The correlation between altmetric score and traditional measures of article impact for studies pertaining to spine trauma

PURPOSE

It is becoming increasingly common for researchers to share scientific literature via social media. Traditional bibliometrics have long been utilized to measure a study's academic impact, but they fail to capture the impact generated through social media sharing. Altmetric Attention Score (AAS) is a weighted count of all the online attention garnered by a study, and it is currently unclear whether a relationship with traditional bibliometrics exists.

METHODS

We identified the five highest-rated spine-specific and five highest-rated general orthopedic journals by Scopus CiteScore 2020. We then identified all the spine trauma studies across a 5-year span (2016-2020) within these journals and compared AAS with traditional bibliometrics using Independent t-tests and Pearson's correlational analyses.

RESULTS

No statistically significant relationships were identified between AAS and traditional bibliometrics for articles pertaining to spine trauma: Level of Evidence (R = - 0.02, p = 0.34), H-Index Primary Author (R =  < - 0.01, p = 0.50), H-Index Senior Author (R = - 0.04, p = 0.24), and Number of Citations (R = 0.01, p = 0.40). The top five articles by AAS include those pertaining to motorcycle injuries (AAS = 687), orthosis in thoracolumbar fractures (AAS = 199), golfing injuries (AAS = 166), smartphone-based teleradiology (AAS = 41), and auto racing injuries (AAS = 39).

CONCLUSION

The lack of overlap between these types of metrics suggests that AAS or similar alternative metrics should be used to measure an article's social impact. The social impact of an article should likewise be a factor in determining an article's overall impact along with its academic impact as measured by bibliometrics.

IgE, IgE Receptors and Anti-IgE Biologics: Protein Structures and Mechanisms of Action

The evolution of IgE in mammals added an extra layer of immune protection at body surfaces to provide a rapid and local response against antigens from the environment. The IgE immune response employs potent expulsive and inflammatory forces against local antigen provocation, at the risk of damaging host tissues and causing allergic disease. Two well-known IgE receptors, the high-affinity FcεRI and low-affinity CD23, mediate the activities of IgE. Unlike other known antibody receptors, CD23 also regulates IgE expression, maintaining IgE homeostasis. This mechanism evolved by adapting the function of the complement receptor CD21. Recent insights into the dynamic character of IgE structure, its resultant capacity for allosteric modulation, and the potential for ligand-induced dissociation have revealed previously unappreciated mechanisms for regulation of IgE and IgE complexes. We describe recent research, highlighting structural studies of the IgE network of proteins to analyze the uniquely versatile activities of IgE and anti-IgE biologics.

Ontogeny of human IgE-expressing B cells and plasma cells

Background

IgE‐expressing (IgE⁺) plasma cells (PCs) provide a continuous source of allergen‐specific IgE that is central to allergic responses. The extreme sparsity of IgE⁺ cells in vivo has confined their study almost entirely to mouse models.

Objective

To characterize the development pathway of human IgE⁺PCs and to determine the ontogeny of human IgE⁺PCs.

Methods

To generate human IgE⁺ cells, we cultured tonsil B cells with IL‐4 and anti‐CD40. Using FACS and RT‐PCR, we examined the phenotype of generated IgE⁺ cells, the capacity of tonsil B‐cell subsets to generate IgE⁺PCs and the class switching pathways involved.

Results

We have identified three phenotypic stages of IgE⁺PC development pathway, namely (i) IgE⁺germinal centre (GC)‐like B cells, (ii) IgE⁺PC‐like ‘plasmablasts’ and (iii) IgE⁺PCs. The same phenotypic stages were also observed for IgG1⁺ cells. Total tonsil B cells give rise to IgE⁺PCs by direct and sequential switching, whereas the isolated GC B‐cell fraction, the main source of IgE⁺PCs, generates IgE⁺PCs by sequential switching. PC differentiation of IgE⁺ cells is accompanied by the down‐regulation of surface expression of the short form of membrane IgE (mIgE_S), which is homologous to mouse mIgE, and the up‐regulation of the long form of mIgE (mIgE_L), which is associated with an enhanced B‐cell survival and expressed in humans, but not in mice.

Conclusion

Generation of IgE⁺PCs from tonsil GC B cells occurs mainly via sequential switching from IgG. The mIgE_L/mIgE_S ratio may be implicated in survival of IgE⁺ B cells during PC differentiation and allergic disease.

Validating the GTP-cyclohydrolase 1-feedback regulatory complex as a therapeutic target using biophysical and in vivo approaches

BACKGROUND AND PURPOSE

6R-L-erythro-5,6,7,8-tetrahydrobiopterin (BH4 ) is an essential cofactor for nitric oxide biosynthesis. Substantial clinical evidence indicates that intravenous BH4 restores vascular function in patients. Unfortunately, oral BH4 has limited efficacy. Therefore, orally bioavailable pharmacological activators of endogenous BH4 biosynthesis hold significant therapeutic potential. GTP-cyclohydrolase 1 (GCH1), the rate limiting enzyme in BH4 synthesis, forms a protein complex with GCH1 feedback regulatory protein (GFRP). This complex is subject to allosteric feed-forward activation by L-phenylalanine (L-phe). We investigated the effects of L-phe on the biophysical interactions of GCH1 and GFRP and its potential to alter BH4 levels in vivo.

EXPERIMENTAL APPROACH

Detailed characterization of GCH1-GFRP protein-protein interactions were performed using surface plasmon resonance (SPR) with or without L-phe. Effects on systemic and vascular BH4 biosynthesis in vivo were investigated following L-phe treatment (100 mg·kg(-1) , p.o.).

