Three-dimensional distribution of bone density in the proximal humerus

Bone quality of the proximal humerus is important for the surgical treatment of proximal humeral fractures and rotator cuff tears. However, very few studies have evaluated the areal bone mineral density (BMD) of the proximal humerus. The aim of this study was to analyze the volumetric BMD (vBMD) using peripheral-quantitative-computed-tomography. Total, trabecular and cortical vBMD were determined separately for the proximal and distal half of the humeral head, the surgical neck and seven specific regions of interest. The greater tuberosity (GT) was divided into three regions, and the lesser tuberosity (LT) and articular surface (AS) were each divided into two regions. The proximal head showed a significantly higher trabecular (+ 46%) and cortical vBMD (+ 15%) than the distal one. The mean trabecular vBMD of AS was significantly higher (+ 80%), and the cortical vBMD was significantly lower (- 11%) than that of the tuberosities. In the proximal half of GT, trabecular vBMD was higher in the posterior than in the middle and anterior regions. Cortical vBMD was higher in middle region than in the anterior and posterior ones. In the distal half of GT, trabecular vBMD was significantly higher in the posterior than in the middle region, and cortical vBMD was significantly higher in the anterior than in the middle region. In one. These results point to bone sites that may provide stronger fixation for implants, reduce the risk of implant loosening, and therefore improve patient outcome.

The presence of smooth muscle actin in fibroblasts in the torn human rotator cuff

The rotator cuff frequently sustains athletic and occupational injury, often resulting in chronic pain and disability. However, despite the high incidence of such shoulder problems, the pathophysiology of rotator cuff injury and healing has not yet been fully elucidated. The notable finding of this study was the presence of a contractile actin isoform, alpha-smooth muscle actin (SMA), in nonvascular cells in all of the seven torn human rotator cuff specimens evaluated immunohistochemically. Up to 95% of cells in any one region, and over 95% of elongated cells found in association with crimped collagen, contained SMA. Most of the cells staining positive for SMA in these sections had morphological features of the fibroblast, though a small number were chondrocyte-like. Treatment of cells growing out from human rotator cuff explants with TGF-beta1 significantly increased the amount of SMA evaluated by Western blot analysis. PDGF-BB and IFN-gamma had no effect on the cell content of SMA. This is the first documentation of the presence of SMA-positive cells in the human rotator cuff tendon. SMA has been found in a number of other healing connective tissues including skin, ligament, meniscus, cartilage, and other types of tendon. Of importance are previous findings that SMA-positive cells can contract a collagen-glycosaminoglycan analog of extracellular matrix in vitro. The results of the present study thus suggest that SMA-containing cells could contribute to the retraction of the torn ends of a ruptured rotator cuff and play an important role in healing.

Patient-held shared care records for individuals with mental illness. Randomised controlled evaluation

BACKGROUND

Few formalized shared care schemes exist within psychiatry and the evidence base for sharing psychiatric care is weak.

AIMS

To evaluate the utility of patient-held shared care records for individuals with long-term mental illness.

METHOD

Cluster-randomised controlled parallel-group 12-month trial involving 90 patients with long-term mental illness drawn from 28 general practices.

RESULTS

Carrying a shared care record had no significant effect on mental state or satisfaction with psychiatric services. Compared with controls, patients in the shared care group were no more likely to be admitted (relative risk 1.2, 95% CI 0.86-1.67) and attend clinic (relative risk 0.96, 95% CI 0.67-1.36) over the study period. Uptake of the shared care scheme was low by patients and professionals alike. Subjects with psychotic illness were significantly less likely to use their records (relative risk 0.51, 95% CI 0.27-0.99).

CONCLUSIONS

Patient-held records may not be helpful for patients with long-term mental illness.

Evidence-based psychopharmacology 3. Assessing evidence of harm: what are the teratogenic effects of lithium carbonate?

Critical appraisal techniques are not only useful in evaluating evidence of therapeutic trials. In this final article of the series of evidence-based psychopharmacology, the evidence about the teratogenic effects of lithium carbonate is considered. This exercise highlights the importance of assessing the evidence oneself and not relying on the interpretation others put on it.

Evidence-based psychopharmacology 2. Appraising a systematic review: is risperidone better than conventional antipsychotics in the treatment of schizophrenia?

