Fragile X Mental Retardation Protein and Cerebral Expression of Metabotropic Glutamate Receptor Subtype 5 in Men with Fragile X Syndrome: A Pilot Study

Multiple lines of evidence suggest that a deficiency of Fragile X Mental Retardation Protein (FMRP) mediates dysfunction of the metabotropic glutamate receptor subtype 5 (mGluR5) in the pathogenesis of fragile X syndrome (FXS), the most commonly known single-gene cause of inherited intellectual disability (ID) and autism spectrum disorder (ASD). Nevertheless, animal and human studies regarding the link between FMRP and mGluR5 expression provide inconsistent or conflicting findings about the nature of those relationships. Since multiple clinical trials of glutamatergic agents in humans with FXS did not demonstrate the amelioration of the behavioral phenotype observed in animal models of FXS, we sought measure if mGluR5 expression is increased in men with FXS to form the basis for improved clinical trials. Unexpectedly marked reductions in mGluR5 expression were observed in cortical and subcortical regions in men with FXS. Reduced mGluR5 expression throughout the living brains of men with FXS provides a clue to examine FMRP and mGluR5 expression in FXS. In order to develop the findings of our previous study and to strengthen the objective tools for future clinical trials of glutamatergic agents in FXS, we sought to assess the possible value of measuring both FMRP levels and mGluR5 expression in men with FXS. We aimed to show the value of measurement of FMRP levels and mGluR5 expression for the diagnosis and treatment of individuals with FXS and related conditions. We administered 3-[18F]fluoro-5-(2-pyridinylethynyl)benzonitrile ([18F]FPEB), a specific mGluR5 radioligand for quantitative measurements of the density and the distribution of mGluR5s, to six men with the full mutation (FM) of FXS and to one man with allele size mosaicism for FXS (FXS-M). Utilizing the seven cortical and subcortical regions affected in neurodegenerative disorders as indicator variables, adjusted linear regression of mGluR5 expression and FMRP showed that mGluR5 expression was significantly reduced in the occipital cortex and the thalamus relative to baseline (anterior cingulate cortex) if FMRP levels are held constant (F(7,47) = 6.84, p < 0.001).These findings indicate the usefulness of cerebral mGluR5 expression measured by PET with [18F]FPEB and FMRP values in men with FXS and related conditions for assessments in community facilities within a hundred-mile radius of a production center with a cyclotron. These initial results of this pilot study advance our previous study regarding the measurement of mGluR5 expression by combining both FMRP levels and mGluR5 expression as tools for meaningful clinical trials of glutamatergic agents for men with FXS. We confirm the feasibility of this protocol as a valuable tool to measure FMRP levels and mGluR5 expression in clinical trials of individuals with FXS and related conditions and to provide the foundations to apply precision medicine to tailor treatment plans to the specific needs of individuals with FXS and related conditions.

Cerebral Expression of Metabotropic Glutamate Receptor Subtype 5 in Idiopathic Autism Spectrum Disorder and Fragile X Syndrome: A Pilot Study

Multiple lines of evidence suggest that dysfunction of the metabotropic glutamate receptor subtype 5 (mGluR5) plays a role in the pathogenesis of autism spectrum disorder (ASD). Yet animal and human investigations of mGluR5 expression provide conflicting findings about the nature of dysregulation of cerebral mGluR5 pathways in subtypes of ASD. The demonstration of reduced mGluR5 expression throughout the living brains of men with fragile X syndrome (FXS), the most common known single-gene cause of ASD, provides a clue to examine mGluR5 expression in ASD. We aimed to (A) compare and contrast mGluR5 expression in idiopathic autism spectrum disorder (IASD), FXS, and typical development (TD) and (B) show the value of positron emission tomography (PET) for the application of precision medicine for the diagnosis and treatment of individuals with IASD, FXS, and related conditions. Two teams of investigators independently administered 3-[18F]fluoro-5-(2-pyridinylethynyl)benzonitrile ([18F]FPEB), a novel, specific mGluR5 PET ligand to quantitatively measure the density and the distribution of mGluR5s in the brain regions, to participants of both sexes with IASD and TD and men with FXS. In contrast to participants with TD, mGluR5 expression was significantly increased in the cortical regions of participants with IASD and significantly reduced in all regions of men with FXS. These results suggest the feasibility of this protocol as a valuable tool to measure mGluR5 expression in clinical trials of individuals with IASD and FXS and related conditions.

Reduced Expression of Cerebral Metabotropic Glutamate Receptor Subtype 5 in Men with Fragile X Syndrome

Glutamatergic receptor expression is mostly unknown in adults with fragile X syndrome (FXS). Favorable behavioral effects of negative allosteric modulators (NAMs) of the metabotropic glutamate receptor subtype 5 (mGluR5) in fmr1 knockout (KO) mouse models have not been confirmed in humans with FXS. Measurement of cerebral mGluR5 expression in humans with FXS exposed to NAMs might help in that effort. We used positron emission tomography (PET) to measure the mGluR5 density as a proxy of mGluR5 expression in cortical and subcortical brain regions to confirm target engagement of NAMs for mGluR5s. The density and the distribution of mGluR5 were measured in two independent samples of men with FXS (N = 9) and typical development (TD) (N = 8). We showed the feasibility of this complex study including MRI and PET, meaning that this challenging protocol can be accomplished in men with FXS with an adequate preparation. Analysis of variance of estimated mGluR5 expression showed that mGluR5 expression was significantly reduced in cortical and subcortical regions of men with FXS in contrast to age-matched men with TD.

