Portal vein: US-guided localization prior to transjugular intrahepatic portosystemic shunt placement

To mark the portal vein prior to transjugular intrahepatic portosystemic shunt (TIPS) placement, metallic coils adjacent to (n = 18) and a wire within (n = 18) the portal vein were placed with ultrasonographic (US) guidance. The mean number of punctures for successful portal vein entry was 3.0 with coils and 2.9 with a wire, and the mean total procedure time was 127.5 and 110.0 minutes, respectively (differences, not significant), and mean time at US was 20 and 10 minutes, respectively.

Diagnosis and selective cure of Cushing's disease during pregnancy by transsphenoidal surgery

The diagnosis of Cushing's Disease during pregnancy is complex because the biochemical features are obscured by changes in the normal hypothalamo-pituitary-adrenal axis that occur during gestation. To date, treatment has not been successful and there is a high incidence of maternal and fetal complications. We report the case of a 24-year-old woman with Cushing's disease who presented during her 16th week of pregnancy. Diagnosis was confirmed by the finding of elevated serum and urinary free cortisol levels with loss of the normal circadian rhythm of serum cortisol. Cortisol levels failed to suppress after a low-dose dexamethasone test but suppressed after a high-dose test. There was an exaggerated serum cortisol and plasma adrenocorticotrophin (ACTH) response to corticotrophin-releasing hormone (CRH). Magnetic resonance (MR) scanning demonstrated a pituitary tumour and cure was effected by transsphenoidal surgery where tumour immunostaining for ACTH was removed. Postoperatively the patient made an uncomplicated recovery; serum cortisol and plasma ACTH levels were undetectable at 9 days following surgery and recovery of the hypothalamo-pituitary axis occurred at 99 days after surgery. Caesarean section was performed at 38 weeks of pregnancy and a healthy but small female infant was delivered. This case illustrates the biochemical features of Cushing's disease during pregnancy and is the first report of the use of CRH testing and MR scanning in this clinical situation. The cure by surgery and successful outcome for mother and infant, with preservation of normal anterior pituitary function, suggest that transsphenoidal surgery may be the treatment of choice.

Continuing professional education: luxury or necessity?

The author sets out to define what is meant by continuing professional education, the implications of the terminology and the contribution that it makes to nursing. She then moves on to discuss the distinction between education and learning, and the importance of 'life-long learning' to nursing. The relative merits of voluntary and compulsory education are considered and the attitudes and expectations of both nurses and their managers are examined. Obstacles to the up-take of educational opportunities are outlined, and some of the issues behind this are explored. The assessment of educational requirements and the evaluation of educational offerings are reviewed, along with the importance of assuring quality, not only in the context of proposals for postregistration education and the current market ethos in the United Kingdom, but also with regard to the potential benefits to be gained in the health care of the general public.

Primary hyperaldosteronism due to an adrenal adenoma in a 14-year-old boy

Conn's syndrome due to an adrenal adenoma is very rare in children. This paper reports a 14-year-old boy with primary hyperaldosteronism due to an adrenal adenoma. His biochemistry data were compatible with either bilateral adrenal hyperplasia or an adrenal adenoma. A dexamethasone test did not suppress aldosterone levels. Venous catheter sampling and 75Se-selenomethylcholesterol scanning suggested that the hyperaldosteronism originated at the right adrenal. Computed tomography showed an 8-mm low-density nodule in the right adrenal gland and magnetic resonance imaging confirmed the nodule which had high signal intensity on T2-weighted images consistent with a functioning adenoma. Surgery confirmed the right adrenal adenoma, and the patient was cured by right adrenalectomy. This case illustrates the difficulty of defining the aetiology of primary hyperaldosteronism and we review the biochemical and scanning techniques available to aid in diagnosis. Hypertension is unusual in children and endocrine causes are very rare, but Conn's syndrome should always be considered in the differential diagnosis.

Abnormal hypothalamic-pituitary-adrenal axis function in rheumatoid arthritis. Effects of nonsteroidal antiinflammatory drugs and water immersion

OBJECTIVE

To investigate the effects of nonsteroidal antiinflammatory drug (NSAID) therapy and water immersion on hypothalamic-pituitary-adrenal (HPA) axis function in rheumatoid arthritis (RA).

METHODS

Plasma levels of adrenocorticotropic hormone (ACTH) and serum and urine levels of cortisol were compared in untreated RA patients, NSAID-treated RA patients, and healthy control subjects.