KEY RESULTS

GCH1 and GFRP proteins interacted in the absence of known ligands or substrate but the presence of L-phe doubled maximal binding and enhanced binding affinity eightfold. Furthermore, the complex displayed very slow association and dissociation rates. In vivo, L-phe challenge induced a sustained elevation of aortic BH4 , an effect absent in GCH1(fl/fl)-Tie2Cre mice.

CONCLUSIONS AND IMPLICATIONS

Biophysical data indicate that GCH1 and GFRP are constitutively bound. In vivo, data demonstrated that L-phe elevated vascular BH4 in an endothelial GCH1 dependent manner. Pharmacological agents which mimic the allosteric effects of L-phe on the GCH1-GFRP complex have the potential to elevate endothelial BH4 biosynthesis for numerous cardiovascular disorders.

Inhibition of allergen-dependent IgE activity by antibodies of the same specificity but different class

IgG4 purified from patients undergoing specific allergen immunotherapy inhibits the activities of the serum IgE in in vitro assays and is thought to reduce the symptoms of the disease. However, it is not known whether this is related to an intrinsic property of this subclass or only the allergen specificity. We tested the hypothesis that allergen specificity is the critical determinant for this activity using a panel of antibodies with identical specificity but different subclasses. The different antibodies were all able to inhibit the activity of IgE to the same extent. We demonstrate that specificity is the dominant factor determining the ability of an antibody to block allergen-dependent IgE activity.

Surface plasmon resonance: towards an understanding of the mechanisms of biological molecular recognition

With the introduction of new instruments and improved sensor chip chemistries, surface plasmon resonance (SPR) is finding new applications for molecular interaction studies. Easy access to high-quality kinetic and thermodynamic data for macromolecular binding events is providing insights into the fundamental mechanisms of molecular recognition. Progress is being made to allow larger-scale interaction studies. In addition, combining SPR with other analytical methods is enabling SPR-based analysis of interaction proteomics.

The structure of the IgE Cepsilon2 domain and its role in stabilizing the complex with its high-affinity receptor FcepsilonRIalpha

The stability of the complex between IgE and its high-affinity receptor, FcepsilonRI, on mast cells is a critical factor in the allergic response. The long half-life of the complex of IgE bound to this receptor in situ ( approximately 2 weeks, compared with only hours for the comparable IgG complex) contributes to the permanent sensitization of these cells and, hence, to the immediate response to allergens. Here we show that the second constant domain of IgE, Cepsilon2, which takes the place of the flexible hinge in IgG, contributes to this long half-life. When the Cepsilon2 domain is deleted from the IgE Fc fragment, leaving only the Cepsilon3 and Cepsilon4 domains (Cepsilon3-4 fragment), the rate of dissociation from the receptor is increased by greater than 1 order of magnitude. We report the structure of the Cepsilon2 domain by heteronuclear NMR spectroscopy and show by chemical shift perturbation that it interacts with FcepsilonRIalpha. By sedimentation equilibrium we show that the Cepsilon2 domain binds to the Cepsilon3-4 fragment of IgE. These interactions of Cepsilon2 with both FcepsilonRIalpha and Cepsilon3-4 provide a structural explanation for the exceptionally slow dissociation of the IgE-FcepsilonRIalpha complex.

Specificity and binding kinetics of murine lupus anti-DNA monoclonal antibodies implicate different stimuli for their production

The origin and relative biological importance of the many different DNA-reactive antibodies that appear in systemic lupus erythematosus are not well understood. A detailed analysis of their fine specificity and binding characteristics with DNA is a necessary step in understanding their biology. We have examined here two monoclonal antibodies (mAb) IV-228 and V-88 that are, respectively, characteristic of antibodies, which bind exclusively to single-stranded (ss) DNA and to both double-stranded (ds) DNA and ssDNA. By surface plasmon resonance (SPR) on BIAcore, we characterized the kinetics of binding of each antibody to synthetic ss and ds oligonucleotides. Antibody V-88 and IV-228 showed different patterns of reactivity for both ss and ds oligonucleotides, characterized by distinctly different kinetic parameters. Analysis of their binding kinetics indicates the importance of base composition in defining DNA epitopes, and shows that some epitopes, such as that recognized by mAb V-88, are expressed on dsDNA and ssDNA, whereas others, as recognized by IV-228, are not. The base preferences of V-88 for ds GC-rich structures over AT-rich, and of IV-228 for ss T-rich structures, also reveal distinct differences between these antibodies. We conclude that the different binding properties of the antibodies will relate to their biological activities. The base preferences of the antibodies suggest that they might be induced by different immunological stimuli, such as those that could be provided by the various DNA fragments and structures released during programmed cell death.

Conformation of the isolated cepsilon3 domain of IgE and its complex with the high-affinity receptor, FcepsilonRI

Immunoglobulin E (IgE) exhibits a uniquely high affinity for its receptor, FcepsilonRI, on the surface of mast cells and basophils. Previous work has implicated the third domain of the constant region of the epsilon-heavy chain (Cepsilon3) in binding to FcepsilonRI, but the smallest fragment of IgE that is known to bind with full affinity is a covalent dimer of the Cepsilon3 and Cepsilon4 domains. We have expressed the isolated Cepsilon3 in Escherichia coli, measured its affinity for FcepsilonRI, and examined its conformation alone and in the complex with FcepsilonRI. Sedimentation equilibrium in the analytical centrifuge reveals that this product is a monomer. The kinetics of binding to an immobilized fragment of the FcepsilonRI alpha-chain, measured by surface plasmon resonance, yields an affinity constant K(a) = 5 x 10(6) M(-)(1), as compared with 4 x 10(9) M(-)(1) for IgE. The circular dichroism spectrum and measurements of fluorescence as a function of the concentration of a denaturant do not reveal any recognizable secondary structure or hydrophobic core. On binding to the FcepsilonRI alpha-chain fragment, there is no change in the circular dichroism spectrum, indicating that the conformation of Cepsilon3 is unchanged in the complex. Thus the isolated Cepsilon3 domain is sufficient for binding to FcepsilonRI, but with lower affinity than IgE. This may be due to the loss of its native immunoglobulin domain structure or to the requirement for two Cepsilon3 domains to constitute the complete binding site for FcepsilonRI or to a combination of these factors.

