Search

Southern Hemisphere humpback whales (Megaptera novaeangliae) generally undertake annual migrations from polar summer feeding grounds to winter calving and nursery grounds in subtropical and tropical coastal waters. Evidence for such migrations arises from seasonality of historic whaling catches by latitude, Discovery and natural mark returns, and results of satellite tagging studies. Feeding is generally believed to be limited to the southern polar region, where Antarctic krill (Euphausia superba) has been identified as the primary prey item. Non-migrations and / or suspended migrations to the polar feeding grounds have previously been reported from a summer presence of whales in the Benguela System, where feeding on euphausiids (E. lucens), hyperiid amphipods (Themisto gaudichaudii), mantis shrimp (Pterygosquilla armata capensis) and clupeid fish has been described. Three recent research cruises (in October/November 2011, October/November 2014 and October/November 2015) identified large tightly-spaced groups (20 to 200 individuals) of feeding humpback whales aggregated over at least a one-month period across a 220 nautical mile region of the southern Benguela System. Feeding behaviour was identified by lunges, strong milling and repetitive and consecutive diving behaviours, associated bird and seal feeding, defecations and the pungent "fishy" smell of whale blows. Although no dedicated prey sampling could be carried out within the tightly spaced feeding aggregations, observations of E. lucens in the region of groups and the full stomach contents of mantis shrimp from both a co-occurring predatory fish species (Thyrsites atun) and one entangled humpback whale mortality suggest these may be the primary prey items of at least some of the feeding aggregations. Reasons for this recent novel behaviour pattern remain speculative, but may relate to increasing summer humpback whale abundance in the region. These novel, predictable, inter-annual, low latitude feeding events provide considerable potential for further investigation of Southern Hemisphere humpback feeding behaviours in these relatively accessible low-latitude waters.

Cell pairing is central for many processes, including immune defense, neuronal connection, hyphal fusion, and sexual reproduction. How does a cell orient toward a partner, especially when faced with multiple choices? Fission yeast Schizosaccharomyces pombe P and M cells, which respectively express P and M factor pheromones [1, 2], pair during the mating process induced by nitrogen starvation. Engagement of pheromone receptors Map3 and Mam2 [3, 4] with their cognate pheromone ligands leads to activation of the Gα protein Gpa1 to signal sexual differentiation [3, 5, 6]. Prior to cell pairing, the Cdc42 GTPase, a central regulator of cell polarization, forms dynamic zones of activity at the cell periphery at distinct locations over time [7]. Here we show that Cdc42-GTP polarization sites contain the M factor transporter Mam1, the general secretion machinery, which underlies P factor secretion, and Gpa1, suggesting that these are sub-cellular zones of pheromone secretion and signaling. Zone lifetimes scale with pheromone concentration. Computational simulations of pair formation through a fluctuating zone show that the combination of local pheromone release and sensing, short pheromone decay length, and pheromone-dependent zone stabilization leads to efficient pair formation. Consistently, pairing efficiency is reduced in the absence of the P factor protease. Similarly, zone stabilization at reduced pheromone levels, which occurs in the absence of the predicted GTPase-activating protein for Ras, leads to reduction in pairing efficiency. We propose that efficient cell pairing relies on fluctuating local signal emission and perception, which become locked into place through stimulation., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Whereas body contouring surgery after massive weight loss in women emphasizes sculptured adipose and broader lower torso, little attention has been devoted to accentuating the male physique., Objective: To determine if boomerang excision pattern correction of gynecomastia with J torsoplasty combined with an abdominoplasty with oblique excisions directly over bulging flanks provide effective and safe optimizing of muscle visibility and upper torso dominance., Methods: A description of comprehensive body contouring through an abdominoplasty and a series of obliquely oriented ellipses of the male torso is followed by review of 19 consecutive patients., Results: Seventeen patients were performed in a single stage. Nine of the last ten cases included J torsoplasty and oblique excision extensions over the flanks. Of the 17 patients responding to a ten-question survey, 15 were satisfied with chest improvement. One of the first eight patients with a transverse lower body lift was satisfied with the flank bulges. All of the last eight cases with direct oblique flank excisions were satisfied with their lower body. Five patients (26 %), having a total of 74 operative procedures, had significant complications of chest hematoma, persistent hip and buttock seromas, superior NAC edge necrosis, and distal necrosis of the fleur de lis abdominoplasty. One boomerang correction underwent minor revisions. One transverse lower body lift underwent major revision. No complications occurred in the last ten patients, having oblique flank excisions instead of transverse lower body lifts., Conclusion: Comprehensive excisional body contouring surgery of a central high tension abdominoplasty with a series of obliquely oriented ellipses throughout the torso appears to provide low risk improved body contour for the muscular male., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The management of a patient presenting with unsatisfactory labor epidural analgesia poses a severe challenge for the anesthetist wanting to provide safe anesthetic care for a cesarean delivery. Early recognition of unsatisfactory labor analgesia allows for replacement of the epidural catheter. The decision to convert labor epidural analgesia to anesthesia for cesarean delivery is based on the urgency of the cesarean delivery, airway examination, and the existence of a residual sensory and motor block.  We suggest an algorithm which is implemented in our department, based on the urgency of the cesarean delivery.