Systematic reviews are increasingly used to combine the results of several studies in order to define the treatment effect with a high degree of precision. However, reviews of this nature may lead to spurious results and should not be accepted uncritically. This article, the second in a series on evidence-based psychopharmacology, is intended to illustrate the process of critical appraisal of a systematic review. In this example, a systematic review of studies comparing risperidone with conventional antipsychotics is appraised. Interpretation of the results of the systematic review may be hampered by the way in which studies were selected.

Evidence-based psychopharmacology 1. Appraising a single therapeutic trial: what is the evidence for treating early Alzheimer's disease with donepezil?

Expertise in setting appropriate, answerable clinical questions, undertaking an accurate search of databases, and appraising the evidence found are all key elements to practising evidence-based medicine. Using the published evidence of the utility of donepezil in Alzheimer's disease as an example, I have attempted to illustrate the process of critical appraisal of a therapeutic intervention. The study appraised was well conducted and the results indicate that donepezil may benefit some patients with Alzheimer's disease.

Quality of life and social issues in older depressed patients

Depression is a common disorder in old age, affecting at least 10% of individuals over 65. In older people, the relationship between depression and impaired social functioning and quality of life is complex and ill defined. Despite well-tolerated and effective treatments, many depressed individuals are undiagnosed or under-treated. The impact of depression on the quality of life (QOL) and social functioning of older people can be considerable. Furthermore, impairment of social functioning, consequent on the social isolation and functional disability that goes hand-in-hand with ageing, may be a causative factor in old age depression. Once depression develops, it may result in further narrowing of social repertoire, compounding the problem. Notwithstanding some of the difficulties in measuring social functioning and quality of life, progress has been made in defining the extent of these problems in older depressed individuals. The impact treatment of depression has on these parameters is becoming increasingly recognised and evaluated in clinical trials.

Organization of the human glucokinase regulator gene GCKR

Glucokinase plays an important role in regulating insulin secretion in response to changes in blood glucose levels. As a result, one form of maturity onset diabetes of the young (MODY) results from haploinsufficiency of glucokinase. In both liver and pancreatic islet, glucokinase is allosterically regulated by an inhibitory protein (glucokinase regulatory protein, GCKR). GCKR has therefore become an important gene for functional analysis in type 2 diabetes. To allow genetic assessment of any such role, we have determined the structure of the human GCKR gene. Characterization of P1 and YAC clones containing GCKR shows it to consist of 19 exons spanning 27 kb. RT-PCR, RACE, and RNase protection experiments defined a transcriptional start site for GCKR 66 bp upstream of the initiation codon, but provided no evidence for islet cell specific alternative splicing in the rat. By SSCP screening, a common polymorphic sequence variant has been defined within exon 15 of human GCKR, at nt 1400 of the cDNA. This alters amino acid residue 446 from proline, conserved in rat and Xenopus, to leucine.

P67L: a cystic fibrosis allele with mild effects found at high frequency in the Scottish population

Only three mutant cystic fibrosis (CF) alleles have to date been established as conferring a dominant mild effect on affected subjects who are compound heterozygotes. We now add a fourth, P67L, which occurs on about 1.4% of Scottish CF chromosomes. Among 13 patients (12 unrelated) with this allele, the average age at diagnosis was 22.5 +/- 11.3 years. None of the cases had consistently raised sweat chloride concentrations, the average value being 57 +/- 9 mmol/l; 77% of the patients were pancreatic sufficient. When compared to three other established mild CF alleles, R117H, A455E, and 3849 + 10kb C-T, a compound heterozygote for P67L has minimal disease and clinical suspicions are unlikely to be confirmed other than by DNA typing.

Psychiatrists and their patients: views on forms of dress and address

BACKGROUND

Dress styles and forms of address vary among psychiatrists.

METHOD

A semi-structured interview was administered to a sample of psychiatric in-patients, and a questionnaire was sent to junior and consultant psychiatrists, to identify preferences for dress styles and terms of address.

RESULTS

Forty-nine (71%) of the in-patient sample participated. A preference was found for smart attire and white coats. Of the 69 (80%) doctors returning questionnaires, the majority supported smart dress as the most appropriate attire. Most patients preferred to be called by their first name while addressing doctors by title and surname. Junior doctors preferred to use first names when talking to patients while almost all consultants used title and surname. Doctors of all grades liked to be called by their title and surname.

