Strategic management to optimize response to cardiac resynchronization therapy registry

Background

Cardiac resynchronization therapy (CRT) is guideline-recommended for the treatment of symptomatic heart failure (HF) in patients (pts) with reduced LVEF and prolonged QRS. Clinical trials report Clinical Composite Score (CCS) response rates from 60 to 75%. However, patients with common comorbidities, such as atrial fibrillation, are often under-represented in clinical trials. The Strategic MAnagement to optimize response to cardiac Resynchronization Therapy (SMART) Registry (NCT03075215) was designed to examine outcomes in CRT patients in the real world.

Methods

The SMART Registry was a global, multicenter, prospective, clinical registry that enrolled subjects undergoing a de novo CRT-D implant or upgrade from pacemaker to CRT-D using a quadripolar LV lead. CCS was assessed at 12 months post-implant.

Results

For study design and CCS outcomes see Figure 1. CCS at 12 months showed that 58.8% of pts improved and 20.1% stabilized. Of the 21.1% of pts that worsened, 8.4% were due to death, 7.8% non-fatal heart failure event, and 5% worsening of NYHA or patient global assessment. Notably, this registry had a high prevalence of pts with NYHA I/II (51%), Non-LBBB (50%), AF (37%), diabetes (35%), and bradycardia (31%) at baseline. Age (>65), diabetes, ischemia, non-LBBB, atrial fibrillation (AF) and renal dysfunction correlated with worsened CCS outcomes. NYHA III/IV patients had significantly higher HF hospitalization (HFH) rates than NYHA I/II (P-value <0.001) (Figure 2a) and patients with AF had higher HFH rates than those without (P-value <0.001) (Figure 2b). Similar effects of NYHA score and AF were seen on mortality. The use of ACE/ARB, or ARNI, and MRA correlated with better outcomes, whereas diuretics and anticoagulants correlated with poorer outcomes.

Conclusions

In this large registry, clinical outcomes across important sub-populations are in line with expectations, with older age, ischemia, renal dysfunction, AF, non-LBBB, and diabetes associated with a lower likelihood of response to CRT. By including these patients, this study provides a clearer picture of the effectiveness of CRT in the real world. Future studies should examine optimization approaches to facilitate CRT effectiveness in these under studied patient populations.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This registry was funded by Boston Scientific (BSC)

916The impact of anesthesia choice on subcutaneous implantable cardioverter defibrillator outcomes: acute and one year results from the post approval study

Funding Acknowledgements

This study was financially supported by Boston Scientific

The influence of anesthesia technique on the outcomes of subcutaneous implantable cardioverter defibrillator (SICD) implantation has not been prospectively evaluated.

The aim of the present analysis was to characterize the effect of anesthesia choice acutely and over a year follow-up in the large "real-world" cohort of the SICD Post Approval Study (SICD-PAS).

Patients received either general anesthesia (GA), conscious sedation (CS), or monitored anesthesia care (MAC) at the implanting physicians" discretion.  Acute results and complications over one year were compared between GA, CS and MAC.

1,631 patients were studied.  64.3% received GA , 29.2% received CS and 6.6% received MAC.  Procedure times were shortest for MAC versus GA and CS (Table 1).  Cross-over from CS and MAC to GA occurred in 2.9% and 1.9% of procedures, respectively.  The mean left ventricular ejection fraction (LVEF) was lower in the MAC cohort compared with GA and CS.  GA patients were less often discharged the same day than CS and MAC.  Patients who had GA were more likely to have had intra-operative DFT testing, while successful DFT testing at implant did not differ among groups (Table 1).  At one year, freedom from total complications did not differ between groups (93.3% for GA, 92.9% for CS and 87.8% for MAC, p = 0.095) nor did freedom from inappropriate shocks (94% for GA, 94.2% for CS, 88.9% for MAC, p = 0.138) nor appropriate shocks (95.8% for GA, 95% for CS, 95% for MAC, p = 0.747).

All three anesthesia techniques had similar acute and one year outcomes but, despite having worse LVEF, patients who received MAC had shorter procedure times and infrequently required conversion to GA.  GA was associated with higher rates of next day patient discharge.  These results suggest that MAC may be preferred for the majority of patients. This observation should be confirmed with prospective trials.

Table 1:Characteristics and Outcomes Parameter Conscious Sedation General Anesthesia Monitored Anesthesia Care P value Gender[%(N/Total)] Male 68.1 (324/476) 69.3 (726/1048) 66.4 (71/107) 0.77 Age (years) mean ± SD 54 ± 15 53 ± 15 54 ± 13 0.61 Body Mass Index mean ± SD 30 ± 7 30 ± 8 29 ± 6 0.41 Creatinine (mg/dL) mean ± SD 2 ± 2 2 ± 4 2 ± 2 0.43 LVEF (%) mean ± SD 33 ± 15 32 ± 15 26 ± 9 <0.001 Procedure Time (min) mean ± SD 85 ± 42 75 ± 33 65 ± 30 <0.001 Same Day Discharge % 70.3% 64.3% 72.6% 0.03 DFT Attempted % 84% 89.1% 81.3% 0.004 Successful DFT % 98.7% 98.6% 98.8% 0.97

Occupational stress, job characteristics, coping, and the mental health of nurses

OBJECTIVES

 This study investigated the relationships between job characteristics and coping in predicting levels of anxiety and depression in nurses. The study was based on current theories of occupational stress, and predictors included job demands, social support, decision authority and skill discretion control, effort, over-commitment, rewards, and ways of coping. It was predicted that job demands, extrinsic effort, over-commitment, and negative coping behaviours would be positively associated with depression and anxiety, and social support, rewards, decision authority, skill discretion control, and positive coping would be negatively associated with depression and anxiety.

