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Fourteen cases of Turner syndrome (45,X), two cases of mosaic Turner syndrome (45,X/47,XXX and 45,X/ 46,XX), and one case of Turner syndrome involving an isochromosome X [46,X,i(X)(q10)] were ascertained by prenatal maternal serum alpha-fetoprotein (MSAFP) and free beta human chorionic gonadotropin (hCG) screening or by ultrasound. Patient-specific risks for Down syndrome were calculated and used as the criteria to determine offering further testing. Eleven of the 17 cases had hydrops and presented with an increased Down syndrome risk based on MSAFP and free beta hCG screening. The median MOM level was 0.98 and 4.04 for MSAFP and free beta hCG, respectively. Three cases had hydrops but screened negative. The two cases of mosaic Turner syndrome were non-hydropic and screened positive. The 46,X,i(X)(q10) case was non-hydropic but had elevated MSAFP and free beta hCG levels. These data suggest that Turner syndrome pregnancies do not appear to screen positive due to hydrops alone, but screening may also be influenced by the inherent genetic imbalance in the fetus and placenta. Because the MSAFP levels in our series were within the normative range in all except one case with an elevated MSAFP, free beta hCG alone was the most effective screening marker for Turner syndrome pregnancies.

CD8+ T lymphocytes (TCD8+) play an important role in cellular immune responses. TCD8+ recognize MHC class I molecules complexed to peptides of 8 to 10 residues derived largely from cytosolic proteins. Proteins are generally thought to be fragmented in the cytoplasm and delivered to nascent class I molecules in the endoplasmic reticulum (ER) by a peptide transporter encoded by the MHC. To explore the extent to which TCD8+ induction in vivo is limited by proteolysis or peptide transport into the ER, mice were immunized with recombinant vaccinia viruses containing mini-genes encoding antigenic peptides (bypassing the need for proteolysis), or these peptides with a NH2-terminal ER insertion sequence (bypassing the requirements for both proteolysis and transport). Additionally, mice were immunized with recombinant vaccinia viruses encoding rapidly degraded fragments of proteins. We report that limitations in induction of TCD8+ responses vary among Ags: for some, full length proteins are as immunogenic as other forms tested; for others, maximal responses are induced by peptides or by peptides targeted to the ER. Most importantly, in every circumstance examined, targeting peptides to the ER never diminished, and in some cases greatly enhanced, the TCD8+ immune response and provide an important alternative strategy in the design of live viral or naked DNA vaccines for the treatment of cancer and infectious diseases.

In this report, we have outlined our experiences with the direct surgical treatment of 16 patients with supraventricular tachyarrhythmias (SVTA). Re-entry supraventricular tachycardia (SVT) was demonstrated by the 4 patients who had retrograde-conducting Kent pathways. The SVT was corrected by the successful division of the Kent bundle in 3 and a partially successful His bundle division in one patient. The remaining 9 patients with re-entry, which included 6 with Kent pathways and WPW, all had His bundle section. The remaining 3 with His interruption had focal tachycardias associated with dysfunction of the atrioventricular (AV) node. Of the 13 His bundle interruptions, nine were successful, three resulted in questionable AV conduction, and one failed. Problems with suture ligation and cautery explained the failures. Cryothermia was the most successful procedure used. However, excision of that portion of the atrium containing the AV node shows promise of being satisfactory. The possibility is discussed of using measures much more precise and less destructive than His bundle interruption for SVTA.

A case of cryoglobulinemia type II with membranoproliferative glomerulonephritis and vasculitis is described. Clinically and serologically the patient responded to cyclophosphamide and prednisone therapy. This correlated with improvement in the glomerular and interstitial lesions on renal biopsy specimens, although skin and renal vasculitis persisted over a 2-year period. These observations suggest important differences in the immunopathologic mechanisms involved in the vascular versus glomerular injury. Infiltration of macrophages were demonstrated in the glomerular capillary lumen while polymorphonuclear cells predominated in the vascular lesion. The presence of macrophages in the glomerular capillary lumen correlated with clinical proteinuria. A review of the literature also suggests that cyclophosphamide in combination with prednisone appears to be an effective therapeutic regimen for the glomerulonephritis of cryoglobulinemia. However, the correlation of clinical response and renal morphology in cryoglobulinemia has heretofore not been emphasized.