Cross-reactivity of antiidiotypic antibodies with DNA in systemic lupus erythematosus

OBJECTIVE

To assess the functional relationship between antibodies reactive with DNA and antibodies reactive with the idiotypes (idiopeptides) of anti-DNA antibodies that are associated with systemic lupus erythematosus (SLE) in mice.

METHODS

Antiidiotypic antibodies that appeared spontaneously in lupus mice, and others that were induced by immunization of normal, non-lupus mice, were analyzed for their reactivity by a range of direct binding, competition enzyme-linked immunosorbent assay (ELISA), and surface plasmon resonance (SPR) methods. Their reactions were assessed against synthetic peptides representing sequences of the V(H) region of anti-DNA monoclonal antibody (mAb) V-88, against the native mAb itself, and against mammalian DNA.

RESULTS

In lupus mice, only sera with the highest reactivity against double-stranded DNA (dsDNA) also reacted with idiopeptides in ELISA, and this showed a strong statistical correlation. However, there was no significant relationship between antiidiotypic antibodies and anti-single-stranded DNA antibodies. Immunization of (BALB/c x NZW)F1 mice with idiopeptides p64 (V(H) residues 64-80) or p92 (V(H) residues 92-105) induced antibodies that reacted not only against the respective peptides, but also against the native parent anti-DNA mAb V-88. Furthermore, the immune antiidiopeptide antibodies cross-reacted with dsDNA. Competition SPR experiments with the BIAcore system supported this observation. The binding reaction of V(H) peptide p64 (representing the CDR-H2/FR-H3 region of V-88) with antiidiopeptide antibodies was inhibited by dsDNA.

CONCLUSION

This study identified a unique set of autoantibodies in SLE. They react with both autoantibody idiotopes and with dsDNA, thus having a dual specificity for 2 autoantigens. Because these antiidiotope antibodies arise naturally during the development of lupus disease, and because they bind also to dsDNA, this provides a mechanism whereby the production of anti-dsDNA antibodies is stimulated. These idiotopes on autoantibodies in lupus act as natural mimotopes for inducing anti-dsDNA antibodies, which, due to their dual specificity, may significantly contribute to the pathology of nephritis in SLE.

Solution structure of the proapoptotic molecule BID: a structural basis for apoptotic agonists and antagonists

Members of the BCL2 family of proteins are key regulators of programmed cell death, acting either as apoptotic agonists or antagonists. Here we describe the solution structure of BID, presenting the structure of a proapoptotic BCL2 family member. An analysis of sequence/structure of BCL2 family members allows us to define a structural superfamily, which has implications for general mechanisms for regulating proapoptotic activity. It appears two criteria must be met for proapoptotic function within the BCL2 family: targeting of molecules to intracellular membranes, and exposure of the BH3 death domain. BID's activity is regulated by a Caspase 8-mediated cleavage event, exposing the BH3 domain and significantly changing the surface charge and hydrophobicity, resulting in a change of cellular localization.

Solution structure and dynamics of the bioactive retroviral M domain from Rous sarcoma virus

A biologically active construct of the retroviral M domain from the avian Rous sarcoma virus is defined and its solution structure described. This M domain is fully active in budding and infectivity without myristylation. In spite of a sequence homology level that suggests no relationship among M domains and the family of matrix proteins in mammalian retroviruses, the conserved structural elements of a central core allow an M domain sequence motif to be described for all retroviruses. The surface of the M domain has a highly clustered positive patch comprised of sequentially distant residues. An analysis of the backbone dynamics, incorporating rotational anisotropy, is used to estimate the thermodynamics of proposed domain oligomerization.

Identification of contact residues in the IgE binding site of human FcepsilonRIalpha

The high-affinity receptor for immunoglobulin E (IgE), FcepsilonRI, is an alphabetagamma2 tetramer found on mast cells, basophils, and several other types of immune effector cells. The interaction of IgE with the alpha-subunit of FcepsilonRI is central to the pathogenesis of allergy. Detailed knowledge of the mode of interaction of FcepsilonRI with IgE may facilitate the development of inhibitors for general use in the treatment of allergic disease. To this end we have performed site-directed mutagenesis on a soluble form of the FcepsilonRI alpha-chain (sFcepsilonRIalpha). The effects of four mutations in the second immunoglobulin-like domain of sFcepsilonRIalpha upon the kinetics of binding to IgE and fragments of IgE have been analyzed using surface plasmon resonance. As described in the preceding paper of this issue [Henry, A. J., et al. (1997) Biochemistry 36, 15568-15578], biphasic binding kinetics was observed. Two of the mutations had significant effects on binding: K117D reduced the affinity of sFcepsilonRIalpha for IgE by a factor of 30, while D159K increased the affinity for IgE by a factor of 7, both principally through changes in the rates of dissociation of the slower phase of the interaction. Circular dichroism spectra of sFcepsilonRIalpha incorporating either of these mutations were indistinguishable from those of wild-type sFcepsilonRIalpha, demonstrating that the native conformation had not been disrupted. Our results, together with those from site-directed mutagenesis on fragments of IgE presented in the accompanying paper, define the contact surfaces in the IgE:sFcepsilonRIalpha complex.