Dataset of quantitative structured office measurements of movements in the extremities

A low-cost quantitative structured office measurement of movements in the extremities of people with Parkinson's disease [1,2] was performed on people with Parkinson's disease, multiple system atrophy, and age-matched healthy volunteers. Participants underwent twelve videotaped procedures rated by a trained examiner while connected to four accelerometers [1,2] generating a trace of the three location dimensions expressed as spreadsheets [3,4]. The signals of the five repetitive motion items [1,2] underwent processing to fast Fourier [5] and continuous wavelet transforms [6]. The dataset [7] includes the coding form with scores of the live ratings [1,2], the raw files [3], the converted spreadsheets [4], and the fast Fourier [5] and continuous wavelet transforms [6]. All files are unfiltered. The data also provide findings suitable to compare and contrast with data obtained by investigators applying the same procedure to other populations. Since this is an inexpensive procedure to quantitatively measure motions in Parkinson's disease and other movement disorders, this will be a valuable resource to colleagues, particularly in underdeveloped regions with limited budgets. The dataset will serve as a template for other investigations to develop novel techniques to facilitate the diagnosis, monitoring, and treatment of Parkinson's disease, other movement disorders, and other nervous and mental conditions. The procedure will provide the basis to obtain objective quantitative measurements of participants in clinical trials of new agents.

Rapid phenotypic evolution following shifts in life cycle complexity

Life cycle strategies have evolved extensively throughout the history of metazoans. The expression of disparate life stages within a single ontogeny can present conflicts to trait evolution, and therefore may have played a major role in shaping metazoan forms. However, few studies have examined the consequences of adding or subtracting life stages on patterns of trait evolution. By analysing trait evolution in a clade of closely related salamander lineages we show that shifts in the number of life cycle stages are associated with rapid phenotypic evolution. Specifically, salamanders with an aquatic-only (paedomorphic) life cycle have frequently added vertebrae to their trunk skeleton compared with closely related lineages with a complex aquatic-to-terrestrial (biphasic) life cycle. The rate of vertebral column evolution is also substantially lower in biphasic lineages, which may reflect the functional compromise of a complex cycle. This study demonstrates that the consequences of life cycle evolution can be detected at very fine scales of divergence. Rapid evolutionary responses can result from shifts in selective regimes following changes in life cycle complexity.

Targeting the undruggable: immunotherapy meets personalized oncology in the genomic era

Owing to recent advances in genomic technologies, personalized oncology is poised to fundamentally alter cancer therapy. In this paradigm, the mutational and transcriptional profiles of tumors are assessed, and personalized treatments are designed based on the specific molecular abnormalities relevant to each patient's cancer. To date, such approaches have yielded impressive clinical responses in some patients. However, a major limitation of this strategy has also been revealed: the vast majority of tumor mutations are not targetable by current pharmacological approaches. Immunotherapy offers a promising alternative to exploit tumor mutations as targets for clinical intervention. Mutated proteins can give rise to novel antigens (called neoantigens) that are recognized with high specificity by patient T cells. Indeed, neoantigen-specific T cells have been shown to underlie clinical responses to many standard treatments and immunotherapeutic interventions. Moreover, studies in mouse models targeting neoantigens, and early results from clinical trials, have established proof of concept for personalized immunotherapies targeting next-generation sequencing identified neoantigens. Here, we review basic immunological principles related to T-cell recognition of neoantigens, and we examine recent studies that use genomic data to design personalized immunotherapies. We discuss the opportunities and challenges that lie ahead on the road to improving patient outcomes by incorporating immunotherapy into the paradigm of personalized oncology.

Distribution, abundance, and genetic diversity of Clinostomum spp. metacercariae (Trematoda:Digenea) in a modified Ozark stream system

Land-use alterations can have profound influences on faunal distributions, including host-parasite relationships. Yellow grub trematodes ( Clinostomum spp.) have complex life cycles involving 3 hosts: a snail, a fish or amphibian, and a bird. Here, we analyze the distribution, prevalence, intensity, abundance, and genetic diversity of encysting metacercariae of Clinostomum spp. in salamanders and fishes throughout an aquatic system that includes a natural Ozark stream and man-made ponds. We found Clinostomum sp. infecting permanently aquatic Oklahoma salamanders ( Eurycea tynerensis ; 56% prevalence) and larval grotto salamanders ( Eurycea spelaea ) immediately downstream from a man-made pond. However, Clinostomum sp. did not infect any salamanders in the spring that supplies this pond, or in sections farther downstream (~0.5 and 2 km). Metacercariae of Clinostomum sp. were present in ~90% of introduced largemouth bass ( Micropterus salmoides ) in the man-made pond adjunct to the stream. Morphological examination and phylogenetic analyses based on the mitochondrial gene cytochrome oxidase 1 ( Co1 ) and the nuclear ribosomal gene 18S show that fishes and salamanders at this site are primarily infected with Clinostomum marginatum . There is a relatively high degree of mitochondrial haplotype diversity in C. marginatum at this site but no consistent genetic difference between parasites in largemouth bass from the man-made pond and those in salamanders from the stream. Based on the microgeographic distribution and relationships of metacercariae of C. marginatum at this site, we hypothesize that the adjunct man-made pond has created an ecological situation that brings the cercariae of this parasite into contact with novel stream salamander hosts.

