Influence of perfusion and cyclic compression on proliferation and differentiation of bone marrow stromal cells in 3-dimensional culture.

Until now, there has been no in vitro model that duplicates the environment of bone marrow. The purpose of this study was to analyze proliferation and differentiation of human bone marrow stromal cells (hBMSC) under the influence of continuous perfusion and cyclic mechanical loading. hBMSC of seven individuals were harvested, grown in vitro, and combined. 10(6) hBMSC were seeded on a bovine spongiosa disc and incubated in a bioreactor system. Cell culture was continued using three different conditions: Continuous perfusion (group A), 10% cyclic compression at 0.5Hz (group B) and static controls (group C). After 24h, 1, 2, and 3 weeks, we determined cell proliferation (MTS-assay) and osteogenic differentiation (osteocalcin ELISA, Runx2 mRNA). Tenascin-C mRNA was quantified to exclude fibroblastic differentiation. In groups A and B, proliferation was enhanced after 2 weeks (48.6+/-19.6x10(3) (A) and 44.6+/-14.3 x 10(3) cells (B)) and after 3 weeks (46.6+/-15.1 x 10(3) (A) and 44.8+/-10.2 x 10(3) cells (B)) compared with controls (26.3+/-10.8 x 10(3) (2 weeks) and 17.1+/-6.5 x 10(3) cells (3 weeks), p<0.03). Runx2 mRNA was upregulated in both stimulated groups after 1, 2, and 3 weeks compared to control (group A, 1 week: 5.2+/-0.7-fold; p<0.01, 2 weeks: 4.4+/-1.9-fold; p<0.01, 3 weeks: 3.8+/-1.7-fold; p=0.013; group B, 1 week: 3.6+/-1.1-fold, p<0.01, 2 weeks: 4.2+/-2.2-fold, p<0.01; 3 weeks: 5.3+/-2.7-fold, p<0.01). hBMSC stimulated by cyclic compression expressed the highest amount of osteocalcin at all time points (1 week: 294.5+/-88.4 mg/g protein, 2 weeks: 294.4+/-73.3mg/g protein, 3 weeks: 293.1+/-83.6 mg/g protein, p0.03). The main stimulus for cell proliferation in a 3-dimensional culture of hBMSC is continuous perfusion whereas mechanical stimulation fosters osteogenic commitment of hBMSC. This study thereby contributes to the understanding of physical stimuli that influence hBMSC in a 3-dimensional cell culture system.

Meningeal involvement in Wegener's granulomatosis confirmed and monitored by positive circulating antineutrophil cytoplasm in cerebrospinal fluid.

MRI and CSF investigations revealed meningeal involvement in a 29-year-old patient with biopsy-confirmed Wegener's granulomatosis. The intracranial manifestation of Wegener's granulomatosis was supported by the detection of pathologic circulating antineutrophil cytoplasm (c-ANCA) in the CSF. We monitored disease activity by c-ANCA measurement in the CSF. After repeated cycles of intrathecal administration of methotrexate and corticoids, progression of meningeal infiltration stopped, and CSF c-ANCA titers became negative.

Treatment modalities and ANCA in Takayasu's arteritis.

As other vasculitic-syndromes Takayasu's-Arteritis needs a long-term immunosuppressive therapy in order to control disease-activity. As steroids create many problems in the long run other immunosuppressives should be considered. We report 3 cases treated with low-dose methotrexate. In all patients the arteritis was controlled, steroids reduced or stopped. In the effort to find autoantibodies 16 patients were screened for c-/p-ANCA and neutrophil granular enzymes. In no patient a positive result could be obtained.

The Le Fort III advancement osteotomy in the child under 7 years of age.

This is a longitudinal study of 12 patients with craniofacial synostosis syndromes (Crouzon's, Apert's, Pfeiffer's) who underwent Le Fort III advancement under the age of 7 years (average age 5.1 years, range 4.0 to 6.7 years). The average follow-up was 5.0 years and included clinical, dental, and cephalometric examinations according to a prescribed protocol. The study demonstrated that the procedure could be safely performed in the younger child with an acceptable level of morbidity. There was a remarkable degree of postoperative stability of the maxillary segment. However, although vertical (inferior) growth or movement of the midfacial segment was demonstrated, there was minimal, if any, anterior or horizontal growth. Any occlusal disharmony developing during the period of follow-up could be attributed to anticipated mandibular development and could be corrected by orthognathic surgery. The roles of surgical overcorrection and anterior-pull headgear therapy after release of intermaxillary fixation are also discussed. The Le Fort III osteotomy is justifiably indicated during early childhood for psychological and physiologic reasons.

