Treatment of bone loss in proximal femurs of postmenopausal osteoporotic women with AGN1 local osteo-enhancement procedure (LOEP) increases hip bone mineral density and hip strength: a long-term prospective cohort study

This first-in-human study of AGN1 LOEP demonstrated that this minimally-invasive treatment durably increased aBMD in femurs of osteoporotic postmenopausal women. AGN1 resorption was coupled with new bone formation by 12 weeks and that new bone was maintained for at least 5-7 years resulting in substantially increased FEA-estimated femoral strength.

INTRODUCTION

This first-in-human study evaluated feasibility, safety, and in vivo response to treating proximal femurs of postmenopausal osteoporotic women with a minimally-invasive local osteo-enhancement procedure (LOEP) to inject a resorbable triphasic osteoconductive implant material (AGN1).

METHODS

This prospective cohort study enrolled 12 postmenopausal osteoporotic (femoral neck T-score ≤ - 2.5) women aged 56 to 89 years. AGN1 LOEP was performed on left femurs; right femurs were untreated controls. Subjects were followed-up for 5-7 years. Outcomes included adverse events, proximal femur areal bone mineral density (aBMD), AGN1 resorption, and replacement with bone by X-ray and CT, and finite element analysis (FEA) estimated hip strength.

RESULTS

Baseline treated and control femoral neck aBMD was equivalent. Treated femoral neck aBMD increased by 68 ± 22%, 59 ± 24%, and 58 ± 27% over control at 12 and 24 weeks and 5-7 years, respectively (p < 0.001, all time points). Using conservative assumptions, FEA-estimated femoral strength increased by 41%, 37%, and 22% at 12 and 24 weeks and 5-7 years, respectively (p < 0.01, all time points). Qualitative analysis of X-ray and CT scans demonstrated that AGN1 resorption and replacement with bone was nearly complete by 24 weeks. By 5-7 years, AGN1 appeared to be fully resorbed and replaced with bone integrated with surrounding trabecular and cortical bone. No procedure- or device-related serious adverse events (SAEs) occurred.

CONCLUSIONS

Treating femurs of postmenopausal osteoporotic women with AGN1 LOEP results in a rapid, durable increase in aBMD and femoral strength. These results support the use and further clinical study of this approach in osteoporotic patients at high risk of hip fracture.

Endocarditis caused by culture-negative organisms visible by Brown and Brenn staining: utility of PCR and DNA sequencing for diagnosis

Two cases of culture-negative endocarditis with cocci seen in valve vegetations are presented. The organisms were identified by molecular analysis using broad-range PCR primers complementary to the 16S rRNA gene, sequencing, and database search using BLAST software. The results and utility of this method are discussed.

Evaluation of very low-dose subcutaneous vitamin K during postoperative warfarin therapy

STUDY OBJECTIVE

To determine the effect of very low-dose subcutaneous vitamin K (SCVK) compared with withholding warfarin for above-target international normalized ratio (INR) values after joint surgery.

DESIGN

Historical controlled study.

SETTING

University hospital.

SUBJECTS

One hundred thirty-nine patients beginning warfarin after total joint surgery.

INTERVENTION

For a high INR, warfarin was either withheld or SCVK 100, 300, or 400 microg was administered, depending on INR value.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was change in INR from the day of intervention (day 1) to the next day (day 2). Adjusting for day 1 INR, the mean day 2 INR was 2.10 (95% confidence interval [CI] 1.86-2.33) after SCVK, compared with 2.73 (95% CI 2.50-2.96) in controls. This corresponded to declines of -0.72 and -0.08, respectively (p=0.001).

CONCLUSION

In orthopedic patients starting warfarin therapy, very low-dose SCVK was more effective than withholding warfarin in reducing high INRs. Investigations in other populations and assessment of the effect of low-dose SCVK on postoperative bleeding are indicated.

Platelet PlA2 polymorphism enhances risk of neurocognitive decline after cardiopulmonary bypass. Multicenter Study of Perioperative Ischemia (McSPI) Research Group

BACKGROUND

Neurocognitive decline, often produced by atherosclerotic plaque embolization, remains a frequent complication of cardiopulmonary bypass. Plaque fragments may initiate local thrombosis, which, in turn, aggravates the embolic insult. Prothrombotic genetic factors may exacerbate this process. We investigated whether the PlA2 polymorphism of platelet GPIIIa, a prothrombotic risk factor in other cardiovascular settings, is associated with early neurocognitive decline after cardiopulmonary bypass.

METHODS

Neurocognitive changes were evaluated by the Mini-Mental State Examination administered preoperatively and on postoperative day 4 and the PlA genotype determined in 70 patients undergoing cardiopulmonary bypass.

RESULTS

Forty-nine patients were PlA1/A1, and 21 were PlA1/A2 or PlA2/A2. Fifty-two patients (74%) demonstrated post-cardiopulmonary bypass neurocognitive decline, of which 34 were PlA1/A1 and 18 were PlA1/A2 or PlA2/A2 Multivariate analysis revealed that the PlA2 genotype and baseline Mini-Mental State Examination were significantly associated with greater neurocognitive decline (decreased Mini-Mental State Examination scores, p = 0.036 and 0.024, respectively).

CONCLUSIONS

This study demonstrates a link between the PlA2 allele of platelet GPIIIa and more severe neurocognitive decline after cardiopulmonary bypass. Although the mechanism is unknown, it could represent exacerbation of platelet-dependent thrombotic processes associated with plaque embolism.