A new approach for assessing early osteoarthritis in the rat

Several animal models have been developed to investigate osteoarthritis and potential disease-modifying therapeutics. However, early disease data from these models are limited by the resolution of current imaging modalities. In this in-vitro study, an optical coherence tomography (OCT) system with an axial resolution of 15 micro m was used to track sequential changes in osteoarthritic rat knees. Osteoarthritis was induced via transection of the medial collateral ligament and an artificial full thickness meniscal tear. Imaging occurred at one, two, and three weeks after surgery. OCT successfully detected early signs of osteoarthritic change, including alteration of the cartilage surface and disruption of the bone-cartilage interface. This study demonstrates that OCT, along with the induction of mechanical injury, provides an excellent model for monitoring the sequential changes of osteoarthritis.

Dynamic lateral patellar tilt in the anterior cruciate ligament-deficient knee. A magnetic resonance imaging analysis

An open-configuration magnetic resonance imaging scanner was used to document patellar tracking abnormalities in 11 anterior cruciate ligament-injured knees. The contralateral normal knees were used as controls. Images were obtained with the quadriceps muscles at rest (knee flexion at 40 degrees, 25 degrees, and 10 degrees) and with the quadriceps muscles contracted (knee flexion at 40 degrees and 25 degrees). When the quadriceps muscles were at rest there were no differences in patellar alignment between the anterior cruciate ligament-injured knees and the contralateral normal knees. When the quadriceps muscles were maximally contracted at 40 degrees of flexion, the patellae of the anterior cruciate ligament-injured knees tilted laterally 3.6 degrees relative to the resting state. When the quadriceps muscles were contracted at 25 degrees of flexion, the patellae of the anterior cruciate ligament-injured knees tilted laterally approximately 4 degrees relative to the resting state. Quadriceps-active lateral patellar tilt at 25 degrees of flexion was greater in the anterior cruciate ligament-injured knees than in the contralateral normal knees, and it correlated with instrumented measurements of anterior tibial translation. Dynamic lateral patellar tilt during open kinetic chain exercises and during other activities that produce anterior tibial translation may contribute to extensor mechanism dysfunction in the anterior cruciate ligament-injured knee.

Brain blood flow changes in depressed patients treated with interpersonal psychotherapy or venlafaxine hydrochloride: preliminary findings

BACKGROUND

Functional brain imaging studies in major depression have suggested abnormalities of areas, including the frontal cortex, cingulate gyrus, basal ganglia, and temporal cortex. We hypothesized that venlafaxine hydrochloride and interpersonal psychotherapy (IPT) might each alter brain blood flow in some or all of these areas on sequential single photon emission computed tomography (SPECT) scans.

METHODS

Twenty-eight men and women aged 30 to 53 years with a DSM-IV major depressive episode, a 17-item Hamilton Rating Scale for Depression (HAM-D) rating of 18 or higher, and antidepressant-naive for at least 6 months were studied. After baseline (99m)technetium-hexa-methyl-propylene-amine-oxime scan, 1-T magnetic resonance imaging, and psychometric ratings, patients were assigned to different treatments. Thirteen patients had 1-hour weekly sessions of IPT from the same supervised therapist (E.M.). Fifteen patients took 37.5 mg twice-daily of venlafaxine hydrochloride. Single-photon emission computed tomography scans and ratings were repeated at 6 weeks.

RESULTS

Both treatment groups improved substantially, more so with venlafaxine (mean [SD] HAM-D scores at pretreatment: IPT, 22.7 [2.7], and venlafaxine, 22.4 [3.1]; and posttreatment: IPT, 16.2 [7.1], and venlafaxine, 10.9 [8.6]). No patients had structural brain abnormalities. On analysis with statistical parametric mapping 96, the venlafaxine group showed right posterior temporal and right basal ganglia activation (P =.01), while the IPT group had limbic right posterior cingulate and right basal ganglia activation (P =.01).

CONCLUSIONS

This preliminary investigation has shown limbic blood flow increase with IPT yet not venlafaxine, while both treatments demonstrated increased basal ganglia blood flow. This was, however, a short trial with a small sample, no control group, and different symptom reduction in the 2 groups.

Distribution of smooth muscle actin-containing cells in the human meniscus

This is the first report of a contractile actin isoform, a-smooth muscle actin (SMA), in the cells of the human meniscus that lacked meniscal tears based on gross anatomical appearance. Approximately 25% of the cells in the tissue contained SMA by immunohistochemistry. Most of the SMA-positive cells were chondrocytic in morphology.

Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression

BACKGROUND

Arthroscopic subacromial decompression and arthroscopic resection of the acromioclavicular joint as separate procedures have been well documented. However, there is little information on the success rate of resection with concomitant decompression. In this study, we retrospectively evaluated the results of a consecutive group of patients who underwent arthroscopic resection of the acromioclavicular joint with concomitant subacromial decompression.

METHODS

We evaluated the surgical results in thirty-one consecutive patients (thirty-two shoulders) with acromioclavicular pathology with concomitant subacromial impingement. The mean age of the patients at the time of surgery was thirty-six years (range, eighteen to sixty-seven years). Twenty-five patients, including four professional athletes, were actively involved in sports activities. The mean duration of follow-up was four years and ten months (range, three to eight years). The follow-up examination included clinical evaluation, chart review, radiographic analysis, and isokinetic testing of both upper extremities.

