Hypoxia-Inducible Factor 1α Stabilization Restores Epigenetic Control of Nitric Oxide Synthase 1 Expression and Reverses Gastroparesis in Female Diabetic Mice

BACKGROUND & AIMS

Although depletion of neuronal nitric oxide synthase (NOS1)-expressing neurons contributes to gastroparesis, stimulating nitrergic signaling is not an effective therapy. We investigated whether hypoxia-inducible factor 1α (HIF1A), which is activated by high O2 consumption in central neurons, is a Nos1 transcription factor in enteric neurons and whether stabilizing HIF1A reverses gastroparesis.

METHODS

Mice with streptozotocin-induced diabetes, human and mouse tissues, NOS1+ mouse neuroblastoma cells, and isolated nitrergic neurons were studied. Gastric emptying of solids and volumes were determined by breath test and single-photon emission computed tomography, respectively. Gene expression was analyzed by RNA-sequencing, microarrays, immunoblotting, and immunofluorescence. Epigenetic assays included chromatin immunoprecipitation sequencing (13 targets), chromosome conformation capture sequencing, and reporter assays. Mechanistic studies used Cre-mediated recombination, RNA interference, and clustered regularly interspaced short palindromic repeats (CRISPR)-CRISPR-associated protein 9 (Cas9)-mediated epigenome editing.

RESULTS

HIF1A signaling from physiological intracellular hypoxia was active in mouse and human NOS1+ myenteric neurons but reduced in diabetes. Deleting Hif1a in Nos1-expressing neurons reduced NOS1 protein by 50% to 92% and delayed gastric emptying of solids in female but not male mice. Stabilizing HIF1A with roxadustat (FG-4592), which is approved for human use, restored NOS1 and reversed gastroparesis in female diabetic mice. In nitrergic neurons, HIF1A up-regulated Nos1 transcription by binding and activating proximal and distal cis-regulatory elements, including newly discovered super-enhancers, facilitating RNA polymerase loading and pause-release, and by recruiting cohesin to loop anchors to alter chromosome topology.

CONCLUSIONS

Pharmacologic HIF1A stabilization is a novel, translatable approach to restoring nitrergic signaling and treating diabetic gastroparesis. The newly recognized effects of HIF1A on chromosome topology may provide insights into physioxia- and ischemia-related organ function.

PRMT5 links lipid metabolism to contractile function of skeletal muscles

Skeletal muscle plays a key role in systemic energy homeostasis besides its contractile function, but what links these functions is poorly defined. Protein Arginine Methyl Transferase 5 (PRMT5) is a well-known oncoprotein but also expressed in healthy tissues with unclear physiological functions. As adult muscles express high levels of Prmt5, we generated skeletal muscle-specific Prmt5 knockout (Prmt5MKO ) mice. We observe reduced muscle mass, oxidative capacity, force production, and exercise performance in Prmt5MKO mice. The motor deficiency is associated with scarce lipid droplets in myofibers due to defects in lipid biosynthesis and accelerated degradation. Specifically, PRMT5 deletion reduces dimethylation and stability of Sterol Regulatory Element-Binding Transcription Factor 1a (SREBP1a), a master regulator of de novo lipogenesis. Moreover, Prmt5MKO impairs the repressive H4R3 symmetric dimethylation at the Pnpla2 promoter, elevating the level of its encoded protein ATGL, the rate-limiting enzyme catalyzing lipolysis. Accordingly, skeletal muscle-specific double knockout of Pnpla2 and Prmt5 normalizes muscle mass and function. Together, our findings delineate a physiological function of PRMT5 in linking lipid metabolism to contractile function of myofibers.

Differential Contributions of mSWI/SNF Chromatin Remodeler Sub-Families to Myoblast Differentiation

Mammalian SWI/SNF (mSWI/SNF) complexes are ATP-dependent chromatin remodeling enzymes that are critical for normal cellular functions. mSWI/SNF enzymes are classified into three sub-families based on the presence of specific subunit proteins. The sub-families are Brm- or Brg1-associated factor (BAF), ncBAF (non-canonical BAF), and polybromo-associated BAF (PBAF). The biological roles for the different enzyme sub-families are poorly described. We knocked down the expression of genes encoding unique subunit proteins for each sub-family, Baf250A, Brd9, and Baf180, which mark the BAF, ncBAF, and PBAF sub-families, respectively, and examined the requirement for each in myoblast differentiation. We found that Baf250A and the BAF complex were required to drive lineage-specific gene expression. KD of Brd9 delayed differentiation. However, while the Baf250A-dependent gene expression profile included myogenic genes, the Brd9-dependent gene expression profile did not, suggesting Brd9 and the ncBAF complex indirectly contributed to differentiation. Baf180 was dispensable for myoblast differentiation. The results distinguish between the roles of the mSWI/SNF enzyme sub-families during myoblast differentiation.

Protein arginine methyltransferase 5 (Prmt5) localizes to chromatin loop anchors and modulates expression of genes at TAD boundaries during early adipogenesis

Protein arginine methyltransferase 5 (Prmt5) is an essential regulator of embryonic development and adult progenitor cell functions. Prmt5 expression is mis-regulated in many cancers, and the development of Prmt5 inhibitors as cancer therapeutics is an active area of research. Prmt5 functions via effects on gene expression, splicing, DNA repair, and other critical cellular processes. We examined whether Prmt5 functions broadly as a genome-wide regulator of gene transcription and higher-order chromatin interactions during the initial stages of adipogenesis using ChIP-Seq, RNA-seq, and Hi-C using 3T3-L1 cells, a frequently utilized model for adipogenesis. We observed robust genome-wide Prmt5 chromatin-binding at the onset of differentiation. Prmt5 localized to transcriptionally active genomic regions, acting as both a positive and a negative regulator. A subset of Prmt5 binding sites co-localized with mediators of chromatin organization at chromatin loop anchors. Prmt5 knockdown decreased insulation strength at the boundaries of topologically associating domains (TADs) adjacent to sites with Prmt5 and CTCF co-localization. Genes overlapping such weakened TAD boundaries showed transcriptional dysregulation. This study identifies Prmt5 as a broad regulator of gene expression, including regulation of early adipogenic factors, and reveals an unappreciated requirement for Prmt5 in maintaining strong insulation at TAD boundaries and overall chromatin organization.

ZIP11 Regulates Nuclear Zinc Homeostasis in HeLa Cells and Is Required for Proliferation and Establishment of the Carcinogenic Phenotype

Zinc (Zn) is an essential trace element that plays a key role in several biological processes, including transcription, signaling, and catalysis. A subcellular network of transporters ensures adequate distribution of Zn to facilitate homeostasis. Among these are a family of importers, the Zrt/Irt-like proteins (ZIP), which consists of 14 members (ZIP1-ZIP14) that mobilize Zn from the extracellular domain and organelles into the cytosol. Expression of these transporters varies among tissues and during developmental stages, and their distribution at various cellular locations is essential for defining the net cellular Zn transport. Normally, the ion is bound to proteins or sequestered in organelles and vesicles. However, though research has focused on Zn internalization in mammalian cells, little is known about Zn mobilization within organelles, including within the nuclei under both normal and pathological conditions. Analyses from stomach and colon tissues isolated from mouse suggested that ZIP11 is the only ZIP transporter localized to the nucleus of mammalian cells, yet no clear cellular role has been attributed to this protein. We hypothesized that ZIP11 is essential to maintaining nuclear Zn homeostasis in mammalian cells. To test this, we utilized HeLa cells, as research in humans correlated elevated expression of ZIP11 with poor prognosis in cervical cancer patients. We stably knocked down ZIP11 in HeLa cancer cells and investigated the effect of Zn dysregulation in vitro. Our data show that ZIP11 knockdown (KD) reduced HeLa cells proliferation due to nuclear accumulation of Zn. RNA-seq analyses revealed that genes related to angiogenesis, apoptosis, mRNA metabolism, and signaling pathways are dysregulated. Although the KD cells undergoing nuclear Zn stress can activate the homeostasis response by MTF1 and MT1, the RNA-seq analyses showed that only ZIP14 (an importer expressed on the plasma membrane and endocytic vesicles) is mildly induced, which may explain the sensitivity to elevated levels of extracellular Zn. Consequently, ZIP11 KD HeLa cells have impaired migration, invasive properties and decreased mitochondrial potential. Furthermore, KD of ZIP11 delayed cell cycle progression and rendered an enhanced senescent state in HeLa cells, pointing to a novel mechanism whereby maintenance of nuclear Zn homeostasis is essential for cancer progression.