Rapid reconstitution of Epstein-Barr virus-specific T lymphocytes following allogeneic stem cell transplantation

Epstein-Barr virus (EBV)-specific CD8 T lymphocytes are present at remarkably high frequencies in healthy EBV(+) individuals and provide protection from EBV-associated lymphoproliferative diseases. Allogeneic peripheral blood stem cell transplantation (allo-PBSCT) is a commonly used therapy in which T-cell surveillance for EBV is temporarily disrupted. Herein, human leukocyte antigen (HLA) class I tetramers were used to investigate the reestablishment of the EBV-specific CD8 T-cell repertoire in patients following allo-PBSCT. CD8(+) T cells specific for lytic and latent cycle-derived EBV peptides rapidly repopulate the periphery of matched sibling allo-PBSCT patients. The relative frequencies of T cells specific for different EBV peptides in transplantation recipients closely reflect those of their respective donors. Investigation of patients at monthly intervals following unmanipulated allo-PBSCT demonstrated that the frequency of EBV-specific T cells correlates with the number of EBV genome copies in the peripheral blood and that expansion of EBV-specific T-cell populations occurs even in the setting of immunosuppressive therapy. In contrast, patients undergoing T-cell-depleted or unrelated cord blood transplantation have undetectable EBV-specific T cells, even in the presence of Epstein-Barr viremia. The protective shield provided by EBV-specific CD8 T cells is rapidly established following unmanipulated matched sibling allo-PBSCT and demonstrates that HLA class I tetramers complexed with viral peptides can provide direct and rapid assessment of pathogen-specific immunity in this and other vulnerable patient populations. (Blood. 2000;96:2814-2821)

Pediatric AIDS-associated lymphocytic interstitial pneumonia and pulmonary arterio-occlusive disease: role of VCAM-1/VLA-4 adhesion pathway and human herpesviruses

Because the mechanisms of lymphocyte accumulation in the lungs of children with AIDS-associated lymphocytic interstitial pneumonia (LIP) are unknown, we studied the relative contributions of known adhesion pathways in mediating lymphocyte adherence to endothelium and the potential role of human herpesviruses in the expansion of these lesions. LIP was characterized by lymphoid hyperplasia of the bronchus-associated lymphoid tissue (BALT) and infiltration of the pulmonary interstitium with CD8(+) T lymphocytes. In some individuals there was expansion of the alveolar septae with dense aggregates of B lymphocytes, many containing the Epstein-Barr viral (EBV) genome. Patients with concurrent EBV infection also demonstrated large-vessel arteriopathy characterized by thickening of the intimae with collagen and smooth muscle. Venular endothelium from the lung of children with LIP, but not uninflamed lung from other children with AIDS or lung from children with nonspecific pneumonitis, expressed high levels of vascular cell adhesion molecule-1 (VCAM-1) protein. In turn, inflammatory cells expressing very late activation antigen-4 (VLA-4), the leukocyte ligand for VCAM-1, were the predominant perivascular infiltrate associated with vessels expressing VCAM-1. Expression of other endothelial adhesion molecules, including intracellular adhesion molecule-1 and E-selectin, was not uniformly associated with LIP. Using a tissue adhesion assay combined with immunohistochemistry for VCAM-1, we show that CD8(+) T cell clones that express VLA-4 bind preferentially to pulmonary vessels in sites of LIP: vessels that expressed high levels of VCAM-1. When tissues and cells were pretreated with antibodies to VCAM-1 or VLA-4, respectively, adhesion was inhibited by >/=80%. Thus, infiltration of alveolar septae with CD8(+) T cells was highly correlative with VCAM-1/VLA-4 adhesive interactions, and focal expansion of B cells was coincidental to co-infection with EBV.

Reduced incidence of Epstein-Barr virus-associated posttransplant lymphoproliferative disorder using preemptive antiviral therapy

BACKGROUND

Posttransplant lymphoproliferative disorder (PTLD) has been observed with increasing frequency consequent to the availability of more effective and potent immunosuppression. Prior work suggested that a peripheral blood monitoring strategy detecting peripheral B lymphoproliferation was effective in the early diagnosis of PTLD among 7 of 179 (3.9%) consecutive transplant recipients. Each of those seven patients received at least one course of antithymocyte globulin, Minnesota antilymphocyte globulin, or OKT3 before developing PTLD.

METHODS

To determine whether antiviral prophylaxis might reduce the incidence of PTLD, a subsequent group of 198 consecutive recipients received either ganciclovir or acyclovir during antilymphocyte antibody administration. When the donor or recipient were cytomegalovirus-seropositive, ganciclovir was given; acyclovir was used when both were cytomegalovirus-seronegative. Baseline and protocol posttransplant cell surface profiles were obtained using immunofluorescence and flow cytometry to detect T cells, lymphocyte activation markers, and the CD19 B cell antigen.

RESULTS

Demographic factors, including the incidence of recipients more than 50 years of age, non-Caucasians, previous transplantation, and diabetes mellitus, were similar in both groups. Additionally, the number of patients receiving antilymphocyte preparations was similar. However, only one patient (0.5%) from the latter group who received preemptive antiviral therapy developed PTLD. Although elevations in CD19+ B cells preceded clinical PTLD among each of the seven earlier patients, evidence of peripheral B cell proliferation was not demonstrated for the sole patient from the latter group, which suggests a possible effect of antiviral therapy.

CONCLUSIONS

Prophylactic antiviral therapy may reduce the sensitivity of peripheral monitoring for B lymphoproliferation, but the dramatic reduction in PTLD incidence strongly supports its use among transplant recipients at risk.

