Repair of defects and containment in revision total knee replacement: a comparative biomechanical analysis.

The treatment of bony defects of the tibia at the time of revision total knee replacement is controversial. The place of compacted morsellised bone graft is becoming established, particularly in contained defects. It has previously been shown that the initial stability of impaction-grafted trays in the contained defects is equivalent to that of an uncemented primary knee replacement. However, there is little biomechanical evidence on which to base a decision in the treatment of uncontained defects. We undertook a laboratory-based biomechanical study comparing three methods of graft containment in segmental medial tibial defects and compared them with the use of a modular metal augment to bypass the defect. Using resin models of the proximal tibia with medial defects representing either 46% or 65% of the medial cortical rim, repair of the defect was accomplished using mesh, cement or a novel bag technique, after which impaction bone grafting was used to fill the contained defects and a tibial component was cemented in place. As a control, a cemented tibial component with modular metal augments was used in identical defects. All specimens were submitted to cyclical mechanical loading, during which cyclical and permanent tray displacement were determined. The results showed satisfactory stability with all the techniques except the bone bag method. Using metal augments gave the highest initial stability, but obviously lacked any potential for bone restoration.

Thermal protective uniforms and hoods: impact of design modifications and water content on burn prevention in New York City firefighters: laboratory and field results.

OBJECTIVES: To determine (1) the effectiveness of hoods in reducing head burns, (2) the impact of clothes worn under the protective outer uniform (modern = long sleeve shirt and long pants; modified modern = short sleeve T-shirt and short pants) on burns, and (3) whether water content (dry, damp or saturated) affects the level of thermal protection. SETTING: Fire Department of the City of New York (FDNY). METHODS: Laboratory tests (fully dressed manikin) evaluated the different uniform and water conditions when exposed to an average 24 cal/cm2 heat flux, approximately 2,250 degrees F air temperature. FDNY field results compared (1) head burns during winters wearing the hood to winters without hood and (2) upper and lower extremity burns during summers wearing traditional, modern, and modified modern uniforms. RESULTS: Laboratory tests showed that thermal protection was: (1) dramatically improved by the hood with protection increasing as water content increased and (2) not significantly different between modern and modified modern uniforms, regardless of water content. FDNY field results confirmed these tests showing (1) significant decreases in neck burns (by 54%), ear burns (by 60%), and head burn totals (by 46%) wearing the hood and (2) no significant differences in upper or lower extremity burns wearing modern compared with modified modern uniforms. CONCLUSIONS: Based on combined laboratory and field results, we strongly recommend the use of modern thermal protective hoods and the modified modern uniform.

The impact of protective hoods and their water content on the prevention of head burns in New York City firefighters: laboratory tests and field results.

The New York City Fire Department (FDNY) is the largest fire department in the United States. In 1996, FDNY added the thermal protective hood to its modern protective uniform. The purpose of this study is to determine 1) the effectiveness of hoods in reducing head burns and 2) whether hood water content (dry, damp, or saturated) affects the level of thermal protection. Laboratory tests (radiant heat performance, thermal protective performance, and fully dressed manikin) and FDNY field results were used. Laboratory tests evaluated 4 different conditions (no hood, dry, damp, and saturated hoods) exposed to 4 different heat fluxes (0.1, 0.25, 0.5, and 2.0 cal/cm2/sec) equivalent to approximate air temperatures of 200, 400, 600, and 2,250 degrees F. Field results compared FDNY head burns during 3 winters wearing the hood to 3 winters without hood. Wearing a hood dramatically reduced head burns. This was true for all laboratory tests, at all heat flux exposures, and all hood water content conditions. At 0.1 cal/cm2/sec, dry hoods were superior to wet hoods. At all other heat flux exposures, thermal protection was either not significantly different between water content conditions or improved as water content increased. Confirming these laboratory tests, FDNY field results showed significant decreases in neck burns (by 54%), ear burns (by 60%), and head burn totals (by 46%). Based on combined laboratory and field results, we strongly recommend the use of modern thermal protective hoods.

Acute bilineage leukemia after chronic myelogenous leukemia.

