mean +/- 1 standard deviation) to 1.8 +/- 0.8 D (P = 0.02) and an improvement in anterior corneal surface regularity (surface regularity index: initial = 1.40 +/- 0.2; final = 1.0 +/- 0.2; P = 0.04). Three eyes were fit with a well-centered RGP lens; two eyes were fit with lenses that rode off-center. Increased irregular astigmatism in the two eyes with decentered contact lenses suggests the importance of centering RGP lenses with respect to corneal grafts. The best corrected spectacle visual acuity either improved or remained unchanged in four of five eyes after contact lens wear. One eye demonstrated a decrease in best corrected spectacle acuity by one Snellen line after 3 months of lens wear. Further clinical studies are needed to determine the potential of postoperative use of RGP lenses to improve corneal surface regularity, to decrease astigmatism, and to optimize visual results.


A prospective multicenter clinical trial to assess safety and efficacy of Menicon SF-P RGP lenses for extended wear. A prospective, multicenter, national clinical trial was undertaken to assess the safety and efficacy of Menicon SF-P (melafocon A) rigid gas permeable (RGP) contact lenses for extended wear in healthy human eyes. Ten investigators enrolled 167 patients (334 eyes), of which 143 (286 eyes) were initially fit with lenses for the 12-month study. Most subjects were reexamined at 18 months or more, with findings essentially unchanged from those noted at 1 year. Two hundred-two eyes (71%) completed the study. Seventy-two eyes (25%) discontinued, and 12 (4%) elected to continue extended wear. During the study, no significant adverse clinical reaction attributable to the lens was observed. Surface irritation, occasional punctate staining, and lens binding were very rare. The average wearing time was 6.2 days, mandated partially by FDA restrictions as well as patient response. As expected, keratometric shifts were principally vertical: less than 0.99 D (69%), 1.00-1.99 D (28%), and 2.00-2.99 D (4%). The majority of changes observed were toward sphericity. Two hundred lens replacements were required, 24% for adjustments in power/base curve. Only 16 lenses were replaced for warpage, and none for discoloration or crazing. Of those completing the study, 76% rated overall lens comfort and satisfaction to be very good. These results suggest that RGP lens extended wear can be safe and effective and offer patients an acceptable alternative to extended wear of disposable hydrogel lenses.


Architecture of the lid-cornea juncture. The details of the lid-cornea-tear film juncture influence the encounter of the lid with the top edge of an interpalpebrally fit rigid gas permeable contact lenses. During blink, fluid circulation at right angles to the globe can be hypothesized in the tear prism of the upper lid. This circulation prevents formation of a stratified tear layer, although lipid may always be present at the air interface. Water soluble or dispersed materials will be uniformly distributed in the tear film of the open eye. The collection of tears in the upper margin during a blink is shown to favor movement of tears away from the center of the upper lid. Tears on the temporal side of the center move along the upper lid to the fornix and then along the lower lid to the lower punctum. Tear fluid on the nasal side of center moves directly to the upper punctum.


Contact lens articles in the literature. We searched the ophthalmic literature of the past 5 years looking for patterns in the publication of contact lens articles. Contact lens articles constituted 2.59% of all ophthalmology articles. We found that a substantial percentage of the articles published in The CLAO Journal and selected optometric journals concerned contact lenses; this, however, was not the case with the major ophthalmology journals (American Journal of Ophthalmology [AJO], Ophthalmology, and Archives of Ophthalmology [Archives]). One recent contact lens development, disposable lenses, was covered by both The CLAO Journal and the major ophthalmology journals, but the coverage differed in that the orientation of the articles in the major ophthalmology journals was essentially negative. Articles about another recent development (rigid gas permeable contact lenses for extended wear), although found in The CLAO Journal, could not be found in the other ophthalmology journals. Finally, when the abstracts of all contact lens articles were reviewed, we found a negative slant to articles published in AJO and Archives. We believe that the major ophthalmology journals present a rather negative view of contact lenses; this, we think, impedes unbiased dissemination of information about new contact lens developments.


Early diagnosis of infectious keratitis with in vivo real time confocal microscopy. The tandem scanning confocal microscope (TSM) was adapted for in vivo examination of the cornea in rabbits with experimental bacterial and fungal keratitis. Compared to slit lamp biomicroscopy, the TSM provides superior lateral and axial resolution and serial optical sectioning capability, which may be useful for identification of corneal pathogens in the early stages of infection. We used the TSM to examine normal rabbit eyes infected with bacteria (Bacillus cereus) and a filamentous fungus (Aspergillus). We also examined a human cornea removed by penetrating keratoplasty after a clinical diagnosis of amoebic keratitis. In the early stages of bacterial infection, slit lamp examination revealed a nonspecific minimal stromal haze and limbal injection indistinguishable from sterile ulcers and epithelial defects. With the TSM, bacteria were visible as highly refractile bodies in the epithelium and superficial stroma. Branching fungal hyphae were also easily identified by the TSM, as were Acanthamoeba cysts and parasites in the subepithelial stroma. Our results indicate that this technique may provide a new modality for quickly and accurately identifying the agent of corneal infection, thereby facilitating prompt and appropriate treatment.


N-glycosylation of serum proteins in disease and its investigation using lectins. The majority of serum proteins are glycosylated. When disease is present, subtle changes occur in this glycosylation. These changes could provide the basis for more sensitive and more discriminative clinical tests. In order to address this possibility, a review is given of serum protein glycosylation in liver disease, inflammation and cancer. It is concluded that liver disease is accompanied by reduced sialylation and increased glycan branching; whereas cancer is accompanied by increased sialylation and increased fucosylation. In inflammation, the type of glycosylation change observed seems to depend upon the disease studied. Glycoprotein analysis can already be used for diagnosis in a few clinical situations; however, further studies are required in most diseases to provide a more detailed picture of the glycosylation changes that are occurring. This situation will change with the increasing availability of simpler techniques for glycoprotein analysis. One such group of techniques are lectin-based methods. The usefulness of these methods for glycoprotein analysis and the suitability for analysing clinical specimens are discussed in detail.


Prenatal diagnosis of Niemann-Pick disease type C. Niemann-Pick disease type C (NPC) was demonstrated in two successive pregnancies by strongly reduced activity of sphingomyelinase in amniotic fluid cells. By contrast, chorionic villi from the first pregnancy had shown normal sphingomyelinase activity. The prenatal diagnosis of NPC in the two fetuses was confirmed, after termination of the pregnancies, by (phospho)lipid analyses of the fetal livers, by the assay of sphingomyelinase in the fetal fibroblasts and by the demonstration of a defective esterification of exogenous cholesterol and of cholesterol accumulation by filipin staining. Retrospective analysis of cultured amniocytes for cholesterol esterification and filipin staining confirmed the feasibility of these methods for prenatal diagnosis. In a recent pregnancy in the same mother the three available methods were applied to amniotic fluid cells and an unaffected child was correctly predicted. Lipid analysis of liver tissue from the patient with NPC and the two fetuses showed a 3-5 times increased level of cholesterol, a 2-3 times increased level of sphingomyelin and a remarkable increase of bis (monoacylglyceryl) phosphate.


High-performance liquid chromatographic microassay for L-alanine:glyoxylate aminotransferase activity in human liver. We examine the suitability of a rapid and sensitive liquid chromatographic technique to determine L-alanine:glyoxylate aminotransferase (AGT) activity in human liver. Homogenised tissue was incubated for 30 min in the presence of substrates and the generated pyruvate was converted into the corresponding phenylhydrazone which was determined using reversed-phase high-performance liquid chromatography (HPLC). The procedure allowed the detection of the enzyme activity expressed by 10 micrograms of liver protein and was rapid enough resulting more sensitive and less time-consuming than the previous colorimetric one. We found that AGT activity in two hyperoxaluria type 1 patients was reduced as compared with controls. Also, cirrhotic patients had very low enzyme activities, even in the absence of detectable disorders of oxalate metabolism and this was ascribed to abnormal liver morphology. This may represent a misleading drawback if diagnosis of type 1 primary hyperoxaluria (PH1) uniquely relies on AGT assay.


Serum triglyceride and insulin levels are associated with erythrocyte sodium-lithium counter-transport activity in normoglycaemic individuals. The relationship between erythrocyte sodium-lithium counter-transport activity, serum insulin, lipids and demographic factors was examined in 93 normoglycaemic predominantly normotensive individuals with mild fasting hypercholesterolaemia (greater than 5.2 mmol/l). The major significant univariate correlates of sodium-lithium counter-transport activity were fasting serum triglycerides, HDL cholesterol, the ratio of fasting glucose: insulin, apo A1, alcohol consumption and apo B. Stepwise multiple regression analysis revealed 24% of the variability in sodium-lithium counter-transport activity could be accounted for by independent contributions of fasting serum triglycerides, alcohol consumption, the fasting glucose/insulin ratio and apo A1 and ANOVA confirmed a significant relationship with fasting insulin measures that was independent of serum triglycerides (P less than 0.05). The relationship between erythrocyte sodium-lithium counter-transport activity and concentrations of serum triglycerides, HDL components, insulin and additionally alcohol consumption, could reflect the influence of those variables on erythrocyte structure and function.