RESULTS

ACTH levels were significantly higher in untreated RA patients (mean +/- SEM integrated area 11,377 +/- 5,246 hours ng/liter) than in NSAID-treated RA patients (2,285 +/- 388 hours ng/liter) or healthy controls (1,845 +/- 35.5 hours ng/liter) (P < 0.001). Serum and urine cortisol levels were not significantly different between groups. Two-hour head-out water immersion had no effect.

CONCLUSION

Elevated ACTH levels without hypercortisolemia occur in untreated RA. NSAID therapy alters HPA axis response, but immersion has no effect.

An audit of the insulin tolerance test in adult subjects in an acute investigation unit over one year

OBJECTIVE

We audited our practice of insulin tolerance testing (ITT) in terms of safety and technical success. We reviewed the results of those tests performed over a 12-month period. By relating peak cortisol response to 0900 h screening cortisol level, we determined whether we could reduce the number of tests performed.

DESIGN

The results of all ITTs performed on our unit between 1 January and 31 December 1991 were reviewed.

PATIENTS AND MEASUREMENTS

Patients were prescreened by measurement of serum cortisol and thyroxine, and recording of an electrocardiogram. A subnormal serum thyroxine (< 58 nmol/l), 0900 h serum cortisol (< 100 nmol/l) or an abnormal ECG were taken as contraindications to the test. Minimum glucose and maximum cortisol levels were recorded, along with peak GH responses when measured. The peak cortisol response was compared to the screening and basal cortisol levels.

RESULTS

A total of 161 tests were performed, 135 of which fulfilled our inclusion criteria. The test was technically successful in all but 5 of these; a significant adverse event occurred in one patient with full recovery after reversal of hypoglycaemia. Thirty-two patients had a suboptimal serum cortisol response to hypoglycaemia: screening cortisol level ranged from 128 to 493 nmol/l and 0900 h serum cortisol measured prior to the ITT from 97 to 431 nmol/l. The lowest level of screening cortisol above which all patients would be expected to achieve the normal peak cortisol of 580 nmol/l or over is therefore 494 nmol/l. If this cut-off level had been adopted, 10 (8%) ITTs need not have been performed if their only purpose had been to assess cortisol reserve. Altering the criterion for the necessary peak cortisol to 500 nmol/l did not affect the number of ITTs required. Our lower limit for testing could not be revised upwards from 100 nmol/l. Adequacy of cortisol reserve did not predict a normal GH response to insulin-induced hypoglycaemia.

CONCLUSIONS

When performed in an experienced endocrine unit with adequate supervision, the insulin tolerance test is a safe procedure. According to the current sample, fewer tests would be performed without detriment to patient care if those with a screening cortisol of greater than 500 nmol/l did not proceed to testing, unless the purpose of the test was also to exclude GH deficiency. A lower limit of 100 nmol/l appears reasonable and need not be revised upwards.

Hepatic arterial chemoembolization for metastatic neuroendocrine tumors

PURPOSE OF THE STUDY

To evaluate the effectiveness of chemoembolization of the liver with doxorubicin and iopamidol emulsified in ethiodized oil for the treatment of metastatic neuroendocrine tumors.

PATIENTS AND METHODS

Twenty patients with hepatic islet cell or carcinoid metastases were treated with selected hepatic arterial embolization consisting of an emulsion of doxorubicin and iopamidol emulsified in ethiodol followed by Gelfoam powder embolization. Fifteen patients had failed intravenous chemotherapy. Two of the patients with carcinoid tumors had three embolizations over 4 and one 6 years earlier with gelatin sponge only.

RESULTS

In 14 patients with hormonally active tumors, hormones secretion decreased 90% (range 69-98%) in 10 days with relief of symptoms in all patients. Average tumor size decrease was 84%. Average hospital stay was 8 days. Six patients are alive and asymptomatic at 14-33 months postembolization. Fourteen patients have died 2-16 months postembolization. Ten patients died 2-37 months postembolization from progressive liver disease. One of these patients was 103 months post-Gelfoam embolization and 13 months postchemoembolization. In 8 patients, the pancreas was the primary site: 5 were nonfunctioning islet cell carcinomas, 1 glucagonoma, 1 gastrinoma and 1 carcinoid. The primary site in 1 patient with carcinoid was the bronchus, and the primary site was unknown in 1 patient with gastrinoma. The remaining 4 patients died with liver disease under control from renal failure, peritonitis, carcinoid heart failure and generalized bone metastases. The response rate was 95% with median duration of response 8.5 months. The median survival was 24 months.