Blastic transformation of chronic myelogenous leukemia may involve any hematopoietic lineage, including that of lymphocytes. In a minority of cases, the blasts express characteristics of both myeloid and lymphoid cells (biphenotypic) or comprise two separate populations of myeloid and lymphoid cells (bilineage leukemia). In a coordinated effort, we used a sequence of morphologic, cytochemical, immunocytochemical, and molecular biological studies to identify a case of bilineage blastic transformation of CML with a predominance of lymphoid blasts. The patient was treated for ALL and responded. The case presented illustrates the need for greater flexibility by the physician and laboratory to determine the specific diagnostic requirements for patients with hematologic malignancy with unusual phenotypic characteristics.

HLA-DR53 protects against thrombotic thrombocytopenic purpura/adult hemolytic uremic syndrome.

Class I and Class II HLA antigens were tested in patients treated for thrombotic thrombocytopenic purpura or hemolytic uremic syndrome (TTP/HUS) to determine whether there is a disease association. Based on the results of a pilot trial, retrospective HLA-typing of 18 patients with a diagnosis of TTP/HUS and prospective typing of 12 newly diagnosed patients with TTP/HUS were performed. Twenty-one patients were non-Hispanic Caucasians, 7 were African-Americans, and 2 were Hispanic-Caucasians. Of 30 patients tested, 28 were positive for DR52 (chi-squared = 5.14, P < 0.05), and only two were positive for DR53 compared to 57% of controls (chi-squared = 18.5, P < 0.0005). Diverse DR52 subtypes (DRB3*0101, DRB3*02, and DRB3*0301) were found by oligonucleotide testing in 15 patients, suggesting the association was not with DR52 but with absence of the DR53 antigen. The 2 patients with DR53 were not homozygous. This study suggests that the supertypic antigen, DR53, may govern susceptibility to TTP/HUS, since the relative risk of this disease among DR53 positives is reduced at 0.09 (95% confidence interval, 0.01-0.28). This finding indicates a possible immunogenetic component in the pathogenesis of TTP.

Posttransplantation plasma cell dyscrasias.

BACKGROUND: Lymphoproliferative disorders that occur in patients receiving cyclosporine for immunosuppression after solid organ transplantation typically are B-cell neoplasms associated with Epstein-Barr virus (EBV), which may be polyclonal or monoclonal in origin. Although these tumors may have partial B-cell differentiation, (manifested as plasmacytoid features), terminal differentiation to plasma cells that secrete a monoclonal immunoglobulin is rare. The case of a patient who developed a posttransplantation lymphoproliferative disorder that was composed of multiple plasmacytomas located in the abdomen and urinary bladder after liver transplantation is presented. The patient also had high levels of an immunoglobulin-G kappa monoclonal paraprotein. METHODS: The plasmacytoma was examined for the presence of EBV by both polymerase chain reaction and in situ hybridization, and the possibility of a codon-12 mutation in the ras gene was investigated by digestion of DNA amplification products with the HpaII-restriction endonuclease. RESULTS: Epstein-Barr virus genomes were demonstrated by DNA amplification of sequences in the long, internal, direct repeat region, and in situ hybridization showed expression of EBV RNA transcripts that annealed to an EBER-1 probe. Immunohistochemistry showed clonally restricted expression of kappa light chains but failed to reveal evidence of expression of the latent membrane protein 1 encoded by EBV. Mutations of codon-12 in the H-ras gene were not detected. CONCLUSIONS: Resolution of the tumor and the paraprotein after radiation and reduction of immunosuppression indicates that terminal plasmacytic differentiation does not necessarily portend an unfavorable prognosis, even in a clonal lesion.

Cytometric detection of DNA amplified with fluorescent primers: applications to analysis of clonal bcl-2 and IgH gene rearrangements in malignant lymphomas.