Liver transplantation modifies serum cholestanol, cholesterol precursor and plant sterol levels. Proportions of cholesterol precursors (squalene, delta 8-cholestenol, desmosterol and lathosterol), plant sterols (campesterol and sitosterol) and cholestanol to cholesterol in serum were measured before and serially after liver transplantation in eight patients with primary biliary cirrhosis (PBC) and three with acute liver necrosis. The preoperative proportions of cholestanol were 12 and 3-times higher in the PBC and necrosis groups, respectively, than in a control group of 27 individuals, while those of lathosterol were low in both groups and the campesterol/sitosterol ratio in the PBC group. During the operation the proportions of cholestanol fell sharply and those of lathosterol rose especially in the PBC group. During the postoperative follow-up of 5 weeks the proportions of the non-cholesterol sterols were markedly improved especially in the necrosis group yet those of cholestanol remained high and the campesterol/sitosterol ratios low, particularly in the PBC group. The proportions of lathosterol increased gradually almost to the control limits within the postoperative 5-week period, whereas those of desmosterol decreased. The non-cholesterol sterol values were not related to acute rejections, while significant correlations of cholestanol to liver function tests was found especially at the end of the follow-up.


Influence of workload on the antihypertensive effect of exercise. 1. The relation between workload and the antihypertensive effect of exercise therapy in hypertensive patients, and the mechanism of that effect, were investigated. 2. Twenty-six patients participated in the study and were randomly assigned to 10 weeks of either low or high workload exercise. In the low workload group, 16 mild hypertensive patients were treated with bicycle ergometer exercise at approximately 50% of their maximum oxygen consumption (VO2max) for 60 min three times a week for 10 weeks. In the high workload group, 10 mild hypertensive patients exercised on the same schedule, but at approximately 75% of VO2max. 3. After 10 weeks of exercise, the low workload group had significantly lower systolic (9 mmHg), mean (6 mmHg) and diastolic (6 mmHg) blood pressures. In the high workload group, decreases in systolic (3 mmHg), mean (4 mmHg) and diastolic (5 mmHg) blood pressure were not statistically significant. 4. In the low workload group, changes in haemodynamic and humoral variables were not significant, except for a reduction in plasma norepinephrine at week 7. Cardiac index and plasma norepinephrine tended to decrease. In the high workload group, plasma norepinephrine and the renin-angiotensin system were transiently stimulated after 4 weeks of exercise. Stroke volume significantly increased (+26.4%) after 10 weeks of high workload exercise. 5. Based on these results and better patient compliance with the exercise programme in the low workload group than in the high workload group, low workload exercise therapy was recommended to mild hypertensive patients.


Effects of acute superior cervical ganglionectomy on cerebral blood flow and metabolism in stroke-prone spontaneously hypertensive rats subjected to cerebral ischaemia. 1. The effects of acute bilateral superior cervical ganglionectomy on cerebral blood flow and metabolism were investigated in stroke-prone spontaneously hypertensive rats (SHRsp), before and during cerebral ischaemia. 2. The resting cerebral blood flow was comparable between the control and denervated animals. 3. There was no significant difference in cerebral blood flow or concentration of tissue energy metabolites (adenosine triphosphate [ATP], lactate and pyruvate) between the sham-operated control and denervated animals during ischaemia. 4. The results suggest that sympathetic innervation of cerebral vessels originating from superior cervical ganglia may not play a major role in the progression of cerebral ischaemia in SHRsp.


The effect of ovine prolactin on the epididymal sialic acid concentration in male rats. 1. Previous experiments have shown that the level of sialic acid in the epididymis is influenced by factors originating in the testis. 2. To exclude interference from these factors, both orchidectomized and duct-ligated rats were used to study the potential role of prolactin in the epididymis. 3. When ovine prolactin was injected in orchidectomized rats, a dose-related increase in the level of sialic acid was observed in the epididymis. 4. That this action of prolactin is independent of androgen was confirmed by studies using bromocriptine, which decreases circulating endogenous prolactin. 5. The physiological role(s) of epididymal sialic acid production in response to prolactin remain to be established.


Platelet-activating factor in bronchoalveolar lavage fluid of patients with adult respiratory distress syndrome. 1. To clarify the role of platelet-activating factor (PAF) in the development of adult respiratory distress syndrome (ARDS), we performed bronchoalveolar lavage (BAL) in 19 patients with ARDS and examined cell populations, albumin concentrations and PAF levels. PAF levels were measured by a newly developed radioimmunoassay. 2. In the BAL fluid of ARDS patients, neutrophil percentages and albumin concentrations markedly increased compared with control subjects. 3. PAF was detected in 14 of 19 patients with ARDS, whereas it did not exist in the control subjects. 4. Furthermore, we investigated the priming effect of recombinant human tumour necrosis factor-alpha (TNF alpha), which is known to be one of the most important mediators in the development of ARDS, on PAF production induced by the calcium ionophore in neutrophils. 5. Pre-incubation with TNF alpha dose-dependently increased both extracellular and intracellular PAF production in neutrophils. 6. These results suggest that PAF might play an important role in the development of ARDS.


Comparative effects of dopamine and dobutamine on the pulmonary haemodynamic response to hypoxia in dogs ventilated with a hypoxic gas mixture. 1. The effects of dopamine and dobutamine on the pulmonary haemodynamic response to hypoxia were studied in nine anaesthetized dogs under hypoxaemia induced by ventilation with hypoxic gas mixture. 2. From the present study, only dopamine infusion reduced arterial oxygenation during hypoxic hypoxaemia, whereas catecholamine maintained it at the same level during normoxaemia. 3. A redistribution of perfusion to the pulmonary vasculature may be related to a reduction of arterial oxygenation with dopamine infusion during hypoxic hypoxaemia. 4. It is presumed that an increase in pulmonary blood flow would emphasize an inhibition of hypoxic pressor response in the pulmonary vasculature, which may not be a direct effect of dopamine.


Ageing has no effect on the volume density of hepatocytes, reticulo-endothelial cells or the extracellular space in livers of female Sprague-Dawley rats. 1. The hepatic reticulo-endothelial cell population is generally assumed to increase in size, along with the liver, during ageing in rats. However, this has not been rigorously established. 2. Using electron microscopy and stereological techniques, the present study has shown that the volume densities of hepatocytes and Kupffer cells (and probably also of endothelial cells, fat storing cells and the extracellular space) of the livers of female Sprague-Dawley rats are the same at 2 and 24-25 months of age. 3. This result indicates that the increase in size of the liver during ageing in the rat is associated with an equivalent increase in the volume of each cell population and the extracellular space.


DNA elimination and its relation to quantities in the macronucleus of Tetrahymena. The macronucleus of Tetrahymena contains a large number of DNA molecules of subchromosomal size. They belong to about 270 species each one occurring at an average number of 45 copies. Macronuclei divide unequally and nothing is known of segregation control. This and the elimination and degradation of DNA during macronuclear amitosis make the clonal stability of macronuclei a problem of qualitative and quantitative control on a subchromosomal level. We studied the contribution of DNA elimination to the quantitative composition of the macronucleus cytophotometrically in single cells of different strains. This was done under standard conditions and under conditions known to influence the amount of macronuclear DNA. The following results were found: Elimination of DNA occurs at almost every division. The size of the elimination body is highly variable but still positively correlated with the macronuclear DNA content. In T. thermophila the amount of eliminated DNA is 2.5% of the G2 content and is not dependent on the growth state. It varies with species, amounting to as much as 8% in T. pigmentosa. During conditions which increase the macronuclear DNA content, very little DNA is eliminated. On the other hand, large amounts are eliminated under other conditions causing the macronuclear DNA content to decrease. DNA to be eliminated at division is synthesized at the same time as bulk DNA. We developed a computer program which helps us study the effects of DNA elimination and unequal divisions upon the copy numbers of subchromosomal DNA classes.(ABSTRACT TRUNCATED AT 250 WORDS)


Variable copy number of macronuclear DNA molecules in Tetrahymena. In Tetrahymena, the DNA of the macronucleus exists as very large (100 to 4,000-kb) linear molecules that are randomly partitioned to the daughter cells during cell division. This genetic system leads directly to an assortment of alleles such that all loci become homozygous during vegetative growth. Apparently, there is a copy number control mechanism operative that adjusts the number of each macronuclear DNA molecule so that macronuclear DNA molecules (with their loci) are not lost and aneuploid death is a rare event. In comparing Southern analyses of the DNA from various species of Tetrahymena using histone H4 genes as a probe, we find different band intensities in many species. These differences in band intensities primarily reflect differences in the copy number of macronuclear DNA molecules. The variation in copy number of macronuclear DNA molecules in some species is greater than an order of magnitude. These observations are consistent with a developmental control mechanism that operates by increasing the macronuclear copy number of specific DNA molecules (and the genes located on these molecules) to provide the relatively high gene copy number required for highly expressed proteins.