Participation of the N-terminal region of Cepsilon3 in the binding of human IgE to its high-affinity receptor FcepsilonRI

The binding of immunoglobulin E (IgE) to its high-affinity receptor (FcepsilonRI) expressed on mast cells and basophils is central to the development of an allergic reaction. Previous studies have implicated the third constant domain of IgE-Fc (Cepsilon3) as the site of the interaction with FcepsilonRI. We have prepared a series of site-directed mutants of human IgE-Fc, particularly focusing on the N-terminal "linker" region and AB loop of Cepsilon3. The kinetics of binding IgE and its Fc fragments to the immobilized receptor were determined by surface plasmon resonance (SPR), and two phases of binding were observed. We identified one mutation in the N-terminal linker region, R334S, that has a dramatic effect on binding. R334S lowers the affinity of IgE-Fc for FcepsilonRI by 120-fold, principally through an increase in the dissociation rate of the slower phase of the interaction. This mutation has a similar effect in Fcepsilon3-4, a truncated form of IgE-Fc which lacks the Cepsilon2 domain pair, and thus it does not exert its effect through altering the quaternary structure of IgE-Fc, firmly implicating Arg334 as a contact residue in the complex. However R334S has no effect on the binding of FcepsilonRII (CD23), the low-affinity receptor for IgE, demonstrating the structural integrity of the mutated IgE-Fc. Circular dichroism spectroscopy and thermal stability studies further indicate that the R334S mutation does not disorder or destabilize the structure of IgE-Fc or Fcepsilon3-4. These results demonstrate the importance of the N-terminal linker region of Cepsilon3 in the interaction of IgE with FcepsilonRI.

Peptide analogs that inhibit IgE-Fc epsilon RI alpha interactions ameliorate the development of lethal graft-versus-host disease

Significant increases in serum levels of IgE have often been observed in allogeneic bone marrow transplantation patients and have generally been thought to be diagnostic of graft-versus-host disease (GVHD), rather than an agent involved in the pathogenesis of the disease. Experimental murine GVHD models have also indicated associations of hyper-IgE activity, yet the role of IgE in GVHD pathogenesis has never been tested directly. In the current study, we have tried to address this issue by using recently developed peptide analog antagonists for the interaction of IgE with the Fc epsilon RI receptor, which is necessary for triggering mast cells and other cell types when cross-linked by antigens. A synthetic cyclized 13-amino acid peptide was previously designed from the modeled C-C' loop region of the Fc epsilon RI alpha-chain and was found to act as a competitive inhibitor of IgE-Fc epsilon RI alpha binding. The peptide was generated in two forms, a cyclic L-(L-IgEtide) and retro D-amino acid composition (rDIgEtide), the latter to increase resistance to protease degradation for in vivo applications. These two inhibitor peptides were then used to test the hypothesis that IgE could be involved in the pathogenesis of acute GVHD, in the B10.D2-->DBA/2 (900 cGy) strain combination, with GVHD directed to minor histocompatibility antigens. Both peptides demonstrated significant inhibition of the development of lethal GVHD, supporting the involvement of IgE at some level of disease pathogenesis.

Structure based design and characterization of peptides that inhibit IgE binding to its high-affinity receptor

We have designed synthetic peptide inhibitors of the interaction between IgE and its high affinity receptor, Fc epsilon RI. The structure of the second domain of CD2 was used as a modelling template for the second alpha-chain domain of Fc epsilon RI, the C-C' loop of which has been implicated in the interaction with IgE. An L-amino acid peptide and a retro-enantiomeric D-amino acid peptide were designed to mimic the conformation of the C-C' region. Both peptides were cyclized by disulphide bond formation between terminal cysteine residues, and show mirror image symmetry by circular dichroism analysis. The C-C' peptide mimics act as competitive inhibitors of IgE binding. The cyclic L- and retro D-peptides exhibited KDs of approximately 3 microM and 11 microM, respectively, for IgE. Further, the peptides inhibit IgE-mediated mast cell degranulation, an in vitro model of an allergic response.

Calreticulin binding affinity for glycosylated laminin

Several lines of evidence indicate that calreticulin has lectin-like properties. As a molecular chaperone, calreticulin binds preferentially to nascent glycoproteins via their immature carbohydrates; this property closely resembles that seen for calnexin, a chaperone with extensive molecular identity to calreticulin. A cell surface form of calreticulin also exhibits lectin-like properties, binding specific oligomannosides including those covalently linked to laminin. In the present study we examined the interaction between calreticulin and laminin by means of surface plasmon resonance. The results show that calreticulin specifically binds to glycosylated laminin but fails to specifically bind tunicamycin-derived unglycosylated laminin or bovine serum albumin. Calreticulin binding to glycosylated laminin requires calcium and is abolished in the presence of EDTA. Scatchard analysis of binding yields an apparent association constant, Ka, of 2.1 +/- 0.9 x 10(6) m-1 while kinetic analysis yields an estimate of the association on rate, (Kassoc), as 2 x 10(5) m-1 s-1. The composite results support calreticulin's lectin-like properties as well as its proposed role in laminin recognition, both in the cell interior and on the cell surface.

Histopathologic changes following irradiation for uveal tract melanoma

Histopathologic studies were performed on 38 eyes in patients with uveal melanoma who had enucleation. Of the 38 eyes examined, enucleation was required in 11 (29%) following episcleral radioactive plaque therapy (RPT), which was performed in 83 patients. The reasons for enucleation in the 11 patients who had RPT were progressive tumor in 5 and treatment complications in 6 eyes. The histologic findings in these 11 patients were compared to those seen in 7 patients (18%) who received a planned course of preoperative external beam radiotherapy (RT) prior to enucleation and with 20 uveal melanoma patients (53%) who were treated with enucleation alone. Tumor necrosis was found in the eyes of patients from all three groups examined. It was, however, seen more frequently and to a greater extent in the 11 RPT patients as compared to the 7 preoperative RT and 20 enucleation alone patients, p = .01. There was no difference in the incidence or extent of tumor necrosis in the 7 preoperative RT patients as compared to the 20 primary enucleation patients, p = .18. In all 3 study groups, no correlation was found between tumor size and necrosis. In the 11 RPT patients, necrosis was independent of cell type and the radiation dose. As expected, the RPT patients had a greater incidence of neovascularization on the iris and scleral necrosis than those of the other two study groups (70 vs. 12.5% and 33 vs 0%, respectively), p = .004. A major effort needs to be made to optimize episcleral RPT in order to reduce treatment complications and increase the incidence of primary tumor control.