Follicular lymphomas comprise almost two thirds of the US adult non-Hodgkin's lymphomas (NHL) and are the most common malignancy of B-lineage lymphocytes. Polymerase chain reaction (PCR) protocols have been developed to detect the t(14;18) translocation, which juxtaposes the bcl-2 proto-oncogene to the Ig heavy-chain (IgH) gene in 85% of follicular lymphomas and monoclonal rearrangements of the IgH gene in B-cell NHL that lack bcl-2 rearrangements. We used PCR to amplify bcl-2 and IgH rearrangements in DNA from patients with lymphoproliferative disorders and analyzed the products in parallel by gel electrophoresis and flow cytometry, which detected PCR products incorporating fluoresceinated oligonucleotide primers by sequence-specific capture to oligonucleotide-coated magnetic beads. Overall, flow cytometry was superior to electrophoresis of ethidium-bromide-stained agarose gels for detection of products of nested PCR to detect intergenic rearrangements involving bcl-2 and single primer-pair amplification of clonal rearrangement of IgH. Flow cytometric analysis detected bcl-2 translocations in 12 of 13 CD10+ B-cell lymphomas and clonal IgH rearrangements in 14 of 17 monoclonal B-cell populations. In contrast, analysis by gel electrophoresis detected bcl-2 translocations in only 10 of 13 CD10+ and clonal IgH gene rearrangements in only 9 of 17 monoclonal B-cell populations. Flow cytometric analysis was more sensitive than gel electrophoresis and could detect a 16-fold greater dilution of a bcl-2-amplified product than gel electrophoresis. Similarly, flow cytometry could detect an amplification product when template DNA was diluted 10,000-fold, whereas gel electrophoresis only detected amplification products when template was subjected to dilution between 100- and 1,000-fold. This shows the utility of flow cytometry for the analysis of DNA amplification products incorporating fluorochrome-labeled primers as a rapid, objective alternative to conventional strategies. Because current-generation clinical laboratories emphasize automation, flow cytometric analysis of PCR-amplified products shows increased analytic sensitivity and offers a vehicle for automation of DNA amplification tests.

Age-related changes in rat adipose tissue cellularity are altered by dietary restriction and exercise.

This study examined the effects of diet restriction and exercise training during aging on adipocyte size and number in male Wistar rats. An average of 30 weanling rats each were assigned to one of four experimental groups: ad libitum access to food, nonexercised; diet restricted, nonexercised; ad libitum access to food, exercised; diet restricted, exercised. Diet-restricted groups were allowed free access to food every other day, and, over the course of the study, they consumed 18-25% less than the groups allowed ad libitum access. Exercise training consisted of swimming on alternate days for up to 3 h per exercise period. Fat cell size, number and fat depot mass were determined in the inguinal, epididymal and perirenal fat depots at 12 mo of age and every 4 mo thereafter until 28 mo of age. Fat cell number was not influenced by age, exercise or food restriction in the epididymal or perirenal fat depots. Inguinal cell number was lower (P < 0.05) in the diet-restricted, exercised group at all ages compared with all other treatments. Dietary restriction and exercise training significantly decreased fat depot mass and fat cell size, with dietary restriction having the greatest effect. A bimodal distribution of adipocytes was observed in the epididymal, perirenal and inguinal depots of animals allowed ad libitum access to food. The presence of a large population of small fat cells (< 35 microns) indicated that even in the very aged animal there was the propensity for large variations in fat pad mass. The influence of diet restriction, exercise and aging on adipocyte cell size was highly variable and these effects were dependent on adipose tissue depot location.

Total parenteral nutrition with short- and long-chain triglycerides: triacetin improves nitrogen balance in rats.

Little is known about the long-term metabolic effects of parenteral administration of short-chain triglycerides. These studies were undertaken to investigate triacetin, the water-soluble triglyceride of acetate when it is incorporated into nutritionally balanced total parenteral nutrition formulas. Male Sprague-Dawley rats (n = 22) were fed an isovolemic, isocaloric and isonitrogenous diet for 7 d. The lipid energy represented 30% of the nonprotein energy with short-chain triglycerides representing 0, 50 or 90% of the lipid energy. Plasma acetate concentration was determined as well as indicators of protein metabolism: daily and cumulative nitrogen balance, whole body leucine kinetics and rectus muscle and liver fractional protein synthetic rates. No overt toxic effects were observed at any point during the study. As the proportion of short-chain triglycerides in the diet increased from 0 to 50 or 90% of the lipid energy, cumulative nitrogen balance increased 50 or 120%, respectively (P less than 0.05). Whole-body and tissue leucine kinetics (determined during the last 2.5 h of the 7-d study) were unaffected by the lipid composition of the diet. Plasma acetate concentration was not significantly different among groups. These results indicate that incorporation of the short-chain triglyceride, triacetin, in nutritionally balanced total parenteral nutrition formulas improves nitrogen balance with no overt toxic effects. These data indicate that triacetin may have a future role as a parenteral nutrient, and that further studies of its use are warranted.