This article contrasts the ideal appearance of the female upper arm, axilla, and upper midlateral chest with the sagging and/or oversized deformity. The constellation of postbrachioplasty aesthetic deformity is introduced. These aesthetic shortcomings are best avoided, because they are difficult to correct. The L brachioplasty with liposuction is described in a recent case and applied to a variety of deformities to show the range of applicability and quality of results. The role of liposuction in arm reshaping is examined. The aesthetic advantages and low complication rate of the L brachioplasty are contrasted with other currently popular brachioplasties., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Most filler procedures in the United States are performed with hyaluronic acid (HA) derivatives. Artefill (Suneva Medical, Inc, San Diego, California), the only polymethylmethacrylate (PMMA)-enhanced dermal filler approved by the US Food and Drug Administration (FDA), has been well tolerated by patients for treatment of nasolabial folds and has a safety profile similar to other approved fillers., Objectives: The authors investigate the safety and efficacy of Artefill for malar augmentation., Methods: This prospective, multisite, open-label study included a total of 24 patients with age-related lipoatrophy. Only patients with mild to moderate lipoatrophy were considered candidates for treatment. Artefill was injected in the supraperiosteal layer of the malar region, at a maximum volume of 6 mL (3 mL/side). Touch-up injections were performed at weeks 4 and 6, up to a maximum total volume of 8.8 mL. Standardized assessments of results were made at 2, 6, and 12 months. Outcome measures included the Global Aesthetic Improvement Scale (GAIS), change in malar lipoatrophy grade, and patient satisfaction. Standardized photographs of each patient were collected., Results: Average patient age was 48 ± 5 years. Average volume of injections was 5.55 ± 1.87 mL. Based on both the patient- and physician-rated GAIS, 95.8% of study participants were reported as being "improved" or "very much improved." The change in malar lipoatrophy grade was significantly improved from baseline to 1 year by 0.96 ± 0.98 (P < .0003). Patients also reported high levels of satisfaction, with 87.5% being "satisfied" or "very satisfied." There were no reported adverse safety events in the study., Conclusions: Artefill demonstrated improvement in malar atrophy with a high level of patient satisfaction and an excellent safety profile. The absence of any adverse events in our study patients was notable, and we believe this is a result of the uniform nature of the PMMA particles in the Artefill and the strict and sterile manner in which this PMMA dermal filler is produced.