METHODS

 Participants were 870 nurses, who responded to a bulk mail sent randomly to 4,000 nurses from the south of England.

RESULTS

 The results showed that job demands, extrinsic effort, and over-commitment were associated with higher levels of anxiety and depression. Social support, rewards, and skill discretion were negatively associated with mental health problems. Few interactions were found between the variables. Coping behaviours significantly added to the explanation of variance in anxiety and depression outcomes, over and above the use of demand-control-support, and effort-reward factors alone.

CONCLUSION

 The results from the study demonstrated the importance of coping factors in work-stress research, in accordance with the multi-factorial premise of transactional stress models. It is argued that multi-factor research is needed to help develop effective organizational interventions.

Differentiation of parkinsonian syndromes according to differences in executive functions

Groups of patients with Parkinson's disease (PD), striatonigral degeneration-type multiple system atrophy (MSA) or progressive supranuclear palsy (PSP) with motor disability stages II and III according to Hoehn and Yahr, and a healthy control group were compared using neuropsychological tests of executive functions. The results indicate that all three patient groups were impaired in the tests of executive functions. In comparison with healthy subjects, the three patient groups showed impaired performance regarding verbal fluency, problem solving and verbal and figural working memory. Patients with PD differed significantly from healthy subjects in a test of verbal recency, while patients with MSA or PSP were unimpaired. The comparison of patient groups revealed no differences between PD and MSA patients. However, patients with PSP showed greater impairment in both phonemic and semantic fluency than patients with PD or MSA. Using discriminant function analysis, it was found that variables derived from four verbal fluency tasks (simple and alternate semantic and phonemic fluency) discriminated among the three patient groups at a level significantly exceeding chance. Over 90% of patients with PSP were correctly classified. Patients with PD and MSA were correctly classified in over 70% of cases. These results suggest that verbal fluency tasks may be sensitive measures in the differential diagnosis of PD, MSA and PSP.

Far-field responses to stimulation of the cochlear nucleus by microsurgically placed penetrating and surface electrodes in the cat

OBJECT

A new generation of penetrating electrodes for auditory brainstem implants is on the verge of being introduced into clinical practice. This study was designed to compare electrically evoked auditory brainstem responses (EABRs) to stimulation of the cochlear nucleus (CN) by microsurgically implanted surface electrodes and insertion electrodes (INSELs) with stimulation areas of identical size.

METHODS

Via a lateral suboccipital approach, arrays of surface and penetrating microelectrodes with geometric stimulation areas measuring 4,417 microm2 (diameter 75 microm) were placed over and inserted into the CN in 10 adult cats. After recording the auditory brainstem response (ABR) at the mastoid process, the CN, and the level of the inferior colliculus, EABRs to stimulation of the CN were recorded using biphasic, charge-balanced stimuli with phase durations of 80 microsec, 160 microsec, and 240 microsec at a repetition rate of 22.3 Hz. Waveform, threshold, maximum amplitude, and the dynamic range of the responses were compared for surface and penetrating electrodes. The EABR waveforms that appeared for both types of stimulation resembled each other closely. The mean impedance was slightly lower (30 +/- 3.4 kohm compared with 31.7 +/- 4.5 kohm, at 10 kHz), but the mean EABR threshold was significantly higher (51.8 microA compared with 40.5 microA, t = 3.5, p = 0.002) for surface electrode arrays as opposed to penetrating electrode arrays. Due to lower saturation levels of the INSEL array, dynamic ranges were almost identical between the two types of stimulation. Sectioning of the eighth cranial nerve did not abolish EABRs.

CONCLUSIONS

Microsurgical insertion of electrodes into the CN complex may be guided and monitored using techniques similar to those applied for implantation of surface electrodes. Lower thresholds and almost equivalent dynamic ranges indicate that a more direct access to secondary auditory neurons is achieved using penetrating electrodes.