CONCLUSIONS

Paying more attention to the way we present ourselves and interact at work may help to facilitate the therapeutic alliance.

Strength of fixation with transosseous sutures in rotator cuff repair

The effect of various configurations of placement of transosseous sutures on the immediate strength of fixation was studied in forty-five fresh-frozen humeri from cadavera of older individuals (mean age at the time of death, sixty-three years). The ultimate strength (the strength to failure) was significantly greater (p < 0.05) when the sutures were placed at sites more distal to the tip of the greater tuberosity or when the sutures were tied over a wider bone bridge. Cortical augmentation with use of a plastic button through which the transosseous sutures were tied increased the ultimate strength approximately 1.9-fold. The increase in the ultimate strength of the transosseous repair corresponded significantly with the increasing mean thickness of the cortical bone as the sutures were placed more distally along the lateral aspect of the humerus. We concluded that the strength of the fixation of a rotator cuff repair can be increased by placing the transosseous sutures at least ten millimeters distal to the tip of the greater tuberosity and by tying them over a bone bridge that is at least ten millimeters wide. When bone is very osteoporotic, cortical augmentation with a readily available plastic button strengthens the repair.

BRCA1 5382insC mutation in sporadic and familial breast and ovarian carcinoma in Scotland

A restriction site-generating polymerase chain reaction (RG-PCR) assay was developed to detect the BRCA1 5382insC mutation that has been reported in multiple, apparently unrelated breast/ovarian carcinoma families. The assay has been used to screen tumour DNA from 250 breast cancer patients (aged 19-86 years) and from 80 ovarian cancer patients (aged 25-90 years) in a local population of patients with no known family history. Altogether, 0/80 (0%) ovarian and 1/250 (0.4%) breast tumour DNAs were found to have the 5382insC mutation. The sole positive case was a 26-year-old woman (BC185) with no known family history. One of the reasons for carrying out this analysis was that the 5382insC mutation had previously been shown to segregate with the disease in a very large Scottish 'West Lothian' kindred having breast/ovarian carcinoma. To investigate whether this apparently isolated case and the known family might be related, haplotypes for the markers D17S855, D17S1322, D17S1323 and D17S1327 were analysed. The mutant haplotype in the large kindred was identical to that reported in all other 5382insC mutation families for all markers with the exception of D17S1327. This implies that there has been a recombination event at the telomeric end of common ancestral haplotype in this family. Since the isolated case we identified carries the 'complete' common haplotype, it is unlikely that she is closely related to the West Lothian family.

A general method for the detection of large CAG repeat expansions by fluorescent PCR

The expansion of a tandemly repeated trinucleotide sequence, CAG, is the mutational mechanism for several human genetic diseases. We present a generally applicable PCR amplification method using a fluorescently labelled locus specific primer flanking the CAG repeat together with paired primers amplifying from multiple priming sites within the CAG repeat. Triplet repeat primed PCR (TP PCR) gives a characteristic ladder on the fluorescence trace enabling the rapid identification of large pathogenetic CAG repeats that cannot be amplified using flanking primers. We used our method to test a cohort of 183 people from myotonic dystrophy families including unaffected subjects and spouses. Eighty five clinically affected subjects with expanded alleles on Southern blot analysis were all correctly identified by TP PCR. This method is applicable for any human diseases involving CAG repeat expansions.

Co-localization of the ketohexokinase and glucokinase regulator genes to a 500-kb region of chromosome 2p23