RESULTS

Of the twenty-five patients who participated in sports, twenty-two (including the four professional athletes) returned to their previous level of sports activity. Twenty-six patients had no pain, three reported mild pain on strenuous repetitive overhead activity, two (both weight-lifters) had occasional pain in the acromioclavicular joint and the lateral aspect of the shoulder with bench-pressing, and two (both baseball players) had mild pain in the posterior aspect of the shoulder with throwing. All of the patients were satisfied with the results. In the absence of a complete rotator cuff tear, isokinetic strength-testing of both upper extremities failed to demonstrate any weakness of the involved shoulder. The mean functional score for individual activities was 2.7 points (range, 2.1 to 3.0 points) preoperatively and 3.9 points (range, 3.6 to 4.0 points) postoperatively (p = 0.0001). No patient had superior migration of the clavicle. The amount of distal clavicular resection averaged 9 mm (range, 7 to 15 mm). One patient had heterotopic ossification at the resection site, with mild pain on direct palpation of the acromioclavicular joint and on strenuous overhead activity. Five patients had calcification at the anterior deltoid insertion into the acromion that was asymptomatic, with no impingement on overhead activity and no pain on direct palpation.

CONCLUSIONS

We found excellent results with arthroscopic resection of the acromioclavicular joint and concomitant subacromial decompression. When this procedure is performed on properly selected patients, the results are similar to those of an open approach.

Histological changes in the human anterior cruciate ligament after rupture

BACKGROUND

Four phases in the response to injury of the ruptured human anterior cruciate ligament are observed histologically; these include an inflammatory phase, an epiligamentous repair phase, a proliferative phase, and a remodeling phase. One objective of this study was to describe the histological changes that occur in the ruptured human anterior cruciate ligament during these phases. Myofibroblast-like cells that contain alpha-smooth muscle actin are present in the midsubstance of the intact human anterior cruciate ligament. A second objective of this study was to determine whether an increased number of myofibroblast-like cells is found in the midsubstance of the ruptured human anterior cruciate ligament because it was thought that those cells might be responsible in part for the retraction of the ruptured anterior cruciate ligament. In the early phase of this study, it was found that the number of myofibroblast-like cells in the midsubstance of the ruptured anterior cruciate ligament was actually decreased, and this hypothesis was abandoned. During the epiligamentous repair phase, synovial tissue was formed that covered the ends of the ruptured anterior cruciate ligament. Most of the synovial lining cells were myofibroblast-like cells that contained alpha-smooth muscle actin. The primary objective of this study was to determine the location and the characteristics of the alpha-smooth muscle actin-containing myofibroblast-like cells that appear in the human anterior cruciate ligament following rupture.

METHODS

Twenty-three ruptured and ten intact human anterior cruciate ligaments were evaluated for cellularity, nuclear morphology, blood vessel density, and percentage of cells containing a contractile actin isoform, alpha-smooth muscle actin. The histological features of the synovial and epiligamentous tissues were also described.

RESULTS

At no time after rupture was there evidence of tissue-bridging between the femoral and tibial remnants of the anterior cruciate ligament. The ruptured ligaments demonstrated a time-dependent histological response, which consisted of inflammatory cell infiltration up to three weeks, gradual epiligamentous repair and resynovialization between three and eight weeks, and neovascularization and an increase in cell number density between eight and twenty weeks. Compared with the intact ligaments, there was a decrease in the percentage of myofibroblast-like cells containing alpha-smooth muscle actin within the remnant of the ligament. However, many of the epiligamentous and synovial cells encapsulating the remnants contained alpha-smooth muscle actin.

CONCLUSIONS

After rupture, the human anterior cruciate ligament undergoes four histological phases, consisting of inflammation, epiligamentous regeneration, proliferation, and remodeling. The response to injury is similar to that reported in other dense connective tissues, with three exceptions: formation of an alpha-smooth muscle actin-expressing synovial cell layer on the surface of the ruptured ends, the lack of any tissue bridging the rupture site, and the presence of an epiligamentous reparative phase that lasts eight to twelve weeks. Other characteristics reported in healing dense connective tissue, such as fibroblast proliferation, expression of alpha-smooth muscle actin, and revascularization, also occur in the ruptured human anterior cruciate ligament.

CLINICAL RELEVANCE

Unlike extra-articular ligaments that heal after injury, the human intra-articular anterior cruciate ligament forms a layer of synovial tissue over the ruptured surface, which may impede repair of the ligament. Moreover, a large number of cells in this synovial layer and in the epiligamentous tissue express the gene for a contractile actin isoform, alpha-smooth muscle actin, thus differentiating into myofibroblasts. These events may play a role in the retraction and lack of healing of the ruptured anterior cruciate ligament.

Outgrowth of chondrocytes from human articular cartilage explants and expression of alpha-smooth muscle actin

The objectives of this study were to investigate the effect of various enzymatic treatments on the outgrowth of chondrocytes from explants of adult human articular cartilage and the expression of a specific contractile protein isoform, alpha-smooth muscle actin, known to facilitate wound closure in other connective tissues. Explants of articular cartilage were prepared from specimens obtained from patients undergoing total joint arthroplasty. The time to cell outgrowth in vitro was determined and the expression of alpha-smooth muscle actin shown by immunohistochemistry. Treatment of the explants with collagenase for 15 minutes reduced the time to outgrowth from more than 30 days to 3 days. Hyaluronidase, chondroitinase ABC, and trypsin applied for the 15-minute period had no effect on the time to cell outgrowth when compared with untreated controls. Pretreatment with hyaluronidase prior to collagenase reduced the time to outgrowth. A notable finding of this study was that the majority of chondrocytes in the adult human articular cartilage specimens and virtually all of the outgrowing cells contained alpha-smooth muscle actin. We conclude that human articular chondrocytes have the capability to migrate through enzymatically degraded matrix and express a contractile actin isoform. Collagenase treatment reduces the time required for cell outgrowth.