CONCLUSION

Chemoembolization with doxorubicin and iopamidol emulsified in ethiodized oil is less morbid than embolization with particulate matter alone, is more convenient and less costly, and it is less morbid than the effects of systemic chemotherapy. The median survival, duration and response compare favorably with other reported therapies.

Aging, vertebral density, and disc degeneration alter the tensile stress-strain characteristics of the human anterior longitudinal ligament

The mechanical properties of the human lumbar anterior longitudinal ligament were investigated, and the influence of aging, disc degeneration, and vertebral bone density on these properties was determined. Tensile mechanical properties of the vertebra-anterior longitudinal ligament-vertebra complex were determined for 16 segments from cadavera of individuals who had been 21-79 years old (mean, 52.1 years) at the time of death. Regional strain patterns associated with three sites across the width and three sites along the length of the anterior longitudinal ligament were measured with use of a video-based motion analysis system. In the young, normal anterior longitudinal ligament, the elastic moduli of the insertion and substance regions of the ligament were similar (approximately 500 MPa). During aging (21-79 years), the elastic modulus of the substance region increased 2-fold, whereas the elastic modulus of the insertion decreased 3-fold; this resulted in an approximately 5-fold difference in elastic modulus between these regions in the older spine. The strength of the bone-ligament complex decreased approximately 2-fold (from 29 to 13 MPa) over this same age range. The outer portion of the anterior longitudinal ligament consistently had the highest peak tensile strains (11.8 +/- 2.7%) in all of the specimens examined. Preparations with nondegenerated discs and high bone density were significantly stronger (66%) and failed in the ligament substance; in contrast, segments from older individuals with degenerated discs and lower bone density failed in the ligament insertion regions.

Ambient oxygen tension modulates endothelial fibrinolysis

PURPOSE

Vascular procedures reoxygenate ischemic endothelial cells (EC) and arterialize saphenous vein (HSV) EC. The balance between the EC-derived fibrinolytic components, plasminogen activator (tPA), and plasminogen inhibitor (PAI-1) contributes to maintaining thromboresistance. This balance also affects proteolysis through plasmin generation, mediating matrix metabolism endothelial migration, angiogenesis, and theoretically affecting the development of intimal hyperplasia.

METHODS

To explore the impact of varying oxygen tensions on EC fibrinolysis, HSV and human umbilical vein (HUV) were subjected to Po2 of 40 mm Hg for 24 hours with restoration of Po2 to 150 mm Hg for 24 hours. The tPA and PAI-1 antigen and tPA/PAI-1 antigen ratio in conditioned media (CM), expressed as increases or decreases % change, normalized for cell count, versus controls, were analyzed by enzyme-linked immunosorbent assay. Cellular tPA and PAI-1 mRNAs were assessed by Northern analysis.

RESULTS

The tPA but not PAI-1 was significantly decreased after the first 24 hours in HSVEC and significantly decreased after 48 hours in both HUVEC and HSVEC when compared with controls. Messenger RNA for tPA was unchanged but PAI-1 mRNA increased significantly for HSVEC and HUVEC after 24 hours of Po2 of 40 mm Hg, returning to baseline within 24 hours of Po2 to 150 mm Hg restoration.

CONCLUSIONS

These data support the hypothesis of a fibrinolytic shift after altered ambient O2 tensions exposure in endothelium and demonstrate that HSVEC are more sensitive to altered O2 tension than HUVEC. Altered O2 tensions depress EC fibrinolysis in this model.

The relationship between cortisol production rate and serial serum cortisol estimation in patients on medical therapy for Cushing's syndrome

OBJECTIVE

The aim was to determine the target range into which mean daily serum cortisol should be lowered in patients on medical therapy for Cushing's syndrome, using isotopically estimated cortisol production rates as 'gold standard'.

DESIGN

Patients with Cushing's syndrome on medical treatment were given 12 ng of tritiated cortisol intravenously and a 24-hour urine collection was made in a single day. On the same day, serum cortisol was measured at 0900, 1200, 1500, 1800, 2100, and at 2400 h in in-patients. In addition, serum cortisol was measured at the same times as above in a group of healthy volunteers.