The glucokinase regulator (GCKR) is a 65-kDa protein that inhibits glucokinase (hexokinase IV) in liver and pancreatic islet. The role of glucokinase (GCK) as pancreatic beta cell glucose sensor and the finding of GCK mutations in maturity onset diabetes of the young (MODY) suggest GCKR as a further candidate gene for type 2 diabetes. The inhibition of GCK by GCKR is relieved by the binding of fructose-1-phosphate (F-1-P) to GCKR. F-1-P is the end product of ketohexokinase (KHK, fructokinase), which, like GCK and GCKR, is present in both liver and pancreatic islet. KHK is the first enzyme of the specialized pathway that catabolizes dietary fructose. We have isolated genomic clones containing the human GCKR and KHK genes. By fluorescent in situ hybridization (FISH), KHK maps to Chromosome (Chr) 2p23.2-23.3, a new assignment corroborated by somatic cell hybrid analysis. The localization of GCKR, originally reported by others as 2p22.3, has been reassessed by high-resolution FISH, indicating that, like KHK, GCKR maps to 2p23.2-23.3. The proximity of GCKR and KHK was further demonstrated both by two-color interphase FISH, which suggests that the two genes lie within 500 kb of each other, and by analysis of overlapping YAC and P1 clones spanning the interval between GCKR and KHK. A new microsatellite polymorphism was used to place the GCKR-KHK locus between D2S305 and D2S165 on the genetic map. The colocalization of these two metabolically connected genes has implications for the interpretation of linkage or allele association studies in type 2 diabetes. It also raises the possibility of coordinate regulation of GCKR and KHK by common cis-acting regulatory elements.

Electrocardiographic changes in patients receiving neuroleptic medication

The precise aetiology of sudden death in patients receiving neuroleptic medication is uncertain, but cardiac arrhythmias are a possible cause. We investigated the link between neuroleptic medication and electrocardiographic changes predictive of malignant cardiac arrhythmias. Electrocardiographs were performed on 111 patients receiving neuroleptic medication and on 42 unmedicated controls. Prolonged QTc intervals were more common in the patient sample, but QTc dispersion was not significantly increased. QTc interval prolongation was more likely in patients on doses above 2000 mg chlorpromazine equivalents daily (odds ratio 4.28, P < 0.02). Neuroleptic medication, especially at high doses, is associated with ECG changes that may herald more serious cardiac problems.

The use of risperidone in treatment-resistant schizophrenia: two case reports

The role of risperidone in the management of treatment-resistant schizophrenia remains unclear. We describe two patients with treatment-resistant schizophrenia characterized by unremitting delusions, thought disorder and self-neglect who had a sustained improvement in their symptoms soon after starting risperidone. Risperidone may be a suitable alternative to clozapine in some patients unresponsive to conventional antipsychotics.

A human parthenogenetic chimaera

In mice, parthenogenetic embryos die at the early postimplantation stage as a result of developmental requirements for paternally imprinted genes, particularly for formation of extraembryonic tissues. Chimaeric parthenogenetic<==>normal mice are viable, however, due to non-random differences in distribution of their two cell types. Species differences in imprinting patterns in embryo and extra-embryonic tissues mean that there are uncertainties in extrapolating these experimental studies to humans. Here, however, we demonstrate that parthenogenetic chimaerism can indeed result in viable human offspring, and suggest possible mechanisms of origin for this presumably rare event.

Chromosomal organisation of a repeated gene cluster expressed in mammalian stages of Leishmania

The genomic organisation of a large Leishmania gene cluster, expressed predominantly in intracellular, infective parasite stages, has been determined. Using cosmid cloning, parasite DNA fingerprinting, partial digestion and mapping with 'end-specific' probes, the Lm cDNA2 gene array has been localised to a 55-kb ClaI fragment within the L. major genome. Six tandemly linked gene copies are transcribed to produce an abundant 6-kb transcript; the seventh and last copy of the cluster is truncated at its 3' end. It is likely that these genes encode one or more proteins specific to infective stages of the parasite life cycle.

A second locus for hereditary hemorrhagic telangiectasia maps to chromosome 12

Hereditary hemorrhagic telangiectasia (HHT) or Osler-Rendu-Weber (ORW) disease is an autosomal dominant vascular dysplasia. Initial linkage studies identified an ORW gene localized to 9q33-q34 but with some families clearly excluding this region. A probable correlation in clinical phenotype between the 9q3-linked families and unlinked families was described with a significantly lower incidence of pulmonary arteriovenous malformations observed in the unlinked families. In this study we examined four unrelated ORW families for which linkage to chromosome 9q33-q34 has been previously excluded. Linkage was established for all four families to markers on chromosome 12, with a combined maximum lod score of 10.77 (theta = 0.04) with D12S339. Mapping of crossovers using haplotype analysis indicated that the candidate region lies in an 11-CM interval between D12S345 and D12S339, in the pericentromeric region of chromosome 12. A map location for a second ORW locus is thus established that exhibits a significantly reduced incidence of pulmonary involvement.