Background: Patients with massive volume or skin laxity typically are not ideal candidates for liposuction treatment due to the excess amounts of loose skin after the procedure. The feasibility, safety, and efficacy of a novel radiofrequency device (BodyTite system) for radiofrequency-assisted liposuction (RFAL) were prospectively evaluated with overweight and weight loss patients., Methods: In this study, 17 women with an average aspirated volume of 1,759 ml in the arms, abdomen, or thighs were treated. The treatment technique is described with the resulting weight, circumferential, and contraction measurements collected at a follow-up assessment after 6 and 12 weeks. Three-dimensional scanning was used to document volume changes in selected cases. Patient satisfaction also was recorded. Body contour and area tightening results were evident for all the patients, with high posttreatment satisfaction. Skin contraction was significant at 6 weeks and continued past 12 weeks of follow-up evaluation., Results: On the average, after 12 weeks, patients had lost 6.2% of their original abdominal circumference, 4.4% of their original thigh circumference, and 9.2% of their original arm circumference. The mean vertical contraction was 7.9% for the abdomen, 3.6% for the thighs, and 2.4% for the arms. The maximum results showed a circumference loss of 16.5% for the abdomen, 11.4% for the thighs, and 17.7% for the arms. The maximum vertical contraction was 15.7% for the abdomen, 7.4% for the thighs, and 3.3% for the arms. The average follow-up period was 13.3 months (range, 3-26 months)., Conclusion: The RFAL approach is a viable means of energy-assisted liposuction for overweight and massive weight loss patients. Significant volumes of fat can be removed safely and effectively with improved contour and clinically significant skin tightening.

Massive weight loss patients suffer severe arm deformity, extending through the axilla and onto the chest. We found current operations inadequate, often with conspicuous scars. The L-brachioplasty was evolved to treat the entire deformity through the excision of two right angle unequal ellipses, leaving natural contours and an unobtrusive L-shaped scar. The upper body deformity consists of loose upper arm skin, oversized axilla, descent of the posterior axillary fold, flattening and elongation of the anterior axillary fold, and lateral chest rolls of skin. By tissue gathering and pinching, a hemi-ellipse is drawn over the lower half of the inner arm, sweeping up to the deltopectoral groove. Then a shorter ellipse is extended through the axilla onto the chest. These ellipses are connected by an inverted V-resection through the axilla. After skin resection the wound margins are closed with a triangular flap advancement of the posterior axillary fold. The result is a properly contoured reduced arm, axilla, and lateral chest with a sweeping inverted L-scar coursing upward along the lower medial arm to cross the dome of the axilla and then drop vertically along the mid lateral chest. Over the past four years more than fifty weight loss patients have been treated with aesthetic reshaping of the upper arm leaving inconspicuous scars and only minor complications. There have been 8 scar revisions, including two Z-plasties for contracture. The rationale and results compare favorably with contemporary techniques. L-brachioplasty is our procedure of choice for the massive weight loss patient and can be selectively applied to the aging arm.

Background: Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth., Methods: A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis., Results: Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm., Conclusion: The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.

Cutaneous T-cell lymphomas (CTCLs) are malignancies of T cells that have a special affinity for the skin. We have previously reported that much of the T-cell receptor repertoire is altered in CTCL, and both malignant and nonmalignant clones are numerically expanded, presumably in response to T-cell trophic cytokines. We therefore examined levels of the T-cell trophic cytokines IL-2, IL-4, IL-7, IL-12, IL-13, and IL-15 in plasma in 93 CTCL patients and healthy controls. Only IL-7 levels were elevated in CTCL. We next looked at lesional skin from patients with CTCL and found elevated levels of IL-7 mRNA. Explant cultures of normal and lesional CTCL skin biopsies revealed significantly more IL-7 protein production in CTCL skin. Additionally, cultures of CTCL skin released greater numbers of T cells than normal skin; this was blocked by the addition of an IL-7 neutralizing antibody. Finally, these cultures induced proliferation of normal peripheral skin-homing T cells that were added to the cultures. These observations led us to postulate that IL-7 produced by skin cells contributes to the survival and proliferation of T cells within skin lesions and is likely the source of elevated circulating IL-7 in CTCL.

