Up-regulation of the phosphoinositide 3-kinase pathway in human lamina propria T lymphocytes.

Human intestinal lamina propria T lymphocytes (LPT), when investigated ex vivo, exhibit functional properties profoundly different from those of peripheral blood T lymphocytes (PBT). One prominent feature represents their enhanced sensitivity to CD2 stimulation when compared to PBT. Given that LPT are hyporesponsive to T cell receptor (TCR)/CD3 stimulation, an alternative activation mode, as mimicked by CD2 triggering in vitro, may be functional in mucosal inflammation in vivo. This study provides insight into signalling events associated with the high CD2 responsiveness of LPT. When compared to PBT, LPT show an increased activation of the phosphoinositide 3/protein kinase B/glycogen synthase kinase 3beta (PI3-kinase/AKT/GSK-3beta) pathway in response to CD2 stimulation. Evidence is provided that up-regulation of this pathway contributes to the enhanced CD2-induced cytokine production in LPT. Given the importance of TCR-independent stimulation for the initiation of intestinal immune responses analysis of signalling pathways induced by 'co-stimulatory' receptors may provide valuable information for therapeutic drug design.

Excimer laser assisted angioplasty for the treatment of critical limb ischemia.

Two decades after the clinical introduction of percutaneous transluminal angioplasty (PTA), controversy still exists about the role of PTA for the treatment of occlusive disease in the femoropopliteal and infragenicular arteries. For the patient with critical limb ischemia (CLI), where diffuse disease and long occlusions are the rule, the results with PTA have not been optimal. Surgical revascularization has long been considered the gold standard for this patient population, but this procedure is associated with significant morbidity and mortality and up to 37% of patients may be poor surgical candidates. With advances in laser catheter design and refinement of recanalization techniques, improved results have been seen with laser assisted angioplasty of complex peripheral arterial disease. There has been renewed interest in excimer laser angioplasty for the treatment of patients with long total occlusions and diffuse disease who otherwise would have limited options for treatment. Excimer laser assisted angioplasty has been shown to be a successful approach to the treatment of long occlusions in the superficial femoral artery. Data from the recently completed Laser Angioplasty for Critical Limb Ischemia Phase 2 Trial (LACI) suggest that this is a viable treatment strategy for patients with CLI who are otherwise not good candidates for bypass surgery.

"Optimally spaced" excimer laser coronary catheters: performance analysis.

BACKGROUND: Excimer laser angioplasty is a percutaneous treatment modality for management of selected patients with severe obstructive coronary artery disease. This technology entails application of multifiber catheters that vaporize intra-arterial plaque and thrombus with the 308-nm wavelength light. A coronary laser catheter ("OS") with increased space between its optic fibers (90 microns) at the tip was recently developed. The previous design used a closely packed fiber bundle ("CP") with a smaller space between the fibers (77 microns). We sought to determine the ablation characteristics of the new, OS design. METHODS: Experiments testing the new catheter and comparing it to the existing catheter included: (1) measurement of the laser output beam sizes and divergences; (2) evaluation of particulate matter generation during ablation of atherosclerotic tissue; (3) measurement of ablation hole sizes and tissue penetration rates; (4) histopathologic examination of laser-induced in vivo vessel wall injury. RESULTS: The new OS catheters produce a wider beam with higher divergence than the traditional CP catheters (6.7 degrees vs. 4.7 degrees, respectively). Testing two different levels of energy revealed the generation of a reduced number of particulate matter and shallower penetration depth with the OS catheter compared with traditional CP catheters. The OS catheters created a larger diameter of ablated hole than the CP catheters (for 2.0-mm catheters: 2.7 mm2 vs. 1.5 mm2, respectively, p = 0.01). Lasing with the OS catheters with slow advancement rates (0.2-0.5 mm/sec) resulted in creation of significantly larger-diameter holes than those produced at higher speeds (1-3 mm/sec). The in vivo vessel wall injury scores were similar among the two types of catheters tested. CONCLUSIONS: A new design of spaced optical fibers for coronary laser catheters provides increased tissue ablation in comparison to the traditional closely packed fibers catheter. Slow advancement rates during lasing with the new OS catheter are crucial for achievement of adequate plaque debulking.

Next generation catheters for excimer laser coronary angioplasty.