A rationally designed CD4 analogue inhibits experimental allergic encephalomyelitis

Experimental allergic encephalomyelitis (EAE) is an acute inflammatory autoimmune disease of the central nervous system that can be elicited in rodents and is the major animal model for the study of multiple sclerosis (MS). The pathogenesis of both EAE and MS directly involves the CD4+ helper T-cell subset. Anti-CD4 monoclonal antibodies inhibit the development of EAE in rodents, and are currently being used in human clinical trials for MS. We report here that similar therapeutic effects can be achieved in mice using a small (rationally designed) synthetic analogue of the CD4 protein surface. It greatly inhibits both clinical incidence and severity of EAE with a single injection, but does so without depletion of the CD4+ subset and without the inherent immunogenicity of antibody. Furthermore, this analogue is capable of exerting its effects on disease even after the onset of symptoms.

Keratitis as a complication of bilateral, simultaneous radial keratotomy

During a one-month period, we examined four patients referred for evaluation of probable microbial keratitis after bilateral, simultaneous radial keratotomy. Each patient had midstromal infiltrates compatible with microbial keratitis that involved one or more of the radial incisions. In two patients the keratitis was bilateral. All patients had been treated empirically with antibiotic agents; superficial cultures with cotton-tipped applicators and corneal scraping by inserting a platinum spatula into the radial incisions were negative. Corneal biopsy of one patient disclosed gram-positive rods and culture of the biopsy specimen grew diphtheroids. The infiltrates gradually resolved over a period of several months with intensive antibiotic therapy. Sight-threatening infectious keratitis can occur after radial keratotomy, and we believe that simultaneous bilateral ocular surgery of any kind should be discouraged.

Keratocyte loss after corneal deepithelialization in primates and rabbits

PURPOSE

To evaluate the response of stromal keratocytes to central corneal deepithelialization.

METHODS

Rabbits and monkeys underwent unilateral mechanical deepithelialization with a blunt instrument and were killed at intervals ranging from 15 minutes to 24 hours after surgery. Two rabbits underwent unilateral deepithelialization under a fluid bath containing corneal preservation medium. Two rabbits were treated unilaterally with corneal preservation medium topically applied every 15 minutes for 16 hours after epithelial removal. Four rabbits underwent linear keratotomy immediately after deepithelialization of the cornea or on normal unoperated corneas and were killed 1 day (two animals) and 14 days (two animals) after surgery.

RESULTS

Deepithelialization resulted in severe ultrastructural changes in keratocytes within 30 minutes after surgery. After 24 hours, the number of keratocytes in the anterior stroma underneath the deepithelialized area had decreased significantly in rabbits (P = .0001) and in monkeys (P = .0007) compared with controls. The wound healing was altered and delayed when the epithelium was not present after keratotomy. The use of storage media during and after deepithelialization minimized the early keratocyte changes and appeared to stimulate reepithelialization.

CONCLUSIONS

Removal of corneal epithelium causes loss of superficial stromal keratocytes in rabbits and monkeys. Keratocyte death may results from osmotic changes that alter the corneal wound healing response.

Holmium laser thermokeratoplasty

PURPOSE

Corneal curvature can be altered by shrinking stromal collagen with a pulsed solid-state holmium: YAG laser in a procedure termed laser thermokeratoplasty.

METHODS

The authors performed laser thermokeratoplasty in 40 human cadaver eyes using a ring pattern of 32 spots, each spot having a diameter of 300 microns.

RESULTS

The amount of induced corneal steepening decreased as ring diameter was increased in 1 mm increments, with 22.2 +/- 3.3 and 3.7 +/- 2.0 diopters (D) of central steepening with diameters of 3 and 7 mm, respectively. Results of histologic examination showed a cone-shaped zone of increased stromal hematoxylin uptake extending posteriorly for 90% of stromal thickness. Energy levels greater than those needed to induce topographic changes produced limited endothelial injury in rabbit corneas and, in some cases, intraocular inflammation. A computerized, finite element model of the globe demonstrated central corneal steepening as a result of heat-induced stromal contraction to a depth of 75% corneal thickness.

CONCLUSIONS

These data support previous studies indicating that central corneal topography can be modified by heating corneal stroma in a controlled fashion with the mid-infrared holmium:YAG laser.

Direct involvement of the CDR3-like domain of CD4 in T helper cell activation

The CD4 glycoprotein, a member of the Ig super-family, has long been known to play an important role in the immunologic activation of Th cells. The precise manner in which CD4 participates in this activation process is not yet understood. In an attempt to further define its role in Th cell activation, we modeled the D1 domain of the murine CD4 protein (L3T4) based on the experimentally determined high resolution structure of the human CD4 protein. Because the D1 domain of CD4 strongly resembles the V kappa chain of an antibody, we addressed the question of whether the CDR-like regions of CD4 are also involved in mediating protein-protein interactions. Consequently, we used the modeled L3T4 structure as a template in the design of conformational mimics of the CDR3-like region (residues 86-94). Only the analog designed to mimic both the sequence and conformation of this region exhibited highly specific inhibition of CD4-dependent responses. Because the inhibitory activity could be localized to the Th cell itself, it appears that this analog acts by uncoupling a CD4 association (independent of an APC) critical to generating a proliferative response.