Protein Arginine Methyltransferase PRMT5 Regulates Fatty Acid Metabolism and Lipid Droplet Biogenesis in White Adipose Tissues

The protein arginine methyltransferase 5 (PRMT5) is an emerging regulator of cancer and stem cells including adipogenic progenitors. Here, a new physiological role of PRMT5 in adipocytes and systemic metabolism is reported. Conditional knockout mice were generated to ablate the Prmt5 gene specifically in adipocytes (Prmt5AKO). The Prmt5AKO mice exhibit sex- and depot-dependent progressive lipodystrophy that is more pronounced in females and in visceral (than subcutaneous) white fat. The lipodystrophy and associated energy imbalance, hyperlipidemia, hepatic steatosis, glucose intolerance, and insulin resistance are exacerbated by high-fat-diet. Mechanistically, Prmt5 methylates and releases the transcription elongation factor SPT5 from Berardinelli-Seip congenital lipodystrophy 2 (Bscl2, encoding Seipin) promoter, and Prmt5AKO disrupts Seipin-mediated lipid droplet biogenesis. Prmt5 also methylates Sterol Regulatory Element-Binding Transcription Factor 1a (SREBP1a) and promotes lipogenic gene expression, and Prmt5AKO suppresses SREBP1a-dependent fatty acid metabolic pathways in adipocytes. Thus, PRMT5 plays a critical role in regulating lipid metabolism and lipid droplet biogenesis in adipocytes.

Wnt-induced, TRP53-mediated Cell Cycle Arrest of Precursors Underlies Interstitial Cell of Cajal Depletion During Aging

BACKGROUND & AIMS

Gastric dysfunction in the elderly may cause reduced food intake, frailty, and increased mortality. The pacemaker and neuromodulator cells interstitial cells of Cajal (ICC) decline with age in humans, and their loss contributes to gastric dysfunction in progeric klotho mice hypomorphic for the anti-aging Klotho protein. The mechanisms of ICC depletion remain unclear. Klotho attenuates Wnt (wingless-type MMTV integration site) signaling. Here, we examined whether unopposed Wnt signaling could underlie aging-associated ICC loss by up-regulating transformation related protein TRP53 in ICC stem cells (ICC-SC).

METHODS

Mice aged 1-107 weeks, klotho mice, APC^Δ468 mice with overactive Wnt signaling, mouse ICC-SC, and human gastric smooth muscles were studied by RNA sequencing, reverse transcription-polymerase chain reaction, immunoblots, immunofluorescence, histochemistry, flow cytometry, and methyltetrazolium, ethynyl/bromodeoxyuridine incorporation, and ex-vivo gastric compliance assays. Cells were manipulated pharmacologically and by gene overexpression and RNA interference.

RESULTS

The klotho and aged mice showed similar ICC loss and impaired gastric compliance. ICC-SC decline preceded ICC depletion. Canonical Wnt signaling and TRP53 increased in gastric muscles of klotho and aged mice and middle-aged humans. Overstimulated canonical Wnt signaling increased DNA damage response and TRP53 and reduced ICC-SC self-renewal and gastric ICC. TRP53 induction persistently inhibited G₁/S and G₂/M cell cycle phase transitions without activating apoptosis, autophagy, cellular quiescence, or canonical markers/mediators of senescence. G₁/S block reflected increased cyclin-dependent kinase inhibitor 1B and reduced cyclin D1 from reduced extracellular signal-regulated kinase activity.

CONCLUSIONS

Increased Wnt signaling causes age-related ICC loss by up-regulating TRP53, which induces persistent ICC-SC cell cycle arrest without up-regulating canonical senescence markers.

Hyperglycemia Increases Interstitial Cells of Cajal via MAPK1 and MAPK3 Signaling to ETV1 and KIT, Leading to Rapid Gastric Emptying

BACKGROUND & AIMS

Depletion of interstitial cells of Cajal (ICCs) is common in diabetic gastroparesis. However, in approximately 20% of patients with diabetes, gastric emptying (GE) is accelerated. GE also occurs faster in obese individuals, and is associated with increased blood levels of glucose in patients with type 2 diabetes. To understand the fate of ICCs in hyperinsulinemic, hyperglycemic states characterized by rapid GE, we studied mice with mutation of the leptin receptor (Lepr^db/db), which in our colony had accelerated GE. We also investigated hyperglycemia-induced signaling in the ICC lineage and ICC dependence on glucose oxidative metabolism in mice with disruption of the succinate dehydrogenase complex, subunit C gene (Sdhc).

METHODS

Mice were given breath tests to analyze GE of solids. ICCs were studied by flow cytometry, intracellular electrophysiology, isometric contractility measurement, reverse-transcription polymerase chain reaction, immunoblot, immunohistochemistry, enzyme-linked immunosorbent assays, and metabolite assays; cells and tissues were manipulated pharmacologically and by RNA interference. Viable cell counts, proliferation, and apoptosis were determined by methyltetrazolium, Ki-67, proliferating cell nuclear antigen, bromodeoxyuridine, and caspase-Glo 3/7 assays. Sdhc was disrupted in 2 different strains of mice via cre recombinase.

RESULTS

In obese, hyperglycemic, hyperinsulinemic female Lepr^db/db mice, GE was accelerated and gastric ICC and phasic cholinergic responses were increased. Female Kit^K641E/+ mice, which have genetically induced hyperplasia of ICCs, also had accelerated GE. In isolated cells of the ICC lineage and gastric organotypic cultures, hyperglycemia stimulated proliferation by mitogen-activated protein kinase 1 (MAPK1)- and MAPK3-dependent stabilization of ets variant 1-a master transcription factor for ICCs-and consequent up-regulation of v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog (KIT) receptor tyrosine kinase. Opposite changes occurred in mice with disruption of Sdhc.

CONCLUSIONS

Hyperglycemia increases ICCs via oxidative metabolism-dependent, MAPK1- and MAPK3-mediated stabilization of ets variant 1 and increased expression of KIT, causing rapid GE. Increases in ICCs might contribute to the acceleration in GE observed in some patients with diabetes.

FAM96A is a novel pro-apoptotic tumor suppressor in gastrointestinal stromal tumors

The ability to escape apoptosis is a hallmark of cancer-initiating cells and a key factor of resistance to oncolytic therapy. Here, we identify FAM96A as a ubiquitous, evolutionarily conserved apoptosome-activating protein and investigate its potential pro-apoptotic tumor suppressor function in gastrointestinal stromal tumors (GISTs). Interaction between FAM96A and apoptotic peptidase activating factor 1 (APAF1) was identified in yeast two-hybrid screen and further studied by deletion mutants, glutathione-S-transferase pull-down, co-immunoprecipitation and immunofluorescence. Effects of FAM96A overexpression and knock-down on apoptosis sensitivity were examined in cancer cells and zebrafish embryos. Expression of FAM96A in GISTs and histogenetically related cells including interstitial cells of Cajal (ICCs), "fibroblast-like cells" (FLCs) and ICC stem cells (ICC-SCs) was investigated by Northern blotting, reverse transcription-polymerase chain reaction, immunohistochemistry and Western immunoblotting. Tumorigenicity of GIST cells and transformed murine ICC-SCs stably transduced to re-express FAM96A was studied by xeno- and allografting into immunocompromised mice. FAM96A was found to bind APAF1 and to enhance the induction of mitochondrial apoptosis. FAM96A protein or mRNA was dramatically reduced or lost in 106 of 108 GIST samples representing three independent patient cohorts. Whereas ICCs, ICC-SCs and FLCs, the presumed normal counterparts of GIST, were found to robustly express FAM96A protein and mRNA, FAM96A expression was much reduced in tumorigenic ICC-SCs. Re-expression of FAM96A in GIST cells and transformed ICC-SCs increased apoptosis sensitivity and diminished tumorigenicity. Our data suggest FAM96A is a novel pro-apoptotic tumor suppressor that is lost during GIST tumorigenesis.