Epstein-Barr virus suspension cell assay using in situ hybridization and flow cytometry

We have developed a procedure for quantitative assay of Epstein-Barr virus (EBV)-infected cells in suspension in either latent or replicative phase using in situ hybridization and flow cytometry. The cells were hybridized with EBV-specific digoxigenin or biotin-labeled oligonucleotide probes, followed by binding to fluorescein-conjugated anti-digoxigenin or phycoerythrin-conjugated streptavidin, respectively. The cells hybridizing to the specific probes were quantitated by flow cytometry. A strong shift in fluorescence intensity (20-fold) was observed when the EBV-positive culture cells were hybridized with a specific EBER1 antisense probe. The sensitivity of the assay was at least one positive cell out of 9,000 beyond the normal control mean +/- 2 S.D. We performed two-color in situ hybridization/flow cytometry using probes to an EBV replication phase-specific mRNA and EBER1 on B95-8 cells in which a small portion (2-4%) of cells induce spontaneously into the replicative phase. In addition, we have developed a method for simultaneous analysis of the cell surface phenotype and EBV nucleic acid content in individual cells.

Cementless hemispheric acetabular components. A 4- to 8-year follow-up report

A retrospective radiographic analysis was performed on 71 cementless acetabular components followed from 4 to 8 years after surgery. A Harris-Galante (Zimmer, Warsaw, IN) cup was used in 46 cases and an Optifix (Smith & Nephew Richards, Memphis, TN) cup was used in 25 cases. There were 66 primary and 5 revision cases. Nonprogressive radiolucencies were common in both types of cups (64% of Optifix, 70% of Harris-Galante). Radiolucencies were almost exclusively less than or equal to 1 mm in width and were most common in zones 1 and 3. Ten cups had continuous but nonprogressive radiolucencies, none greater than 1 mm in all three zones. No radiolucent lines wider than 2 mm were seen in any case. Four cups had progressive radiolucency that stabilized. Radiolucency around fixation screws was seen in one case, and demonstrated stable ingrowth at revision surgery. No cases of osteolysis, screw breakage, migration, or loss of fixation surface occurred. A single case of a broken locking mechanism of a Harris-Galante cup 2 years after liner exchange is reported.

Posterior cruciate ligament strain biomechanics in total knee arthroplasty

To evaluate the role of the posterior cruciate ligament in total knee arthroplasty, 8 normal whole-leg cadaveric legs were studied. Strain patterns of the posterior cruciate ligament were measured during active and passive knee flexion extension. Total knee arthroplasty was performed, and posterior cruciate ligament strain was measured again. The standard tibial insert was removed, and 3 additional tibial trays were used: flat, 10 degrees sloped, and 15 degrees sloped. The posterior cruciate ligament strain was recorded for each tibial insert. Total knee arthroplasty with a standard insert produced a large range of posterior cruciate ligament strain values (+/- 6%). Of the 8 specimens, 3 produced excessively taut posterior cruciate ligament strain, 3 were slack, and 2 returned strain to the baseline strain value. Changing the surface contour and slope of the tibial inserts did not produce any consistent change in the posterior cruciate ligament strain pattern. The ability of total knee arthroplasty to reproduce normal posterior cruciate ligament strain behavior has not been demonstrated.

Tibial plateau coverage in total knee arthroplasty

Optimizing coverage of the resected tibial plateau is an important consideration in total knee arthroplasty. The tibial coverage of eight different tibial tray designs was examined in 35 resected tibial specimens. When no component overlap was permitted, the average tibial coverage of the different designs ranged from 76.4% to 80.8%. When the component was allowed slight overlap, a "surgical fit," the average coverage ranged from 78.5% to 85.5%. As a group, the six symmetric designs provided more coverage than the two asymmetric designs (p < 0.05). Areas of poor coverage were identified, and different tray geometries were compared. Asymmetric tibial components are thought to be more anatomic in nature and therefore cover the tibial plateau surface more completely than symmetric components. The results of this study do not support this, and in fact demonstrate that symmetric components can provide more coverage when compared with two asymmetric component designs.

Cementless hemispheric acetabular components. 2-4-year results

A retrospective clinical and radiographic analysis was performed on 99 patients (106 hips) undergoing total hip arthroplasty with noncemented Harris-Galante (Zimmer, Warsaw, IN) or Optifix (Smith Nephew Richards, Memphis, TN) acetabular components. There were 94 primary and 12 revision procedures with a minimum follow-up period of 24 months (range, 24-52 months). The cups were evaluated for evidence of vertical and horizontal migration, as well as the presence of radiolucencies at the bone-implant interface. Age, sex, component inclination and medialization, cup coverage, and number of fixation screws used were examined to determine the influence of these factors on the incidence of cup migration or radiolucent line formation. A radiolucent line was present in at least one zone in 60% of the Harris-Galante and 45% of the Optifix cups. Progressive radiolucent lines were noted in two of the Optifix and three of the Harris-Galante components. Two Harris-Galante cups (1.9%) were revised. There were no Optifix cup migrations or evidence of instability in the Optifix or remaining Harris-Galante cups. Although there was a trend toward an increased incidence of radiolucencies in those cups lacking complete coverage, no statistically significant radiographic predictors for failure or impending failure could be determined from this short-term follow-up study. With the exception of the two revisions, all acetabular components performed well clinically over the study period.

Failure of the polyethylene liner leading to notching of the femoral component in bipolar prostheses

Polyethylene wear is an increasingly recognized problem in joint replacement surgery. Three cases of polyethylene wear in bipolar hip prostheses are presented. Owing to failure of the polyethylene liner, impingement of the metal shell produced notching of the femoral component.