Effects of harvest and selected cartilage repair procedures on the physical and biochemical properties of articular cartilage in the canine knee

This study utilizes a canine model to quantify changes in articular cartilage 15-18 weeks after a knee joint is subjected to surgical treatment of isolated chondral defects. Clinical and experimental treatment of articular cartilage defects may include implantation of matrix materials or cells, or both. Three cartilage repair methods were evaluated: microfracture, microfracture and implantation of a type-II collagen matrix, and implantation of an autologous chondrocyte-seeded collagen matrix. The properties of articular cartilage in other knee joints subjected to harvest of articular cartilage from the trochlear ridge (to obtain cells for the cell-seeded procedure) were also evaluated. Physical properties (thickness, equilibrium compressive modulus, dynamic compressive stiffness, and streaming potential) and biochemical composition (hydration, glycosaminoglycan content, and DNA content) of the cartilage from sites distant to the surgical treatment were compared with values measured for site-matched controls in untreated knee joints. No significant differences were seen in joints subjected to any of the three cartilage repair procedures. However, a number of changes were induced by the harvest operation. The largest changes (displaying up to 3-fold increases) were seen in dynamic stiffness and streaming potential of patellar groove cartilage from joints subjected to the harvest procedure. Whether the changes reported will lead to osteoarthritic degeneration is unknown, but this study provides evidence that the harvest procedure associated with autologous cell transplantation for treatment of chondral defects may result in changes in the articular cartilage in the joint.

Healing of canine articular cartilage defects treated with microfracture, a type-II collagen matrix, or cultured autologous chondrocytes

The effects of three different treatments on the healing of articular cartilage defects were compared with use of a previously developed canine model. In the articular surface of the trochlear grooves of 12 adult mongrel dogs, two 4-mm-diameter defects were made to the depth of the tidemark. Four dogs were assigned to each treatment group: (a) microfracture treatment, (b) microfracture with a type-II collagen matrix placed in the defect, and (c) type-II matrix seeded with cultured autologous chondrocytes. After 15 weeks, the defects were studied histologically. Data quantified on histological cross sections included areal or linear percentages of specific tissue types filling the defect, integration of reparative tissue with the calcified and the adjacent cartilage, and integrity of the subchondral plate. Total defect filling (i.e., the percentage of the cross-sectional area of the original defect filled with any type of reparative tissue) averaged 56-86%, with the greatest amount found in the dogs in the microfracture group implanted with a type-II collagen matrix. The profiles of tissue types for the dogs in each treatment group were similar: the tissue filling the defect was predominantly fibrocartilage, with the balance being fibrous tissue. There were no significant differences in the percentages of the various tissue types among dogs in the three groups.

Migration of cells from human anterior cruciate ligament explants into collagen-glycosaminoglycan scaffolds

Regeneration of the human anterior cruciate ligament after complete rupture offers several theoretical advantages over reconstruction, including maintenance of the complex insertion sites and fan-shape of the ligament and preservation of remaining proprioceptive fibers within the ligament substance. Well vascularized connective tissues, such as dermis, heal as a result of migration of fibroblasts into a provisional scaffold, the fibrin clot. Wound closure is subsequently facilitated by a contractile cell phenotype. This study was designed to determine if fibroblasts intrinsic to the human anterior cruciate ligament were capable of migrating from their native extracellular matrix onto an adjacent provisional scaffold in vitro. Another objective was to determine whether any of the cells that successfully migrated into the scaffold expressed the contractile actin isoform, alpha-smooth muscle actin, associated with wound contraction in other tissues. The results demonstrated that the cells intrinsic to the human anterior cruciate ligament were able to migrate into a collagen-glycosaminoglycan scaffold, bridging a gap between transected fascicles in vitro. As a result of this cell migration and proliferation, areas in the scaffold contained cell number densities similar to those seen in the human anterior cruciate ligament in vivo. No extracellular matrix or tissue formation was seen in the gap between directly apposed transected ends of the anterior cruciate ligament explants cultured without an interposed collagen-glycosaminoglycan scaffold. The fascicle-collagen-glycosaminoglycan-fascicle constructs and the fascicle-fascicle explants displayed minimal adherence after 6 weeks in culture. Any disruption in the contact area between explant and scaffold, even as small a gap as 50 microm, prevented cell migration from the explant to the collagen-glycosaminoglycan scaffold at the area of loss of contact. All cells that migrated into the scaffold at early time periods expressed the alpha-smooth muscle actin isoform. These results demonstrate that cells that migrate into and proliferate within the collagen-glycosaminoglycan matrix have contractile potential as reflected in their expression of the alpha-smooth muscle actin isoform. The role of these contractile cells in the healing process warrants further investigation. Moreover, this study demonstrates the potential of cells intrinsic to the human anterior cruciate ligament to migrate into collagen-glycosaminoglycan scaffolds that may ultimately be investigated as implants to facilitate ligament healing and regeneration.