Direct involvement of the CDR3-like domain of CD4 in T helper cell activation

The CD4 glycoprotein, a member of the Ig super-family, has long been known to play an important role in the immunologic activation of Th cells. The precise manner in which CD4 participates in this activation process is not yet understood. In an attempt to further define its role in Th cell activation, we modeled the D1 domain of the murine CD4 protein (L3T4) based on the experimentally determined high resolution structure of the human CD4 protein. Because the D1 domain of CD4 strongly resembles the V kappa chain of an antibody, we addressed the question of whether the CDR-like regions of CD4 are also involved in mediating protein-protein interactions. Consequently, we used the modeled L3T4 structure as a template in the design of conformational mimics of the CDR3-like region (residues 86-94). Only the analog designed to mimic both the sequence and conformation of this region exhibited highly specific inhibition of CD4-dependent responses. Because the inhibitory activity could be localized to the Th cell itself, it appears that this analog acts by uncoupling a CD4 association (independent of an APC) critical to generating a proliferative response.

Infectious crystalline keratopathy with ring opacity

A 41-year-old physician was treated for 3 months with antiviral medications, antibiotics, and steroids for presumed herpetic keratitis. When seen by us, an annular infiltrate was observed, along with crystalline-like opacities in the superficial one third of the stroma. Cultures of scrapings and of subsequent biopsies were positive for Streptococcus mitis of the viridans group; histopathology demonstrated large aggregates of cocci between the stroma lamellae. Tapering of topical corticosteroids and treatment with topical penicillin resulted in resolution of the infiltrates. The clinical appearance and findings in this patient suggest that infectious crystalline keratitis can produce an annular infiltrate. Injection of the organism into rabbit corneas produced a crystalline infiltrate, but no annular opacity was observed. Corticosteroids altered the clinical and histopathologic appearance of the lesions in rabbits.

Unsuccessful excimer laser phototherapeutic keratectomy. Clinicopathologic correlation

A 46-year-old man underwent phototherapeutic keratectomy with a 193-nm excimer laser in an attempt to remove a superficial corneal scar that had been present for 36 years. The scar proved to be resistant to ablation with the laser, while relatively normal stroma was easily ablated. Histopathologic examination of the corneal button removed 3 months after excimer laser surgery revealed absence of Bowman's membrane in the area of ablation, superficial stromal disorganization and scarring, raised nodules of collagenous tissue extending into the epithelium, and no calcification within the lesion. Ultrastructural examination was remarkable for irregularly oriented collagen fibers within the scar. The resistance of this lesion to excimer laser ablation appears to have been the consequence of marked differences in rates of ablation between normal stroma and the very long-standing scar.

Human papillomavirus DNA in tissues and ocular surface swabs of patients with conjunctival epithelial neoplasia

DNA from human papillomavirus (HPV) type 16 has been recently identified in conjunctival epithelial dysplasia and carcinoma. In other body sites, HPV 16 is thought to play a role in the development of dysplastic lesions. To further explore the relationship between HPV and conjunctival neoplasia, we examined paraffin-embedded tissue samples from 42 biopsies or excisions from 38 patients whose lesions ranged from mild dysplasia to infiltrating squamous carcinoma of the conjunctiva. We also examined limbal swabs from six patients with dysplasia or carcinoma, five of whom also had tissue samples available for study. HPV 16 DNA was present in 37 (88.1%) tissue samples, including duplicate samples from four patients. Five (83.3%) of six patients who had conjunctival swabs had HPV 16 DNA present in the swabs, including two patients whose lesions had been excised one and eight years before swabs were done. We conclude there is a high prevalence of HPV 16 DNA in conjunctival epithelial neoplasia, suggesting that the development of neoplasia is related somehow to the presence of this virus. However, based on its presence in clinically uninvolved eyes and on the persistence of infection many years after successful eradication of the lesions, HPV apparently does not act alone in the development of conjunctival epithelial neoplasia.

Traction retinal detachment due to preretinal proliferation of surface epithelium

A seven-year-old boy sustained severe blunt trauma with globe rupture. After repair of the globe and lensectomy and vitrectomy, a fistula was noted along with epithelial downgrowth on the posterior surface of the cornea. Extensive peripheral preretinal membrane formation resulted in traction retinal detachment. The fistula was excised and the preretinal membranes were removed. Pathologic examination of the membrane revealed it to be composed of surface epithelium. Retinal reattachment was achieved with intravitreal injection of silicone oil. This case illustrates that surface epithelium can proliferate on the inner retina and can lead to tractional retinal detachment.

Fluorescence of blood-stained cornea

Corneal blood staining represents deposition of hemoglobin and its breakdown products within the cornea. Pathologic examination of these corneas typically reveals degenerating endothelial cells and keratocytes. These degenerative changes have typically been attributed to the blunt trauma itself or to toxicity of the erythrocytic debris (a "localized hemosiderosis"). Another possible mechanism for this injury, however, is porphyrin-induced photosensitivity. Examination of frozen sections of an acutely blood-stained human cornea demonstrated fluorescence within all layers of the cornea, similar to that seen with hematoporphyrin derivative. The production of cytotoxic oxygen species within the blood-stained cornea exposed to light may contribute to endothelial and keratocyte degeneration. Limiting light exposure of blood-stained corneas or eyes with hyphemas might theoretically reduce light-induced and porphyrin-mediated toxicity.