Induction of mammary epithelial cell differentiation and inhibition of dimethylbenz(A)anthracene-induced mammary tumour by co-administration of a pure antiestrogen ICI 182,780 and testosterone enanthate

Epidemiological studies have shown that early first pregnancy is associated with a life-long reduction in breast cancer risk. The terminal differentiation associated with pregnancy and lactation has been proposed as a mechanism underlying the protective effect of pregnancy. We report that treatment of rats with ICI 182,780 (ICI) caused a marked reduction in epithelial cells and Ki-67 labelling index as compared to controls and testosterone enanthate-treated (TE) mammary glands. TE increased the Ki-67 labelling index, stimulated lobuloalveolar and ductal growth, as well as the secretory activity of acinar cells. Co-administration of TE and ICI resulted in a reduction in Ki-67 labelling index. Mammary epithelial cells became differentiated, resembling that observed at the end of pregnancy and during lactation as indicated by marked increase in secretory activity, lipid accumulation and presence of basal nuclei. The expression of differentiation markers such as whey acidic protein, mammary derived growth inhibitor, alpha-casein and beta-casein was detected only in TE plus ICI treated mammary tissues. Unlike TE, ICI caused a significant reduction in DMBA-induced tumour incidence, number of tumour bearing and tumour size. Tumour incidence was reduced to 8% when both ICI and TE were co-administered. Our data provide the novel molecular interactions between the estrogen and androgen in regulation of mammary growth and differentiation. These observations may give insight into novel actions of ICI and TE on breast differentiation and protection against carcinogenesis which may be useful in designing novel strategies for cancer prevention and/or treatment based on maximizing mammary epithelial cell differentiation.

[Anterior interosseous nerve syndrome as differential diagnosis of closed isolated flexor tendon lesion]

Lesions of the anterior interosseus nerve can result in a variety of clinical manifestations, depending on location and degree of axonal damage. Clinical presentation with an isolated palsy of the flexor pollicis longus muscle is difficult to distinguish from a closed tendon rupture, especially when a trauma occurred. We would like to present five of our cases and discuss the diagnostic and therapeutic modalities.

Workshop IV: drug treatment guidelines for the long-term management of Parkinson's disease

An attempt was made to establish a decision algorithm for the treatment of idiopathic Parkinson's disease at various stages and in different subgroups such as akinetic-rigid or tremor dominance type. We suggest treating young patients with selegiline and a dopamine agonist. In the tremor dominance type we use either budipine or a dopamine agonist. Due to levodopa-induced dyskinesia, we try to avoid levodopa in the early stages of the disease and use it only later in more advanced situations in a combination therapy with dopamine agonists. Since IPS is not only based upon dopamine deficiency but also on resulting glutamatergic overstimulation, we advocate the use of a glutamate antagonist such as amantadine or budipine. Catechol-O-methyl inhibitors are very helpful when wearing-off occurs. Anticholinergics are only used in the early stages of tremor-dominant IPS because we fear enhancing the risk of dementia.

Epitope insertion into variable loops of HIV-1 gp120 as a potential means to improve immunogenicity of viral envelope protein

We report on the properties of a set of HIV-1 IIIB Env mutants carrying a linear gp41 epitope insertion (LLELDKWASL) in the V1, V2, V3 or V4 variable loop. Insertion of the epitope, which is defined by the HIV-1 neutralizing MAb 2F5, was well tolerated in the V1, V2 and V4 loops, as these mutants were properly expressed, retained reactivity to conformation-dependent monoclonal antibodies and exhibited patterns similar to the parental Env molecule. However, insertion of this epitope in the V3 loop was associated with drastically reduced protein expression. Relative to parental Env molecule, the V1, V2 and V4 insertion mutants demonstrated significantly increased binding to mAb 2F5 in vitro. To evaluate immunogenicity, mice and guinea pigs were immunized with plasmid expression vectors for the mutant proteins. For both mice and guinea pigs, all four mutants elicited anti-gp120 antibody responses. In mice the V1 and V3 insertion mutants, but neither the V2 or V4 insertion mutant nor the parental env, elicited significant titers against the epitope peptide, whereas in guinea pigs, V2 insertion mutant was most effective in eliciting anti-2F5 peptide antibody responses. While original V2 2F5 insertion mutant failed to elicit anti-2F5 peptide responses in mice, studies with 14 additional V2 insertion mutants revealed several insertion sites at which the epitope was able to induce epitope-specific antibody responses. This indicates that the precise position at which the epitope insertion takes place dictates the ability of the mutant to induce the epitope-specific antibody responses. When tested for virus neutralization activity, the guinea pig sera that contain high titers of anti-2F5 peptide antibody failed to enhance the virus neutralizing activity, suggesting that the configuration of 2F5 epitope plays a critical role in inducing neutralizing antibody responses. The results from this study may have potential implications with respect to modification of the HIV-1 Env molecule for the purpose of improving HIV-1 Env immunogenicity.