Acidic polyamino acids inhibit human eosinophil granule major basic protein toxicity. Evidence of a functional role for ProMBP.

Eosinophil granule major basic protein (MBP), a potent toxin for helminths and mammalian cells in vitro, is a single polypeptide chain rich in arginine. MBP has been localized on damaged helminths and tissues in hypersensitivity diseases including bronchial asthma. The MBP cDNA indicates that MBP is translated as a slightly acidic preproprotein with an acidic propart. To test the hypothesis that the acidic pro-part of proMBP inhibits the toxicity of mature MBP, acidic polyamino acids (aa) were used as antagonists of MBP toxicity to K562 cells and guinea pig tracheal epithelium and used as antagonists of MBP airway hyperresponsiveness in primates. The acidic poly aa inhibited MBP toxicity and MBP airway hyperresposiveness. The acidic poly aa inhibited MBP toxicity in a charge-dependent manner similar to that proposed for proMBP, suggesting that the acidic pro-part of proMBP functions to mask mature MBP toxicity. This inhibition was not limited to MBP, but also applied to polyarginine and eosinophil cationic protein. These acidic poly aa may be useful to inhibit the actions of a number of cationic toxins released by the eosinophil in numerous hypersensitivity diseases.

The molecular biology of eosinophil granule proteins.

Here, we briefly review the molecular biology of the human eosinophil granule proteins, major basic protein (MBP), eosinophil peroxidase (EPO), eosinophil cationic protein (ECP) and eosinophil-derived neurotoxin (EDN). The nucleotide sequence of MBP cDNA indicates that MBP is translated as a 25.2-kilodalton preproprotein; the mpb gene consists of 6 exons and 5 introns spanning 3.3 kilobases (kb). The approximately 2.1-kb nucleotide sequence of EPO cDNA corresponds to a prosequence, light chain and heavy chain in that order; similarities to other peroxidases suggest the existence of a multigene family. EDN and ECP cDNAs and genes are remarkably similar throughout, suggesting a relatively recent divergence. Promoter regions of the 4 genes show interesting differences and similarities which may be related to differential gene regulation.

Structure and chromosome localization of the human eosinophil-derived neurotoxin and eosinophil cationic protein genes: evidence for intronless coding sequences in the ribonuclease gene superfamily.

Human genomic DNAs for the eosinophil granule proteins, eosinophil-derived neurotoxin (EDN) and eosinophil cationic protein (ECP), were isolated from genomic libraries. Alignment of EDN (RNS2) and ECP (RNS3) gene sequences demonstrated remarkable nucleotide similarities in noncoding sequences, introns, and flanking regions, as well as in the previously known coding regions. Detailed examination of the 5'-noncoding regions yielded putative TATA and CAAT boxes, as well as similarities to promoter motifs from unrelated genes. A single intron of 230 bases was found in the 5' untranslated region and we suggest that a single intron in this region and an intronless coding region are features common to many members of the RNase gene superfamily. The RNS2 and RNS3 genes were localized to the q24-q31 region of human chromosome 14. It is likely that these two genes arose as a consequence of a gene duplication event that took place approximately 25-40 million years ago and that a subset of anthropoid primates possess both of these genes or closely related genes.

In vitro killing of microfilariae of Brugia pahangi and Brugia malayi by eosinophil granule proteins.