SUBJECTS

Twenty-two patients on medical therapy for Cushing's syndrome were studied on a total of 29 occasions. In addition, serum cortisol profiles were obtained in 12 healthy volunteers.

RESULTS

The median serum cortisol in patients with Cushing's syndrome was 400 (range 66-839) nmol/l, and in the healthy volunteers 178 (range 137-299) nmol/l. The median isotopic cortisol production rate in the patients with Cushing's syndrome was 84 mumol/24 h, range 10-343 (normal range 22-83) mumol/24 h. In the patients with Cushing's syndrome, the correlation of mean serum cortisol to cortisol production rate was +0.77 (P < 0.001). Normal rates were found when mean serum cortisol levels were between 150 and 300 nmol/l.

CONCLUSIONS

The aim of drug therapy for Cushing's syndrome should be to lower the mean serum cortisol through the day into the range 150-300 nmol/l.

Gut feelings about gut feeding: enteral feeding for ventilated patients in a district general hospital

This article looks at the role that nutrition plays in the maintenance of gut integrity and function in the critically ill patient. It refers to previous studies that have highlighted the relevance of facilitating the bacteriocidal function of gastric secretions as a means to minimize the development of nosocomial pneumonias in ventilated patients. A small trial was set up to investigate the merits and difficulties associated with two different enteral feeding regimes for ventilated patients in the intensive therapy unit (ITU) of a district general hospital. This project and its results are described and evaluated; conclusions and issues for practice are highlighted.

In vitro expression of the alpha-smooth muscle actin isoform by rat lung mesenchymal cells: regulation by culture condition and transforming growth factor-beta

alpha-Smooth muscle actin (alpha SM actin)-containing cells recently have been demonstrated in intraalveolar lesions in both rat and human tissues following lung injury. In order to develop model systems for the study of such cells, we examined cultured lung cell lines for this phenotype. The adult rat lung fibroblast-like "RL" cell lines were found to express alpha SM actin mRNA and protein and to organize this actin into stress fiber-like structures. Immunocytochemical staining of subclones of the RL87 line demonstrated the presence in the cultures of at least four cell phenotypes, one that fails to express alpha SM actin and three distinct morphologic types that do express alpha SM actin. The proportion of cellular actin that is the alpha-isoform was modulated by the culture conditions. RL cells growing at low density expressed minimal alpha SM actin. On reaching confluent densities, however, alpha SM actin increased to at least 20% of the total actin content. This effect, combined with the observation that the most immunoreactive cells were those that displayed overlapping cell processes in culture, suggests that cell-cell contact may be involved in actin isoform regulation in these cells. Similar to the response of some smooth muscle cell lines, alpha SM actin expression in RL cells also was promoted by conditions, e.g., maintenance in low serum medium, which minimize cell division. alpha SM actin expression was modulated in RL cells by the growth factor transforming growth factor-beta. Addition of this cytokine to growing cells substantially elevated the proportion of alpha SM actin protein.(ABSTRACT TRUNCATED AT 250 WORDS)

Control over work pace, job strain and cardiovascular responses in middle-aged men

OBJECTIVE

To assess the effects of control over work pace on cardiovascular stress responses in healthy middle-aged men.

DESIGN

The study involved administration in the laboratory of visual matrix and mirror drawing tasks, the pace of tasks being either under the control of the subject (self-paced) or determined externally (externally paced). The work demands in the two conditions were equated.

METHOD

Forty men aged 55-65 years were randomly assigned to self-paced or externally paced conditions. Blood pressure (recorded continuously using the Finapres), heart rate, cardiac baroreflex sensitivity, salivary cortisol, skin conductance and breathing pattern were monitored at rest, during task performance and at recovery following tasks.

RESULTS

Blood pressure and heart rate responses were significantly greater under the externally paced than self-paced conditions. The mean increase in blood pressure during the visual matrix task averaged 19.8/9.4 versus 34.1/15.5 mmHg for the self- and externally paced conditions, and 28.2/13.7 versus 41.8/19.5 mmHg in response to mirror drawing, respectively. Performance of the matrix task was less accurate under externally paced than self-paced conditions, but the two groups did not differ in mirror drawing. A reduction in baroreflex sensitivity and increases in cortisol, respiration rate, tidal volume and skin conductance responses were recorded during tasks, but these responses did not distinguish the two groups. Men were divided on the basis of reported job strain associated with their regular work, using the demand-control model. Blood pressure and heart rate responses were particularly pronounced among men reporting high job strain who were allocated to the externally paced condition.