Epigenetics and chromatin dynamics: a review and a paradigm for functional disorders

BACKGROUND

Motility and functional gastrointestinal disorders have high prevalence in the community, cause significant morbidity, and represent a major health care burden. Despite major advances in our understanding of the cellular and molecular basis of gastrointestinal neuromuscular functions, many of these diseases still defy mechanistic explanations. The biopsychosocial model underlying the current classification of functional gastrointestinal disorders recognizes and integrates the pathogenetic role of genetic, environmental, and psychosocial factors but has not been associated with specific molecular mechanisms.

PURPOSE

Here, we propose that this integrative function is encoded in the chromatin, composed of the DNA and associated histone and non-histone proteins and non-coding RNA. By establishing epigenetically heritable 'molecular memories' of past stimuli including environmental challenges, the chromatin determines an individual's responses to future insults and translates them into high-order outputs such as symptoms and illness behavior. Thus, surveying epigenetic signatures throughout the genome of affected cells in individual patients may make it possible to better understand and ultimately control the phenomena described by the biopsychosocial model. In this review, we provide a high-level but comprehensive description of the concepts and mechanisms underlying epigenetics and chromatin dynamics, describe the mechanisms whereby the environment can alter the epigenome and identify aspects of functional gastrointestinal and motility disorders where epigenetic mechanisms are most likely to play important roles.

Bochdalek hernia in adulthood: an unusual presentation and diagnostic dilemma

Bochdalek diaphragmatic hernia is one of the most important surgically correctable causes of respiratory distress in the newborn. Delayed presentation in adult life is uncommon. We present a case of a 46-year-old, multigravida Kashmiri woman, who was misdiagnosed earlier and treated for pulmonary tuberculosis. Diagnosis was established pre-operatively by plain chest radiograph and barium meal. A dorso-lateral defect was located on left side of diaphragm which was corrected by using a prolene mesh.

Early passive mobilization after digital nerve repair and grafting in a fresh cadaver

In the clinical management of combined tendon and nerve injuries, there are competing treatment strategies. Isolated tendon injuries should be rapidly mobilized after repair to prevent adhesion formation, whereas isolated nerve repairs are usually immobilized to prevent disruption and to allow axon regrowth. Recommendations in the published literature for the management of combined tendon and nerve injuries are vague and advise up to 3 weeks of immobilization. The goals of this study were to determine which length of nerve gap resulted in rupture of a repair following postoperative mobilization with the modified Duran protocol and with unrestricted motion and to determine whether nerve grafts are at risk of rupture after mobilization. A total of 100 digital nerves from 10 cadaver hands were tested with the modified Duran and the unsplinted protocols. Each digital nerve on each hand was sequentially resected and repaired at five progressively larger gap lengths after testing with both protocols. The mean nerve gaps at which disruption occurred were significantly different between the splinted (9.7 +/- 0.8 mm, n = 100) and unsplinted (7.3 +/- 1.9 mm, n = 100) protocols (t test, p < 0.001). One hundred percent of repairs remained intact, with up to 5 mm of resection with the modified Duran protocol (n = 100) and with up to 2.5 mm of resection with the unsplinted protocol (n = 100). All nerve grafts remained intact after mobilization within a dorsal-blocking splint (n = 100). Considering mechanical integrity of the nerve repair only, these data suggest that early mobilization with tendon protocols may be considered after a nerve injury to avoid the detrimental tendon sequelae that result from immobilization. The adequacy of functional recovery of mobilized nerves is yet to be determined.

Effects of nerve growth factor on nerve regeneration through a vein graft across a gap

The limited availability of donor sites for nerve grafts and their inherent associated morbidity continue to stimulate research toward finding suitable alternatives. In the following study, the effect of direct administration of nerve growth factor (NGF) into a nerve conduit across a gap was tested in a rat sciatic nerve model. A 1-cm segment of the right sciatic nerve in Sprague-Dawley rats was resected, and the gap was then bridged using one of three methods: group I (NGF-treated group, n = 12), a vein graft filled with NGF (100 ng in 0.3-ml phosphate buffered saline); group II (control group, n = 12), a vein graft filled with phosphate buffered saline only; group III (standard nerve graft, n = 11), a resected segment of the sciatic nerve. All animals were evaluated at 3 and 5 weeks by behavioral testing and at 5 weeks by electrophysiologic testing. At 3 weeks, sensory testing showed that the latency to a noxious stimulus in group I animals (8.0 +/- 5.4 sec, mean +/- SD) was significantly lower than that of group II animals (13.2 +/- 6.5 sec), indicating that sensory recovery was superior in the animals receiving NGF. The mean latency of animals in group III was 12.9 +/- 6.5 sec, but the difference between the latencies of group I and group III did not reach statistical significance. At 5 weeks, there was no difference in sensory testing between groups. Motor function in groups I and III as measured by walk pattern analysis was superior to that of group II at 5 weeks (toe spread ratios 0.66 +/- 0.09, 0.48 +/- 0.07, and 0.69 +/- 0.09 for groups I, II, and III, respectively). Mean motor conduction velocities across the 1-cm gap were 8.6 +/- 4.7 m/sec, 2.5 +/- 0.7 m/sec, and 6.9 +/- 2.9 m/sec in groups I, II, and III respectively. The difference between groups I and III was not statistically significant, but the motor conduction velocity of group II was significantly slower than that of either group I or III (p < 0.002). The positive effects of NGF on regeneration of nerves across a gap seen in this study suggest that it may be useful for treating peripheral nerve injuries in combination with autogenous vein grafts.

Chromosome 11q13 and atopic asthma

Asthma is a complex syndrome in which bronchial inflammation and smooth muscle hyperactivity lead to labile airflow obstruction. The commonest form of asthma is that due to atopy, which is an immune disorder where production of IgE to inhaled antigens leads to bronchial mucosal inflammation. The ultimate origins of asthma are interactive environmental and genetic factors. The genetics is acknowledged to be heterogeneous, and one chromosomal region of interest and controversy has been 11q13. To clarify the nature of the chromosome 11q13 effect in atopy and asthma, we conducted a genetic association study in subjects with marked atopic asthma and matched controls, which incorporated the study of 13 genetic variants over a distance of 10-12 cM and which took account of detailed immune and clinical phenotyping. Association with high IgE levels was limited to the interval flanked by D11S1335 and CD20 in a 0.8-Mb interval and was greatest for variants of Fc epsilonRIbeta and HTm4; these variants also associated with asthma (recurrent wheeze with labile airflow obstruction and need for regular inhaler treatment). At the more telomeric marker, D11S480, variants associated with asthma, but not with high IgE levels. The data might support the possibility of multiple loci relevant to atopic asthma on chromosome 11q13.

Ischemic preconditioning improves the survival of skin and myocutaneous flaps in a rat model

Inadequate blood supply of pedicle flaps results in partial necrosis, and prolonged ischemia during free-tissue transfer can result in partial or complete flap necrosis. Recent research in the field of cardiovascular surgery has shown that ischemic preconditioning (repeated brief episodes of coronary artery occlusion followed by reperfusion) improves myocardial muscle survival when the heart is subsequently subjected to prolonged ischemia. Preconditioning of skin or myocutaneous flaps as either pedicle or free flap models has never been studied. The goal of this investigation was to measure the effect of ischemic preconditioning on myocutaneous and skin flap survival areas and total necrosis rates after variable periods of global ischemia. In 220 rats, 100 transverse rectus abdominis myocutaneous flaps and 120 dorsal cutaneous flaps were randomized into treatment and control groups. The treatment flaps underwent preconditioning by three cycles of 10 minutes of pedicle clamping followed by 10 minutes of reperfusion for a total preconditioning period of 1 hour. The control flaps were perfused without clamping for 1 hour. Both control and treatment flaps then underwent global ischemia for 0, 2, 4, 6, 10, or 14 hours by pedicle clamping. Flap survival area was measured on the fifth postoperative day. Statistical analysis was performed with analysis of variance, student's t tests, and probit analysis. Preconditioning improved survival areas of pedicle myocutaneous flaps (0-hour group) from 47 +/- 16 percent (mean percent area surviving +/- SD) to 63 +/- 5 percent. This difference was statistically significant (t test, p < 0.04). There was no statistically significant improvement in pedicle skin flap survival. For free flap models (flaps undergoing global ischemia), preconditioning increased the survival areas of skin and myocutaneous flaps (analysis of variance, p < 10(-5)). For the skin flap model, statistical significance of the survival area difference was reached at 6, 10, and 14 hours of ischemia (t test, p < 10(-4)). The magnitude of this effect was higher in the myocutaneous flap model and reached statistical significance at 2, 4, 6, and 10 hours of ischemia (p < 10(-3)). Preconditioned flap survival areas were increased by two to five times that of non-preconditioned flaps at these ischemia times. Preconditioning lowered total necrosis rates at all ischemia times for both flap models. The critical ischemia time when 50 percent of skin flaps became totally necrotic (CIT50) improved from 6.9 to 12.4 hours by preconditioning. Similarly, preconditioning improved the CIT50 of myocutaneous flaps from 3.6 to 9.2 hours. For the first time, statistically significant improvements of partial necrosis areas and total necrosis rates have been demonstrated through intraoperative ischemic preconditioning of skin and myocutaneous flaps. In clinical practice, application of this technique may lead to improved survival during pedicled or free transfer of myocutaneous flaps and free transfer of skin flaps.