Hypertelorism correction in the young child.

This series reports on 20 patients who underwent orbital hypertelorism correction under 5.3 years of age (average age 3.9 years). The patients were followed an average of 5 years, and six patients were followed in excess of 7 years with clinical and cephalometric parameters. The study demonstrated that the procedure could be safely performed at this age and was aesthetically desirable. There was minimal clinical or cephalometric evidence of skeletal orbital relapse except in three patients, for whom individual explanations are given. During the period of postoperative study, nasomaxillary growth and development proceeded as expected, except in those patients with associated clefting. All patients demonstrated increased cranial width measurements preoperatively and postoperatively, but bigonial and bimastoid measurements were generally within normal range. Excessive resection of nasoglabellar skin at the time of hypertelorism correction appeared to adversely affect nasal development.

The role of rigid skeletal fixation in bone-graft augmentation of the craniofacial skeleton.

The type of fixation (rigid skeletal vs. wire) was assessed against embryologic origin (membranous vs. endochondral) and recipient site (depository vs. resorptive) as variables affecting inlay and onlay bone-graft survival in 20 mature dogs. Wet weight and volume measurements were made at operation and at sacrifice (16 weeks). The results were as follows: (1) Rigid skeletal fixation increased bone-graft volume survival over wire fixation (p less than 0.05). (2) Fixation (i.e., rigid skeletal) and embryologic origin (i.e., membranous) were equal determinants of bone-graft volume survival (p less than 0.001); the recipient site was not significant for onlay bone graft survival. (3) Embryologic origin was the only significant determinant of weight survival (p less than 0.001). (4) Inlay bone grafts demonstrated greater weight and volume survival than onlay bone grafts (p less than 0.05). (5) Histologic and microradiographic studies demonstrated bony union of bone grafts fixed with rigid skeletal fixation, while fibrous union predominated in bone grafts fixed with wire technique.

Tricalcium phosphate and osteogenin: a bioactive onlay bone graft substitute.

The disadvantages of autogenous bone grafts has prompted a search for a dependable onlay bone graft substitute. A combination of tricalcium phosphate, a resorbable ceramic, and osteogenin, an osteoinductive protein, was evaluated as an onlay bone graft substitute in a rabbit calvarial model. Twenty-eight tricalcium phosphate implants (15 mm diameter x 5 mm; pore size, 100-200 microns) were divided into experimental and control groups and placed on the frontal bone of 14 adult New Zealand White rabbits. In the experimental animals, 185 micrograms of osteogenin was added to each implant. In the control animals, the implants were placed untreated. Implants were harvested at intervals of 1, 3, and 6 months, and evaluated using hematoxylin and eosin histology, microradiography, and histomorphometric scanning electron microscope backscatter image analysis. At 1 month there was minimal bone ingrowth and little tricalcium phosphate resorption in both the osteogenin-treated and control implants. At 3 months, both the osteogenin-treated and control implants showed a modest increase in bone ingrowth (8.85 percent versus 5.87 percent) and decrease in tricalcium phosphate (32.86 percent versus 37.08 percent). At 6 months, however, the osteogenin-treated implants showed a statistically significant increase in bone ingrowth (22.33 percent versus 6.96 percent; p = 0.000) and decrease in tricalcium phosphate (27.25 percent versus 37.80 percent; p = 0.004) compared with the control implants. The bone within the control implants was mostly woven at 6 months, whereas the osteogenin-treated implants contained predominantly mature lamellar bone with well-differentiated marrow. All implants maintained their original volume at each time interval studied. The tricalcium phosphate/osteogenin composite, having the advantage of maintaining its volume and being replaced by new bone as the tricalcium phosphate resorbs, may be applicable clinically as an onlay bone graft substitute.

Tissue engineered bone repair of calvarial defects using cultured periosteal cells.