Switching from depot antipsychotics to risperidone: results of a study of chronic schizophrenia. The Schizophrenia Treatment & Assessment Group

Designed to provide information about patients with schizophrenia who switch from depot neuroleptics to the oral, atypical antipsychotic risperidone, this multicenter observational study enrolled patients who wished to stop the depot, had an unsatisfactory response, or experienced unacceptable side effects. Individuals remained on depot medication for 4 weeks and then received risperidone monotherapy for 3 months. Of the 143 patients who entered the study, 130 received risperidone, 109 completed the initial 16-week study, and 88 entered an optional 12-week follow-up. Symptoms and side effects did not change significantly during the depot phase (mean Positive and Negative Syndrome Scale [PANSS] score 72.2 at baseline, 71.6 at visit 2), but PANSS scores, global assessment of functioning, parkinsonism, and dyskinesia improved significantly during the risperidone phase (mean PANSS score decreased from 71.6 to 55.5 after 3 months). The number of contacts with healthcare professionals fell significantly during the risperidone phase; in addition, symptomatic improvements were maintained during follow-up, and movement disorders continued to decrease significantly. The investigators considered that 81% of patients had switched successfully. Patient acceptance of risperidone was significantly higher than for depot medication (83% vs 23%; P < .001), and 65% considered risperidone better than their previous treatment. Indications for depot medication should be reviewed, and patients may benefit from a switch to risperidone.

Current concepts of total knee arthroplasty

Total knee arthroplasty has become a reliable surgical procedure to treat painful degenerative arthritis. Pain relief and functional improvement is excellent and can allow patients to maintain an active lifestyle. Criteria for the type of prostheses selected should include diagnosis, age, functional level, severity of the disease, and patient expectations. Improved instrumentation, attention to surgical detail, including soft tissue balancing of the knee, and the use of polyethylene inserts greater than 8 mm have led to excellent long-term results and low failure rates. Recent improvements in revision total knee systems should significantly improve the long-term results of revision knee arthroplasty. The addition of modular implants has greatly increased the versatility of most systems and allows the surgeon to custom tailor the implant, contingent upon the amount of bony and ligamentous deficiency of the knee. The future goals of total knee arthroplasty include the development of knee systems that mimic normal joint kinematics with improved fixation and decreased polyethylene wear rates.

Press-fit condylar total knee arthroplasty. 5- to 9-year follow-up evaluation

Between November 1984 and December 1987, 378 consecutive Press-Fit Condylar (PFC, Johnson & Johnson Professional, Raynham, MA) total knee arthroplasties were performed in 290 patients. The average age at surgery was 67 years (range, 22-91 years). The average follow-up period was 6.5 years (range, 5-9 years). Scoring was carried out according to the Knee Society scoring system. The average preoperative knee score was 28, and the average postoperative knee score was 88. The average preoperative functional knee score was 49, and the average postoperative functional knee score was 72. Ninety-five percent of the patients had no pain on level walking and were satisfied with their functional result. The average postoperative knee flexion was 110 degrees. No implant showed any evidence of radiographic loosening. There were 17 complications, all requiring reoperation. Complications included excessive wear of a metal-backed patella in 8 knees. If complications resulting from the earlier use of a metal-backed patella are eliminated, the overall complication rate is 2.9%, which is comparable to or lower than the rates for other total knee systems with similar follow-up periods.

Suprascapular neuropathy. Results of non-operative treatment

We retrospectively reviewed the results of non-operative treatment of suprascapular neuropathy in fifteen patients seen between November 1983 and February 1991. The clinical diagnosis was confirmed with electrodiagnostic studies. The treatment consisted of a program of physical therapy to improve the range of motion of the shoulder and to strengthen the surrounding muscles. The average duration of follow-up was three years and eleven months (range, one year to eight years and ten months). The latest evaluation included electrodiagnostic studies of the affected extremity and dynamic isokinetic testing of both upper extremities. The result was excellent for five patients and good for seven. The three remaining patients had operative treatment because of persistent symptoms; one of these patients had an excellent result, one had a good result, and one had a poor result. The results suggest that, in the absence of a well defined lesion producing mechanical compression of the suprascapular nerve, suprascapular neuropathy should be treated non-operatively.

Primary total knee arthroplasty after patellectomy

The results of twenty-two consecutive primary total knee replacements, performed an average of nine years (range, one to twenty-three years) after a patellectomy in twenty-two patients, were reviewed retrospectively. The average duration of follow-up was seven years (range, three to fifteen years). The average age of the patients at the time of the arthroplasty was sixty-seven years (range, thirty-six to eighty-nine years). The average Hospital for Special Surgery knee score was 46 points (range, 22 to 74 points) preoperatively and 76 points (range, 45 to 97 points) postoperatively. Thirteen patients had an excellent or good result and seven had a fair or poor result; in two patients, the operation was considered a failure. Except for one patient who had myasthenia gravis, all patients could climb stairs in reciprocal manner. Four patients lacked 5 to 20 degrees of active extension compared with passive extension. With respect to the over-all results, there was no significant difference among the four types of prostheses that were used (p = 0.2). The patients who had received an Insall-Burstein posterior stabilized prosthesis had better scores for pain and function than did the patients who had received a total condylar I prosthesis (p = 0.005 and 0.01, respectively). There was a direct correlation between the knee score and the number of years that had elapsed since the patellectomy. The longer the interval between the patellectomy and the total knee replacement, the higher the postoperative knee score (r = 0.78, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Coping with chronic illness

Families suffer in many ways when a member is stricken with chronic illness. Nurses frequently feel a sense of frustration when working with the chronically ill because cure is not possible. The author reviews the goals of care and coping tasks common to the chronically ill. Family coping styles are reviewed with suggestions for effective nurse behaviors with each style.