Ischemic preconditioning of musculocutaneous flaps: effects of ischemia cycle length and number of cycles

Previous work in our laboratory has indicated that ischemic preconditioning improves musculocutaneous flap survival 2.5 times that of the control flap area when the flaps are subsequently subjected to 4 hours of global ischemia. The preconditioning protocol used in this study was arbitrarily designed to be 10 minutes of pedicle clamping followed by 10 minutes of reperfusion. This sequence was repeated for three cycles with a total preconditioning time of 1 hour. There are no published works comparing different preconditioning protocols in musculocutaneous flaps. The goal of this study was to determine if the ischemic cycle time and the number of cycles influenced the effectiveness of ischemic preconditioning. Fifty-one male Sprague-Dawley rats were divided into one control and six treatment groups of 6 to 10 animals in each group. A transverse rectus abdominis musculocutaneous flap based on the inferior epigastric vessels was elevated in each animal. Flaps were preconditioned by pedicle clamping and reperfusion for either 5 or 10 minutes per cycle. This was repeated for one, two, or three cycles. Controls were simply perfused for 30 minutes. Each flap was then subjected to 4 hours of global ischemia. Flap surface survival area was calculated on the fifth postoperative day by computerized video planimetry. Differences in survival areas between control and preconditioned flaps were compared using analysis of variance and t-tests. There was an overall statistical significance in the comparison of flap survival of preconditioned flaps with that of controls. A single 5-minute cycle improved flap survival 2.5 times the mean control area. Two and three 5-minute cycles resulted in a reduction of the preconditioning effect, with flap survival no different than controls. Ten-minute preconditioning cycles increased flap survival 1.5 to 3 times the mean control area. Flap survival was improved by increasing the number of 10-minute cycles. Cycle time and number of cycles have definite effects on the survival areas of preconditioned musculocutaneous flaps. Ischemic preconditioning with 10-minute cycles is superior to 5-minute cycles. Three cycles of 10-minute preconditioning is statistically superior to one or two cycles. Future studies are planned to study four or more cycles and longer cycle times.

The effect of prolonged clamping and vascular stasis on the patency of arterial and venous microanastomoses

During free tissue transfer, an artery and one or two veins must be sutured. Either the artery or the vein can be repaired first, but the optimal order of vascular repair has not been established. Maintaining a clamp on a vessel is associated with vessel injury, and releasing the clamp may cause bleeding and vascular stasis. The purpose of this study was to determine if the order of vessel repair and the length of vascular clamping affects surgical outcome. Free flaps were created on Sprague-Dawley rats (400-450 g) as follows: Bilateral abdominal skin flaps (3 x 3 cm) based on the superficial inferior epigastric vessels were elevated. The femoral artery and vein were tied and divided distal to the branching of the inferior epigastric vessels. Proximal to the branching, the artery and vein were divided. The animals were then randomized into four groups as follows: In group I (N=16), the artery was repaired and then the clamps were released to revascularize the flap. Venous stasis occurred as the vein was being repaired because of the venous clamp. In group II (N=15), the artery was repaired, but the clamp was maintained to prevent blood from coming in contact with the fresh arterial anastomosis and to prevent venous stasis. The vein was then repaired. In group III (N=15), the vein was repaired first but the venous clamp was not released until the artery was repaired. In group IV (N=15), the vein was repaired first and the clamps were released, allowing venous blood to contact the fresh anastomosis while the artery was being repaired. After final clamp removal, all anastomoses were assessed immediately for evidence of thrombosis. Five days postoperatively the skin flap was evaluated for evidence of necrosis and the anastomosis was inspected for evidence of late thrombosis. The anastomoses were resected for histopathological evaluation. Flap success was compared between groups using chi-squared analysis. Eleven of 16 flaps failed (69%) in group I, and 3 of 15 flaps failed (20%) in each of groups II, III, and IV. Statistical significance was reached in comparing group I with the other three groups (p < 0.01). All failures in group I were caused by immediate venous thrombosis. The other failures were secondary to arterial thrombosis. Histopathological analysis failed to demonstrate any differences between the groups. According to these results, arterial repair followed by clamp release prior to the completion of the venous repair results in a low success rate, probably secondary to venous stasis within the draining vein while the venous anastomosis is being completed. If the arterial repair is performed first, then it is recommended that the arterial clamp be maintained until the venous repair is completed. If the vein is repaired first, then it can be clamped or unclamped with similar results.

Comparison of the effects of ischemic preconditioning and surgical delay on pedicled musculocutaneous flap survival in a rat model

Both surgical delay (SD) and ischemic preconditioning (IP) have been shown to be effective in improving the survival of pedicled musculocutaneous flaps. The goal of our study was to determine the effects of IP and SD, separately and together, on the survival of pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps in a rat model. Thirty-two male Sprague-Dawley rats were divided into four groups of 8 rats each: (1) control, (2) 2-week SD, (3) IP, and (4) SD plus IP. A TRAM flap was elevated in each rat. Flap viability was assessed on the fifth postoperative day by computerized video planimetry. Mean area of flap survival was compared between the control, IP, SD, and SD plus IP groups using analysis of variance and Student's t-test. Improvement in surface area survival was seen in musculocutaneous flaps subjected to IP, SD, and SD plus IP compared with the control. IP and SD improved survival 1.3 and 1.4 times the control area respectively. Differences between treatment and control flaps were statistically significant (p < 0.04). In addition, the combination of SD plus IP improved survival by 1.8 times, which is statistically different from controls and from either technique individually (p < 0.002). IP and SD have similar efficacy in improving survival in this musculocutaneous flap model. The effects of IP and SD appear to be additive. The advantage of IP over SD is that IP can be performed during the same operative session as the flap elevation and only adds 1 hour to the surgical procedure.

Transferring vascular territories from one axial pattern flap to another: a comparison of delay procedures

The delay technique is an established method of enhancing flap survival. This investigation attempts to determine which of two delay techniques results in the best delay effect by measuring their relative abilities to capture adjacent vascular territories in a rat model. A dorsal flap based on the iliac branch of the iliolumbar artery with a captured random zone corresponding to the axial territory of the lateral thoracic artery was used in the evaluation. Sprague-Dawley rats (350-400 g) were randomly assigned into three groups. Group I was the control group. In group II, the circumferential borders of the animal's dorsum were incised without undermining and the dominant pedicle of the lateral thoracic flap was divided. In group III, the medial and lateral borders of the flap were incised and undermined as a bipedicled flap, violating the musculocutaneous perforators. The dominant pedicle of the lateral thoracic artery was also divided. Group III had the greatest survival with only 9% of flap area necrosis compared to 28% and 21% for groups I and II, respectively. These differences were statistically significant. The results suggest that musculocutaneous perforators provide a substantial vascular source to the tissue at risk and should be considered in selecting a delay technique.

Surgical delay in TRAM flap breast reconstruction: a comparison of 7- and 14-day delay periods

Thirty-one transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstructions were performed after a delay period either of 1 week (group I, N = 15) or 2 weeks (group II, N = 16). The preliminary delay procedure consisted of bilateral deep inferior epigastric and superficial inferior epigastric artery and vein ligation. In group I the diameter and flow in the superior epigastric artery increased from baseline values of 1.3 +/- 0.3 mm and 7.25 +/- 0.8 ml per minute to 1.8 +/- 0.3 mm and 18.2 +/- 2.7 ml per minute at 1 week. In group II the diameter and flow in the superior epigastric artery increased from baseline values of 1.2 +/- 0.3 mm and 5.85 +/- 1.5 ml per minute to 1.7 +/- 0.4 mm and 23.4 +/- 6.2 ml per minute at 2 weeks. The differences between 1 and 2 weeks were not statistically significant. The complication rate in either group was similar. We conclude that a preliminary delay procedure is highly effective at augmenting TRAM flap vascularity and may be implemented between 1 and 2 weeks prior to TRAM flap breast reconstruction in high-risk patients.