CONCLUSIONS

Middle-aged men showed greater stress-related cardiovascular responses when they performed tasks at a pace that they could not control. This pattern may be relevant to the mechanisms through which job strain (high demands associated with low control) influences cardiovascular disease risk.

T cells specific for the myelin oligodendrocyte glycoprotein mediate an unusual autoimmune inflammatory response in the central nervous system

Myelin oligodendrocyte glycoprotein (MOG)-specific T cells mediate an autoimmune inflammatory response in the central nervous system (CNS) that differs radically from conventional models of T cell-mediated experimental allergic encephalomyelitis (EAE). Using synthetic peptides an encephalitogenic T cell epitope of MOG for the Lewis rat was identified within the extracellular IgG V-like domain of the protein, amino acids 44-53 (FSRVVHLYRN). The adoptive transfer of CD4+ T cells specific for this epitope induce an intense, dose-dependent inflammatory response in the CNS of naive syngeneic recipients. However, unlike the inflammatory response induced by myelin basic protein (MBP)-specific T cell lines, inflammation mediated by the MOG peptide-specific T cells failed to induce a gross neurological deficit. This unexpected observation was not due to a reduction in the overall inflammatory response in the CNS, but was specifically associated with a decrease in the extent of parenchymal (as opposed to perivascular) inflammation, a selective decrease in the number of ED1+ macrophages infiltrating the CNS, and a total lack of peripheral nerve inflammation. The decreased recruitment of macrophages into the CNS could not be ascribed to deficiencies in the synthesis of interferon-gamma, tumor necrosis factor-alpha, interleukin (IL)-6 or IL-2 by the T cell line. Moreover, this sub-clinical inflammatory response induced severe blood-brain barrier dysfunction as demonstrated by the induction of severe clinical disease following intravenous injection of a demyelinating MOG-specific monoclonal antibody. The neurological deficit in EAE thus exhibits an unexpected dependence on the identity of the target autoantigen, which determines the extent and nature of the local inflammatory response and ultimately the extent of the neurological deficit.

IGFBP-1: a metabolic signal associated with exercise-induced amenorrhoea

Severe exercise in young females is a potent cause of menstrual irregularity, although the exact pathogenesis is currently unknown. We performed a cross-sectional endocrine and metabolic analysis of a group of elite athletes and dancers in order to establish which variable, if any, was specifically associated with changes in menstruation. By using a step-wise discriminant analysis, two independent predictors, elevated serum cortisol and insulin-like growth factor binding protein 1 (IGFBP-1) levels, were found to account for the majority (67%) of the variance. IGFBP-1 is a hepatic protein which is acutely and inversely regulated by insulin, and is thought to modulate the peripheral actions of IGF-1. While the change in serum cortisol may reflect activation of central stress pathways, these findings suggest for the first time that there is a second peripheral signal, IGFBP-1, which may relate the availability of metabolic fuels to the control of reproduction.

Age influences magnitude but not duration of response to levodopa

Following an all-night fast, 45 patients with Parkinson's disease were examined using certain motor items present in the United Parkinson's Disease Rating Scale. All were given a single tablet of carbidopa 25 mg and levodopa 250 mg and re-examined 90 minutes later. In addition to this evaluation, 23 of these patients underwent further scoring over a 4-hour period. A significant negative correlation was found between age and one important aspect of drug-derived benefit: magnitude of response. In contrast, age had no apparent influence on duration of benefit from the drug. Although baseline (fasting) scores were predictably correlated with duration of disease, magnitude of response was not adversely influenced by this variable. Not all Parkinsonian signs were equally influenced by age. Whereas the poor response of gait and bradykinesia appeared to be dependent on age, no such effect was noted on rest tremor scores. The data indicate that in patients with Parkinson's disease treated long term, factors associated with age rather than duration of disease may have a stronger adverse influence on magnitude of response to levodopa.

Placental protein 14 secretion during in vitro fertilization cycles with and without human chorionic gonadotropin for luteal support

OBJECTIVE

To investigate levels of placental protein 14 (PP14) in in vitro fertilization (IVF) patients with and without exogenous human chorionic gonadotropin (hCG) for luteal support.

DESIGN, PATIENTS

Thirty-one women undergoing IVF were studied. For 18 women, hCG was administered in the luteal phase, and 12 became pregnant. Five pregnancies occurred in 13 women not receiving exogenous hCG.