Human glucokinase regulatory protein (GCKR): cDNA and genomic cloning, complete primary structure, and chromosomal localization

Null mutations in the glucokinase (GCK) gene can cause autosomal dominant type 2 diabetes (maturity onset diabetes of the young, MODY); however, MODY is genetically heterogeneous. In both liver and pancreatic islet, glucokinase is subject to inhibition by a regulatory protein (GCKR). Given the role of GCK in MODY, GCKR is itself a candidate type 2 diabetes susceptibility gene. Here we describe the structure of full-length (2.2 kb) cDNA for human GCKR, from the hepatoblastoma cell line HepG2. The human GCKR translation product has 625 amino acids and a predicted molecular weight of 68,700. It has 88% amino acid identity to rat GCKR. Yeast artificial chromosomes (YAC clones) containing human GCKR were isolated, and the gene was mapped to Chromosome (Chr) 2p23 by fluorescent in situ hybridization and somatic cell hybrid analysis.

Clozapine and urinary incontinence

Urinary incontinence may occur in patients with severe mental illness. Psychosis and neuroleptic medication have both been implicated, but there has been a lack of systematic evaluation of the precise relationship between these phenomena. Incontinence has been recognized as a complication of clozapine treatment and we examined this in 16 consecutively treated patients. Thirteen were established on therapeutic doses, one of whom was excluded from further study due to pre-existing incontinence. Retrospective assessment revealed that nocturnal incontinence was experienced by five of the remaining 12 patients, occurring in the first 3 months of treatment and resolving spontaneously in all cases. Incontinence was documented in the case notes in only one of the five cases and there was a tendency for affected patients to be embarrassed and reluctant to report it to staff. Specific enquiry may be necessary to elicit this phenomenon and incontinence should be considered as a possible factor in poor compliance with clozapine.

The ASP1 gene of Saccharomyces cerevisiae, encoding the intracellular isozyme of L-asparaginase

Saccharomyces cerevisiae produces two L-asparaginases (ASPs), intracellular ASP I and cell-wall ASP II. In this report, the ASP-I-encoding gene, ASP1, has been identified by homology cloning based on the structures of ASPs from other organisms. Its deduced protein product has a subunit M(r) of 41,414, and shows substantial sequence homology to the bacterial amidohydrolase family. The product of the S. cerevisiae ASP3 gene, a further member of this family, encoding the nitrogen catabolite-regulated cell-wall ASP II, has 46% overall sequence identity to ASP1. Duplication of ancestral asparaginase genes, resulting in separate intra- and extracellular isozymes, appears to have occurred independently in the prokaryotic and eukaryotic lineages. Exact physical mapping of the new cloned ASP1 gene locates it 73% of the distance from the left telomere of chromosome IV, at a position precisely matching the known genetic map location of ASP1. This, along with the structural features of the clone, confirms that ASP1 is the structural gene encoding cytoplasmic ASP I in S. cerevisiae. Sequence analysis of the ethylmethanesulfonate-induced asp1-12 allele of strain XE101-1A revealed a C-->T transition altering Ala176 to Val. This residue lies within a highly conserved region, and the results suggests a critical function for Ala176 in ASP function. Expression of ASP1 and other recombinant ASPs may allow access to improved products for use in the chemotherapy of leukaemia.

A single allele from the polymorphic CCG rich sequence immediately 3' to the unstable CAG trinucleotide in the IT15 cDNA shows almost complete disequilibrium with Huntington's disease chromosomes in the Scottish population

The CCG rich sequence immediately 3' to the CAG repeat that is expanded in Huntington's disease (HD) has recently been shown to be polymorphic with at least 4 alleles differing by multiples of 3 bp being found in the normal population. We have studied the allele distribution in 180 HD families resident in Scotland and have found very strong evidence for disequilibrium in this population. For the 131 families where phase was unambiguously determined, 130 were shown to have a CCG repeat allele of 176 bp cosegregating with the HD chromosome. This observation is significantly different to the normal population distribution where 31% of people have an allele of 185 bp. The evidence for and against a possible founder effect in the Scottish HD population is discussed. We propose the hypothesis that we may have identified a region of the IT15 gene that is critical in Huntington's disease.