Distal dorsal forearm flap

The goal of this study was to investigate the vascular supply of the distal dorsal forearm and the feasibility of using a local skin flap based on perforating vessels of the anterior interosseous artery (AIA) to reconstruct the dorsal aspect of the hand. The results of anatomic studies on 71 adult, fresh-frozen cadaveric upper extremities indicate that a new flap can be designed based on a cutaneous branch of the AIA. The AIA runs along the volar surface of the anterior interosseous membrane. At the proximal border of the pronator quadratus muscle it gives off a dorsal septocutaneous branch (DSCB) that pierces the interosseous membrane and supplies the extensor muscles of the thumb and the skin of the distal two-thirds of the dorsal forearm. The average artery diameter at the origin of the DSCB was 1.1 +/- 0.2 mm (mean +/- standard error of mean). The mean pedicle length was 3.1 +/- 0.6 cm. The pedicle could be extended to 12.4 +/- 0.9 cm if the entire AIA was included. Based on dye injection studies, the smallest skin paddle that could be supported by this vessel ranged from 5 x 9 cm to 8 x 15 cm. The flap can be configured as an island vascular flap based on the DSCB or AIA, a distally based flap, a free flap, a fascial flap, or a composite flap including muscle, bone, nerve, and skin.

Amniotic fluid embolism: emergency management

A case of successful outcome is described in a patient with amniotic fluid embolism presenting to the accident and emergency department. Diagnostic features and guidelines for management are outlined.

Role of the chymotrypsin-like membrane-associated proteinase from Treponema denticola ATCC 35405 in inactivation of bioactive peptides

The ability of washed whole cells of Treponema denticola ATCC 35405 to hydrolyze (inactivate) substance P, bradykinin, and angiotensin I was studied. Substance P was attacked primarily at the Phe-8-Gly-9 bond by a chymotrypsin-like proteinase (CTLP), at Pro-4-Gln-5 by an endo-acting prolyl oligopeptidase (POPase), and at Gln-5-Gln-6 by an endopeptidase (FALGPA-peptidase). Bradykinin was cleaved at Phe-5-Ser-6 by the FALGPA-peptidase and at Pro-7-Phe-8 by the POPase. Angiotensin I was rapidly converted to angiotensin II by the CTLP, and both angiotensin I and angiotensin II were further hydrolyzed at Pro-7-Phe-8 by the POPase. All these enzymes were assumed to be cell associated and were easily extracted with a mild (0.05 to 0.1%) Triton X-100 treatment. Because it was conceivable that the hydrolysis of substance P at the Phe-8-Gly-9 bond was catalyzed by a CTLP described earlier (V.-J. Uitto, D. Grenier, E. C. S. Chan, and B. C. McBride, Infect. Immun. 56:2717-2722, 1988), the enzyme was purified to homogeneity by means of conventional fast protein liquid chromatography procedures. For kinetic studies, Phe-8(4-nitro)-substance P (NSP) (absorption maximum at 309.2 nm, epsilon = 545 M-1 cm-1) was synthesized to replace substance P as a substrate in kinetic studies. In reversed-phase chromatography, both NSP and substance P gave identical results with both whole cells and the purified enzyme. The CTLP has a mass of 95 kDa, and its activity is suggested to be based on an active seryl residue, on an active imidazole group, and on an active carboxyl group but not on metal cations. The enzyme hydrolyzes N-succinyl-L-Ala-L-Ala-L-Pro-L-Phe-p-nitroaniline (SAAPFNA, a typical chymotrypsin substrate) at a high rate and several proteins, such as calf thymus histone, human plasma fibrinogen, milk caseins, and gelatin. Among the substrates tested, substance P showed the highest affinity (Km = 0.22 mM) for the purified enzyme. Depending on conditions, clinically applicable chlorhexidine levels (3.2 mmol/liter, or 0.2%) strongly activated (up to fourfold) the hydrolysis of SAAPFNA by whole cells and the purified CTLP. The hydrolysis of NSP by whole cells and purified CTLP was slightly inhibited by chlorhexidine. The results demonstrated the versatility and the effectiveness of the outer membrane of T. denticola in occasioning a rapid breakdown and inactivation of human bioactive peptides and other peptidolytic catalyses.(ABSTRACT TRUNCATED AT 400 WORDS)

A new technique for endoscopic carpal tunnel decompression

A new one-portal technique for endoscopic carpal tunnel release (ECTR) is introduced with its clinical results. The incision is made at the palmar aspect of the hand. A custom-made glass tube with a groove is inserted, and under endoscope observation, a meniscus knife is pushed forward along the groove to release the flexor retinaculum. This new technique has been studied in ten fresh cadaver hands and used in 123 patients' hands. Results of the cadaver study showed that the flexor retinaculum was released completely in all ten hands. No injuries to tendons, nerves, or arteries were noted. In one case the cotton tip was lost from the stick. All clinical releases were performed uneventfully except for three cases of neuropraxia of the digital nerve of the radial side of the ring finger, one laceration of the motor branch of the median nerve, one mild infection, one loss of cotton tip from the cotton swab stick, and one case of chipping of the glass tube. The case with the laceration of the motor branch of the median nerve occurred early in the series and required the conventional open incision to repair the nerve. The cases with loss of cotton from the stick and chipping of the tube also required a conventional incision to remove the cotton and glass chip. Advantages of this one-portal technique with the glass tube include less scar tenderness than with two-portal techniques, decreased risk of injury to the superficial palmar arch and ulnar nerve because of the distal approach, a view of pathology in the carpal tunnel through the glass tube, and confirmation of release of the flexor retinaculum.

Purification and general properties of an oligopeptidase from Treponema denticola ATCC 35405--a human oral spirochete

An endo-acting oligopeptidase (OPase) was purified to homogeneity from the cells of Treponema denticola ATCC 35405--a human oral spirochete--by a procedure that comprised a mild Triton X-100 extraction (which disintegrates the outer membrane but leaves the cells morphologically intact) and four successive fast protein liquid chromatographic steps of the extract. The activity of this oligopeptidase (formerly named "trypsin-like" enzyme and "BANA-peptidase") together with the proteinase activities of T. denticola and Porphyromonas gingivalis is utilized in a diagnostic test for human periodontal infections, but the enzyme's chemical nature has not been studied. The enzyme is a cell-associated 78-kDa protein with an isoelectric point of 6.1, and its estimated minimum peptide length was 688 amino acid residues. The OPase does not hydrolyze proteins, but hydrolyzes -X-Arg-p-nitroaniline peptides between arginine and the chromogen, the optimum pH of hydrolysis covering a broad pH range (7 to 9). The OPase is not a metalloenzyme, although 1.0 mmol/liter Ca(II) increases the rate of the hydrolysis of all substrates. Ca(II) did not affect the values of the Michaelis constant. The OPase activity is not dependent on reactive SH-groups, but is suggested to depend on the catalytic triad COOH. . .His. . .Ser. The N-terminal sequence for the first 29 amino acid residues is MKQSDFEKPPIAEIKETRFEKFGKTRIDN. The purified enzyme is very sensitive to chlorhexidine acetate (mixed inhibition; Ki = 0.85 microM) and somewhat less sensitive to bacitracin (Ki(app) = 27.5 microM). The present OPase is considered to belong to the serine peptidases, functionally resembling trypsin except that the OPase does not hydrolyze proteins. The OPase may be regarded as an oligopeptidase, the substrate specificity profile of which resembles to a certain extent that of some members of the coagulation cascade.

A new operative technique: cubital tunnel decompression with endoscopic assistance

The final outcome of a surgical decompression of the ulnar nerve depends on the precise release of all potential entrapment points. Careful attention must be given to all anatomic structures around the ulnar nerve and elbow area to ensure adequate dissection and surgical accuracy. In the authors' new endoscopic technique, glass tubes have been specially designed to house an endoscope and guide a meniscus knife, allowing for the release of all involved structures up to 10 cm both proximally and distally through a 3-cm skin incision. The authors present their experience in a cadaver trial and with 26 patients with follow-up of at least 6 months.