This study used transmural multipolar electrodes, ventricular pressure monitoring, and cardiac electrical stimulation techniques to examine the effects of transient aortic occlusion on ventricular refractoriness in a canine model of recent myocardial infarction. Six previously instrumented resting awake dogs were atrially paced, followed by timed premature extrastimuli inserted at epicardial pacing sites adjacent to an apical left ventricular (LV) myocardial infarction or in an LV control zone remote from the myocardial infarction. Electrophysiologic and pressure recordings were obtained before and during periods of transient aortic occlusion. Aortic occlusion was applied before the last beat of an eight-beat atrial pacing sequence and resulted in increased peak LV pressure (92.8 +/- 27.7 mm Hg, p = 0.003). Aortic occlusion shortened LV effective refractory period (ERP) recorded from the myocardial infarction border zone in both the subepicardial (-17.0 +/- 11.8 msec, p = 0.019) and subendocardial (-17.7 +/- 10.9 msec, p = 0.011) regions, whereas LVERP of the control zone was unchanged. Conduction latency of premature beats at equivalent coupling intervals and maximum latency observed were unchanged by aortic occlusion. atrioventricular conduction interval shortened in association with aortic occlusion. Thus transient aortic occlusion reduced ventricular refractoriness in the border zone adjacent to the myocardial infarction while control zone refractoriness was minimally or not changed. Heterogeneity of ventricular myocardial refractoriness may result from mechanical dysfunction, potentially increasing susceptibility to arrhythmias.

Liposuction is a very safe and predictable means of contouring the body's adiposities. It is an effective surgical method for aesthetic sculpturing with minimal complications. Complications are rare and most commonly include waviness or irregularities of the skin from poor patient selection. We have had in the last 1200 patients one case of a hematoma that was attributed to preoperative ingestion of aspirin. No seromas have occurred in this group of patients. The procedure is relatively pain free, and propoxyphene is usually adequate for pain control. The results have been rewarding for both the surgeon and the patient. Liposuction surgery has arrived as a well-accepted, reliable, and safe procedure for treating unwanted adiposities and contouring the face, neck, and body.

The Transplant Service at the University of Minnesota Hospitals has performed over 2,000 kidney transplants. Fourteen of these patients have developed cardiac conditions necessitating surgical intervention at intervals of 9 to 144 months (mean 67 months) following their transplantation. These individuals had a mean age of 42 years, and five (36%) were diabetic. All patients had functioning renal allografts with preoperative serum creatinine levels ranging from 1.0 to 1.8 mg/100 ml (mean 1.4 mg/100 ml). Ten patients underwent aorta-coronary saphenous vein bypass grafting. One patient underwent bypass grafting and concomitant left ventricular aneurysmectomy. Native valvular endocarditis developed in two patients. One had tricuspid valve debridement for fungal endocarditis and the other had aortic valve replacement for bacterial endocarditis. The final patient had calcific aortic stenosis and coronary artery disease necessitating aortic valve replacement and coronary bypass. Two patients (14%) died perioperatively. One was a young woman with juvenile-onset diabetes and preinfarction angina who died suddenly several days after the operation; at autopsy, she was found to have an occluded graft to the right coronary artery and extensive infarction. The other was a 54-year-old woman with calcific aortic stenosis, coronary artery disease, and unstable angina who died perioperatively of uncontrollable arrhythmias. Autopsy suggested that she may have had an unsuspected infarction 1 to 2 days before the operation. The remaining 12 patients had uneventful postoperative courses and returned to Class I functional status from a cardiac standpoint. There has been one late death (7%), 45 months after successful coronary artery bypass grafting, as a result of complications attendant to a perforated gastric ulcer. The remaining 11 patients are alive and well at intervals of 8 to 93 months (mean 31 months) after operation. Postoperative serum creatinine levels at hospital discharge averaged 1.6 mg/100 ml, not significantly changed from preoperative levels. Cardiac operations can be performed safely in patients with functioning renal allografts. Patient survival is acceptable and preservation of renal function has been uniformly successful in surviving patients.

Tricuspid valve Candida albicans endocarditis developed in a multiple-organ transplant recipient six months after successful treatment of Candida peritonitis. She has had no recurrence or valvular incompetence two years after valve-sparing debridement of the vegetation and prolonged therapy with amphotericin B. This is the second report of long-term success following valve-sparing debridement for tricuspid valve Candida endocarditis. In selected patients without annular involvement or gross valve destruction, excision of the fungal vegetation may allow for long-term cure and a competent valve.