Stable and unstable transformation by microinjection of macronucleoplasm in Paramecium. Transformation by microinjection of macronucleoplasm in Paramecium caudatum was investigated. Macronucleoplasm with three genetic markers (behavior, trichocyst, and mating type) was injected into the macronucleus. To facilitate microinjection, in most cases, paramecia were immobilized in a gelatin (7.5%) solution. The injected cells began to express a dominant gene (cnrA+ or cnrB+) of the donor 9-24 hr after injection. Expression did not require cell division suggesting injected macronucleoplasm was capable of expressing a phenotype. The amount of injected macronucleoplasm appears to correlate with the frequency of successful expression but not to correlate with the time required for expression. After a number of fissions, the injected cells produced clones which had cells expressing the phenotype of the donor. This suggests that injected macronucleoplasm was replicated and expressed in the recipient cell lines. The transformed clones were classified into two groups. In one group, transformation was stable. All cell lines derived from the injected cells expressed a phenotype similar to the heterozygote of donor and recipient cells. In the other group, transformation was unstable. During the first five to seven fissions after injection, at each division, cells produced one daughter cell which later reverted to the recipient phenotype. After this unstable period, cells no longer produced the recipient phenotype but produced the donor phenotype exclusively. Donor and recipient phenotypes were, thus, segregated in different cell lines. Observation of genetic markers and analysis by computer simulation shed light on the mode of transmission of injected macronucleoplasm. In stable transformation, injected macronucleoplasm appears to be distributed equally to daughter cells.(ABSTRACT TRUNCATED AT 250 WORDS)


Rate of phenotypic assortment in Tetrahymena thermophila. During vegetative, asexual reproduction in heterozygous Tetrahymena thermophila, the macronucleus divides amitotically to produce clonal lineages that express either one or the other allele but not both. Because such phenotypic assortment has been described for every locus studied, its mechanism has important implications concerning the development and structure of the macronucleus. The primary tools to study assortment are Rf, the rate at which subclones come to express a single allele stably, and the output ratio, the ratio of assortee classes. Because Rf is related to the number of assorting units, a constant Rf for all loci suggests that all genes are maintained at the same copy number. Output ratios reflect the input ratio of assorting units, with a 1:1 output ratio implying equal numbers of alleles at the end of macronuclear development. Because different outcomes would suggest a different macronuclear structure, it is crucial that these parameters be accurately measured. Although published Rf values are similar for all loci measured, there has been no commonly accepted form of presentation and analysis. Here we examine the experimental determination of Rf. First, we use computer simulation to describe how the variability inherent in the assortment process affects experimental determination of Rf. Second, we describe a simple method of plotting assortment data that permits the uniform calculation of Rf, and we describe how to measure Rf accurately in instances when it is possible to score only the recessive allele. Using this method to produce truly comparable Rfs for all published data, we find that most, if not all, loci assort at Rfs consistent with approximately 45 assorting units, as has been asserted.


Inheritance of the group I rDNA intron in Tetrahymena pigmentosa. We have previously argued from phylogenetic sequence data that the group I intron in the rRNA genes of Tetrahymena was acquired by different Tetrahymena species at different times during evolution. We have now approached the question of intron mobility experimentally by crossing intron+ and intron- strains looking for a strong polarity in the inheritance of the intron (intron homing). Based on the genetic analysis we find that the intron in T. pigmentosa is inherited as a neutral character and that intron+ and intron- alleles segregate in a Mendelian fashion with no sign of intron homing. In an analysis of vegetatively growing cells containing intron+ and intron- rDNA, initially in the same macronucleus, we similarly find no evidence of intron homing. During the course of this work, we observed to our surprise that progeny clones from some crosses contained three types of rDNA. One possible explanation is that T. pigmentosa has two rdn loci in contrast to the single locus found in T. thermophila. Some of the progeny clones from the genetic analysis were expanded for several hundred generations, and allelic assortment of the rDNA was demonstrated by subcloning analysis.


Immunocytochemical analysis of secretion mutants of Tetrahymena using a mucocyst-specific monoclonal antibody. Dense-core granules represent an adaptation of specialized secretory cells to facilitate stimulus-regulated release of stored proteins. Such granules are a prominent feature of mammalian neuroendocrine and exocrine cells and are also well developed in the ciliates. In Tetrahymena thermophila, the ability to generate mutants in dense-core granule biosynthesis and fusion presents a versatile system for dissecting steps in regulated exocytosis. We have previously shown that defective granules in such mutants could be characterized by several biochemical criteria, including buoyant density, which increases during maturation, and the degree of proteolytic processing of the content precursors. We have now used indirect immunofluorescence, taking advantage of a monoclonal antibody directed against a granule protein, to visualize the morphology and distribution of both granules and putative granule intermediates in mutant and wild-type cells. The results are consistent with the biochemical analysis and extend our characterization of the mutants, allowing us to distinguish four classes. In addition, the assay represents a powerful technique for diagnosis of new mutants.


Genetic characterization of Tetrahymena thermophila mutants unable to secrete capsules. Under appropriate conditions, Alcian Blue-induced exocytosis of Tetrahymena mucocysts leads to formation of a capsule that surrounds the cell. This phenomenon is an example of regulated secretion, a mechanism of fundamental significance in eukaryotic cells. In order to dissect genetically the mechanism of mucocyst biogenesis and regulated exocytosis, mutants unable to form capsules (Caps-) were isolated. In this paper we report a genetic characterization of Caps- mutants in this collection. The mutations in mutants SB255 and SB281 behave as single recessive Mendelian mutations. The mutation in SB251 is restricted to the macronucleus, and could not be further characterized by the genetic methods we used. Complementation tests suggest the existence of at least 2 genes, named exoA and exoB; additional mutant loci are likely to be included in the mutant collection. Deletion mapping using nullisomic strains showed that exoA and exoB are located on the left arm of chromosome 4. The exo-3 mutation, which behaves as recessive and complements with exoA1 in SB255 and exoB2 in SB281, maps to chromosome 3. These Caps- mutants may be useful for the elucidation of the developmental pathway of mucocyst biogenesis and the control of regulated secretion in eukaryotic cells.


Genetic characterization of the secretory mutant MS-1 of Tetrahymena thermophila: vacuolarization and block in secretion of lysosomal hydrolases are caused by a single gene mutation. The genetics and phenotypic features (light and electron microscopy) of a secretory mutant, MS-1 of Tetrahymena thermophila blocked in secretion of lysosomal acid hydrolases have been analyzed. Although blocked constitutively in secretion, MS-1 contains active lysosomal hydrolases in amounts equivalent to the wild type. The 3:1 segregation in F-2 in sib crosses and the 1:1 segregation in test crosses indicate that the block in secretion of lysosomal hydrolases is controlled by a recessive single gene locus termed sec. The sec allele of MS-1 proved also to be responsible for the highly vacuolarized phenotype the mutant developed when it was transferred from nutrient medium into buffers of low ionic strength. Deletion mapping by crossing MS-1 with nullisomic strains, all secreting lysosomal hydrolases at wild-type rates, was performed. The sec phenotype was expressed in monosomic-4 progeny only, indicating that the sec allele is located on chromosome 4 of T. thermophila.


Locus-dependent profiles of the rescue of nonexcitable behavioral mutants during conjugation in Tetrahymena thermophila. The Tetrahymena nonreversal (TNR) mutants of Tetrahymena thermophila are behavioral mutants with nonexcitable membranes. When cells of the tnrB mutant were mated with wild type, a phenotypic change occurred about 1 h after pair formation. The pairs began to lose their heterotypic character in stimulation solution containing high potassium and, within 1 1/2 h, they were not distinguishable from the wild-type homotypic pairs. On the contrary, although pairs of the tnrA and wild type also lost their heterotypic character about 1 1/2 h after pair formation, they never showed a full response as wild-type homotypic pairs. When tnrA was mated with tnrB, more than 50% of pairs expressed a heterotypic pair character 2 h after pair formation, consistent with the tnrB defect having been rescued but not the tnrA defect. Thus, conjugation rescue of the mutant phenotype is locus dependent and probably reflects the nature of the gene products controlling voltage-dependent Ca2+ channels.


Genes and structural patterns in ciliates: Vance Tartar and the "cellular architects". The one form of cytoplasmic inheritance that has not been assimilated into the Central Dogma is the inheritance of surface structural patterns, a phenomenon most clearly expressed in ciliates. Vance Tartar, although he worked with a genetically undomesticated organism (Stentor coeruleus), provided early evidence for the crucial role of clonally propagated features of the cell cortex. He showed that the capacity for development of cortical organelle systems is associated with a particular relational feature, the "locus of stripe contrast" (LSC), and that clonally inherited cortical variants (homopolar doublets) could be created at will by microsurgical operations that duplicated the LSC. Tartar also hoped to demonstrate the existence of what David Nanney called "cellular architects" by provoking stentors to carry out entirely novel types of morphogenetic performances. He eventually acknowledged failure, although the bizarre juxtapositions by which he attempted to elicit such novel performances did bring about specific and illuminating defects in cortical development. Subsequent analyses of similar defects in other ciliates revealed not the unitary "pattern factor" postulated by Tartar, but rather a hierarchy of distinct patterning mechanisms. Nonetheless, by pursuing an embryological approach toward morphogenesis in a highly regulative ciliate, Tartar uncovered relational aspects of pattern-determination; this, in my view, delineates the major problem that we must solve to gain understanding of intracellular patterning.


The influence of fission line expression on the number and positioning of oral primordia in the cdaA1 mutant of Tetrahymena thermophila. During cytokinesis, furrowing creates new boundaries for daughter cells. Following a shift to a restrictive temperature, cells of the temperature-sensitive cell-division-arrest (cdaA1) mutant of Tetrahymena thermophila complete development of the oral apparatus for the prospective posterior daughter cell before becoming arrested in cytokinesis. When maintained under weak restrictive conditions (35 degrees C), some of the chains were arrested prior to the start of fission line formation (D-shaped chains), whereas others manifested rudimentary unilateral furrowing on the ventral side (B-shaped chains). In their second cell cycle following the temperature shift, the D-shaped chains usually formed only one oral primordium, at a position highly correlated with the length of the entire chain. The B-shaped chains always produced two separate oral primordia, located at irregular positions anterior and posterior to the division furrow, often close to the posterior oral apparatus produced during the first cycle. These results suggest that the formation of the fission line sets a reference boundary to assess the number of oral primordia and influence their position, that appear during subsequent morphogenetic episodes. They also indicate that, during cell division cycles, pre-existing oral apparatuses do not strongly inhibit the formation of new oral apparatuses in their close vicinity.