Effects of c-raf-1 and c-myc expression on radiation response in an in vitro model of human small-cell-lung carcinoma

In this study we examined the radiation survival response of simian virus 40 large tumor antigen-immortalized human bronchial epithelial cells (BEAS-2B) stably transfected with c-raf-1 and/or c-myc. C-raf-1 transfectants (2B-raf), and c-raf-1 and c-myc double transfectants (2B-raf/myc) were relatively radioresistant compared with c-myc (2B-myc) or control vector transfectants (2B-neo) (2B-raf, D0 = 2.445 Gy; 2B-raf/myc, D0 = 2.46 Gy; 2B-myc, D0 = 1.501 Gy; 2B-neo, D0 = 2.029 Gy). The steady state level of superoxide dismutase (SOD) mRNA was higher in radioresistant cells (2B-raf and 2B-raf/myc). In addition, 2B-raf but not 2B-raf/myc or 2B-myc transfectants revealed relatively higher number of cells in G2+M phase of the cell cycle. These findings present experimental evidence that Raf-1 expression correlates with the radiation-resistant response of 2B-raf or 2B-raf/myc transfectants and suggest a role of SOD in Raf-1-associated radiation resistance. Because 2B-raf transfectants are non-tumorigenic, and double transfectants (2B-raf/myc) are tumorigenic with some phenotypic traits found in small-cell lung carcinomas, our data imply a dissociation between the Raf-1-mediated mechanisms of radiation protection and progression of lung neoplasia.

OH-radical formation by ultrasound in aqueous solution--Part II: Terephthalate and Fricke dosimetry and the influence of various conditions on the sonolytic yield

Terephthalate and Fricke dosimetry have been carried out to determine the sonolytic energy yields of the OH free radical and of its recombination product H2O2 in aqueous solutions under various operating conditions (nature of operating gas, power, frequency, temperature). For example, in the sonolysis of Ar-saturated terephthalate solutions at room temperature, a frequency of 321 kHz, and a power of 170 W kg-1, the total yield [G(.OH) + 2 G(H2O2)], equals 16 x 10(-10) mol J-1. This represents the total of .OH that reach the liquid phase from gas phase of the cavitating bubble. The higher the solute concentration, the lower the H2O2 production as more of the OH free radicals are scavenged, in competition with their recombination. Fricke dosimetry, in the absence and presence of Cu2+ ions, shows that the yield of H atom reaching the liquid phase is much lower, with G(H.) of the order of 3 x 10(-10) mol J-1. These sonolytic yields are smaller in solutions that are at the point of gas saturation, and increase to an optimum as the initial sonication-induced degassing and effervescence subsides. The probing of the sonic field has shown that the rate of sonolytic free-radical formation may vary across the sonicated volume depending on frequency and power input.

Does N-acetylcysteine improve hemodynamics and graft function in liver transplantation?

The release of toxic oxidative free radicals induced by ischemia and reperfusion may jeopardize liver graft function. N-acetylcysteine (NAC) has shown protective effects on hypothermic and warm ischemia reperfusion liver injury in animals. NAC improves hemodynamics and survival rates in patients with fulminant hepatic failure. The aim of this study was to investigate whether intraoperative treatment with NAC would improve hemodynamics and postoperative graft function in liver transplantation. Sixty patients with chronic end-stage liver disease were included in a prospective randomized placebo-controlled study. NAC or the same volume of 5% glucose was started during the anhepatic phase. Hemodynamic data and calculated tissue oxygenation parameters were compared throughout the procedure. Postoperative graft function was assessed by measurements of aminotransferases, prothrombin time, and monoethylglycinexylidide test over the 3 first postoperative days. Patient demographics were similar before the infusion of NAC or glucose. Hemodynamic parameters, oxygen consumption, oxygen delivery, oxygen extraction ratio, and lactates were not different throughout the procedure. One hour after the revascularization of the hepatic artery, the oxygen extraction ratio by the liver was similar (17% +/- 7.6% v 17% +/- 6.2%) in both groups. Postoperative graft function was comparable within the 3 first postoperative days. This study failed to show any beneficial effect of the intraoperative administration of NAC on hemodynamics and graft function in liver transplantation in patients with chronic liver disease.

[Granulomatous tumor of the flexor tendon sheath as first manifestation of sarcoidosis]

While osseous tumors of the phalanges are more common, soft-tissue manifestations in the hand are uncommon in patients with sarcoidosis. Our patient presented with a large but painless tumor on the palmar aspect of the right index finger limiting finger flexion. Histology of a biopsy specimen was interpreted as a granuloma of sarcoidosis. Further X-ray investigations revealed large bilateral formations in the hila of the lung interpreted as stage I sarcoidosis in an otherwise healthy individual. Tuberculosis and polyarthritis were excluded by standard tests. The tumor was then radically excised, as it was located within the flexor tendon sheath. After uneventful wound healing the patient had regained full function of his finger at six weeks follow up. Interestingly enough, a chest film at that time showed the hilar changes to have decreased as well, which is considered quite typical for this disease.

Characterization of recombinant hepatitis B surface antigen using surface plasmon resonance

Two commercial monoclonal antibodies were shown to interact with distinct epitopes within the major antigenic a determinant region of yeast recombinant hepatitis B surface antigen (rHBsAg) particles, contained in the hepatitis B vaccine, by using the surface plasmon resonance phenomenon on a BIAcore system. Apparent avidity for these antibodies were compared among different rHBsAg batches, showing the consistency of these epitopes. Furthermore, the effect of the alteration of these epitopes, achieved by chemical modifications, was readily reflected by changes in the apparent avidity for these antibodies. The procedures used in the present study provide a novel and efficient way to characterize rHBsAg particles present in different hepatitis B vaccine products.