Proximal tibial osteotomy with compression plate fixation for tibia vara

A surgical technique for the accurate intraoperative correction of tibia vara deformities with maintainence of postoperative alignment is presented. This was a retrospective study of 13 knees of nine patients with tibia vara deformities treated by proximal tibial and fibular osteotomies using compression-plate fixation. Average age of the patients was 9 + 1 years, with a range of 3 + 1 to 14 + 11 years. The average preoperative deformity was 20 degrees of varus with a range of 15-36 degrees. Average follow-up was 3 + 3 years, with a range of 2 to 4 + 1 years. All patients had intraoperative correction to an average valgus of 5 degrees (range 4-8 degrees valgus), with an overall valgus correction of 25 degrees (range 20-40 degrees). There was one reoperation for unilateral recurrence of deformity in a child who progressed from stage III to stage VI postoperatively. Proximal tibial osteotomy with compression-plate fixation provides an accurate and reliable method for the correction of multiplanar deformities in children and adolescents.

Missed scapular fracture after trauma. A case report and a 23-year follow-up report

Scapular fractures are important in that they are often associated with high morbidity and mortality. Frequently they are overlooked because of the severity of other associated injuries. Extraarticular scapular fractures are often treated conservatively, even when displaced. There is no significant long-term evaluation on this type of treatment and on the management of scapular malunion. This case report presents a missed scapular fracture and associated rib fractures with subsequent malunion and a 23-year follow-up assessment. Surgical resection of a distorted inferior medial border of the scapula and dorsal rib prominences relieved the patient's symptoms. The case presentation, diagnostic modalities, treatment, and possible long-term sequelae of this complex fracture are reviewed.

Atraumatic posterior dislocation of the sternoclavicular joint. A case report and literature review

Atraumatic spontaneous posterior dislocation of the sternoclavicular joint (SCJ) is an extremely rare event. Only three recorded cases exist in the literature, and they are poorly documented and without roentgenographic confirmation. Spontaneous posterior dislocation of the SCJ occurred in an active 50-year-old woman without any known underlying pathology. Closed reduction attempted five days later was unsuccessful, and the patient was treated conservatively with short-term modification of activity. The patient is asymptomatic and followed carefully one year postdislocation. A review of the literature discloses a 25% complication rate involving the vital structures of the superior mediastinum after posterior dislocation of the SCJ. Because of this high complication rate, a thoracic or vascular surgeon must be available should closed or open reduction become necessary.

Acute exacerbation of carpal tunnel syndrome after radial artery cannulation

Acute carpal tunnel syndrome that follows radial artery cannulation has been described. To determine the incidence and predisposing factors, we prospectively studied 151 patients who had perioperative radial artery cannulation. Postoperatively 9 of the 151 patients had symptoms of carpal tunnel syndrome with positive Phalen and Tinel signs on the side on which the radial artery catheter had been inserted. Eight of 12 patients with a prior history of carpal tunnel syndrome had acute exacerbation of symptoms postoperatively. By contrast, only 1 of 139 patients with no prior history of the disorder had symptoms. Fourteen patients had multiple arterial artery punctures or perforations of the posterior wall of the radial artery. In three of these, postoperative symptoms of carpal tunnel syndrome developed but did not reach statistical significance. The only patient with postoperative acute carpal tunnel syndrome but no prior history of the syndrome had multiple arterial punctures. The use of perioperative anticoagulation, the use of wrist-extension splints, and the duration of radial artery cannulation did not influence acute exacerbation of carpal tunnel syndrome. Patients with a prior history of carpal tunnel syndrome are at increased risk of recurrent symptoms after radial artery cannulation. We found no statistically significant relationship between traumatic cannulations and the development of symptoms of carpal tunnel syndrome.

Evaluation of hemostatic analytes after use of hypertonic saline solution combined with colloids for resuscitation of dogs with hypovolemia

The effects of hypertonic saline solution (HTSS) combined with colloids on hemostatic analytes were studied in 15 dogs. The analytes evaluated included platelet counts, one-stage prothrombin time, activated partial thromboplastin time, von Willebrand's factor antigen (vWf:Ag), and buccal mucosa bleeding times. The dogs were anesthetized, and jugular phlebotomy was used to induced hypovolemia (mean arterial blood pressure = 50 mm of Hg). Treatment dogs (n = 12) were resuscitated by infusion (6 ml/kg of body weight) of 1 of 3 solutions: HTSS combined with 6% dextran 70, 6% hetastarch, or 10% pentastarch. The control dogs (n = 3) were autotransfused. Hemostatic analytes were evaluated prior to induction of hypovolemia (baseline) and then after resuscitation (after 30 minutes of sustained hypovolemia) at 0.25, 0.5, 1, 6 and 24 hours. All treatment dogs responded rapidly and dramatically to resuscitation with hypertonic solutions. Clinically apparent hemostatic defects (epistaxis, petechiae, hematoma) were not observed in any dog. All coagulation variables evaluated, with the exception of vWf:Ag, remained within reference ranges over the 24-hour period. The vWf:Ag values were not statistically different than values from control dogs, and actual values were only slightly lower than reference ranges. Significant (P < or = 0.04) differences were detected for one-stage prothrombin time, but did not exceed reference ranges. The results of this study suggested that small volume HTSS/colloid solutions do not cause significant alterations in hemostatic analytes and should be considered for initial treatment of hypovolemic or hemorrhagic shock.