Studies on morphological outcome of cyclosporine-associated arteriolopathy after discontinuation of cyclosporine in renal allografts. Cyclosporine (CSA)-associated arteriolopathy (CAA) is the second most frequent morphological diagnosis in renal allografts and its final outcome remains unclear. The present study was performed to clarify the morphological outcome of CAA by follow-up histological analysis after stopping CSA. Furthermore, the clinical management of patients showing CAA is discussed. Most of the patients came from our early experience with CSA between 1981-1983 when CSA doses and trough levels were high. Twenty recipients were divided into two groups according to the presence of CAA after stopping CSA: group A (n = 9) showed persistent CAA and group B (n = 11) showed no CAA. The majority of the patients, including five incomplete remission in group A, showed obvious improvement of CAA even if the arterioles were severely affected. Improvement of CAA was noted a few months after stopping CSA or after lower dose CSA therapy. There were no significant differences in CSA blood levels or duration of CSA therapy between the groups. The severity of preexistent CAA was significantly greater in group A. Only two patients who died from malignant tumor showed exacerbation of CAA. Eight patients died and eight grafts were lost, seven due to vascular rejection and one to hemolytic uremic syndrome-like CAA. Poor renal function was also noted in four cases with functioning graft owing to vascular rejection even though the improvement of CAA was evident. The complete regression of CAA and the remodelling of arterioles showing well preserved vascular patency were frequently found after stopping or reducing the dose of CSA.(ABSTRACT TRUNCATED AT 250 WORDS)


Idiopathic membranous glomerulonephritis: a clinicopathologic and quantitative morphometric study. We evaluated clinical and morphological findings in 254 patients (138 men and 116 women), with idiopathic membranous glomerulonephritis (IMGN). The mean age was 44 years. At time of biopsy proteinuria was found in 98%, nephrotic syndrome (NS) in 45.2%, hypertension in 10%, elevated serum creatinine concentration of greater than or equal to 1.4 g/dl in 24%, and markedly decreased Ccr (less than or equal to 40 ml/min) in 12.5% of the patients. Of 254 patients, 51 (20%) were classified as Stage I, 131 (52%) as Stage II, 52 (20.5%) as Stage III, 9 (3.5%) as Stage IV and 11 (4.3%) as Stage V, which was a relapsing form. Both intraglomerular, peripheral electron dense deposit-size and mean thickness of the glomerular basement membrane (GBMt) were analyzed by ultrastructural morphometric methods. In patients with NS, both the mean deposit-size and the mean GBMt were largest when compared to all others (p less than 0.01). The largest subepithelial deposits (SED), in mean, were observed in Stages II and V, while the largest incorporated deposits (ICD) were measured in Stages II and IV. The mean GBMt was largest in Stage III. Furthermore, there were strong correlations between the degree of proteinuria and the deposit-size (r = 0.603, p less than 0.001), and GBMt (r = 0.456, p less than 0.001). The GBMt showed a correlation with serum creatinine concentration (r = 0.476, p less than 0.001) and Ccr (r = 0.471, p less than 0.001). We concluded that the size of the electron dense deposits and GBM thickness play an important role in the clinical manifestation of IMGN.


Protein catabolism in sham-hemodialysis: the effect of different membranes. To study whether the contact between dialysis membrane of various materials and blood may trigger protein catabolism in muscle and thus contribute to protein depletion in hemodialysis patients we measured the exchange of free amino acids across the leg in healthy subjects undergoing sham-hemodialysis (i.e. in vivo passage of blood through a dialyzer without circulating dialysate). The effect of dialyzers with regenerated cellulose (group CU, n = 16), cellulose acetate (group CA, N = 8) and polysulfone membranes (group PS, n = 8), respectively was studied. Plasma amino acid concentrations were measured in arterial and femoral venous blood and leg blood flow was determined by venous occlusion plethysmography. In group CU the total efflux of all measured amino acids from leg tissues (muscle) increased from 167 +/- 21 nmol/min/100 g tissue in the basal state to 308 +/- 41 nmol/min/100 g tissue at 345 minutes after the start of sham-hemodialysis procedure (p less than 0.01) indicating a protein catabolic effect of contact between blood and regenerated cellulose membranes. In contrast sham-hemodialysis in group CA and group PS, respectively, did not result in significant increases in amino acid efflux from the leg implying that the protein catabolic effect of blood membrane contact depends on the chemical properties of dialysis membranes. In group CU sham-hemodialysis resulted in enhanced net protein breakdown. Increases in arterial concentrations and leg release of 3-methylhistidine suggest that this may be due primarily to increased protein breakdown.


In vitro production of interleukin-1 from blood mononuclear cells of patients on chronic hemodialysis therapy. A monocyte defect is thought to be involved in the impaired immune response in patients on regular hemodialysis therapy. As an indicator of cell function, we studied in vitro IL-1 beta production of mononuclear cells from hemodialysis patients in comparison to normal controls. Mononuclear cells were stimulated with endotoxin or Staphylococcus epidermidis in parallel with control incubations in tissue culture medium alone. Spontaneous as well as stimulated total IL-1 beta production (cell-associated plus extracellular) did not differ significantly in cells obtained from patients compared to those from normal controls. However, the relative amounts of IL-1 beta released into the cell supernatants were significantly reduced in mononuclear cells from hemodialysis patients when stimulated with endotoxin but not with Staphylococcus epidermidis. These data indicate a stimulus-dependent defect in the mechanism of IL-1 beta release. As IL-1 is necessary for T-cell activation this alteration in mononuclear cell function may play a role in the impaired cellular immunity observed in patients on chronic hemodialysis therapy.


Hepatitis virus infection (HBV and HCV) in eleven Japanese hemodialysis units. To evaluate hepatitis C virus (HCV) and hepatitis B virus (HBV) infection in hemodialysis (HD) units, serum samples from 607 HD patients and 150 staff members at 11 HD units in Japan were collected, and were compared with those from 704 ordinary blood donors as a control. Serum samples subjected to a first generation ELISA for antibody to HCV (anti-C100-3) and were tested by ELISA for HB surface antigen (HBs-Ag), antibody to HBs-Ag, and antibody to HB core antigen (anti-HBc) as HBV markers. We also tested for HCV infection with a second generation ELISA (for antibodies to C22-3, C33c, and C100-3) in 120 HD patients and 30 staff members at 2 selected HD units. Of 607 HD patients, 104 (17%) were positive for anti-C100-3 and 221 (36%) for HBV markers, indicating a much higher prevalence of HCV and HBV infection among HD patients than among ordinary blood donors (0.9% and 18%, respectively). Of 159 patients without a history of blood transfusion, 17 (11%) were positive for anti-C100-3, showing that HCV infection can be acquired without transfusion. The incidence of anti-C100-3 varied from 0% to 53% at different HD units, and HBV markers varied from 17% to 50%. Our study detected a high prevalence of co-infection with HBV and HCV, suggesting that HCV infection may contribute to chronic liver dysfunction in HD patients. Out of 150 staff members, 3 (2%) were positive for anti-C100-3, whereas 25 (17%) were positive for anti-HBc (indicating prior HBV infection).(ABSTRACT TRUNCATED AT 250 WORDS)


Antibody to hepatitis C virus increases with time on hemodialysis. We studied whether chronic hemodialysis is associated with an increased risk of exposure to hepatitis C virus. Utilizing a first generation Elisa assay (C-100 Elisa, Ortho Diagnostic Systems, Raritan, NJ) and the Chiron RIBA HCV second generation assay (RIBA, Chiron, Emeryville, CA and Ortho Diagnostic Systems, Raritan, NJ), antibody to HCV was found in 31 of 87 hemodialysis patients (36%). Patients on hemodialysis less than 2 years had an antibody incidence of 15% (n = 46), as contrasted with a 59% incidence for patients on dialysis greater than or equal to 2 years (n = 41). We were unable to demonstrate a correlation of HCV-antibody positivity with history of blood transfusion. The overall incidence is higher than previously reported for hemodialysis patients in the United States. The very high incidence found in patients on dialysis greater than or equal to 2 years suggests that factors in the hemodialysis unit might contribute to the spread of virus.


Prevalence and incidence of hepatitis C virus (HCV) in hemodialysis patients: study of risk factors. The prevalence of antibodies against hepatitis C virus (HCV) was assessed in 246 hemodialysis patients who attended a dialysis unit in Bari, using a recombinant enzyme immunoassay test (Abbot Lab.). Fifty-six (22.8%) sera were reactive to anti-HCV. The reactivity was confirmed in 46 specimens (18.7%) using the Abbott EIA HCV neutralization test. The anti-HCV prevalence was higher in males than in females and increased with age, duration of dialysis and number of transfusions. Moreover, a correlation between the presence of anti-HCV and the persistent increase of ALT was noted. The HCV-infection attack rate was calculated using the frozen sera collected from 1984 to 1990: the incidence of infection in the first year was 6.1%, and in following years 4.6%, 4.9%, 3.1%, 2.1% and 2.2%, respectively.