Anatomic study of a new axial skin flap based on the cutaneous branch of the medial plantar artery

A new axial skin flap based on the middle cutaneous branch of the medial plantar artery was evaluated in 33 fresh cadaver legs. The vascular pedicle of the skin flap is based on the middle cutaneous artery, its venae comitantes, and segments of the great saphenous vein, if necessary. The middle cutaneous artery is the largest cutaneous branch, arising from the medial plantar artery 2.5 cm distal to its origin. The diameter of its origin is 1.2 mm, and its pedicle is 2 cm long. The midline of the flap runs from the first web space to the heel tip. The upper and lower borders of the flap are 3 to 4 cm on either side of this line. The upper border is medial to the extensor hallucis tendon, and the lower border is medial to the abductor hallucis. Distally, the border begins 2 cm proximal to the metatarsalphalangeal joint; proximally, the border is at the middle of the medial malleolus. The flap diameter can be up to 8 x 12 cm. The middle cutaneous branch of the medial plantar artery was found in all cadaver specimens, except for one with a common trunk. The new flap design leaves the major blood supply to the foot and the plantar aponeurosis intact. It is easy to harvest and may be used either as an island flap or free flap.

An endo-acting proline-specific oligopeptidase from Treponema denticola ATCC 35405: evidence of hydrolysis of human bioactive peptides

An endo-acting proline-specific oligopeptidase (prolyl oligopeptidase [POPase], EC 3.4.21.26) was purified to homogeneity from the Triton X-100 extracts of cells of Treponema denticola ATCC 35405 (a human oral spirochete) by a procedure that comprised five successive fast protein liquid chromatography steps. The POPase is a cell-associated 75- to 77-kDa protein with an isoelectric point of ca. 6.5. The enzyme hydrolyzed (optimum pH 6.5) the Pro-pNA bond in carbobenzoxy-Gly-Pro-p-nitroanilide (Z-Gly-Pro-pNA) and bonds at the carboxyl side of proline in several human bioactive peptides, such as bradykinin, substance P, neurotensin, angiotensins, oxytocin, vasopressin, and human endothelin fragment 22-38. The minimum hydrolyzable peptide size was tetrapeptide P3P2P1P'1, while the maximum substrate size was ca. 3 kDa. An imino acid residue in position P1 was absolutely necessary. The hydrolysis of Z-Gly-Pro-pNA was potently inhibited by the following, with the Ki(app) (in micromolar) in parentheses: insulin B-chain (0.7), human endothelin-1 (0.5), neuropeptide Y (1.7), substance P (32.0), T-kinin (4.0), neurotensin (5.0), and bradykinin (16.0). Chemical modification and inhibition studies suggest that the POPase is a serine endopeptidase whose activity depends on the catalytic triad of COOH ... Ser ... His but not on a metal. The amino acid sequence around the putative active-site serine is Gly-Gly-Ser-Asn-Pro-Gly. The enzyme is suggested to contain a reactive cysteinyl residue near the active site. Amino acid residues 4 to 24 of the first 24 N-terminal residues showed a homology of 71% with the POPase precursor from Flavobacterium meningosepticum and considerable homology with the Aeromonas hydrophila POPase. The ready hydrolysis of human bioactive peptides at bonds involving an imino acid residue suggests that enzymes like POPase may contribute to the chronicity of periodontal infections by participating in the peptidolytic processing of those peptides.

Comparison of proximal and distal one portal entry techniques for endoscopic carpal tunnel release. A cadaver study

Reported complications of endoscopic carpal tunnel release have increased as more surgeons use this technique to release the flexor retinaculum. We used a cadaver model to compare the results of endoscopic carpal tunnel release through a one-portal distal (Group A, 15 specimens) and a one-portal proximal (Group B, 15 specimens) entry site with a new endoscopic technique. Our custom-made glass tube of three different sizes (5, 7, and 9 mm in diameter) is designed to house an endoscope and accommodate a meniscus knife for releasing the flexor retinaculum. Complete release of the flexor retinaculum was obtained in all limbs in both groups. In Group A the one complication (7%) was loss of the cotton tip from the cotton swab stick within the carpal tunnel. In Group B, there was a single case of injury to the superficial palmar arch in one hand and breakage of a glass tube in another hand, for a total complication rate of 13%. No other damage to anatomical structures was noted.

A comparison of periodontal disease among rural Amish and non-Amish adults

Periodontal disease can be more efficiently studied within a homogeneous population where genetic influences and lifestyles are similar enough to negative their effect on the disease process. This study focuses on an Amish population in southern Michigan who isolate themselves from outside influences and their non-Amish neighbors. A total of 425 Amish and 290 non-Amish were contacted resulting in 330 Amish and 215 non-Amish who were examined in their homes giving a participation rate of 76.2%. Ages ranged from 18 to 82 years. Prevalence of periodontal disease tended to be higher among males and increased with age. There were slightly more Amish females (52%) than non-Amish (49%). Means of periodontal conditions for Amish were 1.35 mm for attachment loss, 2.59 mm for pocket depth, 0.24 for calculus, 0.77 for plaque and 0.74 for gingivitis. For non-Amish, the means were 1.03 mm for attachment loss, 2.38 mm for pocket depth, 0.40 for calculus, 0.95 for plaque and 0.87 for gingivitis. It is of interest that the Amish do not practice routine oral hygiene. Only 36.8% of Amish reported brushing at least 1 x a day compared to 84.6% of non-Amish. Similarly, only 8.2% of Amish reported flossing at least 1 x a week compared to 40.8% of non-Amish.

A transverse skin incision approach for decompression of pronator teres syndrome

Pronator teres syndrome is a compressive neuropathy of the median nerve in the proximal part of the forearm and distal part of the arm. The outcome of surgical decompression is occasionally unsatisfactory because of a poor scar. We present the use of a transverse skin incision that allows adequate exploration and decompression distally and proximally, beneath the subcutaneous tissue beyond the volar elbow crease.

Proteolytic and oxidoreductase activity of Treponema denticola ATCC 35405 grown in an aerobic and anaerobic gaseous environment

The cells of a human oral spirochete, Treponema denticola ATCC 35405, and of seven clinical isolates of this organism obtained from the subgingival dental plaque of periodontitis patients were studied for their ability to grow in an aerobic and an anaerobic environment, and for their profile of peptidohydrolase and oxidoreductase enzymes. The growth yield of aerobically grown cultures was either comparable to or higher than that of anaerobically grown ones regardless of whether prereduced broth, freshly prepared broth or oxidized broth was used. However, elimination of certain supplements from the growth media resulted in poor growth regardless of the nature of the gaseous environment. The microscopic morphology and motility of the cells were not affected by differences in the gaseous atmosphere. Quantitative studies on several peptidohydrolase activities suggest that anaerobically grown cells displayed higher specific activity especially toward N alpha-L-prolyl-2-naphthylamine, indicating that increased synthesis of proline iminopeptidase enzymes (or enzyme) of the cells was associated with anaerobic growth conditions. The formation of enzymes hydrolysing N alpha-benzoyl-DL-arginyl-2-naphthylamine (and the corresponding p-nitroaniline) was not affected to the same extent. Growth experiments suggest that T. denticola ATCC 35405 is a facultatively anaerobic spirochete instead of an obligate anaerobe as reported in previous literature. The quantitative enzyme studies suggest that the gaseous growth atmosphere of the cells can exert a selective effect on the activity levels of certain peptidolytic enzymes of this organism. Such effects were not observed when the whole cells were studied by means of qualitative or semi-quantitative enzyme tests. The activities of catalase, peroxidase and superoxide dismutase of the cells were low and variable. Because of this, it was not possible to relate these oxidoreductase activities to the composition of the gaseous atmosphere.

Periodontal disease in an Amish population

Epidemiological studies of periodontal disease have attempted to focus on defined groups in which the variables thought to be responsible for disease could be controlled or more easily identified. This study documents periodontal disease parameters in a unique population of Amish farmers. A total of 371 Amish were contacted and 282 were examined in their homes giving a participation rate of 76%. Ages ranged from 18 to 79 years. Overall means for periodontal conditions were 1.54 mm for attachment loss, 2.63 mm for pocket depth, 0.17 for calculus, 0.63 for plaque and 0.61 for gingivitis. One dental examiner conducted all examinations. Prevalence of periodontal disease tended to be higher among males and increased with age. The majority of Amish examined had little evidence of destructive periodontal disease; about 3.4% of teeth examined had attachment loss of 6 mm or more. These findings indicate a modest level of periodontal disease among the Amish. It is of interest that this population does not generally seek routine dental care. Preliminary analyses of health behavior data collected indicate a lack of regular oral hygiene practices. It appears that the Amish may have protective factors which affect their level of disease.