Periosteum has been demonstrated to have cell populations, including chondroprogenitor and osteoprogenitor cells, that can form both cartilage and bone under appropriate conditions. In the present study, periosteum was harvested, expanded in cell culture, and used to repair critical size calvarial defects in a rabbit model. Periosteum was isolated from New Zealand White rabbits, grown in cell culture, labeled with the thymidine analog bromodeoxyuridine for later localization, and seeded into resorbable polyglycolic acid scaffold matrices. Thirty adult New Zealand White rabbits were divided into groups, and a single 15-mm diameter full-thickness calvarial defect was made in each animal. In group I, defects were repaired using resorbable polyglycolic acid implants seeded with periosteal cells. In group II, defects were repaired using untreated polyglycolic acid implants. In group III, the defects were left unrepaired. Rabbits were killed at 4 and 12 weeks postoperatively. Defect sites were then studied histologically, biochemically, and radiographically. In vitro analysis of the cultured periosteal cells indicated an osteoblastic phenotype, with production of osteocalcin upon 1,25(OH)2 vitamin D3 induction. In vivo results at 4 weeks showed islands of bone in the defects repaired with polyglycolic acid implants with periosteal cells (group I), whereas the defects repaired with untreated polyglycolic acid implants (group II) were filled with fibrous tissue. Collagen content was significantly increased in group I compared with group II (2.90 +/- 0.80 microg/mg dry weight versus 0.08 +/- 0.11 microg/mg dry weight, p < 0.006), as was the ash weight (0.58 +/- 0.11 mg/mg dry weight versus 0.35 +/- 0.06 mg/mg dry weight, p < 0.015). At 12 weeks there were large amounts of bone in group I, whereas there were scattered islands of bone in groups II and III. Radiodensitometry demonstrated significantly increased radiodensity of the defect sites in group I, compared with groups II and III (0.740 +/- 0.250 OD/mm2 versus 0.404 +/- 0.100 OD/mm2 and 0.266 +/- 0.150 OD/mm2, respectively, p < 0.05). Bromodeoxyuridine label, as detected by immunofluorescence, was identified in the newly formed bone in group I at both 4 and 12 weeks, confirming the contribution of the cultured periosteal cells to this bone formation. This study thus demonstrates a tissue-engineering approach to the repair of bone defects, which may have clinical applications in craniofacial and orthopedic surgery.

[Bilateral acute syphilitic posterior placoid chorioretinopathy--angiographic and autofluorescence characteristics]. / Bilaterale akute syphilitische posteriore plakoide Chorioretinopathie (ASPPC). Angiographie- und Autofluoreszenz-Merkmale.

UNLABELLED: Acute syphilitic posterior placoid chorioretinitis (ASPPC) has been described as a rare chorioretinal manifestation in patients with secondary syphilis. The fundus changes may simulate other chorioretinal disorders and thus delay an accurate diagnosis and initiation of appropriate pharmacological therapy. PATIENT: A 54-year-old male patient presented with severely impaired visual acuity in both eyes. Yellowish geographic lesions were noted at the posterior pole. Scanning laser ophthalmoscopy showed corresponding areas of increased fundus autofluorescence. On fluorescein angiography hypofluorescent lesions were noted in the early phase, which became hyperfluorescent in later frames. Indocyanine green agiography demonstrated hypofluorescent lesions both during the early and late frames. Serological examinations were positive for secondary lues (TPHA, FTA-IgM, cardiolipin antibody). Treatment with penicillin was introduced, resulting in complete functional and morphological recovery. CONCLUSION: Fundus and angiographic changes in ASPPC may mimic other chorioretinal diseases, including acute posterior multifocal placoid pigmentepitheliopathy (APMPPE). The angiographic findings suggest that inflammation-associated perfusion abnormalities of the choriocapillaris contribute to the pathophysiological process. Accurate diagnosis of ASPPC as a presenting sign of secondary lues is especially important for the prompt initiation of systemic antibiotic treatment.

Neuromyelitis optica (Devic's syndrome) as first manifestation of systemic lupus erythematosus.

Neurologic symptoms rarely occur as presenting feature of systemic lupus erythematosus (SLE). We describe a 37-year old woman who presented with several episodes of transverse myelitis and optic neuritis. Clinical, radiologic and laboratory findings were compatible with neuromyelitis optica (NMO). Seven years after disease onset clinical and laboratory findings were diagnostic for SLE. This case illustrates that NMO may represent a first manifestation of SLE for many years.

[Uveitis: occurrence in rheumatic diseases and immunosuppressive therapy]. / Uveitiden: Vorkommen bei rheumatischen Erkrankungen und immunsuppressive Therapie.

In 13/53 patients with uveitis an associated rheumatic condition was found. An infectious etiology could be assumed in 3/53 cases. Methotrexate was used in noninfectious uveitis in 11/53 cases, who were refractory to high doses of systemic steroids: all improved, 5 patients achieved complete remission.

Methotrexate in patients with moderate systemic lupus erythematosus (exclusion of renal and central nervous system disease).