Clostridium difficile infection--a poor prognostic sign in uremic patients? Uremia has been reported as a risk factor for the occurrence of infection with Clostridium difficile. During the two-year period 1984-86, 110 episodes of Clostridium difficile infection were encountered in 70 patients on a nephrology ward. Sixty-two patients had chronic renal failure and eight had acute renal failure. Sixty-seven of the patients were uremic and were treated with hemodialysis (n = 35), CAPD (n = 21), intermittent peritoneal dialysis (n = 6) or conservatively with a low protein diet (n = 5). Most of the patients were female (n = 41) and elderly (64 +/- 2 years). Malnutrition was common as indicated by low serum albumin concentrations (26 +/- 1 g/l) prior to the Clostridium difficile infection. Clostridium difficile infection was confirmed by stool culture and/or cytotoxin assay. Asymptomatic infections were found in eight patients. The highest relative risks of subsequent Clostridium difficile infection were calculated for patients treated with cephalosporins and isoxazolyl penicillins. All patients were treated with vancomycin, which often resulted in a dramatic improvement. One to six relapses of Clostridium difficile infection were observed in 22 of the patients. Sixty of the original 70 patients died during the five-year follow-up period. Thirty-four patients died during the first year of follow-up. Seven patients were transplanted, two are still on CAPD treatment and one has only moderate chronic renal failure (serum creatinine 200 mumol/l). Elderly debilitated uremic patients are especially susceptible to infection with Clostridium difficile which may be a poor prognostic sign in chronic renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)


Urinary excretion of glycated albumin in insulin-dependent diabetic patients with micro- and macroalbuminuria. Non-enzymatic glycosylation (glycation) involves both circulating proteins, such as albumin and structural proteins, such as the components of the glomerular basement membrane. Glycated albumin is more anionic than unmodified plasma albumin at physiologic pH. Preferential urinary excretion of glycated proteins has occasionally been reported in diabetes. We therefore investigated the selectivity index (renal clearance of non-glycated/glycated albumin) in 25 insulin-dependent diabetic patients (17 with microalbuminuria and 8 with macroalbuminuria), and 19 healthy subjects. The selectivity index was significantly higher (p less than 0.01) in the microalbuminuric patients than in the macroalbuminuric patients and the control subjects: 1.11 +/- 0.03 SEM vs 0.94 +/- 0.08 vs 0.98 +/- 0.02. These results are not consistent with preferential urinary excretion of glycated albumin in insulin-dependent diabetic patients with increased urinary albumin excretion.


Diagnostic value of technetium-99m-MIBI as a myocardial perfusion imaging agent: comparison of long and short intervals between rest and stress injections. To assess the diagnostic value of technetium-99m-MIBI (99mTc-MIBI) as a myocardial perfusion imaging agent, and if rest and exercise scans could be performed on the same day, 21 patients with coronary artery disease were studied. Qualitative planar 201-thallium (201Tl) scans, coronary angiography, or both were also performed (median between studies 11 days). In 10 patients an injection of 740 mBq of 99mTc-MIBI at stress was followed by a second injection of 740 mBq at rest 24 h later (long interal) (LI). In 11 patients injection of 370 mBq at rest was followed 3 h later by an injection of 740 mBq at stress (short interval) (SI). Exercise scans were performed to similar maximal work load (LI = 6.6 +/- 1.8 METs; SI = 6.3 +/- 1.7 METs; 201Tl = 6.8 +/- 1.2 METs; p = NS) and double product (LI = 19551 +/- 7370; SI = 19900 +/- 6797; 201Tl = 19965 +/- 5282; p = NS). Overall, 99mTc-MIBI and 201Tl agreed in 92% of the patients tested and in 165 of 180 (92%) left ventricular segments in both 99mTc-MIBI protocols using short and long intervals between injections. In 15 patients with significant stenosis, 99mTc-MIBI correctly identified 13 patients (sensitivity of 87%). Thus, 99mTc-MIBI is a useful imaging agent with similar diagnostic value as 201Tl. In spite of its lack of myocardial redistribution, 99mTc-MIBI rest and exercise scans performed on the same day seem to have a similar concordance rate with 201Tl as when performed on separate days.


Pulsed Doppler echocardiographic indices of left ventricular diastolic function in normal subjects. To establish the normal limits for various pulsed Doppler echocardiographic indices of left ventricular diastolic function, 92 healthy volunteers aged from 5 to 75 years were prospectively studied. The influence of various variables including age, gender, body surface area, fractional shortening, and left ventricular mass on these parameters was also assessed. Mean (2SD) values for 15 direct and 11 derived parameters were analyzed from transmitral inflow velocity waveform. No statistically significant differences were observed between males and females for any of these parameters. On stepwise multivariate linear regression analysis, age was found to be an independent strong determinant (p less than 0.001) of peak velocity of early diastolic filling wave, area of atrial filling period, deceleration slope, normalized peak filling rate, and early filling fraction. There was a significant correlation between heart rate and time to peak early diastolic velocity, total diastolic time period, early diastolic period, atrial filling period, and atrial filling fraction. It was further observed that a significant correlation (p less than 0.001) persisted between both age and heart rate with area of early filling period, one-third filling area, one-half filling area, ratio of early to atrial peak velocity and area, atrial filling fraction, and one-third filling fraction. None of the parameters were found to correlate with fractional shortening or left ventricular mass. Thus an effort was made to establish normal limits for various Doppler-derived parameters in healthy volunteers for future comparison in diseased states.(ABSTRACT TRUNCATED AT 250 WORDS)


Hemofiltration as treatment for patients with refractory heart failure. Hemofiltration was performed in 15 patients with refractory congestive heart failure. All of these patients had oliguria, although intensive treatment with diuretics, digitalis, vasodilators, and catecholamines was prescribed. Hemofiltration was performed under hemodynamic monitoring in 14 patients. The water removal by hemofiltration decreased pulmonary arterial pressure, pulmonary capillary wedge pressure and right atrial pressure. Despite these hemodynamic improvements, nine patients (60%) died within one month after the start of hemofiltration; the causes were fatal arrhythmia in three, renal failure in two, sepsis in one and irreversible cardiogenic shock in three. Oliguria for over 15 h or a serum creatinine concentration of more than 4.0 mg/dl at the start of hemofiltration related to poor prognosis. In view of these results, hemofiltration for refractory heart failure should be started earlier and performed carefully in order to avoid arrhythmia, cardiogenic shock, and other complications.


QT interval shortening and ST elevation in intracoronary ECG during PTCA. Percutaneous transluminal coronary angioplasty (PTCA) can provide a unique model of transient and reversible myocardial ischemia. The aim of this study was to assess the serial changes in QT interval during elective PTCA-induced transient ischemia. The serial changes in QT interval before, during, and after PTCA of the left anterior descending artery (LAD) were measured in patients who showed ST elevation in intracoronary electrocardiogram. Twelve consecutive patients who showed ST-segment elevation during PTCA-induced ischemia anterior precordial leads of the electrocardiogram (ECG) were enrolled in the present study. Target lesions for PTCA were all in the LAD. There were six patients with angina pectoris, two with non-Q-wave infarction, and four with Q-wave myocardial infarction. During balloon inflation, QTc interval shortened in both intracoronary ECG (ic-ECG) (0.472 +/- 0.013 vs 0.436 +/- 0.014) and surface ECG (0.462 +/- 0.012 vs 0.438 +/- 0.011). However, a significant shortening of the QT interval was more rapidly observed in the ic-ECG (20 s) than in the surface ECG (40 s). We conclude that the QT interval in both ic-ECG and surface ECG becomes shortened in PTCA-induced myocardial ischemia, and that the ic-ECG might be a good probe for detecting survived viable myocardium in the infarcted zone.


Histologic evidence of myocardial damage in apparently healthy subjects with ventricular arrhythmias and myocardial dysfunction. The association of ventricular arrhythmias and myocardial dysfunction could be considered an early step toward cardiomyopathy; therefore, we studied 28 patients in NYHA class I and II, characterized by complex ventricular arrhythmias (VA) on 24-h Holter monitoring and volumetric and/or contractile abnormalities on a standard two-dimensional echocardiogram (2-D echo). All patients underwent radioisotopic angiography, 20 patients complete hemodynamic study, and 15 patients endomyocardial biopsy. Ambulatory ECG monitoring showed the presence of frequent premature ventricular contractions in 14 patients (50%) and episodes of ventricular tachycardia in 16 patients (57%). 2-D echo showed mono- or biventricular enlargement and dyssynergies in 25 patients (89%) (left ventricle in 6, right ventricle in 11, both in 8). Two patients showed only left ventricle enlargement and one patient isolated left ventricular dyssynergies. Radioisotopic angiography showed mono- or biventricular ejection fraction reduction in 24 patients (85%) and regional dyssynergies in 24 patients (85%) in accordance with 2-D echo. Hemodynamic study showed in all patients normal coronary arteries, and right and left angiography confirmed enlargement and/or regional dyssynergies. Endomyocardial biopsy was abnormal in 11 of 15 patients: various degrees of hypertrophy, parcellar fibrosis, and adipogenic infiltration were found. Our preliminary data suggest that the simultaneous occurrence of ventricular arrhythmias and ventricular dyssynergies and/or enlargement in patients without apparent clinical heart disease may represent an early stage of dilated cardiomyopathy.


Anatomy, histology, and pathology of coronary arteries: a review relevant to new interventional and imaging techniques--Part II. In the last 15 years, intense interest has focused on various interventional, pharmacologic, and mechanical forms of therapy for the treatment of atherosclerotic coronary artery disease. Many techniques and devices (dilating balloons, perfusion catheters, thermal probes and balloons, lasers, atherectomy devices, stents, intravascular ultrasound) have been used or are under study for future use. Many of these techniques and devices require an understanding of histologic and pathologic features of the coronary arteries and diseases which affect them. This article reviews selective areas of anatomy, histology, and pathology relevant to the use of various new interventional techniques. Part II of this four-part review will focus on aging changes seen in the epicardial coronary arteries and will review selected features of atherosclerotic plaque, including fissure and topography.