A study of the Huntington's disease associated trinucleotide repeat in the Scottish population

Accurate measurements of a specific CAG repeat sequence in the Huntington's disease (HD) gene in 337 HD patients and 229 normal controls from the Scottish population showed a range from 35 to 62 repeats in affected subjects and eight to 33 in normal subjects. A link between early onset of symptoms and very high repeat number was seen. For HD patients with the most common affected allele sizes (39 to 42 repeats) absolute repeat size was a poor index for the age at onset of symptoms. There was variability in the transmitted repeat size for both sexes in the HD size range. We observed a significant increase of repeat size for paternal transmission of the disease and greater instability for paternally transmitted CAG repeats in the HD size range.

Structural analysis of the human ret proto-oncogene using exon trapping

A genomic contig of the human ret protooncogene was created with four overlapping cosmid clones isolated from two libraries. After southern analysis with portions of the ret cDNA, eight cosmid fragments were analysed in detail for the presence of ret exons using exon trapping. PCR products corresponding to spliced exons were isolated and subcloned. Exon boundaries were delineated by comparison of the PCR product sequence and the published ret cDNA sequence. The exons were initially positioned on a genomic map defined by BamHI, EcoRI and HindIII restriction sites. The positions of the exons were then refined by amplifying genomic DNA using primer pairs derived from one or more exons along the ret gene, the length of the PCR product indicating the approximate genomic distance between the exon sequences. The ret proto-oncogene is composed of at least 20 exons, ranging in size from 60 bp to 287 bp, distributed along 30 kb of genomic DNA. The extracellular domain is encoded by 10 exons and the cytoplasmic domain by 9 exons. The transmembrane domain is encoded by a single exon.

A new polymerase chain reaction (PCR) assay for the trinucleotide repeat that is unstable and expanded on Huntington's disease chromosomes

The Huntington's Disease (HD) Collaborative Research Group has recently published the sequence of a new cDNA, IT15, containing a polymorphic trinucleotide (CAG)n repeat that is expanded and unstable on HD chromosomes. There is a correlation between the repeat size and the age of onset of symptoms. The suggested polymerase chain reaction (PCR) assay of the (CAG)n repeat requires unusual reaction components and primer concentrations and the use of 5% polyacrylamide sequencing gels to resolve the amplification products. We present a simple PCR assay that produces a smaller product using standard reaction conditions. This gives better resolution of the (CAG)n expansion observed on HD chromosomes by acrylamide gel electrophoresis and allows sufficient product to be obtained to perform assays using agarose gels. This will allow diagnostic labs to do rapid and accurate presymptomatic testing of HD in high risk families.

Emery-Dreifuss muscular dystrophy: linkage to markers in distal Xq28

Emery-Dreifuss muscular dystrophy (EMD) is characterised by (1) early contractures of the Achilles tendons, elbows, and postcervical muscles, (2) slowly progressive muscle wasting and weakness with a predominantly humeroperoneal distribution in the early stages, and (3) cardiomyopathy with conduction defects and risk of sudden death. Inheritance is usually X linked recessive but can be autosomal dominant. Family linkage studies have mapped X linked EMD to the distal long arm of the X chromosome but precise genetic localisation has been hampered by the rarity of this condition. We report three new families with X linked Emery-Dreifuss muscular dystrophy studied with DNA markers from Xq27-qter and three previously published families typed for additional markers. No recombination was observed with the red/green cone pigment locus, RGCP (lod score, Z = 2.46), the factor VIII coagulant gene locus, F8C (Z = 6.39), or with DXS115 (Z = 4.94). Two recombinants were observed which mapped EMD distal to DXS15 (DX13) and DXS52 (St14) respectively. Multipoint linkage analysis gave odds exceeding 200:1 for EMD being distal to these markers. A multipoint analysis incorporating published data gave the map cen-DXS304-9cM-DXS15-3cM-DXS52-2 cM-(RGCP,EMD)-3cM-F8C-2cM-DXS115 with odds of 120:1 in favour of a location for EMD between DXS52 and F8C as compared to the next best position distal to F8C.