Cutaneous vascular anatomy of the thoracic region of the dorsum and its role in flap design in the rat

The cutaneous vascular anatomy of the proximal one-half of the dorsum (the thoracic region) and its role in flap design was studied in the rat. The investigation included anatomical dissection, ink injection into the axial artery, and flap harvesting in live animals. Anatomical dissection and india ink injection of the thoracic region revealed that the skin derives its principal blood supply from the lateral thoracic artery. The cutaneous vascular territory of the lateral thoracic artery was defined as follows: the medial border, along the midline of the back from the level of the inferior angle of the scapula to the lower border of the last rib; the lateral border, anterior axillary line corresponding with the length of the medial border; the cephalic border, a line joining the medial and lateral border at the level of the inferior angle of the scapula; and the caudal border, a line corresponding to the lower border of the last rib. Bilateral vascular pedicle island cutaneous flaps were harvested in living rats based on the vascular territory demarcated by India ink injection. All flaps survived; hence, this flap is reliable, with consistent vascularity, and is easy to harvest, and therefore, can be used as a vascular pedicle experimental model to study flap hemodynamics.

Purification and substrate specificity of an endopeptidase from the human oral spirochete Treponema denticola ATCC 35405, active on furylacryloyl-Leu-Gly-Pro-Ala and bradykinin

An endopeptidase was purified to homogeneity from the cell extracts of Treponema denticola ATCC 35405 (a human oral spirochete) by a procedure that comprised dialysis, anion exchange fast protein liquid chromatography (FPLC), hydroxylapatite FPLC, immobilized metal affinity FPLC, FPLC chromatofocusing, and two consecutive gel permeation FPLC steps. The enzyme is a 62-kDa protein with an isoelectric point of 6.5-7.0. Experiments with enzyme inhibitors suggest that this enzyme is a metallopeptidase and that its activity is not dependent on sulfhydryl or serine residues. The enzyme is active on furylacryloyl-Leu-Gly-Pro-Ala (FALGPA; pH optimum near 6.25), bradykinin (Bk), and several Bk-related peptides. In FALGPA, the cleavage site is the Leu-Gly bond. An imino acid is absolutely necessary in position P'2. The shortest hydrolyzed peptide was FALGPA, the hydrolysis of which is strongly and competitively inhibited by Bk (Ki = 5.0 microM). The pyrophosphate ion and phosphoramidon also inhibited the hydrolysis of FALGPA. The enzyme does not hydrolyze all typical synthetic collagenase substrates, Azocoll, Azocasein, or Type I and Type IV collagens, or any other proteins tested. In Bk-related peptides, the hydrolyzed bond was Phe5-Ser6. Since a Bk antagonist and a Bk-potentiating pentapeptide also were good substrates, it is possible that the enzyme hydrolyzes Bks and related peptides only because of the coincidental, specific amino acid sequence of those substrates. A proposal is made that since a substantial portion of the amino acid sequence of FALGPA is present in collagen (and additionally acknowledging that the furylacryloyl residue structurally resembles that of proline), the natural substrates of this enzyme may be small, soluble collagen fragments produced by other enzymes from periodontal connective tissue, and that such peptides are important for the nutrition and pathogenicity of T. denticola.

Effect of slow-release chlorhexidine mouthguards on the levels of selected salivary bacteria

This study evaluated the effect of an alternate delivery system for chlorhexidine on salivary levels of mutans streptococci (MS) and other selected oral bacteria. On the basis of salivary MS levels > or = 10(4) CFU/ml, 22 subjects were enrolled. All caries lesions were restored prior to treatment. Two pretreatment paraffin-stimulated saliva samples were obtained for culturing at least 1 week apart. Complete-arch vacuum-adapted mouthguards were individually fabricated and coated internally with a 3% w/v chlorhexidine varnish. Mouthguards were worn for an average of 7 h/night for 7 nights. Saliva samples were obtained immediately after treatment and 1 and 3 months later. There was no significant change in levels of any of the monitored bacteria between the two pretreatment samples. A significant and specific reduction in salivary MS levels was observed in the three after-treatment samples as compared with baseline values (p < 0.001, p < 0.001, p < 0.05, respectively). The levels of Actinomyces viscosus were also measured, and there was a significant reduction immediately after treatment (p < 0.05), a return to baseline values at 1 month, and a significant increase above baseline values at 3 months, (p < 0.001). There was no significant change in saliva volume, in total numbers of facultatively anaerobic bacteria, or in levels of lactobacilli or Streptococcus sanguis. This treatment system is capable of significant and specific suppression of MS levels for up to 3 months without retreatment.

A new experimental model: the vascular pedicle cutaneous flap over the dorsal aspect (flank and hip) of the rat

Cutaneous vascular anatomy of the flank and the hip was studied in the rat. Investigation was done by anatomical dissection, ink injection to the axial artery and flap harvesting in living rats. Anatomical dissection and India ink injection revealed that the rat's flank and hip skin derives its blood supply from the iliac branch of the iliolumbar artery, which originates from the lateral aspect of the abdominal aorta. The vascular territory of the iliac branch of the iliolumbar artery was defined as follows: the medial border--along the midline of the back from the 12th rib to the proximal part of the tail; the lateral border-anterior axillary line corresponding with the length of the medial border; the cephalic border--a line joining the medial and lateral border at the level of the 12th rib; and the caudal border--the posterior lateral line of the hip. On the basis of the vascular territory demarcated by India ink injection, bilateral vascular pedicle island cutaneous flaps were harvested in living rats. Results showed total survival of all flaps. This flap is easily made, and it could be used as a reliable model for flap research.

Experimental study on the influence of tension, immobilisation and denervation on muscle transplantation

To observe the effects of tension and immobilisation on denervated muscle, rats' denervated soleus muscles were transplanted orthotopically at different tensions: high, neutral, moderate and low tension with immobilisation. Results were evaluated by measuring muscle mass, twitch and tetanic tension, and histologically by HE staining. The results showed better preservation of muscle weight in the high tension group. Atrophy and loss of function were rapid during the first 4 weeks and were greatest in the low tension group. Rate of atrophy was slowed and relatively stabilised at the eighth postoperative week. We conclude that increased tension with immobilisation produced slower initial atrophy and loss of function in denervated muscle flaps. Although slower, the atrophy continued during the prolonged immobilisation and there was no significant difference compared with neutral tension at a later period. Moreover, immobilisation produced atrophy and affected function regardless of the amount of tension. Increased tension decelerates and decreased tension accelerates denervation atrophy of muscle. Thus denervation, immobilisation and reduced tension are all detrimental in muscle transplantation.

Modeling bacterial damage to pulpal cells in vitro

There is increasing evidence that access to patent dentinal tubules by bacteria and their products rather than trauma from restorative materials is responsible for subsequent pulpitides. The purpose of this study was to compare the relative cytotoxicity of centrifugal fractions of two bacteria, Fusobacterium nucleatum and Treponema denticola, on L929 cells in monolayer cultures and in the "in vitro pulp chamber." Neutrophilic chemotaxis assays and Limmulus assays were performed to verify biological activity of the various fractions of these bacteria. It was found that T. denticola inhibits new protein synthesis in cultured cells to a much greater extent than F. nucleatum, but that only F. nucleatum fractions are chemoattractive for human neutrophils in the absence of serum. While the chemical nature and molecular weights of the "toxic" materials were not determined, it appeared that eukaryotic protein synthesis inhibition caused by the T. denticola pellet fraction in the in vitro pulp chamber was at least 1000 times less than that caused by the same concentrations in monolayer cultures.

Unilateral VATER association

We describe a case of unilateral "VATER association." In addition to the VATER manifestations, the patient had hemihypoplasia, unilateral congenital paralysis of a leg, and delayed ossification of the femoral head and carpal bones. All of the manifestations involved the left side of the body. The only drug exposure identified was a Chinese herbal medicine taken by the mother during early pregnancy.