Acoustic appearance of atrial septal aneurysm. Atrial septal aneurysm in the otherwise normal heart is a very rare and usually asymptomatic condition. A midsystolic click was described as the only clinical manifestation so far. A low-pitched early-to-midsystolic acoustic phenomenon in a 39-year-old woman corresponding with maximal leftward motion of the aneurysmatic interatrial septum during early systole is the subject of this case report. Our experience, plus review of the literature, supports the suggestion that atrial septal aneurysm should be considered in the interpretation of added systolic sounds.


Massive main pulmonary artery embolism diagnosed with two-dimensional Doppler echocardiography. This report describes the usefulness of echocardiography in the differential diagnosis of acute cardiovascular events. In a 66-year-old patient with known aortic stenosis and mitral valve prosthesis, who suddenly deteriorated with severe dyspnea, a thrombus within the pulmonary artery could be detected with 2-D echo. Pulsed-wave Doppler disclosed the resulting flow-velocity disturbances.


Prognosis for patients with initially suspected acute myocardial infarction in relation to presence of chest pain. In all 4,232 patients admitted to a single hospital during a 21-month period due to initially suspected acute myocardial infarction (AMI), the prognosis and risk factor pattern were related to whether patients had chest pain or not. Symptoms other than chest pain that raised a suspicion of AMI were mainly acute heart failure, arrhythmia, and loss of consciousness. In 377 patients (9%) symptoms other than chest pain raised an initial suspicion of AMI. These patients developed a confirmed infarction during the first three days in hospital with a similar frequency (22%) as compared with patients having chest pain (22%). However, patients with "other symptoms" had a one-year mortality of 28% versus 15% for chest pain patients (p less than 0.001). Patients with "other symptoms" more often died in association with ventricular fibrillation and less often in association with cardiogenic shock as compared with chest pain patients. Among the 921 patients who developed early AMI, 64 (7%) had symptoms other than chest pain. They had a one-year mortality of 48% versus 27% for chest pain patients (p less than 0.001). We conclude that in a nonselected group of patients hospitalized due to suspected AMI, those with symptoms other than chest pain have a one-year mortality, which is nearly twice that of patients with chest pain.


Left ventricular diastolic dysfunction in coronary artery disease: effects of coronary revascularization. Left ventricular diastolic dysfunction was studied globally and regionally in patients with coronary artery disease, and the effects of coronary revascularization were evaluated. A total of 25 patients with angina pectoris who had a stenotic lesion (greater than or equal to 90%) in only left anterior descending branch underwent coronary revascularization [percutaneous transluminal coronary angioplasty (PTCA) in 13 patients and coronary artery bypass graft (CABG) in 12]. Nine patients with normal coronary artery were studied as controls. Left ventricular volume and radial axes were measured on serial frames of one cardiac cycle by cine left ventriculography. The radial axes were drawn from the left ventricular gravity to left ventricular wall at every 20 degrees. Left ventricular filling fraction and distension rate of radial axes were calculated at the times of 25%, 50%, 75%, and 100% of diastolic period, 100% being end-diastole. Although there were no significant changes of the systolic function by revascularization, the filling fraction increased from 11.2 +/- 2.6 to 14.5 +/- 3.5% (p less than 0.001) at 25% time of diastole, from 29.9 +/- 4.9 to 32.5 +/- 5.0% (p less than 0.05) at 50% time in the PTCA group, and from 11.8 +/- 3.7 to 13.4 +/- 3.8% (p less than 0.01) at 25% time in the CABG group. The distension rate of radial axis to the anterior wall also increased significantly at 25% and 50% time of diastole after revascularization, and the change was marked in the PTCA group. However, these increases did not apply to the control patients.(ABSTRACT TRUNCATED AT 250 WORDS)


Exercise echocardiography after stabilization of unstable angina: correlation with exercise thallium-201 single photon emission computed tomography. The diagnostic usefulness of predischarge exercise echocardiography in 35 patients with unstable angina who responded to medical therapy was correlated with exercise thallium-201 single photon emission computed tomography (TI-SPECT) performed, on the average, three days after the exercise echocardiography. None of the patients had myocardial infarction prior to hospitalization or before TI-SPECT and none had left bundle-branch block on their rest electrocardiogram (ECG). Exercise echocardiography was positive in 21 patients and TI-SPECT in 24. The results of the two techniques were concordant in 28 of 35 patients (agreement = 80%, k = 0.57 +/- 0.14, p less than 0.001). Wall-by-wall comparison of the distribution of exercise-induced wall motion abnormalities with reversible thallium defects showed complete or partial correlation in all of 19 patients in whom both the tests were positive. A positive exercise ECG and positive exercise echocardiography identified 11 of 11 patients with angiographically verified significant coronary artery disease (CAD) and 11 of 12 patients (92%) with positive TI-SPECT. Thus, exercise echocardiography is a valuable addition to routine predischarge exercise test in the noninvasive diagnosis of myocardial ischemia and shows a good correlation with TI-SPECT in detecting and localizing ischemia in patients with unstable angina stabilized on medical therapy.


Hemodynamic findings during exercise on a bicycle ergometer following balloon valvuloplasty of pulmonary stenosis in children and adolescents. Eleven patients (4 female, 7 male), age range 3.3 to 24.8 years (mean 11.10 years) treated for isolated pulmonary stenosis underwent cardiac catheterization and percutaneous transluminal balloon valvuloplasty (PTVP). The right ventricular systolic pressure (RVSP) before valvuloplasty ranged from 31 to 127 mmHg (mean 79 mmHg) decreasing to 28 to 62 mmHg (mean 42 mmHg) immediately after the dilatation. The peak systolic gradient of the pulmonary valve (delta p RV-PA) before valvuloplasty ranged from 22 to 107 mmHg (mean 61 mmHg) and decreased to a range of 14 and 45 mmHg (mean 23 mmHg) immediately after the dilatation. Balloon valvuloplasty was performed using balloons of 13 to 31 mm in diameter. On 11 patients cardiac catheterization and Doppler echocardiography were repeated between 11 months and 5.3 years (mean 3.11 years) after the balloon valvuloplasty showed a further significant fall in the gradient of pressure. The right ventricular systolic pressure ranged from 20 to 51 mmHg (mean 31.7 mmHg) while the transpulmonary gradient varied from 3 to 24 mmHg (mean 11.6 mmHg). At the time of follow-up examination the patients were aged between 7.2 and 25.7 years (mean 15.9 years). On average the second catheterization was performed 3.11 years following the first hemodynamic study. The follow-up examination encompassed clinical examination, electrocardiogram, Doppler echocardiography, and right heart cardiac catheterization. During right heart cardiac catheterization the children exercised on a bicycle ergometer for three min at 50 or 100 W depending on their body surface area. During this exertion, pressures of the right ventricle and the pulmonary artery as well as heart rate and oxygen saturation were recorded.(ABSTRACT TRUNCATED AT 250 WORDS)


Benefits of the advances in cardiac pacemaker technology. Pacemaker technology has expanded rapidly in the last thirty years. Each phase of development has been marked by both improvements in clinical benefit and disadvantageous interactions of physiology and technology. Each phase of development has led to smaller, more reliable devices with greater programmability. Advances in generator technology and battery design have increased longevity of devices. The first devices used asynchronous pacing which had a significant effect in reducing the mortality of surgically induced complete heart block. Ventricular demand pacemakers overcame the problems of asynchronous competitive pacing, but exposed the pacemaker syndrome. Atrioventricular sequential pacing restored atrioventricular synchrony, resulting in hemodynamic improvement, but created the phenomenon of pacemaker-mediated tachycardia. Alternative dual chamber modes and algorithms have largely resolved this. Adaptive-rate devices have been of benefit to patients with chronotropic incompetence, and are now incorporating an increasing variety of biosensors. Almost all the problems of pacing have been overcome, but the increasing complexity of pacemaker technology is now a major limitation to its proper use.


Anatomy, histology, and pathology of coronary arteries: a review relevant to new interventional and imaging techniques--Part III. In the last 15 years, intense interest has focused on various interventional, pharmacologic, and mechanical forms of therapy for the treatment of atherosclerotic coronary artery disease. Many techniques and devices (dilating balloons, perfusion catheters, thermal probes and balloons, lasers, atherectomy devices, stents, intravascular ultrasound) have been used or are under study for future use. Many of these techniques and devices require an understanding of histologic and pathologic features of the coronary arteries and diseases which affect them. This article reviews selective areas of anatomy, histology, and pathology relevant to the use of various new interventional techniques. Part III of this four-part review focuses on eccentric and concentric plaques, formation of coronary thrombus, and status of the "infarct artery" after mechanical and pharmacologic forms of acute reperfusion therapy.


A case of neurofibromatosis associated with a coronary artery aneurysm and myocardial infarction. Aneurysms of the aorta, vertebral arteries, carotid artery, thyrocervical trunk, and mesenteric and celiac arteries have been described in patients with neurofibromatosis. These aneurysms may have part of the vessel wall replaced by neurofibromatosis tissue. One previous case reports a coronary artery aneurysm in a patient with neurofibromatosis who suffered a myocardial infarction due to thrombosis formation within the aneurysm. We document a second case of aneurysmal dilatation of a coronary artery in a patient with neurofibromatosis. This patient also had a myocardial infarction in a vascular distribution not involved by the aneurysm. The vascular changes associated with neurofibromatosis are reviewed. Aneurysmal dilatation of the coronary arteries may be a further vascular manifestation of this condition.