Purpose: Cutaneous T-cell lymphoma (CTCL) is a malignancy of skin-homing Th2 T cells. Clonal T cells and CTCL skin lesions typically express Th2 cytokines, including interleukin (IL)-4, IL-5, and IL-10, but fail to produce Th1 cytokines. However, the reason for Th2 bias is unknown. IL-18 is a pleiotropic proinflammatory cytokine produced by monocytes/macrophages lineage as well as epithelial cells, such as human keratinocytes. In the absence of IL-12, IL-18 leads to increased immunoglobulin E production from B cells and enhanced production of IL-4 and IL-13 by basophils, mast cells, and CD4(+) T cells. We have analyzed cytokines in CTCL patients, which may bias the immune response around the Th1/Th2 axis., Experimental Design: We examined plasma of 95 CTCL patients and skin of 20 CTCL patients for IL-18, caspase-1, IL-12, and other cytokines. To identify the presence or absence of these cytokine proteins in CTCL and normal skin, we cultured explants from skin biopsies on three-dimensional matrices., Results: Plasma levels of IL-18 and its converting enzyme, caspase-1, were significantly elevated in CTCL. mRNA levels for these factors were also elevated in CTCL skin lesions. Matrices populated with CTCL lesional skin produced significant amounts of IL-18 and caspase-1; however, production of IL-12 protein was barely detectable., Conclusions: We propose that the high levels of IL-18 expression in lesional CTCL skin contribute to increased plasma levels of IL-18 and that this, in the face of significantly lower levels of IL-12, may contribute to the Th2 bias seen in this disease.

We report the use of topical application of recombinant human basic fibroblast growth factor (rhbFGF) to successfully treat therapy-resistant, chronic leg ulcers in scleroderma. Endothelial cell FGF receptors are directly stimulated by bFGF; also, bFGF promotes the regeneration of capillary-rich granulation tissue. We conclude that topical bFGF may be a powerful new pharmacologic tool for treating severe skin ulcers.

Objective: To test the hypothesis that a greater peak internal hip abduction moment is associated with a reduced likelihood of ipsilateral medial tibiofemoral osteoarthritis (OA) progression., Methods: Fifty-seven persons with knee OA (by definite osteophyte presence and symptoms) were evaluated. Baseline assessments included kinematic and kinetic gait parameters, obtained with an optoelectronic camera system and force platform, with inverse dynamics used to calculate 3-dimensional moments at the joints; pain, using a separate visual analog scale for each knee; and alignment, using full-limb radiographs. Radiographs of the knee in a semiflexed position, with fluoroscopic confirmation of tibial rim alignment, were obtained at baseline and 18 months later. Disease progression was defined as worsening of the grade of medial joint space narrowing. Logistic regression obtained with generalized estimating equations was used to estimate odds ratios (ORs) for progression per unit of hip abduction moment, after excluding knees with the worst joint space grade at baseline (which could not progress)., Results: The 57 participants (63% women) with mild to moderate OA had a mean age of 67 years and a mean body mass index of 29. A greater internal hip abduction moment during gait was associated with a reduced likelihood of medial tibiofemoral OA progression, with OR/unit hip abduction moment of 0.52 and a 95% confidence interval (95% CI) of 0.32-0.85. This protective effect persisted after adjustment for age, sex, walking speed, knee pain severity, physical activity, varus malalignment severity, hip OA presence, and hip OA symptom presence, with an adjusted OR of 0.43 a 95% CI of 0.22-0.81., Conclusion: A greater hip abduction moment during gait at baseline protected against ipsilateral medial OA progression from baseline to 18 months. The likelihood of medial tibiofemoral OA progression was reduced 50% per 1 unit of hip abduction moment.