Eosinophil infiltration and degranulation around the tissue-invasive stages of several species of helminths have been observed. Release of eosinophil granule contents upon the worms is supported by localization of two of the major granule proteins, major basic protein (MBP) and eosinophil peroxidase (EPO), on and around species of trematodes, nematodes, and cestodes. In the case of filarial worms, MBP is deposited on degenerating microfilariae (mf) of Onchocerca volvulus. Here, we performed in vitro assays of the toxicity of four purified eosinophil granule proteins, namely, MBP, EPO, eosinophil cationic protein (ECP), and eosinophil-derived neurotoxin (EDN), for the mf of Brugia pahangi and Brugia malayi. MBP, ECP, and EDN killed these worms in a dose-related manner although relatively high concentrations of EDN were necessary. EPO, in the presence of a H2O2-generating system and a halide, was the most potent toxin on a molar basis; here, the most potent halide was I- followed by Br- and Cl-. Surprisingly, EPO in the absence of H2O2 killed mf at concentrations comparable to those required for MBP and ECP. The toxicity of EPO + H2O2 + halide was inhibited by heparin, catalase, or 1% BSA, whereas the toxicity of EPO alone was inhibited only by heparin. Heparin also inhibited killing by both MBP and ECP. Despite the homology of ECP with certain RNases, placental RNasin, an RNase inhibitor, was unable to inhibit ECP-mediated toxicity. These results indicate that all of the eosinophil granule proteins are toxic to mf and they support the hypothesis that eosinophil degranulation causes death of mf in vivo.

Cloning and sequence analysis of the human gene encoding eosinophil major basic protein.

Eosinophil granule major basic protein (MBP), a potent toxin for helminths and mammalian cells, is a single polypeptide rich in arginine. The gene, mbp, was cloned and its nucleotide sequence determined. The 3.3-kb gene consists of six exons and five introns, one of which contains an Alu family repeat. The combined exon sequence is similar to previously reported mbp cDNA sequences. The gene is immediately preceded by a putative promoter containing typical TATA and CCAAT boxes. Southern blots indicate that mbp exhibits limited polymorphism.

Sequence of human eosinophil-derived neurotoxin cDNA: identity of deduced amino acid sequence with human nonsecretory ribonucleases.

Several clones of human eosinophil-derived neurotoxin (EDN) cDNA have been isolated from a lambda gt10 cDNA library prepared from mRNA derived from noninduced HL-60 cells. The amino acid (aa) sequence deduced from the coding sequence of the EDN cDNA is identical to the aa sequence of urinary nonsecretory RNase. Comparison of the aa and/or nucleotide (nt) sequences of EDN and other proteins possessing ribonucleolytic activity, namely bovine seminal RNase, human and rat pancreatic RNases, eosinophil cationic protein (ECP), and human angiogenin, shows extensive identity at half-cystine residues and at aa of active sites. Differences in aa sequences at the active sites are often the result of single nt changes in the codons. The data presented here support the concept of a RNase gene superfamily containing secretory and nonsecretory RNases, angiogenin, EDN and ECP.

Eosinophil cationic protein cDNA. Comparison with other toxic cationic proteins and ribonucleases.

Human eosinophil granules contain several basic proteins including eosinophil cationic protein (ECP), eosinophil-derived neurotoxin (EDN) and major basic protein (MBP). ECP and MBP are potent helminthotoxins while EDN is less so. Both ECP and EDN possess neurotoxic and ribonuclease activities. A clone representing ECP mRNA was isolated from an eosinophil lambda ZAP cDNA library. The cDNA sequence codes for a preprotein of 160 amino acids and a protein of 133 amino acids, the amino terminus of which is identical to the known partial amino acid sequence of ECP. The ECP nucleotide sequence shows similarity to EDN, rat pancreatic ribonuclease, and human angiogenin; all are members of the ribonuclease gene superfamily. Although the deduced amino acid sequence of ECP shares identical active site and substrate binding site residues with EDN, angiogenin, and human pancreatic ribonuclease, the ribonuclease activity of ECP is 50 to 100 times less than that of EDN possibly because of the lack of a positively charged residue at human pancreatic ribonuclease position 122. The calculated isoelectric point (10.8), electronic charge (14.5), and cationic charge distribution of ECP are different from those of EDN but similar to those of MBP, which may account in part for the greater helminthotoxic activity of ECP when compared to EDN. These data suggest that ECP and EDN are derived from a common ancestral ribonuclease gene and that ECP has evolved into a potent helminthotoxin similar in some respects to MBP, while losing much of its ribonuclease activity.

