A different ontogenesis for chronic lymphocytic leukemia cases carrying stereotyped antigen receptors: molecular and computational evidence.

Chronic lymphocytic leukemia (CLL) is uniquely characterized by the existence of subsets of cases with quasi-identical, 'stereotyped' B-cell receptors (BCRs). Herein we investigate this stereotypy in 2662 patients with CLL, the largest series yet, using purpose-built bioinformatics methods based on sequence pattern discovery. Besides improving the identification of 'stereotyped' cases, we demonstrate that CLL actually consists of two different categories, based on the BCR repertoire, with important biological and ontogenetic differences. The first ( approximately 30% of cases) shows a very restricted repertoire and is characterized by BCR stereotypy (clustered cases), whereas the second includes cases with heterogeneous BCRs (nonclustered cases). Eleven major CLL clusters were identified with antigen-binding sites defined by just a few critically positioned residues, regardless of the actual immunoglobulin (IG) variable gene used. This situation is closely reminiscent of the receptors expressed by cells participating in innate immune responses. On these grounds, we argue that whereas CLL cases with heterogeneous BCRs likely derive from the conventional B-cell pool, cases with stereotyped BCRs could derive from progenitor cells evolutionarily adapted to particular antigenic challenges, perhaps intermediate between a true innate immune system and the conventional adaptive B-cell immune system, functionally similar to what has been suggested previously for mouse B1 cells.

Mason type IV fractures of the elbow: a 14- to 46-year follow-up study.

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3 degrees (sd 4) and extension by a mean of 9 degrees (sd 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space. We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.

Displaced fractures of the neck of the radius in adults. An excellent long-term outcome.

We have reviewed 20 women and three men aged 22 to 73 years, who had sustained a Mason type-IIb fracture of the neck of the radius 14 to 25 years earlier. There were 19 patients with displacement of the fractures of 2 mm to 4 mm, of whom 13 had been subjected to early mobilisation and six had been treated in plaster for one to four weeks. Of four patients with displacement of 4 mm to 8 mm, three had undergone excision and one an open reduction of the head of radius. A total of 21 patients had no subjective complaints at follow-up, but two had slight impairment and occasional elbow pain. The mean range of movement and strength of the elbow were not impaired. The elbows had a higher prevalence of degenerative changes than the opposite side, but no greater reduction of joint space. Mason type-IIb fractures have an excellent long-term outcome if operation is undertaken when the displacement of the fracture exceeds 4 mm.

Bone loss following tibial osteotomy: a model for evaluating post-traumatic osteopenia.

The reduced bone mineral density (BMD) found in patients with fractures may, in part, follow rather than precede the fracture. We studied the magnitude and reversibility of bone loss in the 15 months following osteotomy in 21 men and 5 women with localized medial arthritis of the knee. BMD (mean +/- SD), measured using dual-energy X-ray absorptiometry, decreased by a maximum of 35 +/- 21% in the mid-diaphysis of the affected tibia at 9 months after surgery (p < 0.001). At 15 months, reversal of bone loss in non-fractured bones was incomplete; the remaining deficit was 20 +/- 27% relative to baseline (p < 0.001). Maximum bone loss occurred at 9 months at the total body (5 +/- 2%), spine (15 +/- 17%) and at Ward's triangle of the proximal femur of the unoperated limb (10 +/- 17%) (all p < 0.01). In summary, post-traumatic bone loss is region-specific with incomplete reversibility, at least after about 15 months. Deficits in BMD in cross-sectional studies of patients with fractures, held to be responsible for the bone fragility, may, in part, follow rather than precede the fracture.

Jones fracture. Surgical versus nonsurgical treatment.

Sixty-three patients with 66 transverse and short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were evaluated an average of five years (range, one to ten years) after the injury. There were 27 acute fractures and 39 chronic, or stress, fractures. The primary treatment was surgical for one third of the injuries and nonsurgical for the others. Surgical treatment consisted of the insertion of medullary screws. Nonsurgical treatment consisted of the application of either a plaster cast or an elastic bandage. Almost one fourth of the fractures treated nonsurgically later had to be treated surgically because of delayed unions or refractures. Late surgery was required in 12% of acute fractures and in 50% of chronic fractures with sclerosis narrowing the medullary canal. Irrespective of the primary treatment, all the patients had full function at the time of the follow-up evaluation, and no nonunions were diagnosed.

Effects of physical activity on bone mineral content and muscle strength in women: a cross-sectional study.

Physical exercise is known to increase bone mass in men, whereas the effect is less predictable in women. In this cross-sectional report, effects of physical activity on women aged 38-64 years are studied. Bone mass and muscle strength were compared between 30 regularly exercising women jogging only once a week for at least three years and an equal number of controls matched for age. BMC of the distal third of the radius was significantly higher in the active women. The active women over age 50 also had higher trabecular bone mass in the distal end of the radius. Quadriceps strength and balance were also found to be better in the activity group. Active women had a different lifestyle than the non-active women, with less consumption of alcohol, oestrogens, and tobacco. This report supports the hypothesis that regular moderate physical activity might reduce bone loss in women.

Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study.

Thirty consecutive patients who had dislocation of the elbow without concomitant fracture and who were sixteen years old or more were examined under general anesthesia for stability of the joint at an average of four days after the injury. All of the elbows showed medial and sixteen showed both medial and lateral instability. The patients were then randomly assigned to undergo either non-surgical or surgical treatment of the ligamentous injuries. All of the surgically treated elbows showed complete rupture or avulsion of both the medial and lateral collateral ligaments, and in about half of these patients the muscle origins were found to be torn from the humeral epicondyles. At follow-up, both groups showed generally good results; the differences were not statistically significant. There was no evidence that the results of surgical repair of the ligaments were any better than those of non-surgical treatment.

Long-term sequelae of simple dislocation of the elbow.

Fifty-two patients with a radiographically verified dislocation of the elbow were re-examined at an average of twenty-four years after injury. Half of the patients had no residual symptoms or signs whatsoever and more than one-third had a slight or moderate decrease in the range of extension, which was associated with slight degenerative change in the joint or with periarticular calcification. No reduction in joint space was evident. Even when the examination revealed some instability in a few patients they did not register complaints. Among the patients who had sustained the injury when they were less than sixteen years old, there were few with residual symptoms, signs, or radiographic changes.

Arthrography of the dislocated elbow joint.

Arthrography has been suggested as a useful tool for diagnosing ligament ruptures. In 14 consecutive patients with non-fractured elbow dislocations arthrography was performed after reduction of the dislocation. One or two days following arthrography all elbows were examined under general anesthesia with regard to stability and half of them were randomized for surgery with exploration and suture of both the ulnar and the radial collateral ligaments. Arthrography, even if performed within 24 hours after the injury, was found to be unreliable in diagnosing ligament injuries after elbow dislocation. Leakage of the contrast medium was more or less limited to the site of the major injury, which in the dorsal and dorso-radial dislocation was a rupture of the volar aspect of the capsule and the ulnar side of the joint in the radial dislocation.