Total hip arthroplasty in patients 80 years of age and older. One hundred fifty-seven consecutive patients (162 total hip arthroplasties) 80 years of age and older were observed for one year after total hip arthroplasty (THA). Clinical results and complications were recorded. The indication for surgery was degenerative joint disease (DJD) in one half of the patients and complications to proximal femoral fractures in the other half. The mean age was 83 years old in both groups. In 80% of the patients, no complications were recorded during the first year. Three patients died during the first three months. Two deep infections occurred (1.2%). The dislocation rate was 9.2% (15/162). There was a lower dislocation rate (4/84) in the DJD group compared to the fracture group (11/78). All nine recurrent dislocations occurred in the fracture group and were treated with either trochanteric osteotomy (five) or removal of the prosthesis (four). In the patients operated on with trochanteric osteotomy, no further dislocations occurred. The mean hospital stay was 13 days. After one year, 88% (112/127) of the patients who could be observed had good or excellent results. Total hip arthroplasty in the elderly is a reasonably safe method and yields good functional results. Dislocations, however, were common in patients operated on for complications from proximal femoral fractures, and the risk for recurrent dislocation was high (9/11). In these patients, trochanteric osteotomy is recommended.


Femoral head intramedullary stemmed implant. A historical prospective. A historical review reveals that McBride may have been the first to use a femoral head intramedullary stemmed hip implant. It had a threaded stem and limited use. Eicher may have been the first to develop and use the smooth intramedullary stemmed femoral implant with a calcar collar, which was the forerunner of implants used today. Moore subsequently developed the self-locking intramedullary stemmed femoral implant with a calcar collar. Shortly thereafter, Thompson introduced a similar prosthesis. These four surgeons pioneered the development of the intramedullary stemmed femoral head prosthesis, which has been a key contribution to modern hip reconstruction.


Manifestations of ischemic necrosis complicating developmental hip dysplasia. Ischemic or avascular necrosis of the hip is a serious complication of the treatment of developmental hip dysplasia. The degree of ischemic insult can be classified based on an understanding of the vascularity of the proximal femur. Physeal involvement and subsequent growth disturbance, producing late deformity of the proximal femur, can compromise long-term results. Early recognition of ischemic necrosis patterns can be helpful in planning further treatment.


Bead loosening from a porous-coated acetabular component. A follow-up note. Beaded porous-coated implants are commonly used in total joint arthroplasty. In this study, the authors extended the follow-up period for the Davey and Harris study of bead loosening in beaded cementless acetabular components. When 56 primary total hip arthroplasties were first reviewed, at an average of 2.5 years after surgery, the incidence of bead loosening was 8.9%. Reevaluation at a mean of 4.5 years after surgery revealed that the incidence of loosening had increased to 19.6%. Bead loosening was associated with acetabular migration in one component and a broken screw in a second. In the absence of loose beads, there were no broken fixation screws or socket migration. Radiolucencies at the bone-implant interface were seen in association with loose beads in only one case. Although long-term implications of bead loosening are not clear, bead migration may increase the possibility of macrophage response to metallic debris.


Slipped capital femoral epiphysis. The case for internal fixation in situ. The traditional method of treating slipped capital femoral epiphysis by in situ pinning is being challenged. The complication of chondrolysis has been correlated with unrecognized pin penetration into the hip joint. Several studies have shown that black children may be more susceptible to developing chondrolysis. Fifty-five children (89% black) with 80 slipped epiphyses agreed to return for evaluation by the authors at an average of 3.3 years after in situ pinning. The results were classified according to clinical and roentgenographic parameters. The results were excellent or good in 56 (70%) of the 80 slips. Excellent or good results were found in 86% of mild slips, 55% of moderate, and 27% of severe. The complication of chondrolysis developed in three slips (4%) and avascular necrosis in two (3%). Poor pin position could be correlated with the complication in one of the three patients who developed chondrolysis and in both who developed avascular necrosis. Poor pin position was also associated with 12 (60%) of the 20 poor results. The majority of pin problems were secondary to technical problems associated with attempting in situ pinning from the lateral approach. In this study, black children were not more susceptible to chondrolysis than nonblack children.


Acute septic arthritis of the hip joint in infancy and childhood. Forty-three children with 45 hip joint infections were admitted to the hospital between 1983 and 1988. The duration of symptoms was the single most important prognostic feature. Almost all children who were treated within four days of symptoms had a satisfactory outcome. Concomitant osteomyelitis of the proximal femur produced by far a worse prognosis than if the infection was confined to the synovium of the hip joint. In addition, patients whose hips were infected with Staphylococcus aureus bacteria were more likely to have a poor prognosis than those whose hips were infected with non-S. aureus bacteria.


The Clayton total hip arthroplasty. A ten-year follow-up study. Early success has been reported using a long-stem cemented femoral component in total hip arthroplasty (THA). The same patient group reported by the authors' institution at five years were reviewed again at ten years postarthroplasty. Certain trends can now be defined, including gradual deterioration in the Harris hip score, tendency toward failure of acetabular fixation (8.4% loosening rate requiring revision), and increased calcar resorption. Overall, the cemented femoral component has performed admirably, with a 97% success rate at ten-years' post-THA (3.1% revision rate). In this study, success was defined as arthroplasties that did not require revision. Ninety percent of observed patients were rated as good or excellent using the Harris hip score. The Clayton femoral component provides excellent durability by virtue of design.


Stress fracture of the hip. An unusual complication of total knee arthroplasty. Stress fracture of the hip is a rare complication of total knee arthroplasty (TKA). Only eight cases seem to have been reported in the literature. A ninth case is reported in the present study. A 76-year-old obese woman was treated by right TKA for osteoarthrosis with cementing of the tibial component because of insufficient primary fixation. One year after TKA, she complained of tenderness above the right adductor tendons. There was no history of trauma. One month later, bone scintigrams and roentgenograms demonstrated a stress fracture of the femoral neck. Conservative management was successful. Etiologic factors such as rheumatoid arthritis, osteoporosis, steroid medication, or changes in static or dynamic forces of the hip secondary to knee arthroplasty could not be demonstrated in this patient. The increase in activity after TKA may be a factor in the incidence of these stress fractures of the hip. Radionuclear-type bone scan is helpful in diagnosis. The foci of increased isotope uptake are not always seen at the site of the stress fracture and only later visualized by roentgenograms.


Total hip arthroplasty in patients with avascular necrosis of the hip. Follow-up observations on cementless and cemented operations. Thirty-one patients with avascular necrosis of the hip were treated by 34 total hip arthroplasties (THAs). All patients were observed prospectively with a minimum two-year follow-up evaluation (average, 46 months; range, 24-84 months). Twenty had cemented arthroplasties using contemporary cementing techniques. This included insertion of a medullary plug, cleansing of the canal with a medullary brush, pulsatile lavage irrigation, and insertion of the cement with a cement gun. In 14 hips, a cementless prosthesis was used. Patients were rated using a modified Harris hip score. Sequential postoperative roentgenograms were analyzed in each patient. The overall Harris hip score ratings were 88 in the cemented and 84 in the noncemented groups. Mechanical failure with loosening of the femoral component occurred in one patient who developed deep sepsis. Significant thigh pain occurred in four patients in the noncemented group. Previous studies in the literature have generally reported unfavorable results in patients with avascular necrosis of the hip treated with THA. Using cementless and cemented fixation with contemporary cementing techniques, improved results can be expected. A high incidence of thigh pain (29%) in the cementless group remains a problem.


The late course of acute partial anterior cruciate ligament tears. A nine to 15-year follow-up evaluation. Twenty-two patients had an acute anterior cruciate ligament (ACL) tear. Nineteen patients were treated conservatively, except for associated injuries. In three patients, a reinsertion of the torn portion of the ACL was done surgically. All patients were reexamined after nine to 15 years with special emphasis on stability testing; this was done manually and with instruments. Knee function score and activity level were also measured. Standing roentgenograms with the knee in slight flexion were taken as well. At follow-up examination, none of the patients had needed ACL reconstruction. Knee function was good, with a mean Lysholm score of 93 points. Patients had changed activities from recreational team sports to light individual sports. Manual laxity values were similar to the values obtained at the time of initial injury. A 1-mm sagittal laxity increase was found on the injured knee with the Stryker laxity tester. Slight signs for osteoarthrosis were found in more than half of the knees, mainly in cases with chondral fractures or meniscectomy. In general, conservative treatment had a good long-term prognosis.


The lateral trochlear sign. Femoral trochlear dysplasia as seen on a lateral view roentgenograph. Dysplasia of the femoral trochlea is easily detected on an axial roentgenogram of the patellofemoral joint. A roentgenographic sign is described wherein severe trochlear dysplasia can also be readily appreciated on a plain lateral roentgenogram. The subchondral bone of the trochlea is normally seen as a dense white line, which remains parallel to the subchondral bone of the lateral femoral condyle. The intersection of those two lines is indicative of severe trochlear dysplasia and has been named "the lateral trochlear sign."


The Ilizarov apparatus for treatment of melorheostosis. Case report and review of the literature. Traditional conservative and surgical methods of treatment of melorheostosis, such as manipulations, plaster casts, soft-tissue releases, capsulotomies, and osteotomies cause a high recurrence rate. In a 12-year-old girl, flexion contracture of a knee with limb inequality caused by melorheostosis was corrected successfully with the Ilizarov distraction apparatus.