OBJECTIVES: Methotrexate (MTX) has been used in several autoimmune diseases. Apart from its use in rheumatoid arthritis, MTX has been assessed in small studies in patients with vasculitis, uveitis, and inflammatory bowel disease. The aim of this study was to evaluate the efficacy of MTX in a particular group of patients with systemic lupus erythematosus (SLE). PATIENTS: In an open prospective study 22 patients fulfilling the ACR criteria for SLE were included. Patients had one or more of the following manifestations; active non-destructive polyarthritis, dermatitis, vasculitis of the skin, pleuritis. All patients had been treated with corticosteroids for at least six months without achieving remission. Sixteen patients were taking antimalarial drugs in addition to corticosteroids, which were stopped at the beginning of the trial. Patients with renal and central nervous involvement were excluded from the study. All patients received MTX orally at a dose of 15 mg/week over six months. Corticosteroids were continued. As additional medication only indomethacin up to 100 mg/day was permitted if used before the start of the study. The outcome was evaluated using the SLE disease activity index (SLEDAI). RESULTS: Disease activity was evaluated after six months of MTX treatment. All patients completed the study period. The SLEDAI decreased significantly from mean (SD) 12.2 (3.99) to 4 (3.75) (p = 0.001). The prednisolone dose was reduced from a mean (SD) of 17.4 (12.8) at the beginning to 8.8 (5.36) mg/day at the end point of the study (p = 0.01). MTX was well tolerated. Four patients complained of general malaise. Two patients had transient increases in liver enzymes. In no case did MTX have to be stopped. CONCLUSIONS: In an open prospective study methotrexate was used in SLE patients with particular clinical characteristics. MTX was shown to be effective in reducing disease activity and sparing the dose of corticosteroids. Further controlled studies are necessary.

Muscle flap reconstruction of pediatric poststernotomy wound infections.

Sternal wound infections following pediatric open-heart procedures occur infrequently. Four of our last 600 consecutive pediatric open-heart median sternotomies (1991 to 1996) required muscle flap reconstruction for treatment of deeply infected sternotomy wounds. Risk factors included multiple sternotomies, previous superficial infection, and immunocompromised states. Two patients were closed with bilateral pectoralis muscle flaps. The 2 other patients were closed with vertical rectus abdominis muscle flaps; 1 including an attached skin paddle. While the pectoralis major muscle flap is the first flap of choice utilized in adult patients, in pediatric patients a different hierarchy of flap selection is often necessary. The chest wall often has multiple scars from previous procedures, limiting use of the pectoralis muscle. In small infants the pectoralis muscle can be thin and inadequate for large sternal defects. All patients achieved healed wounds. Muscle flap reconstruction of pediatric sternal wounds can be an effective one-stage treatment for deep sternal wound infections with sternal instability.

CRP levels in autoimmune disease can be specified by measurement of procalcitonin.

Autoimmune diseases (AID) are prone to infection particularly under immunosuppression. The differentiation of infection from active AID is often difficult. In order to specify the diagnostic value of measurement of procalcitonin (PCT) in AID 81 patients with anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis were analyzed, 27 with rheumatoid arthritis and 25 patients with systemic lupus erythematosus at various stages of the disease. Although PCT levels (95th percentile) were below 0.5 ng/ml in patients with active systemic lupus erythematosus and rheumatoid arthritis, the cutoff for normal values (95th percentile) in patients with active ANCA-positive vasculitis was 0.89. Therefore PCT levels of < 1 ng/ml are recommended as cutoff for invasive infections in patients with ANCA-positive vasculitis. In view of the increased mortality under immunosuppression in patients with AID and additional bacterial infection the measurement of PCT is helpful when an infectious origin is suspected.

Crouzon's syndrome associated with acanthosis nigricans: ramifications for the craniofacial surgeon.

Crouzon's syndrome is one of many disorders that have been associated with acanthosis nigricans. Previously reported cases documenting this association have been reviewed, and additional cases that have been treated at the Institute of Reconstructive Plastic Surgery at New York University Medical Center have been added. Recommendations for the surgical management of this unique group of patients are presented.

Successful microvascular replantation of a completely amputated ear.

A case of successful microvascular replantation of a traumatically amputated ear is presented. The postoperative course was complicated by venous thrombosis requiring the use of medicinal leeches and systemic heparinization for salvage. This is the tenth successful microvascular ear replantation reported in the literature.

Evaluation of serum ferritin as a marker for adult Still's disease activity.

Extremely high serum ferritin values (greater than 10,000 micrograms/l) were detected in two patients with adult Still's disease. The ferritin concentrations decreased to normal after adequate treatment. During a one year follow up ferritin concentration was helpful in monitoring disease activity and guiding decisions about treatment. Raised concentrations of soluble interleukin 2 receptors (sCD25) were also found. Detection of ferritin values above 3000 micrograms/l should lead to the consideration of Still's disease when there is an acute febrile illness without evidence for bacterial or viral infections, serum ferritin being suitable for monitoring treatment.