[Trigger thumb in the child]

The trigger thumb is a quite frequent finding in the adult woman over 50 years. In newly born and small children we do, however, also occasionally observe trigger thumbs. As even pediatric specialists are not necessarily familiar with this diagnosis, they tend to refer these small patients as emergencies for acute distortions or subluxations. We describe the clinical findings and therapy for trigger thumb in the child and our own results in comparison with the literature. Except in the small child under six months, who displays a spontaneous recovery in about 30% of the cases, early surgical release of the pulley is the treatment of choice.

Affinity maturation of a high-affinity human monoclonal antibody against the third hypervariable loop of human immunodeficiency virus: use of phage display to improve affinity and broaden strain reactivity

The present study set out to investigate whether phage display could be used to improve the properties of a high-affinity human monoclonal antibody directed against the third hypervariable loop (V3 loop) of human immunodeficiency virus (HIV). The aim was to increase affinity through slowing the dissociation rate (off-rate constant of koff), whilst retaining the ability of this antibody to bind diverse V3 loop sequences. When reformatted as a scFv, the antibody fragment retained the properties of the parental IgG, including the ability to neutralise virus. Heavy and light chains were sequentially replaced with repertoires of variable domains from non-immunised human donors followed by selection on biotinylated synthetic peptide. All selected variants derived from the same germline as the parental antibody. Variants of the light chain provided little if any improvement, whereas two residue changes in VHCDR2 and one in VHFR3 resulted in a reduced koff from gp120 protein of the MN strain (MNgp120) and synthetic V3 loop peptides as measured by surface plasmon resonance using the BIAcore instrument (Pharmacia Biosensor). VHCDR3 was modified using synthetic oligonucleotides and several clones with reduced koff identified, a number of different substitutions occurring at a single residue position. The residues in the heavy chain identified as reducing koff were simultaneously randomised by site-directed mutagenesis, resulting in scFv variants with koff slowed up to sevenfold. Far from compromising recognition of variant loops, binding to these sequences was improved; the koff from synthetic peptides modelled on V3 loop variants being slowed to a degree similar to that observed with MNgp120. All four changes were located towards either extremes of CDRs 2 and 3, suggesting that the mechanism of improvement may be one of alternation of loop conformation. This work illustrates that phage display can be used to tailor the properties of a therapeutic monoclonal antibody in a predefined fashion.

The influence of different amounts of n-3 polyunsaturated fatty acids on bleeding time and in vivo vascular reactivity

Mesenteric bleeding time, mesenteric vascular reactivity, platelet and erythrocyte lipid fatty acid composition were measured at 2-3 weeks, 5-6 weeks and 11-22 weeks in normotensive Wistar rats, fed on high (6.5% energy) or moderate (1.6% energy) intakes of eicosapentaenoic acid (20:5n-3; EPA) as fish oil, compared with controls fed on a diet devoid of EPA. All diets contained the same level of linoleic acid (4% energy): the moderate- and high-EPA diets also contained 1.1 and 4.4% of the energy as docosahexaenoic acid (22:6n-3) respectively. Moderate, but not high, intakes of EPA increased mesenteric bleeding time. Similar reductions in erythrocyte and platelet arachidonic acid (20:4n-6) occurred in animals fed on either high or low amounts of EPA, but the proportion of EPA increased dose-dependently. At high intakes of EPA the proportion of oleic acid in platelets and erythrocytes was decreased. Blood pressure platelet counts, mesenteric vessel diameter and mesenteric vascular reactivity to vasopressin were unaffected by treatment. High intakes of fish oil led to a slight fall in packed cell volume. In a second experiment bleeding time and mesenteric vascular reactivity to noradrenaline were increased 2-4 weeks after receiving a moderate intake of EPA and these effects persisted 5-21 d after switching to a control diet. A similar increase in vascular reactivity to noradrenaline was observed in animals given indomethacin (6 mg/kg) but not in those given aspirin (20 mg/kg).

[Distal radius fractures: conservative or surgical treatment?]

The "classical" Colles fracture of the distal radius is the most common fracture in the adult. In order to reduce the still rather high rate of permanent disability, this fracture involving a functionally important joint requires accurate reduction. The AO-fracture classification introduced by Müller not only defines the severity of an injury, but also allows for decision-making as to the most adequate treatment. Besides the purely conservative management by closed reduction and plaster cast for the type-A fractures, we have a number of other treatment modalities for the more complex-B and C-type fractures, such as closed reduction and percutaneous K-wire application or the use of the small external fixator as well as open reduction and internal fixation by plates and screws for a few selected indications.