Posterior cruciate condylar total knee arthroplasty. Average 11-year follow-up evaluation. Forty-two total knee arthroplasties (TKAs) of the posterior cruciate condylar design performed from 1975 until 1978 were reviewed. Follow-up evaluations averaged 11 years. There were 21 knees each of osteoarthrosis and rheumatoid arthritis. The average postoperative knee score was 85.4 points. Thirty-nine knees (92.8%) were rated good or excellent, one (2.4%) was judged fair, and two (4.8%) were considered failures. Postoperative flexion averaged 104 degrees. Analysis of osteoarthritic versus rheumatoid arthritic subgroups demonstrated no significant differences in motion, alignment, or knee score. Roentgenographic review demonstrated no cases of femoral or tibial loosening, but one case of patellar component dislodgement was observed. Nonprogressive radiolucent lines were observed in 75% of the cases. Good results can be expected if satisfactory lower-extremity alignment is attained. Posterior cruciate ligament retention has provided a slightly improved postoperative range of motion. Residual problems appear to be centered about the patellofemoral joint.


The Attenborough and Gallannaugh knee prostheses for total knee arthroplasty. A comparison and survival analysis. The characteristic feature of the Attenborough knee prosthesis was a stabilizing link rod, designed to act in place of the cruciate ligaments and to supplement the function of the collateral ligaments when damaged by disease. However, the reported long-term results obtained with this prosthesis have not been satisfactory, and survival analysis of 505 arthroplasties in which this prosthesis was used demonstrates a cumulative 14-year success rate of only 44.9%. In 1982, a new design incorporating the link rod was developed and the results of 149 knees in which this prosthesis was used show a cumulative seven-year success rate of 98.4%, compared with 70.1% in the Attenborough series. The clinical results of the Gallannaugh series are presented in this study. Knee function has been separated from patient activity, the patients being categorized in groups according to their physical state. Thus, the result of the knee operation can be assessed even in those disabled by age and infirmity. The Gallannaugh prosthesis is of particular value in circumstances where the use of an unconstrained prosthesis would be impractical.


Hip sonography--how reliable? Sector scanning versus linear scanning? Dynamic versus static examination? In Europe, the use of ultrasonography has become a routine procedure for the detection of hip dislocations and dysplasias; clinical and historical data alone are not fully reliable. Under the right conditions, ultrasonographic examination of the hip can reliably detect hip joints in need of treatment. Furthermore, results are reproducible without the use of roentgenograms; thus the danger of "overtreatment" can be avoided. The use of sector scanners for examinations of hip joints leads to distortions in the geometry of the picture. As a result, the use of linear transducer is presently indispensable. Thanks to a reference level, static examinations of the hip joint provide us with the possibility of measuring and comparing individual hip joints. With dynamic examinations, we can quantify the data and assess hip stability. In fact, the static and dynamic approaches do not exclude but, rather, complement each other. The ultrasonographic method must be learned from experts. Given the above-mentioned conditions, all developmental abnormalities of the hip can be diagnosed in the first six weeks of life, and healthy hip joints can be clearly distinguished from those requiring follow-up examination. Based on observations on 8530 cases, hip joints of infants at least 4.5 months of age can be successfully treated in a conservative manner. Femoral head necroses have disappeared altogether and the need for later surgery has decreased dramatically.


Traumatic disruption of the anterior tibial tendon while cross-country skiing. A case report. Closed spontaneous rupture of the anterior tibial tendon is an uncommon injury that occurs after relatively minor trauma in middle-aged and elderly men. A 72-year-old retired physician sustained a complete anterior tibial tendon rupture while he was skiing cross-country. Direct primary repair of the tendon resulted in satisfactory restoration of muscle strength and return to an active life-style.


Fibular stress fracture associated with distal tibiofibular synostosis in an athlete. A case report and literature review. A 19-year-old collegiate football player with progressive ankle syndesmosis ossification developed acute localized fibular tenderness. Roentgenograms demonstrated a fibular stress fracture proximal to the superior extent of the ossific mass. Surgical resection of the mass resulted in uneventful fibular healing, with resolution of acute and chronic symptoms.


Interlocking intramedullary nails. An improved method of screw placement combining image intensification and laser light. Insertion of distal interlocking screws in femoral nails can be technically demanding and may entail substantial exposure. A method of insertion of femoral interlocking screws that uses a laser guiding system in addition to the standard image intensifier was used in an attempt to improve the accuracy of distal screw placement and to limit radiation exposure. Using this technique, 97% of the distal femoral drill holes attempted were successfully made with the first pass of a drill. Little or no resistance to the drill was met from contacting the femoral nail. Average fluoroscopy time was 0.4 minute. Laser-assisted screw placement requires relatively inexpensive modifications of existing equipment and is easy to master. Compared with the more commonly used freehand method, laser-assisted screw placement appears to offer a reduction in the amount of time and radiation exposure required to insert distal interlocking femoral screws.


The segmental tibial fracture.

The segmental tibial fracture. A series of 31 segmental tibial fractures is reported. Eighty-four percent of the patients sustained multiple trauma and 80% of these were open fractures. The series includes treatment with 20 external fixators, seven unreamed intramedullary nails, two casts, and two amputations. Complications included a 48% incidence of elevated compartment pressures necessitating fasciotomy. Despite rapid early decompression, there was a 19% incidence of residual motor and sensory deficit. Other complications observed were a 35% incidence of wound infection, nonunion, and malunion. Eighty-one percent of delayed or nonunions occurred at the distal fracture site. Intramedullary nailing produced the fewest complications. The segmental tibial fracture is at high risk for complications. Close observation of the limb for high compartment pressures is advisable. Treatment for compartment syndrome includes prompt decompression and stabilization of the fracture and, as indicated, intramedullary rods without preliminary reaming.


Spine fracture in ochronosis. Report of a case. Ochronosis, the musculoskeletal manifestation of alkaptonuria, primarily involves the larger joints of the body, including the spine. Ankylosis of the thoracolumbar spine leads to progressive loss of flexibility. The case described is that of a 72-year-old man with ochronosis who suffered a hyperextension injury to his spine in a fall, resulting in a fracture through an ankylosed L2-L3 disk space. To the authors' knowledge, this is the first reported fracture of an ankylosed ochronotic spine.


Acute gonococcal flexor tenosynovitis in an adolescent male with pharyngitis. A case report and literature review. A 15-year-old boy had acute gonococcal flexor tenosynovitis of the middle finger associated with symptomatic gonococcal pharyngitis. The patient had a history of blunt trauma to the hand. The need for a careful history in any sexually active adolescent is emphasized. Acute flexor tenosynovitis may be the only manifestation of disseminated gonococcal infection.


Treatment of acutely infected arthroplasties with incision, drainage, and local antibiotics delivered via an implantable pump. Twelve patients with acutely (symptomatic less than ten weeks) infected arthroplasties were treated with minimal debridement and intraarticular antibiotic, amikacin, delivered via an implantable pump. The infection was suppressed in ten cases. Intraarticular levels of amikacin were obtained in eight cases. These levels ranged from greater than 150 micrograms/ml to 1688 micrograms/ml. The systemic level of amikacin remained below 10 micrograms/ml in all but one case. Duration of hospitalization averaged 19 days. There were no significant toxic side effects to amikacin.


Imaging in congenital dislocation and dysplasia of the hip. Selection of imaging techniques in patients with congenital dislocation or dysplasia of the hip (CDH) depends on the age of the child and whether one is seeking diagnostic or management information. Ultrasound is effective in children up to one year of age and should be used in place of most roentgenograms. Arthrography and computed tomography are used when surgery is planned. Magnetic resonance imaging is still being evaluated for diagnosis of CDH.


Intragluteal spindle cell hemangioendothelioma. An unusual presentation of a recently described vascular neoplasm. A 40-year-old woman noted a large tumor mass in the left buttock that, on microscopic examination, proved to be a recently described, relatively uncommon spindle cell hemangioendothelioma. This particular neoplasm, which has some features of Kaposi's sarcoma, seems not to have been reported previously in a deep, intramuscular location.


Staging and treatment of primary and persistent (recurrent) osteoid osteoma. Evaluation of intraoperative nuclear scanning, tetracycline fluorescence, and tomography. The purposes of this study were (1) to evaluate the various methods of preoperative staging of osteoid osteomas, (2) to compare the different methods of intraoperative localization and excision of the tumor, and (3) to develop a clinical strategy for the treatment of persistent (recurrent) lesions. From 1978 until 1986, 14 consecutive patients had excision of osteoid osteomas. All patients' operative reports, roentgenograms, bone scans, computed tomographic scans and histologic studies were reviewed. With an average follow-up period of 94.5 months, 13 of 14 patients were cured with one operative procedure. One patient required two procedures. No patient developed a recurrence. Eleven of 14 niduses were confirmed on hematoxylin and eosin sections. Computed tomographic scan was the most useful preoperative study in localizing the nidus. It helped determine the surgical approach and the portion of bone to be resected. Intraoperative nuclear scanning (IONS) is a reliable technique in confirming complete removal of the nidus, with no increase in operative time. Intraoperative scanning did not appreciably affect the amount of bone resected. Recurrent tumors can be reliably resected, with a high cure rate, by careful preoperative staging and with use of IONS.


Multidisciplinary preoperative assessment and late function in dysvascular amputees. During a three-year period, 95 adults were treated by lower-extremity amputations for peripheral vascular insufficiency. A multidisciplinary team for presurgical evaluation determined all to be potentially independent walkers with a prosthesis. Patients were graded for level of independent walking before amputation and again at a minimum two-year follow-up examination using a seven-level functional grading system. Seventy-six of 90 patients (84%) ambulated within one functional level of their preamputation status. This return to preamputation level of function was maintained whether comparing preamputation functional level or surgical amputation level. Prosthetic use increased and the use of walking aids decreased with increased functional ambulation levels, but did not correlate with surgical levels. Peripheral vascular insufficiency patients can maintain walking independence. Multidisciplinary presurgical evaluation helps selection of the amputation level and correct prosthetic limb fitting.