SETTING

All the patients attended the University of Southampton/Chalybeate Hospital IVF program.

RESULTS

There was no change in PP14 levels 2 days after embryo transfer (ET), but small significant rises were noted by day 8 in all patients. Thereafter, levels rose further in pregnant subjects but showed no change in nonpregnant patients. The highest level of PP14 was seen in the group of women on hCG support, but there was no overall statistical difference between those on support and those not. In the nonpregnant group, there was no significant correlation between progesterone (P) and PP14 8 days from ET, whereas a highly significant correlation was noted in the pregnant group.

CONCLUSIONS

Neither hCG nor P are primary factors in the control of endometrial PP14 secretion, but PP14 and P may have common underlying control mechanisms.

Mechanical properties of the human lumbar anterior longitudinal ligament

A new technique incorporating a motion analysis system and a materials testing machine was used to investigate regional differences in the tensile mechanical properties of the lumbar spine anterior longitudinal ligament (ALL). Bone-ALL-bone specimens were prepared from young human cadaveric motion segments with no disc or bony pathology. Each specimen was distracted until failure at a constant crosshead displacement rate of 2.5 mm s-1 (approximately 1.0% strain per second). Strains were evaluated from digitized video recordings of markers attached to the ALL at 12 sites along its length and width, including the ligament substance and insertions. The 'overall' strain in the ligament was calculated from the outermost pairs of markers along the ligament length. The average tensile strength, the 'overall' tensile modulus and the 'overall' strain of the ALL at failure were 27.4 MPa (S.D. 5.9), 759 MPa (S.D. 336) and 4.95% (S.D. 1.51), respectively. Large and significant variations in the strains were present along the width and length of the ALL. Peak substance strains were over twofold greater than peak strains at the ligament insertion sites, whereas across the ligament width, peak strains in the outer portion of the ligament were over 40% greater than in the central region. Failure consistently occurred in the ligament mid-substance and ultimate strains at the ligament failure site averaged 12.1% (S.D. 2.3). These results indicate that the strains are highly nonuniform in the normal ALL.

The biomechanical and histopathologic effects of surface texturing with silicone and polyurethane in tissue implantation and expansion

There has been considerable interest in determining the effect of morphologic alterations of prosthetic surfaces on capsule response in breast surgery. The purpose of this study was to provide a precise, three-dimensional evaluation of soft-tissue response to surface modifications in both implantation and expansion. Expandable 100-cc prostheses were designed with one of three surfaces: textured silicone (Biocell), standard smooth silicone, or polyurethane (Natural-Y, Meme). A new submuscular implantation site in the rabbit was developed. Each animal randomly received a smooth-surface device on one side and either a textured silicone or polyurethane device on the other. In one group of animals, the prostheses were expanded monthly. Capsular response was evaluated monthly in vivo using standardized techniques as well as biomechanical methods for up to 6 months in the expander group (n = 7 to 16) and 8 months in the implant group (n = 7 to 15). Analysis of biomechanical and histologic data revealed that prosthetic surface morphology can specifically alter capsular response. Polyurethane was the only effective surface in preventing capsular contracture in implantation. In expansion, both textured silicone and polyurethane surfaces resulted in significantly less capsular contracture and less resistance to expansion than comparable smooth-surfaced controls. Statistical comparisons reveal that the biomechanical methods utilized in this study provide the most precise and objective method of defining overall soft-tissue contracture around implanted biomaterials.

Role and specificity of T-cell subsets in spontaneous recovery from Friend virus-induced leukemia in mice

Spontaneous recovery from Friend virus complex-induced leukemic splenomegaly in H-2Db/b mice correlated with the appearance of Friend virus complex-specific cytotoxic T lymphocytes (CTL) detectable directly in spleen cell populations. By testing CTL on target cells containing expression vectors encoding individual retroviral structural proteins, the main viral protein recognized was shown to be the Friend murine leukemia helper virus envelope glycoprotein. In vivo depletion of CD8-positive T cells drastically reduced the incidence of recovery, providing direct evidence for the role of CD8-positive CTL in the spontaneous recovery process. In vivo depletion of CD4-positive cells had little effect on the early stages of recovery but did cause a marked reduction in the final incidence of recovery at 60 to 90 days. Thus, CD8-positive cells were required for the initiation of the recovery process, whereas CD4-positive cells appeared to be required for maintenance of the recovered status.