Purpose: The T cell repertoire in patients with advanced cutaneous T cell lymphoma (CTCL) is significantly contracted despite the presence of relatively normal absolute numbers of T cells. We propose that many normal T cells were being lost in patients with CTCL, with the remaining normal T cells expanding clonally to fill the T cell compartment. T-cell receptor excision circles (TREC) form as a result of the initial gene rearrangement in naïve T cells. Although they are stable, they do not replicate and are subsequently diluted with the expansion of a population of T cells. Their concentration is therefore a measure of unexpanded naïve T cells relative to T cells that have undergone expansion., Experimental Design: We analyzed TRECs from unfractionated peripheral blood T cells from 108 CTCL patients by quantitative PCR. In patients with obvious peripheral blood involvement, we also analyzed TRECs from clonal and nonclonal T cells., Results: We found a decrease in the number of TRECs in peripheral blood of patients with CTCL at all stages of disease, and this decrease was proportional to the loss of complexity of the T cell repertoire as measured by complementarity-determining region 3 spectratyping. In patients with leukemic CTCL and a numerically expanded clone, we also found a significantly lower-than-expected number of TRECs in the nonclonal normal T cells., Conclusions: We hypothesize that the nonmalignant T cells have proliferated to fill the empty T cell repertoire space left by the loss of other T cells, leading to diminished TRECs and loss of T-cell receptor diversity.

Using MEDLINE and other Internet sources, the authors perform a systematic review of published literature. A total of 109 articles and reports are identified and reviewed that address the development, implementation, outcomes, and trends related to Managed behavioral health care (MBHC). MBHC remains a work in progress. States have implemented their MBHC programs in a number of ways, making interstate comparisons challenging. While managed behavioral health care can lower costs and increase access, ongoing concerns about MBHC include potential incentives to under-treat those with more severe conditions due to the nature of risk-based contracting, the tendency to focus on acute care, difficulties assuring quality and outcomes consistently across regions, and a potential cost-shift to other public agencies or systems. Success factors for MBHC programs appear to include stakeholder involvement in program and policy development, effective contract development and management, and rate adequacy.

Objective: To determine whether the presence of varus thrust at baseline increases the risk of progression of medial tibiofemoral osteoarthritis (OA), whether knees with thrust have a greater adduction moment, whether thrust has any additional impact on top of static varus, and whether thrust is associated with poor physical function outcome., Methods: Two hundred thirty-seven patients with knee OA (definite osteophytes and symptoms) underwent baseline gait observation to assess varus thrust and full-limb radiography to assess alignment. Sixty-four of these 237 patients also underwent quantitative gait analysis to determine the maximum knee adduction moment. Two hundred thirty patients (97%) returned for followup at 18 months. At baseline and 18 months, the 230 participants had semiflexed, fluoroscopically confirmed knee radiographs (with progression defined as worsening of medial joint space grade); self-reported and performance-based measures of function were also assessed. Logistic regression with generalized estimating equations was used to estimate odds ratios (ORs) for medial OA progression, after excluding knees that were not at risk for progression., Results: Varus thrust was present in 67 of 401 knees. Thrust increased 4-fold (age-, sex-, body mass index-, and pain-adjusted OR 3.96, 95% confidence interval [95% CI] 2.11-7.43) the odds of medial progression, with some reduction after further adjustment for varus alignment severity. In varus-aligned knees, thrust increased the odds of OA progression 3-fold (adjusted OR 3.17, 95% CI 1.60-6.31). In the gait substudy, the adduction moment was greater in knees with a thrust compared with knees without a thrust. Having a thrust in both knees versus neither knee was associated with a 2-fold increase in the OR for poor physical function outcome (P not significant)., Conclusion: Varus thrust is a potent risk factor, identifiable by simple gait observation, for disease progression in the medial compartment, the most common site of OA involvement at the knee. Varus thrust may also predict poor physical function outcome. Varus thrust increased the odds of progression among varus-aligned knees considered separately, suggesting that knees with a thrust are a subset of varus-aligned knees at particularly high risk for progression of OA.