Identification of multiple repeat sequences and transcription-related elements within introns 4, 8 and 9 of human Raf-1

Oncogenic activation of the human c-raf-1 protein (Raf-1) occurs by truncation of its aminoterminus (regulatory domain) and retention of the carboxyterminus (kinase domain). To gain insight into the structure of human raf-1 genomic DNA corresponding to the regulatory domain of Raf-1, we analyzed the nucleotide sequences of introns 4, 8, and 9. Very high frequencies of the direct and indirect repeats, and A/T nucleotides were observed within introns 4, 8, and 9; and the DNA sequences, 5'-TTAGTCA-3' and 5'-TGATTCA-3', like the DNA recognition site of transcription factor AP-1, were identified within intron 4 of raf-1 in human normal and tumor DNAs. In addition, several transcriptional elements (CAAT box, TATA sequences, eukaryotic transcription initiation sites, and cellular transcriptional elements) were found within introns 4, 8, and 9 of human raf-1. These data suggest: 1) the high frequency of intron-specific repeats is a possible recombinational mechanism for derivation of truncated oncogenic forms of Raf-1; and 2) the multiple transcriptional elements within introns 4, 8, and 9 may have important implications in the regulation of raf-1 transcription and, therefore, its role in cell growth and proliferation.

[Temporary balloon catheter occlusion for control of bleeding of a blunt injury of the proximal axillary artery. Case report and review of the literature]

We describe the successful placement of an intra-arterial balloon catheter by a femoral approach in order to occlude the proximal arterial end and to control massive bleeding in a patient with rupture of the left axillary artery after blunt scapulo-thoracic dissociation. To our knowledge this technique has so far not been reported in Europe. It allows rapid control of bleeding, minimizes blood loss and markedly facilitates pre- and perioperative management in selected cases. The authors review the relevant literature dealing with this topic.

[Ambulatory hand surgery]

The majority of surgical interventions about the hand can be done on an outpatient basis and in private practice; however, the surgeon must be well-trained in hand surgery and should master all forms of local and regional anesthesia, permitting an atraumatic technique. In addition, he must be prepared to handle any peri- and intraoperative complication and should be able to refer the patient to a close-by hospital in case of need. Since the aftercare appears to be of paramount importance for a successful outcome, the postoperative rehabilitation must be guaranteed as well. As all these conditions require qualified manpower and a good infrastructure, hand surgery is probably best performed within a small group of practising surgeons.

[Vascular injuries--management in a non-university central hospital]

In a retrospective study the surgically treated vascular injuries (n = 35) of the last 10 years were evaluated. One third of the patients had multiple trauma and in 57% of the cases vascular injury was accompanied by a fracture. All patients (n = 28) except those who underwent delayed amputation (amputation rate 14%) have been followed personally for an average of 5.1 years. 90% of these patients showed an excellent or acceptable longtime result in regard to vascularity, nobody complained of claudication. Diagnosis of a vascular injury was mostly confirmed by direct surgical exploration, only one third of the lesions were diagnosed by arteriogram. A positive signal in Doppler examination does not exclude vascular injury and therefore cannot replace arteriography or exact clinical evaluation.

Management of displaced supracondylar fractures of the humerus in children

A series of 33 children with displaced supracondylar fractures of the humerus (SFH) were all treated operatively by open reduction and internal fixation or by closed reduction and percutaneous pinning. A follow-up study was performed on average 29 months (range 3-63 months) after the injury. In 18 per cent of cases primary neurovascular injury was observed and confirmed at operation. Of these patients 32 had open reduction and internal fixation by K-wires; in only one case was closed reduction and percutaneous pinning attempted. If there was preoperative neurological deficit, the nerves were visualized; however nerve suture was not required in our series. In one case we had to reconstruct both the brachial and radial arteries because of intimal lesions totally occluding the vessels. The average hospital stay was 9 days, including pin removal, which was usually performed about 4-5 weeks later, at the time of plaster removal. By Innocenti's criteria, 27 of 30 patients reviewed had an excellent result; three had a good result and three patients were lost to follow-up. There were no complications due to the operation, such as wound healing problems, infections or nerve lesions. In the light of our experience and of the good results, we recommend that displaced SFH be managed by open reduction and internal K-wire fixation. Percutaneous pinning is a good alternative method when closed reduction is successful at the first attempt.

[Recurrent idiopathic arteriovenous malformation of the back of the hand]

This is a case report of a 36-year-old male, operated twice (1974 and 1989) due to an idiopathic arteriovenous malformation on the dorsum of the hand. This rare and often recurrent vascular affection of the hand, its diagnosis and surgical management are reviewed and discussed.

[Infection of the hand: a specific disease picture]

Certain anatomical and physiological features are responsible for the specific clinical presentations of hand infections: The dorsum of the hand possesses a loose mobile areolar layer, whereas the gripping function of the palm has determined the development of a dense, firmly anchored sheet layer of connective tissue. It follows that infections of the dorsum of the hand can spread easily and give rise to extensive cellulitis. This cannot occur on the palmar aspect, where infection always tracks along the path of least resistance into the deep tissues, rapidly reaching the functionally important structures of the flexor compartments, including the subfascial compartments of the deep palmar space and the space of Parona in the forearm. A similar chain of events characterizes infections of the thenar and hypothenar eminences. Distal finger infections around the nail are a separate clinical entity with a considerable risk of running a chronic course and involving bone or the distal interphalangeal joint. In this case the sequence leads form subcutaneous infection or paronychia via bone infection to joint sepsis. There is considerable scope for misdiagnosis of hand infections, and inappropriate conclusions may lead to serious consequences for future function of the hand. The treatment of hand infections is demanding, time-consuming and not infrequently requires the infrastructure of a hospital clinic; therefore, in cases of doubt, early referral is always advisable.