Upstream basal promoter element important for exclusive RNA polymerase III transcription of the EBER 2 gene

The Epstein-Barr virus-encoded small RNA (EBER) genes are transcribed by RNA polymerase III, but their transcription unit appears to contain both class II and class III promoter elements. One of these promoter element, a TATA-like box which we call the EBER TATA box, or ETAB, is located in a position typical for a class II TATA box but contains G/C residues in the normal T/A motif and a conserved thymidine doublet. Experiments using chloramphenicol acetyltransferase constructs and mutations in the TATA box of the adenovirus major late promoter showed that the ETAB promoter element does not substitute for a class II TATA box. However, when the ETAB promoter element sequence was changed to a class II TATA box consensus sequence, the EBER 2 gene was transcribed in vitro by both RNA polymerases II and III. From these results, we conclude that the ETAB promoter element is important for the exclusive transcription of the EBER 2 gene by RNA polymerase III.

The effect of functional knee-braces on strain on the anterior cruciate ligament in vivo

Functional knee-braces are widely used to protect injured or reconstructed anterior cruciate ligaments, despite the fact that few scientific data support their efficacy. We studied seven functional braces, representative of both the typical custom-fit and off-the-shelf designs. The braces were tested on subjects who had a normal anterior cruciate ligament and were scheduled for arthroscopic meniscectomy or exploration of the knee under local anesthesia. After the operative procedure, a Hall-effect strain-transducer was applied to the anterior cruciate ligament. Under low anterior shear loads, two braces provided some protective strain-shielding effect compared with no brace, but this strain-shielding effect did not occur at the higher anterior shear loads expected during the high-stress activities common to athletic events. The DonJoy, Townsend, C.Ti., and Lenox Hill braces demonstrated a strain-shielding effect on the anterior cruciate ligament with an internal torque of five newton-meters applied to the tibia. None of the braces had any effect on strain on the anterior cruciate ligament during active range of motion of the knee from 10 to 120 degrees or during isometric contraction of the quadriceps. Wearing of a brace did not produce an increase in the value for strain on the anterior cruciate ligament. For the activities that were evaluated in this study, none of the braces produced adverse effects on the anterior cruciate ligament, and there were no significant differences in the strain on the anterior cruciate ligament between the use of a custom-fit or an off-the-shelf brace design. There were no apparent advantages of the more expensive custom-made braces compared with the off-the-shelf designs.

Clinical versus instrumented knee testing on autopsy specimens

The accuracy, reliability, and reproducibility of the Genucom Knee Analysis System and Knee Signature System (KSS) for anteroposterior knee laxity evaluations were compared. The devices detected the same relative change in laxity between normal and anterior cruciate ligament-deficient specimens during Lachman and drawer testing; however, the absolute values differed. In a clinical study, two examiners performed three independent Lachman and drawer tests using the Genucom, KSS, and a subjective clinical examination on ten patients. The Genucom demonstrated interexaminer differences during the Lachman test. The clinical examination proved to be more reliable than either instrumented device for both Lachman and drawer testing. The intraexaminer variability of the Genucom and KSS was large, with the average 95% confidence limits about the mean for the Genucom and KSS equal to +/- 4.2 and +/- 2.8 mm, respectively. These findings question the accuracy, reliability, and reproducibility of the instrumented methods.

The measurement of anterior cruciate ligament strain in vivo

This article describes the use of the Hall Effect strain transducer (HEST) in a new arthroscopic technique to study the normal anterior cruciate ligament (ACL) in-vivo. Study participants were patient volunteers with normal ACLs undergoing diagnostic arthroscopic or meniscal surgery under local anaesthesia. The HEST was implanted into the Anterior Medial Band (AMB) of the ACL. Anterior shear loading of the tibia in relation to the fixed femur at 30 degrees of knee flexion (Lachman test), produced significantly greater strain values in comparison to anterior shear loading at 90 degrees (Anterior Drawer test). During isometric quadriceps contraction a significant increase in AMB strain was measured with the knee flexed to 30 degrees, while no significant change was measured at 90 degrees. For quadriceps contraction there were significantly higher values of AMB strain measured at 30 degrees of knee flexion in comparison to that observed at 90 degrees. For active range of motion (AROM) the AMB was strained between 10 degrees and 48 degrees, and unstrained between 48 degrees and 110 degrees. During passive range of motion (PROM) the AMB remained unstrained until the joint was brought into extension. There were significant differences in strain values found between AROM and PROM at the flexion angles 10 degrees, 20 degrees, 30 degrees and 40 degrees, while between 50 degrees and 110 degrees there were no significant differences. These results confirm previous studies that the Lachman test is a superior technique in comparison to the classic anterior drawer test for evaluating the AMB. They suggest that isometric quadriceps activity at 90 degrees of knee flexion can be prescribed for rehabilitation immediately after ACL reconstruction. These data indicate that AROM (between the limits of 50 degrees and 110 degrees) and PROM may also be performed with minimal risk of strain to a reconstructive replacement. The PROM data may also serve as an important standard for the reconstruction of the ACL.

Longitudinal crack propagation in bone around femoral prosthesis

Intraoperative femoral fracture is a well-recognized technical complication of cementless total hip arthroplasty. This study was designed to establish an in vitro model for initiation and propagation of fractures of the proximal femur in cementless THA and to assess the effect of fracture fixation in the form of cerclage wiring and drilling a hole in the distal extent of the fracture line. Fourteen human anatomic femur specimens were studied. Longitudinal cracks were made and propagation was performed on a materials testing system machine. A drill hole at the tip of a longitudinal crack does not prevent crack propagation. However, cerclage wiring has a statistically significant effect (p less than 0.025) on the ability of the fractured femur to withstand increased load.

Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part II. A specific sport review

Eighty-three patients, from a 10 year follow-up study, who underwent ACL reconstruction with a quadriceps patellar tendon graft were reviewed. A questionnaire qualifying their sports performance in 20 possible sports compared their preinjury status to postinjury and postreconstructive surgery. Successful and unsuccessful patients, as determined by our previous investigation, were likewise compared. Sports performance, regardless of the sport or level of competition, decreased substantially postinjury and then rose significantly to near but not equal to patient preinjury status. The most strenuous sports dipped to the lowest performance level after injury and returned with a correspondingly more modest gain after the reconstruction. Not surprisingly, successful patients had a more impressive return in performance than unsuccessful patients, mirroring their clinical grading. Of those deemed unsatisfactory (N = 20), graft failures were no worse off in performance rating than those that were classified as unsatisfactory because of persistent symptoms.

Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I. Long-term followup

Eighty-three patients with ACL reconstructions using the quadriceps patellar tendon graft were evaluated in a 10 year (mean, 5.5 years) follow-up study. A five-part analysis, consisting of physical examination, questionnaire, Genucom analysis, operative note review, and radiographs, was performed. Seventy-six percent were categorized as satisfactory. Ninety-two percent were content with their results, while only 4% were unsatisfied. Ninety-three percent of the patients had no significant pain and 95% had no giving way postreconstruction. Ninety-two percent had no more than a mild functional deficit. Eighty-seven percent and 90% of the patients had no significant Lachman or pivot shift by examination, respectively. Our results showed no increase in failure over time (1 to 10 years), although those operated on during the initial 5 years showed more radiographic degenerative changes. Plotting our results in classification systems of other authors yielded success rates as good as or better than those using our own criteria. An objective means by which to quantify laxity did not reliably correlate with the quantifying of laxity made by physical examination. Only the lack of a formal rehabilitation program greater than 4 months postoperatively and repaired tears of the medial or lateral collateral ligaments proved to be significant risk factors for poor recovery.

Arthroscopic strain gauge measurement of the normal anterior cruciate ligament

This article describes a new arthroscopic technique to study the anterior cruciate ligament (ACL) in vivo. A Hall effect strain transducer (HEST) is inserted arthroscopically into the anterior medial band (AMB) of the ACL. The strain is calculated from HEST displacement data. This method determines a reference length of the AMB when it becomes taut and load bearing. Data from HEST implantation in five patients with normal ACLs are reported. The HEST was implanted in the AMB with patients under local anesthesia. Strain was calculated during anterior-posterior shear testing and isometric quadriceps contractions at 30 and 90 degrees of knee flexion. The results demonstrate that this technique is safe and reliable. Lachman testing (anterior shear testing at 30 degrees) caused significantly higher strain in comparison to the drawer tests (anterior shear testing at 90 degrees). A significant increase in strain occurred during isometric quadriceps contraction when the knee was flexed at 30 degrees. No significant change in strain was measured, however, during isometric quadriceps contraction at 90 degrees of flexion. These results confirm previous studies showing that the Lachman test is a more sensitive clinical method for evaluating the AMB. They suggest that isometric quadriceps activity at 90 degrees of knee flexion can be prescribed for rehabilitation without risk of increased strain of the AMB.

Epstein-Barr virus small RNA (EBER) genes: unique transcription units that combine RNA polymerase II and III promoter elements

The Epstein-Barr virus-encoded small RNA (EBER) genes appear to comprise an interesting subset of class III genes different from any previously identified, including U6 and 7SK. EBER genes have functional A and B box intragenic control regions. In addition, they contain three upstream elements that together stimulate in vivo expression 50-fold and resemble sites associated with typical class II promoters. DNAase I footprinting analyses using purified proteins or oligonucleotide competition demonstrate that nucleotides -40 to -55 bind activating transcription factor (ATF) or a related protein, while nucleotides -56 to -77 bind Sp1 protein or a related protein. The element between positions -23 and -28 resembles a TATA box. EBERs are unusual RNA polymerase III transcripts shown to be controlled by ATF- and Sp1-like promoter elements, suggesting mechanisms for their high level expression in EBV-transformed lymphocytes.

Influence of Burkitt's lymphoma and primary B cells on latent gene expression by the nonimmortalizing P3J-HR-1 strain of Epstein-Barr virus

The Epstein-Barr virus (EBV) genes expressed in B lymphocytes immortalized in vitro or in Burkitt's lymphoma (BL) cells infected in vivo have been characterized previously; however, the viral products which are essential for immortalization or for establishment of EBV latency are still not known. To approach this question, we compared the kinetics of expression of EBV nuclear antigens and the two EBV-encoded small RNAs, EBER1 and EBER2, after infection of primary B cells or EBV genome-negative BL cells with either an immortalizing EBV strain (B95-8) or the nonimmortalizing deletion mutant (HR-1). Following infection of primary cells with B95-8 virus, EBV nuclear antigen (EBNA)-2 was expressed first, followed by EBNA-1, -3, and -4 (also called leader protein [LP]) and the two small RNAs. Infection of EBV genome-negative BL cells with the same strain of virus resulted in a similar pattern of gene expression, except that the EBNAs appeared together and more rapidly. EBERs were not apparent in one BL cell line converted by B95-8. The only products detected after infection of primary B lymphocytes with the HR-1 deletion mutant were the EBNA-4 (LP) family and trace amounts of EBER1. Although HR-1 could express neither EBNA-1, EBNA-3, nor EBER2 in primary cells, all these products were expressed rapidly after HR-1 infection of EBV genome-negative BL cell lines. The results indicate that the mutation in HR-1 virus affects immortalization not only through failure to express EBNA-2, a gene which is deleted, but also indirectly by curtailing expression of several other EBV genes whose coding regions are intact in the HR-1 virus and normally expressed during latency. The pattern of latent EBV gene expression after HR-1 infection is dependent on the host cell, perhaps through products specific for the cell cycle or the state of B-cell differentiation.