Aging of T cells is characterized by a series of alterations in surface antigen expression and a concomitant decline in functional activity in many assays. We have extended this analysis by comparing the ability of T cells from mice of different ages to cause graft-versus-host disease (GVHD) by using a parent into F(1) model (C57BL/6 T cells into C57BL/6 x C3H host animals). Young (3-5 months), adult (12-14 months), or old (19-24 months) T cells were introduced into irradiated F(1) hosts. Animals that had undergone transplantation were assessed for clinical and pathologic evidence of GVHD and for survival. At a given T-cell dose (2 x 10(6) cells), there was a T-cell (donor) age-dependent decline in severity of GVHD, with all recipients of young T cells succumbing to lethal GVHD, 75% of recipients of adult T cells succumbing, and no deaths occurring among recipients of old T cells. In vivo CD4 T-cell expansion was greater for young than old T-cell groups after transplantation, whereas old CD8 cells showed enhanced in vivo expansion compared with young cells. Among CD4 and CD8 cells, the T-cell receptor repertoire, surface antigen expression on activated cells, and homing receptor function were similar for all ages after expansion in vivo. The progeny of old T cells reisolated after transplantation expressed type 1 cytokines (interferon-gamma and tumor necrosis factor-alpha) at a lower frequency than young cells and had decreased cytolytic function against H-2(k)-bearing target cells. This provides a partial explanation for the decreased GVHD. Carboxyfluorescein diacetate succinimidyl ester labeling of transplanted cells showed comparable rates of proliferation when comparing GVHD-competent (12 months) and GVHD-incompetent (19 months) T cells in both syngeneic and F(1) host animals. We suggest that the lack of effector activity demonstrated by old T cells in vivo is a reflection of a cell-autonomous defect downstream of signals required for antigen-driven proliferation.

Objective: Mice deficient in apolipoprotein-E (apoE-/-) experience severe hypercholesterolemia that is exacerbated by a high-fat Western-type diet and atherosclerotic lesions spontaneously develop. In addition, we have reported that deficiency of P-selectin dramatically protects against neointimal lesion formation after arterial injury in apoE-/- mice. To define the mechanism, bone marrow transplantation (BMT) after lethal irradiation was used to generate apoE-/- chimeric mice deficient in platelet, but not endothelial, P-selectin., Methods and Results: Mice underwent vascular injury and were euthanized 4 weeks later. Absence of platelet P-selectin (pPS) expression in apoE-/- mice after BMT was confirmed by flow cytometry and Western blot analysis. Lack of pPS in apoE-/- mice resulted in a 62% reduction in neointimal area (45 000+/-27 000 versus 17 000+/-13 000 microm2, P<0.000001) and a 30% reduction (P<0.02) in macrophage infiltration, compared with control apoE-/- BMT. Absence of pPS was also associated with a reduction in plaque neovascularization as compared with pPS-competent controls (0/8 versus 3/8, P<0.05)., Conclusions: Lack of pPS significantly attenuates macrophage recruitment and neointimal lesion formation, indicating that pPS on platelets lining the vessel wall plays a critical role in inflammation after wire-withdrawal injury of the carotid artery in apoE-/- mice.

Objective: This study tests the hypothesis that the peak external knee adduction moment during gait is increased in a group of ambulatory subjects with knee osteoarthritis (OA) of varying radiographic severity who are being managed with medical therapy. Tibiofemoral knee OA more commonly affects the medial compartment. The external knee adduction moment can be used to assess the load distribution between the medial and lateral compartments of the knee joint. Additionally, this study tests if changes in the knee angles, such as a reduced midstance knee flexion angle, or reduced sagittal plane moments previously identified by others as load reducing mechanisms are present in this OA group., Design: Thirty-one subjects with radiographic evidence of knee OA and medial compartment cartilage damage were gait tested after a 2-week drug washout period. Thirty-one normal subjects (asymptomatic control subjects) with a comparable age, weight and height distribution were also tested. Significant differences in the sagittal plane knee motion and peak external moments between the normal and knee OA groups were identified using t tests., Results: Subjects with knee OA walked with a greater than normal peak external knee adduction moment (P=0.003). The midstance knee flexion angle was not significantly different between the two groups (P=0.625) nor were the peak flexion and extension moments (P> 0.037)., Conclusions: Load reducing mechanisms, such as a decreased midstance knee flexion angle, identified by others in subjects with endstage knee OA or reduced external flexion or extension moments were not present in this group of subjects with knee OA who were being managed by conservative treatment. The finding of a significantly greater than normal external knee adduction moment in the knee OA group lends support to the hypothesis that an increased knee adduction moment during gait is associated with knee OA., (Copyright 2002 OsteoArthritis Research Society International. Published by Elsevier Science Ltd. All rights reserved.)