[After-care following hand surgery]

In hand surgery the after-care constitutes a most important part of the treatment, if full reconstitution of function is to be achieved. We distinguish mainly three periods which may vary in duration: the immediate postoperative period, the period of mobilisation and the specific rehabilitation with ergotherapy. In the early postoperative period, the main concern goes to the wound care, prophylaxis and treatment of pain and swelling by careful and adequate immobilisation and positioning of the hand on one side and mobilisation of elbow and shoulder on the other. The second period of mobilisation of the hand starts once the wounds are healed and the swelling has subsided. The patient is instructed in actively mobilising his injured hand and fingers with the support of resting and dynamic splints. Finally the actual rehabilitation programme is started with application of increasing load and strength as well as building up of the fine sensory and motor function of the fingers.

[Abdominal tuberculosis and open lung tuberculosis caused by mycobacterium bovis]

Abdominal tuberculosis is a rare disease in Western countries and remains difficult to diagnose. The most frequent symptoms are abdominal pain, weight loss, fever, vomiting, constipation and/or diarrhea. Clinical findings include abdominal tenderness, a palpable mass (often in the right fossa due to ileocecal infection), paleness, cachexia and ascites. Suggested radiological investigations include plain abdominal film, upper GI-series and barium enema. Chest X-rays often show signs of either active or inactive tuberculosis. Sputum and gastric juice should be cultured. Coloscopy serves to sample specimens for histology and bacteriology and may help to confirm the diagnosis, which is, however, not ruled out by negative findings. The same holds good for peritoneal biopsy and laparoscopy. Bowel perforation and ileus are frequent complications and always require surgery, whereas uncomplicated cases can be treated by drugs only.

Malignant transformation of human bladder epithelial cells by DNA transfection with the v-raf oncogene

Transfection of the v-raf oncogene into immortalized, nontumorigenic human bladder epithelial cells resulted in the isolation of two tumorigenic transformants. Both were identified as human and of the same origin as the parent cell line by human leukocyte antigen typing and Southern blot analysis. Both the primary tumorigenic transfectants and the cell lines established from the induced tumors expressed v-raf mRNA and v-raf protein. In both tumorigenic transformants the level of c-myc mRNA was enhanced compared with that of the parent cell line.

[The fate of the polytraumatized patient with a "minor injury" of the hand]

In the case of a multiply injured patient an inconspicuous injury in the finger led to a poorly functioning hand despite rehabilitation.

Expression of recombinant platelet-derived growth factor A- and B-chain homodimers in rat-1 cells and human fibroblasts reveals differences in protein processing and autocrine effects

The autocrine effects of platelet-derived growth factor (PDGF) A- and B-chain homodimers (PDGF-AA and PDGF-BB) on rat-1 cells and human fibroblasts have been investigated by using human PDGF A- and B-chain cDNA clones expressed in a retroviral vector. Infection with replication-defective virus carrying the B-chain cDNA resulted in a phenotypical transformation resembling that induced by simian sarcoma virus. The resulting cells were focus forming in monolayer cultures, grew to high saturation densities, and formed large colonies in soft agar. The PDGF A-chain transfectants showed no transformed morphology and lacked focus-forming activity but grew to high saturation density in monolayer culture and formed small colonies in soft agar. A similar but weaker effect was obtained with an A-chain cDNA variant containing a 69-base-pair insertion in the 3' end of the protein-coding domain. A- and B-chain transfectants released PDGF receptor-competing activity into the medium, but only the medium conditioned by the B-chain transfectants possessed potent mitogenic activity on human fibroblasts. Both types of transfectants had downregulated levels of PDGF receptors; however, the B-chain transfectants were downregulated to significantly lower levels. Metabolic labeling and immunoprecipitations with PDGF antiserum showed that the PDGF B-chain protein was processed to a 24-kilodalton cell-associated and a 30-kilodalton secreted dimeric protein. The A-chain protein was rapidly secreted as a 31-kilodalton dimeric protein. The present study shows a marked difference in the autocrine effects of PDGF-AA and -BB expressed under the control of a retroviral promoter and suggests that different biological properties may be assigned to these two PDGF isoforms.