Analysis of chromosome 21 copy number in uncultured amniocytes by fluorescence in situ hybridization using a cosmid contig

A comparison of the use of chromosome 21-specific libraries, DOP-PCR 21 paints, yeast artificial chromosome (YAC) clones, single cosmids, and a 21q cosmid contig as probes for the detection of the copy number of chromosome 21 in interphase cells by fluorescence in situ hybridization shows that the cosmid contig is a satisfactory probe for interphase analysis of chromosome 21. The contig cCMP21.a, which is 55 kb in length, is highly chromosome 21-specific and produces intense, compact signals in a high proportion of interphase cells. A retrospective blind analysis of coded uncultured amniotic fluid samples correctly detected four trisomy 21 cases out of 49 samples.

Patellofemoral stress. A prospective analysis of exercise treatment in adolescents and adults

Thirty patients, 13 skeletally immature individuals and 17 adults, participated in a prospective study designed to evaluate the effect of isometric quadriceps strengthening exercises on patellofemoral pain. Of the 30 patients with anatomically normal lower extremity alignment and no history of previous knee trauma or surgery, there were 34 knees that had a decrease in peripatellar knee pain with a structured exercise program. One additional patient had a decrease in pain after an arthroscopic lateral release and with continued exercises. An equal number of skeletally immature patients and adults had a decrease in peripatellar knee pain. However, 5 of the 17 adults had to limit their activities, while no adolescent patient had to limit activity. Additionally, eight skeletally immature knees had greater than 5 degrees change in their congruence angles, as measured on Merchant tangential radiographs, over the year-long course of this study. Only one adult knee had a similar radiographic improvement. We recommend immediate action to alleviate patellofemoral pain syndrome, even when extremity alignment is normal. An isometric, progressive resistance quadriceps program with iliotibial band and hamstring stretching exercises is the preferred initial treatment.

Anatomy and relationships of the suprascapular nerve: anatomical constraints to mobilization of the supraspinatus and infraspinatus muscles in the management of massive rotator-cuff tears

Thirty-one shoulders in eighteen cadavera were dissected to allow study of the neurovascular anatomy of the rotator cuff and to help determine the limits of mobilization of the cuff for the repair of chronic massive retracted tears. The dissection demonstrated the diameter, length, and relationships of the suprascapular nerve and its branches and made clear the dangers of extensive mobilization and advancement of the supraspinatus and infraspinatus muscles. The suprascapular nerve ran an oblique course across the supraspinatus fossa, was relatively fixed on the floor of the fossa, and was tethered underneath the transverse scapular ligament. In twenty-six (84 per cent) of the thirty-one shoulders, there were no more than two motor branches to the supraspinatus muscle, and the first was always the larger of the two. In twenty-six (84 per cent) of the thirty-one shoulders, the first motor branch originated underneath the transverse scapular ligament or just distal to it. In one shoulder (3 per cent), the first motor branch passed over the ligament. The average distance from the origin of the long tendon of the biceps to the motor branches of the supraspinatus was three centimeters. In fifteen (48 per cent) of the thirty-one shoulders, the infraspinatus muscle had three or four motor branches of the same size. The average distance from the posterior rim of the glenoid to the motor branches of the infraspinatus muscle was two centimeters. The motor branches to the supraspinatus muscle were fewer, usually smaller, and significantly shorter than those to the infraspinatus muscle. The standard anterosuperior approach allowed only one centimeter of lateral advancement of either tendon and limited the ability of the surgeon to dissect safely beyond the neurovascular pedicle. The advancement technique of Debeyre et al., or a modification of that technique, permitted lateral advancement of each muscle of as much as three centimeters and was limited by tension in the motor branches of the suprascapular nerve. In some situations, the safe limit of advancement may be even less. We concluded that lateral advancement of the rotator cuff is limited anatomically and may place the neurovascular structures at risk.