Characterization of infectious crystalline keratitis caused by a human isolate of Streptococcus mitis

Streptococcus mitis isolated from a human with infectious crystalline keratitis was injected intrastromally into corneas of adult New Zealand white rabbits that were treated with tetracycline hydrochloride, methylprednisolone acetate, or a combination of tetracycline and methylprednisolone. Animals were followed up for up to 44 days; untreated corneas and those treated with tetracycline developed no disease or "fluffy" stromal infiltrates with overlying epithelial defects representing an abscess. Corneas treated with the combination of tetracycline and corticosteroid usually developed crystalline stromal opacities that on histopathologic examination were shown to be intrastromal aggregates of cocci. Transmission electron microscopy of crystalline lesions within 10 days of infection revealed typical cocci intermixed with a fibrillar material having periodicity characteristic of fibrinogen or fibrin, and immunoperoxidase staining for fibrinogen was positive. By 1 month, electron microscopy revealed aggregates of degenerated bacteria that were surrounded by cellular processes of activated keratocytes. Our studies demonstrate a model for crystalline keratitis in which organisms are seen to reside within the stroma for up to 44 days without an inflammatory response. Periocular corticosteroids appear to be necessary to create this model. It is possible that the organisms are isolated from the host response by fibrin or by keratocytes.

Human papillomavirus type 16 DNA in ocular and cervical swabs of women with genital tract condylomata

Human papillomavirus type 16 is associated with dysplasias and carcinomas of the conjunctiva and of the uterine cervix. To explore the relationship between cervical and ocular human papillomavirus infection, we examined DNA from bilateral limbal swabs and cervical swabs from 17 women (age range, 17 to 46 years; median, 31.7 years) with biopsy-proven human papillomavirus-related cervical dysplasia who had a normal ocular surface. Using polymerase chain reaction, we identified human papillomavirus 16 DNA in one or both eyes of 13 (76.5%) patients, six (46.2%) of whom had demonstrable human papillomavirus 16 DNA in cervical swabs as well. It thus appears that human papillomavirus 16 is present in the conjunctivae of some patients with human papillomavirus-related genital warts who have no ocular manifestations of infection. Although autoinoculation of conjunctiva may be the source of some ocular human papillomavirus, data suggest that other modes of transmission to the eye also exist. Additional study of the epidemiologic characteristics of ocular human papillomavirus, a widely prevalent virus known to be associated with dysplasias/atypias and cancer, is warranted.

HMB-45 immunohistochemical staining of conjunctival melanocytic lesions

HMB-45 is a monoclonal antibody recently described as being highly specific for melanocytic proliferations of the skin and in metastases of melanotic lesions. To determine a possible role for HMB-45 in ophthalmic pathology, 45 conjunctival lesions, including 23 melanomas, were analyzed using immunohistochemical techniques with anti-S-100 and HMB-45 as primary antibodies. Nineteen (82.6%) of the melanomas exhibited HMB-45 positivity, and 19 (82.6%) contained S-100 protein, with concordance of all but two cases. Seven cases of primary acquired melanosis were studied; one (33%) of three with atypia was HMB-45 positive, as were two (50%) of four without atypia. Among nevi, 1 (9.1%) of 11 showed faint staining with HMB-45. Fifteen conjunctival epithelial dysplasias were negative with HMB-45. At present, HMB-45 appears to offer no great advantage over S-100 protein in the analysis of conjunctival melanomas. Its role in the distinction of benign from atypical or malignant junctional melanocytic proliferations remains unclear.

Percutaneous bone marrow grafting of delayed union and nonunion in cancer patients

Bone marrow is a source of osteoprogenitor cells that are key elements in the process of bone formation and fracture healing. Eight patients with primary sarcomas treated by extensive en bloc resections and reconstruction using internal fixation who developed delayed unions or nonunions were treated by injection of autogeneic bone marrow into the site of failed healing. Five of the eight patients received chemotherapy, with one patient receiving radiation therapy in addition. Bone formation was noted in seven patients after injection. Union was achieved in five of the patients. These results, obtained in difficult clinical circumstances, are encouraging and suggest that autogeneic bone marrow grafting is a useful technique in the treatment of delayed unions and nonunions and warrant further clinical studies.

Conjunctival pterygia. Mechanism of corneal topographic changes

Pterygia induce irregular corneal astigmatism that sometimes necessitates surgical removal before the lesion has advanced close to the visual axis. This astigmatism may occur either due to traction generated by the pterygium mechanically pulling on and distorting the cornea, or by the pooling of tears in advance of the pterygium, or both. To evaluate the effect of localized tear pooling on pterygium-induced astigmatism, corneoscope photographs were obtained before and after absorbing excess tears at the pterygium-corneal interface with a cellulose sponge. Pterygia from these patients were then excised and examined with transmission electron microscopy for the presence of myofibroblasts. The absence of myofibroblasts in these lesions as well as the alterations in corneoscopy induced by localized removal of tears at the advancing edge of the pterygia suggest that corneal distortion in the presence of pterygia is caused in part by local changes in the tear film.

Human papillomavirus DNA in a recurrent squamous carcinoma of the eyelid

The polymerase chain reaction (PCR) is a molecular technique that amplifies specific target DNA sequences in vitro to facilitate identification of DNA. We have applied the PCR to a recurrent infiltrating, well-differentiated squamous carcinoma from the right lower eyelid of a 37-year-old woman. With primers specific for human papillomavirus (HPV) type 16 DNA, PCR yielded a single band of amplified DNA product. The product was positive, with a radiolabeled HPV type 16 probe on dot blot analysis. The presence of HPV type 16 viral DNA in this recurrent squamous carcinoma of the eyelid has implications with regard to the possible origin, treatment, and prognosis of the tumor.