Total knee arthroplasty kinematics. An in vivo evaluation of four different designs

Thirty-four patients who had 42 total knee arthroplasties during the past 5 years were examined. Four types of total knee arthroplasties (Tricon-M, PCA, Variable Axis, and Anametric) were evaluated, using a computerized knee evaluation system. The patients and 10 controls with normal knees were tested for anteroposterior stability with the Lachman test, medial/lateral stability at 20 degrees, varus/valgus stability at 20 degrees, internal/external rotation at 80 degrees and 20 degrees of flexion, and internal/lateral rotation (screw home) over the active range of motion. At 30 degrees of flexion, the Variable Axis prosthesis was 54% more constrained than the normal knee to anterior/posterior shear. The Anametric and the Variable Axis were more lax under varus/valgus stress than the normal knee by 85% and 71%, respectively. There were no statistical differences for any of the other tests.

Isolation and characterization of the genes for two small RNAs of herpesvirus papio and their comparison with Epstein-Barr virus-encoded EBER RNAs

Genes for the Epstein-Barr virus-encoded RNAs (EBERs), two low-molecular-weight RNAs encoded by the human gammaherpesvirus Epstein-Barr virus (EBV), hybridize to two small RNAs in a baboon cell line that contains a similar virus, herpesvirus papio (HVP). The genes for the HVP RNAs (HVP-1 and HVP-2) are located together in the small unique region at the left end of the viral genome and are transcribed by RNA polymerase III in a rightward direction, similar to the EBERs. There is significant similarity between EBER1 and HVP-1 RNA, except for an insert of 22 nucleotides which increases the length of HVP-1 RNA to 190 nucleotides. There is less similarity between the sequences of EBER2 and HVP-2 RNA, but both have a length of about 170 nucleotides. The predicted secondary structure of each HVP RNA is remarkably similar to that of the respective EBER, implying that the secondary structures are important for function. Upstream from the initiation sites of all four RNA genes are several highly conserved sequences which may function in the regulation of transcription. The HVP RNAs, together with the EBERs, are highly abundant in transformed cells and are efficiently bound by the cellular La protein.

Structural analyses of EBER1 and EBER2 ribonucleoprotein particles present in Epstein-Barr virus-infected cells

The ribonucleoprotein (RNP) particles containing the Epstein-Barr virus-associated small RNAs EBER1 and EBER2 were analyzed to determine their RNA secondary structures and sites of RNA-protein interaction. The secondary structures were probed with nucleases and by chemical modification with single-strand-specific reagents, and the sites of modification or cleavage were mapped by primer extension. These data were used to develop secondary structures for the two RNAs, and likely sites of close RNA-protein contact were identified by comparing modification patterns for naked RNA and RNA in RNP particles. In addition, sites of interaction between each Epstein-Barr virus-encoded RNA (EBER) and the La antigen were identified by analyzing RNA fragments resistant to digestion by RNase A or T1 after immunoprecipitation by an anti-La serum sample from a lupus patient. Our results confirm earlier findings that the La protein binds to the 3' terminus of each molecule. Possible functions for the EBER RNPs are discussed.

Localization of Epstein-Barr virus-encoded small RNAs by in situ hybridization

Human B lymphocytes latently infected with Epstein-Barr virus (EBV) synthesize two low molecular weight RNAs designated EBER 1 and 2. Using an in situ hybridization technique we have localized EBER 1 and 2 within the nucleus of single EBV-harboring B lymphocytes from established and recently transformed cell lines. As controls, the locations of the small nuclear RNA, U1, and the small cytoplasmic RNA, 7SL, were examined in HeLa and EBV-harboring cells. Because of possible functional similarities between EBERs and the adenovirus-associated (VA) RNAs, VAI was also localized; it appeared to be in the nucleus and cytoplasm, implying that VAI may have a different role than that of the nuclear-localized EBERs.

Preparation and release characteristics of tobramycin-impregnated polymethylmethacrylate beads

Preparation of tobramycin-impregnated polymethylmethacrylate (PMMA) bone cement beads and release of tobramycin from the beads in vitro and after implantation in a patient are described. Tobramycin sulfate powder 1.2 g was mixed with Palacos PMMA bone cement 40 g in a custom-made mold to produce 25 beads containing 3.26 mg tobramycin (as the sulfate salt) per bead. Chains of the beads, strung on stainless-steel suture, were sterilized with ethylene oxide. Three single beads were each placed in multiple-electrolyte solution (pH 7.4); the solution was removed and replaced with fresh solution every 24 hours for 28 days. The tobramycin content of each day's solution was determined by fluorescence polarization immunoassay. After day 28, solution was removed weekly for assay until day 84. Tobramycin concentrations were measured in drainage from the surgical wound after six chains of tobramycin-PMMA bone cement beads were implanted in the right acetabulum and femur of a patient whose hip prosthesis had been removed because of infection. Tobramycin concentrations in the dissolution medium averaged 34.3 micrograms/mL initially, and 7.5 micrograms/mL on day 2, gradually decreasing to 0.6 microgram/mL on day 28. Release of tobramycin followed a predictable pattern, and variation among samples was small. Over 12 weeks, less than 20% of the theoretically available tobramycin from a single bead was released. Tobramycin concentration in wound drainage was 90.0 micrograms/mL during the first 24 hours after surgery, while serum tobramycin concentrations were less than 0.5 microgram/mL. Extemporaneously prepared beads of bone cement are effective for delivering high concentrations of tobramycin to an infection site.(ABSTRACT TRUNCATED AT 250 WORDS)