Modulation of branched-chain amino acid oxidation in rat hemidiaphragms in vitro by glucose and ketone bodies

Branched-chain amino acid metabolism in hemidiaphragms from 40 h-starved rats is influenced by the provision of glucose as co-substrate. Glucose inhibits 14CO2 production from [l-14C]valine and [U-14C]valine but stimulates 14CO2 production from [l-14C]leucine, [U-14C]leucine and [U-14C]isoleucine. In the presence of glucose, ketone bodies inhibit alanine release and 14CO2 production from [l-14C]valine, [l-14C]leucine and [U-14C]isoleucine, but inhibition is not observed in the absence of glucose as cosubstrate. Glucose-dependent inhibition by ketone bodies of branched-chain amino acid oxidation via inhibition of the branched-chain 2-oxo acid dehydrogenase complex or branched-chain amino acid aminotransferase may account in part for the reported hypoalanaemic action of ketone bodies in vivo.

The role of phosphoenolpyruvate carboxykinase in muscle alanine synthesis

3-Mercaptopicolinic acid (3-MPA) is reportedly a specific inhibitor of phosphoenolpyruvate (PEP) carboxykinase and has hitherto been used accordingly to elucidate the metabolic role of PEP carboxykinase in vitro and in vivo. We show that 3-MPA has multiple effects on intermediary metabolism in hemidiaphragms from 40 h-starved rats. It decreases the release of lactate + pyruvate and alanine in hemidiaphragms provided with no added substrate or with valine, leucine or isoleucine. Moreover, irrespective of the substrate provided (none, valine, leucine, isoleucine, glucose, acetate, oleate), 3-MPA decreases the [lactate]/[pyruvate] ratio. 3-MPA is without effect on 14CO2 production from [U-14C]valine, [1-14C]valine, [1-14C]leucine, [U-14C]isoleucine or [1-14C]oleate, but stimulates 14CO2 production from [U-14C]glucose and [1-14C]pyruvate and inhibits 14CO2 production from [1-14C]acetate. Glycolytic flux (measured as 3H2O formation from [5-3H]glucose) is stimulated by 3-MPA. It is concluded that 3-MPA has site(s) of actions other than PEP carboxykinase and that the putative role of PEP carboxykinase in alanine synthesis de novo in skeletal muscle from tricarboxylic acid-cycle intermediates and related amino acids requires reappraisal.

Odd-carbon fatty acid metabolism in hepatocytes from starved rats

The metabolism of odd-chain fatty acids was investigated in hepatocytes from 24 h-starved rats. Rates of glucose and 14CO2 production from [1-14C]propionate, [1-14C]valerate and [1-14C]nonanoate were maximal at 0.1 mM. Glucose production was greater with propionate as substrate than with valerate or nonanoate. Ketone body, lactate and pyruvate release were not affected by addition of the odd carbon fatty acids. It is concluded that hepatic odd-chain fatty acid metabolism in starvation is partly oxidative and partly gluconeogenic. Vasopressin and angiotensin II stimulated 14CO2 production from [1-14C] valerate and [1-14C]nonanoate but not from [1-14C]propionate and [1-14C]oleate in hepatocytes from starved rats. Nonanoate and valerate generate acetyl-CoA and propionyl-CoA, whereas oleate or propionate produce acetyl CoA and propionyl-CoA respectively. Given this stoichiometry, it is inferred that in hepatocytes from starved rats there must be an input of a tricarboxylic acid cycle intermediate to permit expression of the hormonal sensitivity.

Liposome/white-cell interactions in vivo

The purpose of this study was to establish whether liposomes administered via the intravenous route promote granulocyte aggregation and pulmonary leukostasis. White cells (labelled with [111In]tropolanate) and positively and negatively charged liposomes (containing entrapped [99mTc]DTPA) were administered i.v. to rats. The blood clearance and tissue distribution of 111In label was not altered by the administration of liposomes (and vice versa) and it is inferred that on intravenous liposome administration liposome/white-cell interactions are unlikely to compromise lung function.

Vibrational Excitations in the Even-mass Cadmium Isotopes

The backward-angle scattering of 4He ions from the even-A stable isotopes of cadmium has been investigated at bombarding energies above the Coulomb barrier. At 17� 5 MeV bombarding energy the gross features of the spectra are strikingly regular from one isotope to another, and this may be interpreted in terms of vibrational excitations. Other evidence is presented to support the concept of a uniform vibrational character for all the even-A stable cadmium isotopes. The spectra show no significant evidence for previously unreported levels in the two-quadrupole-phonon excitation region. However, a new level is found at 2304 � 4 keY in l06Cd.