Increased joint loading and elevated bone density may be involved in the initiation or progression of osteoarthritis. Here, we provide an introduction to the literature on this topic and describe recent studies from our laboratories on several cohorts of subjects who had or were scheduled to have a total hip replacement for unilateral end-stage osteoarthritis. This population is very useful for studying the development and progression of osteoarthritis because of the known higher incidence of osteoarthritis in the contralateral hip than in a normal population. Separate studies of the asymptomatic contralateral hip in these subjects have shown that radiographic signs of early osteoarthritis are associated with increased bone mineral density and some of the gait adaptations typically found in subjects with end-stage osteoarthritis. We have also shown in separate studies of similar populations that elevated bone mineral density is associated with a subsequent accelerated joint space narrowing rate and that elevated hip joint loads during gait are similarly associated with an accelerated narrowing rate. Major questions yet to be answered are how joint loading and bone density interact in the development and progression of joint degeneration., (Copyright 2001 S. Karger AG, Basel.)

The purpose of this study was to dynamically assess the functional outcome of patients who had undergone successful anterior cruciate ligament reconstruction using an autologous patellar tendon technique and to determine whether their dynamic knee function was related to quadriceps and hamstring muscle strength. The knee kinematics and kinetics of 22 subjects who had undergone anterior cruciate ligament reconstruction (mean age, 27 +/- 11 years) and of 22 age- and sex-matched healthy control subjects were determined during various dynamic activities using a computerized motion analysis and force plate system. The differences in the sagittal plane angles and external moments between the two groups during light (walking), moderate (climbing and descending stairs), and higher-demand (jogging, jog and cut, jog and stop) activities were related to isokinetic strength measurements. Although patients who are asymptomatic and functioning well after anterior cruciate ligament reconstruction can perform normally in light activities, higher-demand activities reveal persistent functional adaptations that require further study.

Category fluency tasks are an important component of neuropsychological assessment, especially when evaluating for dementia syndromes. The growth in the number of Spanish-speaking elderly in the United States has increased the need for appropriate neuropsychological measures and normative data for this population. This study provides norms for English and Spanish speakers, over the age of 50, on 3 frequently used measures of category fluency: animals, vegetables, and fruits. In addition, it examines the impact of age, education, gender, language, and depressed mood on total fluency scores and on scores on each of these fluency measures. A sample of 702 cognitively intact elderly, 424 English speakers, and 278 Spanish speakers, participated in the study. Normative data are provided stratified by language, age, education, and gender. Results evidence that regardless of the primary language of the examinee, age, education, and gender are the strongest predictors of total category fluency scores, with gender being the best predictor of performance after adjusting for age and education. English and Spanish speakers obtained similar scores on animal and fruit fluency, but English speakers generated more vegetable exemplars than Spanish speakers. Results also indicate that different fluency measures are affected by various factors to different degrees.