A field comparison of the pharyngeotracheal lumen airway and the endotracheal tube

A prospective, sequential study compared ease of use and bag-valve ventilation delivered by an endotracheal tube (ET) with that of the pharyngeotracheal lumen airway (PtL) for 111 victims of cardiac arrest in the pre-hospital setting. The PtL airway was found to be significantly easier to use as measured by the time required to intubate the patient and the number of attempts to place the device. Arterial blood gas determinations were made on arrival at the hospital and repeated 15 minutes later. No statistical significance could be found between the two airway devices for either the first or second blood gas determination. During PtL ventilation, the first arterial blood gas values were PaCO2, 58 +/- 32 mm Hg; PaO2, 163 +/- 180 mm Hg; pH, 7.15 +/- 0.22. During ET ventilation the first arterial blood gas values were PaCO2, 53 +/- 29 mm Hg; PaO2, 156 +/- 178 mm Hg; pH, 7.16 +/- 0.23. No adverse effects were reported. We conclude that the ability of the PtL to deliver effective ventilation is comparable with that of the ET as measured by arterial PCO2. When the ET method of airway control cannot be achieved, the PtL airway offers an effective alternative.

Clinical ratings and plasma HVA during cocaine abstinence

Six patients were evaluated over a 21-day period during inpatient recovery from chronic repeated cocaine use. Serial evaluations of Hamilton depression rating, cocaine craving, plasma homovanillic acid (pHVA), and plasma 3-methoxy-4-hydroxyphenylethyleneglycol (pMHPG) concentrations were determined. There was a distinct increase in cocaine craving between 1 and 2 weeks after the last cocaine use. Levels of pHVA also increased at the time of heightened craving. The data provide preliminary evidence to suggest that changes in cocaine craving during abstinence are positively correlated with changes in dopamine turnover.

The pharyngeo-tracheal lumen airway: an assessment of airway control in the setting of upper airway hemorrhage

Aspiration of blood from nasal and upper airway injuries is a common problem in trauma patients. The pharyngeo-tracheal lumen (PTL) airway uses a large balloon to occlude the oropharynx. We conducted a postmortem radiographic evaluation of the PTL airway's ability to control simulated upper airway hemorrhage using a barium solution. The PTL airway was inserted in ten patients and the barium solution was instilled in the nose until it was full. Radiographs were taken to determine the extent of containment of the radiopaque liquid. The PTL airway successfully controlled the simulated upper airway hemorrhage in nine of the ten cases studied including one patient with a cleft palate. There was leakage in the tenth case due to a balloon leak. The PTL airway may be the prehospital airway of choice in trauma patients due to its ability to control upper airway hemorrhage, but it requires further clinical testing.

Comparative study of three methods of resuscitation: closed-chest, open-chest manual, and direct mechanical ventricular assistance

Presented are the results of a comparison study of three forms of circulatory support during ventricular fibrillation: closed-chest compression (CCC), open-chest manual compression (OCMC), and direct mechanical ventricular assistance (DMVA). DMVA is a method of circulatory support using a bell-shaped device that is affixed to the heart by apical suction and that alternately compresses and expands the ventricles. CCC produced a cardiac index (CI) of 780 mL/min/m2 (19% of control) with a mean arterial pressure (MAP) of 26 mm Hg (23% of control). Both forms of direct cardiac compression produced higher values. OCMC at 60 compressions per minute (CPM) produced a CI of 2,069 mL/min/m2 (52% of control) with an MAP of 50 mm Hg (45% of control). DMVA at the same rate produced a CI of 2,780 mL/min/m2 (70% of control) with an MAP of 72 mm Hg (65% of control). The values for DMVA at 60 CPM were significantly higher than for OCMC at 60 CPM (P less than .005 for CI, and P less than .0005 for MAP). Changing from standard CCC to DMVA at 90 CPM produced the greatest hemodynamic improvements: MAP increased by 250%, and CI increased by 340%. With DMVA at 90 CPM, the systolic pressure, stroke index, and CI were not statistically different from control, prearrest values.

Accuracy and usefulness of a breath alcohol analyzer

We evaluated the accuracy of a hand-held breath alcohol analyzer in the rapid determination of blood alcohol levels in the emergency patient with suspected ethanol intoxication. The Alco -Sensor III breath alcohol analyzer was used to measure alcohol levels in orally and nasally obtained end-expiratory breath samples in 55 patients. These levels were compared to directly measured blood alcohol levels. The patients were categorized into cooperative and uncooperative groups. The mean oral breath alcohol level obtained was 0.187 +/- 0.100 g/dL (range, 0.000 to 0.419) while the mean serum level was 0.217 +/- 0.113 g/dL (range, 0.00 to 400). The overall correlation between these two methods of measuring blood alcohol level was strong (r = .879, P less than .001). In cooperative patients the correlation was even stronger (r = .963, P less than .001), while in uncooperative patients the correlation was less but still significant (r = .723, P = .001). Nasally obtained samples correlated well with blood levels in cooperative patients (r = .874, P less than .001), but the correlation was less strong in uncooperative persons (r = .694, P = .003). Our study indicates that the Alco -Sensor III breath alcohol analyzer is sufficiently accurate to be of use in rapidly assessing blood alcohol levels, even when a patient is unable to cooperate fully.

A case report of splenic pregnancy

A case of splenic pregnancy is reported. The patient was treated surgically with a satisfactory result. The problem of preservation of the spleen in the presence of a spontaneous rupture is highlighted.