In response to the need for maximising debulking in complex lesions, three new excimer laser coronary angioplasty catheter designs have been introduced. The eccentric laser catheter features a fibreoptic bundle disposed opposite the guide-wire lumen at the catheter tip and a torque mechanism that allows the user to rotate the fibre bundle toward the lesion mass. Residual lumens 50% larger than the catheter tip diameter have been obtained when multiple passes were made, with each pass performed using a different tip rotation. A recent case series utilising this catheter in restenosed stents resulted in larger lumens and lower 6-month restenosis rates. The optimal spaced (OS) laser catheter features a fibre bundle placed concentrically around the guide-wire lumen. The 61 microm diameter core fibres are spaced at a nominal centre-to-centre distance of 90 microm, resulting in a 40% increase in ablative area as compared to previous concentric catheter designs. In vitro testing and clinical evaluation demonstrated OS catheters routinely achieve an ablated area > or =90% of the catheter tip size. The 0.9 mm catheter features a high-density fibre pack composed of 65 fibres. Peripheral dead space has been minimised to maximise penetration of calcified plaque. When combined with laser parameters of up to 80 mJ/mm2, and 80 Hz pulse repetition rate, the catheter demonstrated improved hard tissue and calcified tissue penetration in vitro. Clinical evaluation in Canada revealed a 94% lesion recanalisation rate in high-grade stenoses with angiographic evidence of calcification, chronic total occlusions, and lesions which have failed balloon angioplasty.

Bacterial carriers and virus-like-particles as antigen delivery devices: role of dendritic cells in antigen presentation.

Replicating attenuated strains of intracellular bacteria like Salmonella typhimurium, Listeria monocytogenes or Mycobacterium bovis Bacille Calmette Guérin (BCG), and non-replicating virus-like-particles (VLP) consisting, for instance, of the VP1-surface component of polyoma virus offer great potential as heterologous carriers delivering foreign protein antigens for immune recognition. Moreover, attenuated S. typhimurium and L. monocytogenes strains hold also great promise as delivery vehicles for DNA vaccines. Polyoma virus-specific VLP consisting of VP1-pentamers are also of interest as carrier devices for eukaryotic expression plasmids. At first sight these different replicating and non-replicating types of vehicles have little in common, but from an immunological point of view viable bacteria and non-viable VLP are both well suited for evoking protective immune responses via several routes of vaccine administration. As these antigen carriers generate humoral and cell-mediated immunity, the heterologous antigens are not only targeted to appropriate pathways of major histocompatibility (MHC) class I and class II antigen processing and presentation, but also generate an adequate cytokine milieu for promoting antigen-specific responses. The most prominent advantage of these carrier devices is presented by their capacity to directly target antigenic proteins or DNA vaccines to immature dendritic cells (DC) along their maturation pathway. Mature DC are the key antigen presenting cell population which efficiently mediates antigen transport to organised lymphoid tissues for the initiation of T cell responses. In general, uptake of these diverse antigen delivery systems by antigen presenting cells (APC) finally lead to efficacious immune responses in the control of pathogenic microorganisms and tumours.

Effects of 308 nanometer excimer laser energy on 316 L stainless-steel stents: implications for laser atherectomy of in-stent restenosis.

PURPOSE: To determine the effects of the incidental exposure of stents to pulsed 308 nanometer ultraviolet excimer laser energy. METHODS: Five types of 316 L stainless-steel coronary stents were subjected to two types of study. First, for endurance testing, sixty stents were deployed in 3.0Eth 4.0 mm polymer tubes in three geometries. Up to 1,000 laser pulses were delivered while advancing a 2.0 mm eccentric catheter through the lumen of the stent. These stents were next subjected to 400 million simulated heartbeats and then analyzed for metal etching and fatigue. Second, six additional stents were irradiated with 1,000 pulses underwater and then analyzed for particulates, anions and cations liberated from the stent. RESULTS: Photomicroscopy revealed surface etching on a number of stents. Two stent models exhibited multiple strut fractures at the strut joints in both test samples and controls. In no case was a break observed at the site of laser-stent interaction. Breakage frequency was not significantly different between lazed stents and controls. Lazed stents produced a mean of 14 micrograms of sodium and 4 micrograms of iron more than controls. No excess particulates were detected. CONCLUSION: Under model conditions typical of clinical use, excimer laser treatment does not alter stainless-steel stent endurance or liberate clinically significant material from the stent.

Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty.

The procedure of lead removal has recently matured into a definable, teachable art with its own specific tools and techniques. It is now time to recognize and formalize the practice of lead removal according to the current methods of medicine and the health care industry. In addition, since at this time the only prospective scientific study of lead extraction is the PLEXES trial, we suggest that studies relating to the techniques of and indications for lead extraction be designed. Recommendations for a common set of definitions, for a framework of training and reviewing physicians in the art, for general methods of reimbursement, and for consistency among clinical trials have been made. Implementation of these recommendations will require additional effort and cooperation from practicing physicians, medical societies, hospital administrations, and industry.

The platelet-derived-growth-factor receptor, not the epidermal-growth-factor receptor, is used by lysophosphatidic acid to activate p42/44 mitogen-activated protein kinase and to induce prostaglandin G/H synthase-2 in mesangial cells.

In renal mesangial cells, activation of protein tyrosine kinase receptors may increase the activity of mitogen-activated protein (MAP) kinases and subsequently induce expression of prostaglandin G/H synthase-2 (PGHS-2, cyclo-oxygenase-2). As examples, platelet-derived growth factor (PDGF) and epidermal growth factor (EGF) were shown to transiently enhance p42/44 MAP kinase activity, which was an essential step in the induction of PGHS-2 mRNA and protein. Inhibitors of receptor kinase activities, tyrphostins AG1296 and AG1478, specifically inhibited the effects of PDGF and EGF respectively. Activation of p42/44 and p38 MAP kinases and PGHS-2 induction were also mediated by lysophosphatidic acid (LPA), which binds to pertussis-toxin-sensitive G-protein-coupled receptors. LPA stimulation was inhibited by AG1296, but not AG1478, indicating involvement of the PDGF receptor kinase in LPA-mediated signalling. This was confirmed by pertussis-toxin-sensitive tyrosine phosphorylation of the PDGF receptor by LPA, whereas no phosphorylation of the EGF receptor was detected. For comparison, 5-hydroxytryptamine ('serotonin')-mediated signalling was only partially inhibited by AG1296, and also not affected by AG1478. A strong basal AG1296-sensitive tyrosine phosphorylation of the PDGF receptor and a set of other proteins was observed, which by itself was not sufficient to induce p42/44 MAP kinase activation, but played an essential role not only in LPA- but also in phorbol ester-mediated activation. Taken together, the PDGF receptor, but not the EGF receptor, is involved in LPA-mediated MAP kinase activation and PGHS-2 induction in primary mesangial cells, where both protein kinase receptors are present and functionally active.

Cardiac lead extraction with a novel locking stylet.

Extraction of chronically implanted pacing and defibrillator leads is facilitated by using specialized locking stylets placed in the lead to allow application of traction and to stabilize the lead during sheath dissection of fibrotic tissue. We report the initial multicenter series of cases using a novel lead locking device (LLD). In 57 consecutive patients presenting at 6 institutions for lead extraction, 99 leads were treated using the LLD. After removing the pulse generator, leads were severed, the inner coil dilated and an LLD was successfully inserted and locked in the inner lumen of 95/99 (96 %) leads. With traction applied to the LLD, a variety of sheaths were advanced over the lead body to separate it from adhesions. In 97/99 (98 %) leads, all or most of the lead was removed via the implant vein; 2 leads were removed via the femoral vein. No major complications were observed. The LLD deploys safely and reliably, and provides stable support for advancement of dissecting sheaths.

Initial experience with larger laser sheaths for the removal of transvenous pacemaker and implantable defibrillator leads.

BACKGROUND: In a previous randomized trial, the 12F laser sheath removed pacing leads via the implant vein more successfully than traditional mechanical tools alone. Two larger sizes of laser sheath, the 14F and 16F models, were developed to extract defibrillator leads and large-diameter pacing leads implanted for the chronic. These devices use pulsed ultraviolet laser light to core though fibrotic tissue grown over the lead body to free the lead from the vasculature. A mandatory prospective registry studied the safety and effectiveness profiles of the larger laser sheaths vis-à-vis the 12F laser sheath. METHODS AND RESULTS: In this study, 863 patients underwent extraction of 1285 leads at 52 sites. Patients treated with the 14F device tended to have older leads than the 12F population; the 16F population, which comprised mostly defibrillator patients, were younger, had younger leads, and were more often male than the 12F population. Clinical success (extracting the entire lead or the lead body minus the distal electrode) was observed in 91% to 92% of cases for all device sizes. The overall complication rate was 3.6%, with 0.8% perioperative mortality. Incidence of complications was independent of laser sheath size. CONCLUSIONS: The 14F and 16F laser sheaths offer an extraction option for larger long-term transvenous pacemaker and defibrillator leads that is as safe and effective as the 12F laser sheath.

Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trial.

OBJECTIVES: The purpose of this study was to evaluate the safety and effectiveness of pacemaker lead extraction with the excimer sheath in comparison to nonlaser lead extraction. BACKGROUND: Fibrotic attachments that develop between chronically implanted pacemaker leads and to the venous, valvular and cardiac structures are the major obstacles to safe and consistent lead extraction. Locking stylets and telescoping sheaths produce a technically demanding but effective technique of mechanically disrupting the fibrosis. However, ultraviolet excimer laser light dissolves instead of tearing the tissue attachments. METHODS: A randomized trial of lead extraction was conducted in 301 patients with 465 chronically implanted pacemaker leads. The laser group patients had the leads removed with identical tools as the nonlaser group with the exception that the inner telescoping sheath was replaced with the 12-F excimer laser sheath. Success for both groups was defined as complete lead removal with the randomized therapy without complications. RESULTS: Complete lead removal rate was 94% in the laser group and 64% in the nonlaser group (p = 0.001). Failed nonlaser extraction was completed with the laser tools 88% of the time. The mean time to achieve a successful lead extraction was significantly reduced for patients randomized to the laser tools, 10.1 +/- 11.5 min compared with 12.9 +/- 19.2 min for patients randomized to nonlaser techniques (p < 0.04). Potentially life-threatening complications occurred in none of the nonlaser and three of the laser patients, including one death (p = NS). CONCLUSIONS: Laser-assisted pacemaker lead extraction has significant clinical advantages over extraction without laser tools and is associated with significant risks.

Independent regulation of cyclo-oxygenase 2 expression by p42/44 mitogen-activated protein kinases and Ca2+/calmodulin-dependent kinase.

5-Hydroxytryptamine (5-HT, 'serotonin') is a potent inducer of the early response gene cyclo-oxygenase 2 (Cox-2; prostaglandin G/H synthase) in mesangial cells. Protein kinase C (PKC), Ca2+-dependent enzymes and mitogen-activated protein kinase (p42/44 MAPK) have previously been shown to be essential modules of the signalling pathway leading from the pertussis-insensitive 5-HT2A receptor to the induction of Cox-2 mRNA expression. In the present study, PKC activation was linked to the 5-HT-mediated phosphorylation and thus the activation of p42/44 MAPK: the inhibition of PKC by the specific inhibitor GF109203x prevented p42/44 MAPK activation. Ca2+/calmodulin-dependent (CaM) kinase II delta2 was detected in mesangial cells by Western blot analysis. The inhibition of CaM kinase by the inhibitors KN62 or KN93 led to a partial inhibition of 5-HT-induced Cox-2 mRNA expression and decreased basal, but not PMA-mediated, Cox-2 expression. The 5-HT-mediated activation of MAPK was not decreased by KN62 or KN93, excluding CaM kinase as a signalling module upstream of p42/44 MAPK. Taken together, these results indicate a modulatory involvement of CaM kinase in the regulation of 5-HT-mediated Cox-2 mRNA expression in addition to the main pathway that consists of the activation of PKC and p42/44 MAPK.

Cystic fibrosis newborn screening: impact on reproductive behavior and implications for genetic counseling.