HTLV-I--associated B-cell CLL: indirect role for retrovirus in leukemogenesis

Serum containing antibodies to the human T-lymphotropic virus type I (HTLV-I) has been observed at a higher than expected frequency in patients with B-cell chronic lymphocytic leukemia (CLL) in an area endemic for HTLV-I. An attempt was made to determine whether the cells from patients with this leukemia were HTLV-I antigen-committed B cells that had undergone malignant transformation. Cells from two HTLV-I seropositive Jamaican patients with CLL were fused with a human B-lymphoblastoid cell line. The hybridoma cells that resulted from the fusion of CLL cells from patient I.C. produced an immunoglobulin (IgM) that reacted with the p24 gag protein from HTLV-I, HTLV-II, and HTLV-III (now referred to as HIV), but showed preferential reactivity with HTLV-I. The specific immunoglobulin gene rearrangement (IgM, kappa) in the CLL cell was demonstrated in the hybridoma cell line, indicating that the captured immunoglobulin was from the CLL cells. The IgM secreted by the fusion of CLL cells from patient L.L. reacted only with HTLV-I-infected cells and with the HTLV-I large envelope protein (gp61) on Western blots. The CLL cells from these patients appear to be a malignant transformation of an antigen-committed B cell responding to HTLV-I infection, suggesting an indirect role for this retrovirus in leukemogenesis.

Irrigation drainage with intracatheter in severe infections of the hand

Severe infections of the hand and fingers still challenge the surgeon's skill in spite of modern antibiotics. Very often patients are referred too late, with inadequate incisions and insufficient drainage. In addition, wound edges tend to seal up rapidly, even if no sutures are inserted. In the management of such infections we have successfully introduced an irrigation drainage system, using a common intracather (I-Cath). The method described here is simple, atraumatic and shortens the time of treatment.

Characterisation of the ColE8 plasmid, a new member of the group E colicin plasmids

We have determined the restriction map of the ColE8-J plasmid after cloning it into the pBR322 vector. By subcloning and transposon mutagenesis we have localized the colicin immunity gene, the colicin structural gene, and lys, the region that determines MC sensitivity. In contrast to the ColE3-CA38 plasmid, the genes coding for colicin E8 production and immunity cannot be cloned on a single EcoRI fragment. Insertion of Tn5 transposons into the colicin structural gene region of the recombinant plasmid inactivated colicin production and MC sensitivity. Insertion of transposons into the lys region reduced colicin E8 production and MC induced lysis, the extent of which was dependent upon the precise site of insertion. We propose that the colicin E8 structural gene and lys must be transcribed from a common promoter situated proximal to the structural gene, whilst the colicin E8 immunity gene is transcribed from a second promoter. The lys region is responsible both for cell lysis after MC induction and positive regulation of colicin E8 synthesis.

[Carpal tunnel syndrome in tuberculous tendosynovitis of the hand]

A case of tuberculous tendosynovitis of the hand is reported. Since this is a very rare disease nowadays, which if untreated results in caseoid necrosis and destruction of the flexor tendon apparatus, we thought it interesting to draw attention to this observation. The unspecific symptoms and diagnostic signs are discussed. Therapy consists in an early combination of surgery and tuberculostatic therapy. Without treatment, caseoid necrosis and destruction of the flexor tendons ensue.

5'-terminal nucleotide noncoding sequences of retroviruses: relatedness of two old world primate type C viruses and avian spleen necrosis virus

Computer-assisted comparison of the 5'-terminal regions of mammalian type C viruses serves as a useful model of evolutionary divergence of noncoding nucleic acid sequences. It has led to the concept that regions of conserved nucleic acid sequences, the slowly divergent sequences, contain signals of translational, transcriptional, or integrative significance. Interspersed among the conserved regions are rapidly divergent sequences in which base changes, insertions, and deletions are especially prevalent. In the present study, CPC-1, a type C virus isolated from Colobus polykomos, was shown to be related to another Old World type C monkey virus, endogenous stump-tailed monkey virus, MAC-1, by analysis of their 5'-terminal nucleotide sequences. The 5'-terminal regions of CPC-1 and MAC-1 showed a 76% nucleotide correspondence and were of similar lengths, 132 and 127 nucleotides, respectively. Previous strong-stop analyses of other type C viruses have defined two subgroups: (i) Rauscher murine leukemia virus and gibbon ape leukemia virus and (ii) baboon endogenous virus and endogenous cat virus RD114. Based on the present sequence analysis of their 5'-terminal sequences, CPC-1 and MAC-1 formed a third subgroup. Computer-assisted comparison of the 5'-terminal sequences of CPC-1 and MAC-1 to the previously reported sequence of avian spleen necrosis virus (SNV) (Shimotohno et al., Nature [London] 285:550-554, 1980) showed SNV to be a member of that subgroup of mammalian type C viruses. Consistent with the inclusion of SNV in this subgroup of mammalian type C viruses, SNV was distantly related to other mammalian type C viruses. Interestingly, the SNV 5'-terminal sequences showed no significant evolutionary relationship by these criteria to the avian leukemia and sarcoma viruses. CPC-1, MAC-1, and SNV contained conserved regulatory signals in similar positions in their 5'-terminal RNA sequences analogous to those observed in other mammalian type C retroviruses. These sequences included the canonical AAUAAA sequence, a palindrome, a putative ribosome binding site, and an integration site. Some of these highly conserved subsequences were common to 3'- and 5'-terminal noncoding sequences of nonviral eucaryotic mRNA's (Efstratiadis et al., Cell 21:653-668, 1980). Thus, analysis and comparison of 5'-terminal nucleotide sequences have been useful in defining common functional signals and in extending the matrix of relationships among retroviruses.