The rate of evolutionary divergence of initiation factors IF2 and IF3 in various bacterial species determined quantitatively by immunoblotting

Antibodies to Escherichia coli translational initiation factors IF2 and IF3 were used for an immunological comparison of unpurified proteins from the following genera: Salmonella, Serratia, Proteus, Aeromonas, Pseudomonas, Streptococcus, Sarcina and Bacillus. Immunological relatedness was compared by Ouchterlony double diffusion experiments and immunoblotting analysis. Immunoblotting is a quantitative technique for measuring levels of specific proteins in crude cell lysates. We have used this technique to measure immunological distance with the assumption that the levels of the various translational components are essentially the same in the different bacterial cells examined. Both immunodiffusion and immunoblotting analysis showed a similar evolutionary relationship between the various species for the two initiation factors examined: (Escherichia = Salmonella greater than Serratia greater than Proteus greater than Aeromonas greater than Pseudomonas). Little or no crossreactivity was found using either analysis with genera: Streptococcus, Sarcina and Bacillus. Using the immunoblot distance, the two initiation factors were shown to diverge at similar rates. One advantage the immunoblotting analysis has over other immunological techniques is that the antigens can be analyzed structurally. We found, for example, that the two forms of IF2 were present in all bacterial species which cross-reacted with anti-IF2, suggesting that both forms are functionally important. Because of its sensitivity, the immunoblot analysis may be more useful than other immunological techniques in studying species that are more distantly related.

Translational initiation factor and ribosome association with the cytoskeletal framework fraction from HeLa cells

The association of mRNA and ribosomes with the cytoskeleton of eucaryotic cells may be important for protein synthesis and its regulation. HeLa cells were gently lysed with detergent, and soluble and cytoskeletal framework subfractions were prepared by centrifugation. We analyzed these fractions for ribosomes and confirmed earlier findings that polysomes are preferentially associated with the cytoskeletal fraction. The levels of initiation factors eIF-2, eIF-3, eIF-4A, and eIF-4B were quantitated by immunoblotting; all are enriched in the cytoskeletal fraction relative to the soluble fraction. Heat shock, fluoride, pactamycin , and cytochalasin caused the release of both ribosomes and initiation factors into the soluble fraction. However, treatment of the cytoskeletal fraction with EDTA or low levels of ribonuclease resulted in polysome degradation but no release. Therefore initiation factor association with the cytoskeletal framework correlates with the presence of ribosomes, whereas ribosome association does not require intact mRNA.

Levels of ribosomal protein S1 and elongation factor G in the growth cycle of Escherichia coli

The relative levels of ribosomes, ribosomal protein S1, and elongation factor G in the growth cycle of Escherichia coli were examined with two-dimensional polyacrylamide gel electrophoresis. Nonequilibrium pH gradient polyacrylamide gel electrophoresis was used in the first dimension, and polyacrylamide gradient-sodium dodecyl sulfate gel electrophoresis was used in the second dimension. The identities of protein spots containing S1 and elongation factor G were confirmed by radioiodination of the proteins and peptide mapping of the radiolabeled peptides. The levels of ribosomes and ribosomal protein S1 were coordinately reduced during transition from exponential phase to stationary phase. There was no accumulation of S1 in the stationary phase. In marked contrast, the level of elongation factor G showed no significant change from exponential phase to stationary phase. The relative level of elongation factor G compared with ribosomes or S1 increased by about 2.5-fold during transition from exponential phase to stationary phase. The results show that there are differences between the regulation of the levels of elongation factor G and of ribosomal proteins, including S1, apparent during the transition from exponential to stationary phase.

Initiation factor and ribosome levels are coordinately controlled in Escherichia coli growing at different rates

The levels of initiation factors and other translational components were compared in crude lysates of Escherichia coli grown at different rates. Cells were grown in media containing [35S]sulfate and different carbon sources, and harvested during mid-exponential phase after about 10 generations of balanced growth. Initiation factors (IF), elongation factors (EF), and a number of ribosomal proteins were identified unambiguously in gel patterns following two-dimensional polyacrylamide gel electrophoresis. The molar concentration of each protein was calculated from measurements of the radioactivity in excised gel spots and knowledge of the sulfur content of each protein. We found that the ribosomal proteins and elongation factors were present in equimolar amounts except for L7/L12 and EF-Tu which were 4-fold and 5-fold more abundant, respectively, and that the levels of each protein increased in proportion to growth rate. These results are similar to ones obtained previously by other methods, and serve to confirm the validity of our method. We found that the levels of IF2a and IF3 also were approximately proportional to growth rate. We also measured the levels of all three initiation factors using a radioimmune assay, showed that the factors are present in equimolar amounts, and confirmed that their abundance increased in parallel with ribosomes. We conclude that initiation factor levels are coordinately regulated with one another and with ribosome and elongation factor levels.

Thirst, resetting of the osmostat, and water intoxication following encephalitis

A young man developed pathological thirst and hyperdipsia, hyperphagia, disordered temperature regulation, a lowered threshold for aggressive behavior, apathy, impaired memory, and seizures following encephalitis. He had marked hyponatremia. Bouts of water drinking produced water intoxication and precipitated status epilepticus. Studies of water handling with measurements of plasma osmolality and arginine vasopressin (AVP) revealed a very low thirst threshold (below 242 mOsm/kg) with resetting of the osmostat to a new level (255 mOsm/kg) but normal control of plasma osmolality at that level with adequate AVP release.