OBJECTIVE: To evaluate the impact of newborn screening for cystic fibrosis (CF) on the reproductive knowledge and behavior of CF families and to determine if heterozygote detection with the immunoreactive trypsinogen (IRT) method in conjunction with DNA analysis (IRT/DNA) influences knowledge and attitudes about reproduction in false-positive families. METHODS: The Wisconsin CF Neonatal Screening Project investigated 650 340 infants from 1985 to 1994 in a comprehensive randomized controlled trial to study both benefits and risks of newborn screening and to determine if early diagnosis would improve the prognosis of children with CF. Assessments of reproductive knowledge, attitudes, and behaviors of 135 families of children diagnosed as having CF in both the early treatment group and control groups were made 3 months after diagnosis using a questionnaire which was completed by 100 families. The same questionnaire was administered 1 year later to evaluate retention of information. It was completed by 71 families. A follow-up assessment tool was also administered in 1994 and responses obtained from 73 families. Knowledge, attitudes, and behavior among false-positive families were also assessed at the time of the sweat test in 206 families who experienced IRT screening and 109 families tested with the IRT/DNA method. Follow-up assessments were completed 1 year later in 106 IRT families and 63 IRT/DNA families. RESULTS: In families with a CF child, 95% initially understood that there was a 1 in 4 risk in subsequent pregnancies, and there was good retention of this information 1 year later. At the 1994 assessment, 52% of families had not yet conceived more children, but 74% of these already had children. In the couples in whom CF was diagnosed in the first child, 70% (95% confidence interval = 54% to 85%) conceived more children. There were 43 subsequent pregnancies in 31 families. Prenatal diagnosis was used by 26% of the families (8/31) for 21% of the pregnancies (9/43). There were 3 pregnancies with CF detected, all of which were carried to term. In the false-positive groups, >95% of families initially understood that their child definitely did not have CF. There was no difference between false-positive IRT and IRT/DNA groups, and the information was retained at 1 year. Follow-up assessment 1 year after negative sweat tests revealed that 7% of the IRT and 10% of the IRT/DNA families still thought about the results often or constantly. When asked whether the experience of screening affected feelings about having more children, an affirmative response was obtained in 4% of IRT families but in 17% of IRT/DNA families. One year later, more than half of the false-positive IRT/DNA families did not understand that they were at increased risk of having a child with CF. CONCLUSIONS: We conclude that CF neonatal screening does not have a significant impact on the reproductive behavior of most families and that prenatal diagnosis is not used by the majority of CF families. IRT/DNA testing experiences seem to affect attitudes about having more children, and some parents are confused about the implications of the results, even with genetic counseling. However, persistent concerns about the sweat test result are limited. Questions raised by this study confirm the need for more research regarding the process of genetic counseling and its impact on reproductive attitudes and behavior in the newborn screening setting.

Lysophosphatidic acid-mediated signal-transduction pathways involved in the induction of the early-response genes prostaglandin G/H synthase-2 and Egr-1: a critical role for the mitogen-activated protein kinase p38 and for Rho proteins.

During inflammatory processes of the kidney, lesions of the glomerulus lead to aggregation of thrombocytes and infiltration of macrophages, which can release bioactive mediators. One of these important signalling molecules is lysophosphatidic acid (LPA). Incubation of rat mesangial cells with LPA induced mRNA and protein expression of the early-response genes pghs-2 (for prostaglandin G/H synthase-2/cyclo-oxygenase-2) and egr-1. As shown by antisense experiments, induction of egr-1 was related to the strong mitogenic effect of LPA. LPA-mediated gene expression was inhibited by pertussis toxin, indicating coupling to G-proteins of the Gi family. Specific inhibition of proteins of the small G-protein subfamily Rho with toxin B from Clostridium difficile led to changes in mesangial cell morphology without induction of apoptosis. LPA-mediated expression of pghs-2 and egr-1 was reduced to base-line levels by toxin B, indicating a role for Rho proteins in LPA-mediated gene induction. Of the two mitogen-activated protein kinase (MAPK) pathways investigated, the MAPK kinase-extracellular signal-regulated kinase pathway was involved in the induction of both pghs-2 and egr-1 mRNA expression, as shown by the inhibitory effect of PD98059. Activation of the MAPK p38, however, was only related to pghs-2 expression, whereas egr-1 expression was not affected by treatment of mesangial cells with the specific inhibitor SB203580. Taken together our data provide evidence that LPA-mediated activation of MAPK kinase and Rho proteins leads to the induction of the functionally distinct early-response genes pghs-2 and egr-1, whereas activation of MAPK p38 revealed considerable differences between the regulation of these two genes.

Large laser sheaths for pacing and defibrillator lead removal.