Conjunctival melanocytic lesions in children

Seventy-one conjunctival melanocytic proliferations in patients 20 years of age or younger were examined. Sixty-five (91.5%) were nevi; there were three cases (4.2%) of racial or acquired melanosis, and three patients were identified who had malignant melanoma of the conjunctiva. The melanoma patients are presented in detail, and additional cases of conjunctival melanoma in children and adolescents reported in the literature are reviewed to determine factors that might influence prognosis. The number of cases is so small, however, that factors cannot be identified with confidence. Follow-up data are presented. Conjunctival nevi are relatively common in children, and appear to carry no risk for the development of melanoma during childhood. However, -conjunctival melanomas do occur rarely in children and have a variable prognosis.

DNA of human papillomavirus type 16 in dysplastic and malignant lesions of the conjunctiva and cornea

Human papillomaviruses are receiving attention for their role in the pathogenesis of cancer, especially cancer of the anogenital tract. Although strains of human papillomavirus are associated with benign lesions of the conjunctiva, their association with conjunctival dysplastic lesions and carcinomas has remained unclear. We examined a group of neoplastic lesions of the conjunctiva for the presence of DNA sequences for human papillomavirus types 16 and 18, using in vitro gene amplification with the polymerase chain reaction. Tissue specimens of five conjunctival dysplastic lesions and one invasive carcinoma and swab specimens of the mucosa of both corneas of a patient with unilateral corneal dysplasia contained DNA sequences related to human papillomavirus type 16. All dysplastic specimens examined were positive for DNA sequences. Viral DNA was not detected in six control specimens from patients with conjunctival melanoma, papilloma, nevus, or pterygium. We conclude that DNA from human papillomavirus type 16 is present in a substantial percentage of conjunctival premalignant and malignant lesions. It may play a part in the development of conjunctival dysplasia and carcinoma, as it does in cancers of certain other body sites.

Fucosidosis: ultrastructural study of the eye in an adult

The ocular histopathological and ultrastructural features of fucosidosis in a man who survived to the age of 25 years are reported. Virtually all of the cells of the eye contained cytoplasmic, membrane-bound, and confluent areas of fibrillogranular and multilaminated material. The most striking accumulations were present within the endothelial cells lining blood vessels and corneal endothelium, and the least amount was present in the uveal melanocytes.

Detection of human papillomavirus type 6/11 DNA in conjunctival papillomas by in situ hybridization with radioactive probes

Twenty-three conjunctival papillomas and 28 conjunctival dysplasias were examined for human papillomavirus (HPV)-DNA sequences by in situ hybridization with nick-translated 35S-labeled HPV probes. Adjacent paraffin sections were hybridized with HPV type 2, 6, 16, and 18 probes at Tm - 17 degrees C. Fifteen tissues, all papillomas, displayed positive hybridization with the HPV-6 probe. Infection with HPV-6 (or the closely related HPV-11) appeared to be responsible for most of the conjunctival papillomas of children and young adults. The presence of genital tract HPV-6 in these lesions suggests that some of the infections were acquired during passage through an infected birth canal. The lack of hybridization in adult conjunctival dysplasias indicates either that HPVs are not associated with this condition or that the probes and the technique utilized were not adequate for demonstration of this association.

Common leukocyte antigen staining of a primitive sarcoma

A 4-year-old boy presented with symptoms of tracheal obstruction and was found to have a polypoid tracheal mass, which was studied by biopsy. Light microscopy showed a tumor composed of small cells with round to oval dark nuclei, clumped chromatin, one to two nucleoli, and small, variable amounts of indistinct pink cytoplasm. In other areas the tumor had a loose, spindle appearance, with some cells showing more elongated nuclei, and fibrillar pink cytoplasm consistent with strap cells. Cross striations were not found. Electron microscopy showed desmosomes and 7 to 10 nm cytoplasmic filaments forming dense bodies. The findings are most consistent with a primitive sarcoma, probably rhabdomyosarcoma. Immunoperoxidase with three monoclonal antibodies for common leukocyte antigen showed diffuse membraneous staining with fresh-frozen tissue. All other lymphocyte and monocyte marker studies were negative. We believe that this case of anticommon leukocyte antigen staining, a rhabdomyosarcoma, represents the first report of a false positive reaction with monoclonal antibody to common leukocyte antigen.

Demonstration of papillomavirus capsid antigen in human conjunctival neoplasia

To investigate the association of human papillomavirus with conjunctival neoplasia, we identified 50 resected papillomas from 47 patients. Papillomas were composed of papillary or, less commonly, flat proliferations of predominantly nonkeratinizing squamous epithelium with admixed goblet cells. Koilocytosis was focally present in 30 tumors (60%). Atypia that ranged from mild to severe was present in ten lesions (20%). In addition, we examined specimens of conjunctival dysplasia or carcinoma from 61 patients. The lesions were predominantly flat proliferations of atypical epithelial cells. Twenty biopsies performed for suspected sarcoidosis were used as controls. Papillomavirus capsid antigen was demonstrated using an immunoperoxidase technique in nuclei of mature superficial epithelial cells of 23 papillomas (46%) and five dysplasias or carcinomas (8.2%) but not in the control biopsy specimens. These results suggest that papillomavirus may play a role in the etiology of conjunctival papilloma, dysplasia, and carcinoma.

Genital tract papillomavirus type 6 in recurrent conjunctival papilloma

An infant boy born of a mother who had condylomata (genital warts) during pregnancy and at delivery developed recurrent conjunctival papillomas and papillomas on the soft palate and the false vocal cords. A conjunctival lesion was first noticed by the mother when the infant was 4 months old and was excised and histologically diagnosed as a papilloma when he was 11 months old. The DNA sequences of genital tract human papillomavirus type 6 (HPV-6) were identified in conjunctival papilloma tissue by Southern transfer hybridization of tissue DNA extracted from a lesion excised at 29 months of age as well as by in situ hybridization of paraffin sections of the diagnostic biopsy specimen obtained at 11 months of age. It is probable that the infant acquired conjunctival infection from the mother, very likely during passage through the infected birth canal.