Multiple sclerosis plaque mimicking tumour on computed tomography

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Cloning and mapping of a gene for translational initiation factor IF2 in Escherichia coli

A novel method, not relying on genetic complementation of a mutation, was used to clone a gene for translational initiation factor IF2. Two clones from a cosmid library of total Escherichia coli DNA were isolated for their ability to overproduce IF2 in vivo as determined by quantitative immunoblotting. "Maxicell" analysis of cosmid-encoded proteins and specific immune precipitation of the labeled proteins showed that the structural gene for IF2 (inf B) had been cloned. Subcloning fragments from the original cosmids located the inf B gene to a 4.8-kilobase pair HindIII/BamHI fragment. This fragment has been inserted into an integration-deficient recombinant lambda phage that lysogenizes by homology. By mapping the point of lysogenization on the E. coli chromosome, inf B has been located at 68 min, very close to argG, nusA, rpsO, and pnp. Because the gene for initiation factor IF3 is located at 38 min on the chromosome, the genes for translational initiation factors are not grouped together.

Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature

Lhermitte's sign was experienced by 33.3% of 114 patients with multiple sclerosis, and in 16% it occurred in the first episode. Eleven patients with subacute combined degeneration of the cord due to pernicious anaemia also were reviewed, and one reported Lhermitte's sign. Review of the literature suggests that the symptom rarely occurs in other conditions except subacute combined degeneration of the cord, neck trauma, radiation myelitis and prolapsed cervical disc.

Expression of the gene for Escherichia coli initiation factor IE-3 in vivo and in vitro

Expression of protein synthesis initiation factor IF-3 in vivo was studied by measuring its level in exponentially growing cells as a function of gene dosage. A strain haploid for infC, the gene for IF-3, was modified to carry one or two additional infC genes giving diploid and triploid strains. Polyploid strains were achieved by the presence of multicopy plasmids expressing the infC gene. When IF-3 levels were measured by quantitative immunoblotting they were found to be proportional to the gene dosage; the presence of a multicopy plasmid thus causes considerable overproduction of IF-3, enabling large quantities to be purified. When lysates were prepared from freshly grown cells, only IF-3 alpha (the long form) was detected; however when IF-3 was purified from a strain containing a multicopy plasmid which overproduced it, the major product found was IF-3 beta (the short form, lacking six amino acids from the N terminus). The synthesis of the two IF-3 forms was also studied by using a cell-free coupled transcription-translation system dependent on exogenous DNA: the IF-3 gene was found to be very efficiently expressed. IF-3 alpha increased more rapidly than IF-3 beta but following the cessation of protein synthesis IF-3 alpha decreased while IF-3 beta still increased. The results suggest that IF-3 alpha is slowly degraded to the beta form. Addition of non-radioactive IF-3 alpha, up to fivefold molar excess over ribosomes, to the synthesizing system in vitro did not inhibit IF-3 synthesis. Synthesis of IF-3 in vitro appears to be sensitive to guanosine 3'-diphosphate 5'-diphosphate.

A study of the role of the cholinergic system in amygdaloid kindling in rats

The effect of atropine on kindling the amygdala of rats was tested by administering the drug in a dose of 25 mg/kg 1 h before each stimulus was applied. Rats tested with atropine kindled at the same rate as saline-treated controls. Cholinergic activity in the amygdala of rats was assessed, 4 weeks after the completion of kindling, by measuring both muscarinic receptor numbers and sodium-dependent high affinity choline uptake in tissue homogenates. There was no change in either of these parameters attributable to kindling. These results suggest that changes in the cholinergic system are not fundamental either to the development or the maintenance of kindling in the rat amygdala.

A sensitive immunoblotting method for measuring protein synthesis initiation factor levels in lysates of Escherichia coli

Protein synthesis initiation factor levels are measured in crude cell lysates of Escherichia coli MRE600 by use of a sensitive immunoblotting method. The method involves electrophoretic transfer of protein from sodium dodecyl sulfate-polyacrylamide gels onto nitrocellulose paper and subsequent incubation with a specific antiserum and radioactive iodinated second antibody. The measurement of iodinated antibody attached to known amounts of initiation factor is determined by densitometric scanning of autoradiographs or counting radioactivity in excised protein bands. Linear standard curves over the range 1 to 300 ng of factor are obtained by these methods. Unknown amounts of initiation factor in crude cell lysates are measured accurately; values agree with previous radioimmune assay data. The immunoblotting method serves as an alternative to the radioimmune assay in measuring small quantities of protein in complex mixtures. Immunoblotting enjoys three major advantages: it is simple and rapid to execute; it is sensitive; and it is capable of distinguishing multiple forms of the antigen which separate in the gel system employed.

Anticonvulsants and thyroid function

Serum total and free thyroid hormone concentrations were estimated in 42 patients with epilepsy taking anticonvulsants (phenytoin, phenobarbitone, and carbamazepine either singly or in combination). There was a significant reduction in total thyroxine (TT4), free thyroxine (FT4), and free triiodothyronine (FT3) in the treated group compared with controls. Free hormone concentrations were lower than total hormone concentrations, suggesting that increased clearance of thyroid hormones occurs in patients receiving anticonvulsants. Detailed analysis indicated that phenytoin had a significant depressant effect on TT4, FT4, FT3, and reverse T3 (rT3). Phenobarbitone and carbamazepine had no significant main effects, but there were significant interactions between phenytoin and carbamazepine for TT4 and FT4. phenobarbitone and carbamazepine for FT3, and phenytoin and phenobarbitone for rT3.