Humoral immune response to selected subgingival plaque microorganisms in insulin-dependent diabetic children

Juvenile diabetics have been shown to have an increased susceptibility to gingivitis and periodontitis following puberty. However, little data are available on changes in the microbial flora that occur at the onset of puberty. This study was performed to determine if antibacterial antibody titers to selected periodontal disease-associated microorganisms might be helpful in revealing changes in plaque flora at the onset and conclusion of puberty. Sera was obtained from 35 subjects (ages 7 to 18 years) selected from a population of insulin-dependent diabetics. The subjects were given a thorough medical examination which included an assessment of sexual maturation and a dental examination which included the recording of onset and magnitude of bleeding according to the papillary bleeding score. Antibody titers to A. naeslundii (AN), B. intermedius (BI), B. gingivalis (BG), F. nucleatum (FN), A. actinomycetemcomitans (AA), C. ochracea (CO) and T. denticola (TD) were determined using the microELISA. Stratification of antibody titers by age groups (less than or equal to 12 years, 12 to 15 years, greater than 15 years) revealed that titers to AN increased significantly (P less than 0.025, ANOVA) and progressively (P less than 0.05, regression analysis) with increasing age. In contrast, the titers to FN were maximal in the under 12 year group and decreased with age (ANOVA, P less than 0.05; regression analysis, P less than 0.05). There were no significant variations in titers observed for the other microorganisms. Stratification by sexual maturity revealed a similar progressive decrease of the titer to FN (ANOVA, P less than 0.05; regression analysis, P less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Enzyme profiles of oral spirochetes in RapID-ANA system

Enzyme profiles of oral Treponema species were determined by using RapID-ANA (Innovative Diagnostic System, Atlanta, Ga.), a 4-h test system which detects 18 enzymatic reactions, including aminopeptidases and glycosidases. Seventy-two clinical isolates of Treponema denticola, four reference strains of T. denticola (ATCC 35404, ATCC 35405, ATCC 35520, and ATCC 33521), one strain of T. vincentii (ATCC 35580), and two strains of T. socranskii subspecies (T. socranskii subsp. buccale ATCC 35534 and T. socranskii subsp. socranskii ATCC 35536) were used in this study. All T. denticola strains produced indole and a variety of aminopeptidases and glycosidases. These organisms could be differentiated into two groups on the basis of tetrazolium reductase and serine, phenylalanine, and glycine aminopeptidase activities. T. vincentii produced N-acetylglucosaminidase and arginine aminopeptidase, which facilitated the differentiation of this organism from T. socranskii subspecies and the T. denticola group. T. socranskii subspecies gave positive reactions for alkaline phosphatase only. These findings suggest that the RapID-ANA system is useful for enzymatic characterization and differentiation of oral spirochetes.

The effects of periodontal therapy on serum antibody (IgG) levels to plaque microorganisms

The influence of periodontal therapy on serum antibody titers to selected periodontal disease-associated microorganisms was assessed in 23 patients having chronic inflammatory periodontal disease (CIPD). The immunoglobulin G (IgG) titers were determined by the microELISA technique in serum samples obtained prior to treatment; following a hygienic phase which included scaling, root planing, and oral hygiene instruction; following surgical treatment; and one year and two years following hygienic phase (maintenance phase). Considerable individual variability existed in the magnitude of immune response to specific bacterial preparations. Significant reductions in the mean antibody titers were seen to A. viscosus, S. sanguis, F. nucleatum, S. sputigena, B. gingivalis, B. intermedius, B. melaninogenicus, T. vincentii, and T. denticola by the end of the second year of maintenance. There was no consistent response to Capnocytophaga. When individual patient responses were examined, 6 of the 23 were found to have elevated titers to at least one of the microorganisms in the interval between pretreatment and the end of the hygienic phase; however, in all but one case, the titers at the end of the second year of maintenance were below pretreatment levels. Antibody levels to bacteria such as S. sanguis were modified during therapy. This would indicate that immune responses to microbes not generally considered to be "periodontal pathogens" may be modified by adjuvant activity associated with subgingival plaque or changes in the environment of the sulcus and that subsequent changes in titer do not necessarily reflect a role of that microorganism in the disease process.

Combined antibiotic (metronidazole) and mechanical treatment effects on the subgingival bacterial flora of sites with recurrent periodontal disease

5 patients in maintenance, 1-3 years after periodontal therapy who showed sites with reinfected pockets and bleeding despite regular recall visits were selected. Darkfield microscopy from 3 sites in each patient showed an average of 41% spirochetes and 21% motile rods. Probing depths ranged from 7 to 9 mm and loss of clinical attachment from 6 to 13 mm in these sites. The patients were given 3 times 250 mg/day of metronidazole (Flagyl) for 10 days. Darkfield microscopy and microbiological cultures of the subgingival plaque were performed twice prior to the study, at the end of the medication and after 3 weeks, 3 and 6 months. The plaque and gingival indices, probing depth and loss of clinical attachment were recorded. During the medication and at 3 and 6 months, the teeth were scaled and root planed. The samples were obtained with 3 paper points and cultured anaerobically in the glove box on non-selective and selective media and representative bacterial colonies identified by aerobic growth, gram stain and rapid biochemical tests. Presumptive pathogenic micro-organisms including Bacteroides were identified. The % of spirochetes, motile rods and non-motile bacteria were enumerated by darkfield microscopy. The clinical results show that administration of metronidazole and repeated root planing significantly decreased gingival inflammation, probing depth and loss of clinical attachment in reinfected sites. After treatment, these sites harbored significantly less spirochetes and more non-motile bacteria, while motile rods tended to return to baseline levels with time. The combined antibiotic and mechanical therapy resulted in a statistically significant decrease of gram-negative rods, Fusobacteria and Bacteroides gingivalis over 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of three dispersion procedures for quantitative recovery of cultivable species of subgingival spirochetes

Spirochetes are usually the predominant organisms observed microscopically in subgingival plaques removed from tooth sites associated with periodontitis, but these organisms are rarely isolated by cultural means, presumably because the media do not support their growth and/or because these fragile organisms are disrupted by the various procedures used to disperse plaque samples. In the present investigation, three dispersal procedures, sonification, mechanical mixing, and homogenization, were compared for their ability to permit the isolation of Treponema denticola, Treponema vincentii, Treponema socranskii, and Treponema pectinovorum from plaque samples on media that support the growth of these species. Plaque samples in which the spirochetes averaged 50% of the microscopic count were chosen. The highest viable recoveries of spirochetes were observed when the plaques were dispersed with a Tekmar homogenizer, and the lowest occurred with sonification. The highest recoveries averaged only about 1% of the total cultivable counts, indicating either that the sought-after species were minor members of the flora or that the dispersal procedures were still too harsh. A total of 91% of the isolates were T. denticola, 5% were T. socranskii, and 4% were a heretofore-undescribed species.

Trypsin-like activity in subgingival plaque. A diagnostic marker for spirochetes and periodontal disease?

Taxonomic screening of subgingival plaque organisms with various enzyme assays have shown that Treponema denticola, Bacteroides gingivalis and an unspeciated Capnocytophaga species possess a trypsin-like enzyme (TLE) that can be detected by the hydrolysis of N-benzoyl-DL-arginine-2-naphthylamide (BANA). As these organisms can be considered to be periodontopathic, it was of interest to determine whether this BANA hydrolyzing enzyme could be detected directly in subgingival plaque samples. Subgingival plaque samples were collected from single sites of known pocket depth, and after dispersal by vortexing, aliquots were incubated overnight with BANA and were counted microscopically. The color reactions were developed with fast garnet, read by the eye and classified as positive (red to red-orange), negative (yellow) and questionable. In the BANA-positive plaques, the spirochetes averaged 43% of the microscopic count, whereas in the BANA negative plaques the spirochetes averaged 8% of the microscopic count. The average pocket depth of BANA-positive plaques was 6.7 mm, whereas the average pocket depth of BANA-negative plaques was 4.5 mm. When both of these parameters were combined, the presence of a positive BANA reaction was usually indicative of subgingival plaques containing greater than 34% spirochetes removed from sites that had probing depths of 7 mm or more. Seventy-one per cent of the plaques removed from untreated periodontal patients were BANA-positive, while only 8% of the plaques removed from successfully treated patients seen at maintenance recall visits were BANA-positive.(ABSTRACT TRUNCATED AT 250 WORDS)