BACKGROUND AND OBJECTIVE: In a recent clinical trial, the 12-F laser sheath showed 95% success in completely explanting chronically implanted pacing leads smaller than 7.5-F diameter. For larger leads, two new sizes of laser sheath have been implemented, the 14-F and 16-F (outer diameter) devices, which accommodate leads up to 9.5- and 11.5-F, respectively. The object of this study was to determine the cutting ability of the larger devices compared to the 12-F design. MATERIALS AND METHODS: The rate of device advancement through fresh porcine aorta was measured for three sizes of laser sheath as pulsed ultraviolet light from a 308-nm XeCl excimer laser was applied. Dependent variables were fluence (mJ/mm2), laser pulse repetition rate, and pressure applied between the device and the tissue. RESULTS: At 60 mJ/mm2, 40 Hz repetition rate and 1.4 kg/cm2 pressure, all devices produced cutting rates in the range of 9-13 microns/pulse. Improvement in advancement per laser shot can be attained by increasing any independent variable studied. CONCLUSIONS: Physicians must apply only slightly greater force to the larger laser sheaths, and maximum available repetition rate and fluence implies maximum cutting speed.

Validation of radiographic criteria for the diagnosis of Down syndrome in stillborn infants.

We assessed the utility of radiographic findings as aids to the diagnosis of Down syndrome (DS) in stillborn infants. The iliac index may help to confirm the diagnosis of DS in stillborn infants in whom it is suspected clinically, but in whom it cannot be confirmed cytogenetically. It also can serve as a screening procedure to select stillborns in whom fluorescent in situ hybridization of fixed tissues should be completed. An iliac index of 59 degrees differentiates between control and affected stillborns with the highest accuracy, but false positives persist above 55 degrees, and false negatives are common below 64 degrees. We recommend that a conservative cutoff value of 55 degrees be used if the radiographic data serve as the principal means of diagnosing DS in stillborn infants. A cutoff value of 64 degrees may be appropriate if the radiographic data are used to screen stillborn infants for fluorescent in situ hybridization studies.

Biophysical bases for delayed and aberrant motor development in young children with achondroplasia.

Achondroplasia, the most common skeletal dysplasia, is characterized by delayed and aberrant motoric development in childhood. Delays and aberrancy are secondary to the anatomical differences inherent in people with achondroplasia. We present a photographic essay documenting biophysical differences, aberrant pre-orthograde movement strategies, and selected adaptive techniques. A parental questionnaire assessed the presence of, predominance, and ages at which various types of pre-orthograde locomotion were observed. Fine and gross motor skills were assessed contemporaneously by use of the Denver Developmental Screening Test in 93 children with achondroplasia and were found to be more delayed than previously reported. Physicians, therapists, early-childhood educators, and parents should recognize that aberrant does not mean maladaptive and that different development is not defective development.

Modulation of phospholipase D stimulation in c-src transfected mesangial cells.

Stimulation of rat mesangial cells with platelet-derived growth factor BB (PDGF-BB) enhanced phospholipase D (PLD) activity in a concentration dependent manner. Mesangial cells overexpressing the tyrosine kinase pp60c-src (c-Src) were used to determine the effect of this non transforming protooncogene on PLD activation. Overexpression of c-Src interfered with PDGF-BB-mediated activation of PLD. This modulation was dependent on the tyrosine kinase activity of c-Src, since overexpression of tyrosine kinase-negative mutants of c-Src did not affect PLD activation. No effect of c-Src overexpression was observed, when PLD was activated by ATP or guanosine 5'-3-O-(thio)triphosphate (GTP gamma S). The results indicate that the tyrosine kinase c-Src specifically interfered with PDGF-mediated but not with ATP- or GTP gamma S-mediated PLD activation.

Prevention of fixed, angular kyphosis in achondroplasia.

Transient kyphotic deformity arises in most infants with achondroplasia. In a minority, a fixed and angular kyphosis develops, which can cause serious neurologic sequelae later in life. We assessed a protocol for preventing development of such fixed kyphosis in a sequential, unselected series of 66 infants with achondroplasia. This study demonstrates the efficacy of early prohibition of unsupported sitting and, in those in whom such prohibition proves insufficient, use of bracing. When the proposed algorithm was followed, none of the infants had development of a progressive kyphotic deformity. On this basis, it appears that the secondary risks of angular kyphosis, previously estimated to be between 10 and 15% in individuals with achondroplasia, can be completely eliminated.