Modification of the oxygen affinity and intracellular hemoglobin concentration of normal and sickle cells by means of an osmotic pulse.

Important properties of red blood cells (RBCs), including oxygen affinity and intracellular hemoglobin concentration, may be modified by means of an osmotic pulse. The pulse is developed by rapid dilution of a suspension of RBCs to which dimethylsulfoxide has been added. The nature and degree of RBC modification is dependent on the composition of the diluent solution. The purpose of this investigation was to explore the dependence of these changes on diluent composition and to determine the stability of altered cellular properties with in vitro incubation. For both normal control RBCs (A cells) and RBCs from patients with sickle cell anemia (S cells), cells with increased volume and markedly decreased intracellular hemoglobin concentration (65% to 70% of control) or with normal volume and moderately decreased hemoglobin concentration (80% to 85% of control) were prepared. These modifications were accomplished with hemoglobin yields ranging from 60% to 90%, depending on the diluent used, the cell type, and the intensity of treatment. For the same degree of inositol hexaphosphate (IHP) incorporation into A cells, as shown by the shift in oxygen half-saturation pressure (P50), diluent formulations with constant total osmolality but varying IHP concentration gave the same degree of hemoglobin loss per cell. Posttreatment cell size, however, ranged from slightly smaller than control to approximately 20% larger. On incubation, the larger cells returned toward normal size, whereas those with normal posttreatment size remained constant. S cells showed the same general changes with treatment and incubation but with greater variation. The treated S cells exhibited markedly reduced morphologic sickling on deoxygenation.

Acidic precursor revealed in human eosinophil granule major basic protein cDNA.

Eosinophil granule major basic protein (MBP), a potent toxin for helminths and various cell types, is a 13.8-kD single polypeptide rich in arginine with a calculated isoelectric point (pI) of 10.9. A cDNA for human MBP was isolated from a gamma GT10 HL-60 cDNA library. The nucleotide sequence of the MBP cDNA indicates that MBP is translated as a 25.2-kD preproprotein. The 9.9-kD pro-portion of proMBP is rich in glutamic and aspartic acids and has a calculated pI of 3.9, while proMBP itself has a calculated pI of 6.2. We suggest that MBP is translated as a nontoxic precursor that protects the eosinophil from damage while the protein is processed through the endoplasmic reticulum to its sequestered site in the granule core toxic MBP, and we present results from the literature suggesting that other cationic toxins, which damage cell membranes, may also be processed from nontoxic precursors containing distinct anionic and cationic regions.

Comparative toxicity of purified human eosinophil granule proteins for newborn larvae of Trichinella spiralis.

Eosinophils have been implicated in both in vivo and in vitro destruction of helminths. One approach toward elucidating the role of the eosinophil in parasite killing has been to test the toxicity of purified eosinophil granule proteins for parasites in vitro. Previously, major basic protein (MBP) and eosinophil cationic protein (ECP) were shown to be toxic for schistosomules of Schistosoma mansoni, while eosinophil-derived neurotoxin (EDN) was only marginally so. We tested the toxicity of MBP, ECP, and EDN over a range of concentrations (0.006-5 X 10(-4) M) for newborn larvae of Trichinella spiralis. Our observations confirm previous reports of toxicity of mildly reduced and alkylated (R & A) MBP. At concentrations of 5 X 10(-5) M and above, R & A MBP killed 75% or more of the larvae within the first hour of culture. ECP was an effective toxin for these larvae after 3 hr of culture, and by 12 hr, dose-related toxicity was evident. After 24 hr, 100% of the larvae were killed at 5 X 10(-5) M ECP. EDN was much less toxic; after 12 hr, 90% of the larvae survived at concentrations of 1 X 10(4) M, while 5 X 10(-4) M EDN killed all the larvae. At the optimal toxic concentrations of 5 X 10(-5) M ECP and 5 X 10(-4) M EDN, kinetics of killing by these 2 proteins were essentially the same. Thus, on a molecular basis, both MBP and ECP appear to be potent helminthotoxins whereas EDN is much less so.