Purpose of the Study: This prospective study was conducted to analyze the mechanisms of gait compensation in patients with painful hip and to search for correlations with preoperative clinical and radiographic findings., Material and Methods: Optoelectronic and multicomponent force-plate datas were used to calculate joint motion, moments and intersegmental forces for 26 patients with unilateral hip pain and 20 normal age and sex-matched patients. Height was similar in the two groups but mean weight in the study group (83 kg) was greater than in the controls (68 kg). The preoperative Harris score was 53 in the study group and 16 patients had a permanent flexion contracture of the knee (mean 15 degrees, range 5-30 degrees). Radiographically, there were 22 cases of osteo-arthritis hip disease and 4 cases of necrosis., Results: Gait analysis showed a significant 0.66 +/- 0.06 m (12 p. 100) reduction in step length. Patients who had severe hip pain walked with a decreased dynamic range of motion (18 +/- 5 degrees, p<0.0001) with a curve reversal as they extended the hip. They also reduced dynamic range of motion of the knee and ankle. Patients who presented a reversal in their dynamic hip range of motion had a greater passive flexion contracture and a greater loss in range of motion during gait than those with a smooth regular pattern (p<0.0001). Patients with hip pain walked with significantly decreased external extension, adduction, and internal and external rotation moments (p<0.0001). They also unloaded the ipsilateral knee and ankle. The decreased hip extension moment was significantly correlated with an increased level of pain (p<0.0001). There was no correlation with radiological findings., Discussion: Reversal of dynamic hip range of motion was interpreted as a mechanism to increase effective hip extension during stance phase through increased anterior pelvic tilt and lumbar lordosis., Conclusion: Patients with painful hip walked with a manner that was asymmetric. These gait modifications were related to hip limitation in passive motion and pain. Patients with flexion contracture adopted a compensatory gait mechanism. This study confirms relation between hip pain and forces across the hip joint.

This article discusses methods for evaluating the progression of osteoarthritis through dynamic functional imaging as opposed to current static techniques. Comparison is made between static and dynamic methods of evaluating knee alignment. The correlation between dynamic knee moments during gait and bone mineral content is discussed. Knee loading is considered in terms of high tibial osteotomy, knee braces, pain, and non-steroidal anti-inflammatory drugs. New image-processing techniques for quantitating cartilage loss are described, and computational methods for generating true three-dimensional (3-D) maps of cartilage thickness are developed. Finally, new approaches to cross-correlate magnetic resonance images with kinematic measurements are described. These new techniques promise to become powerful diagnostic tools to detect and characterize pathological load distributions across articular cartilage.

Objective: To determine whether patients with a rapid rate of joint space narrowing (JSN) in the hip have higher initial bone mineral density (BMD) in the proximal femur and/or lumbar spine than corresponding patients with a slow rate of JSN., Methods: Twenty-eight patients undergoing unilateral total hip replacement (THR) for osteoarthritis (OA), but whose contralateral hips were asymptomatic and had minimal or no radiographic OA, were evaluated. The contralateral proximal femur (i.e., non-operated hip) and lumbar spine were scanned by dual energy x-ray absorptiometry at baseline (prior to THR) and at 2 years. The rate of JSN was determined by serial longitudinal quantification of the joint spaces over the 2 year period following THR from conventional radiographs, and the patients were divided into a group with a slow rate of JSN (< or = 0.2 mm/yr, n = 20) and a group with a rapid rate of JSN (> 0.2 mm/yr, n = 8)., Results: The baseline BMD z and t scores at the femoral neck, Ward's triangle, and lumbar spine of the patients with subsequent rapid rates of JSN were significantly higher than those of patients with slower rates (p < 0.05). There was no difference between the rapid and slow narrowers at the greater trochanter (p > 0.2). Age, sex, weight, height, body mass index, Kellgren- Lawrence scores, and initial joint space width were not significantly different between the 2 groups., Conclusion: Patients with a rapid rate of JSN of the asymptomatic hip after unilateral THR are characterized by elevated local and remote BMD. The local elevation in BMD implies that increased local bone density may contribute to or serve as a marker for increased risk of development of OA (assuming that JSN can be used as a predictive marker). The presence of elevated BMD in the spine suggests that there are systemic as well as local aspects of OA pathogenesis, at least in patients with one THR and rapid JSN in the contralateral hip.

Objective: This objective of this study was to determine the effect of presurgical nasoalveolar molding on long-term nasal shape in complete unilateral clefts., Design: The study was retrospective, and the subjects were chosen at random. Nasal casts of the subjects were scanned in three dimensions. Each nose was best fit to its mirror image, and a numerical asymmetry score was determined., Setting: All patients were treated at the Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, New York., Patients: The study subjects (n = 10) were selected from a group that had undergone presurgical nasal molding in conjunction with alveolar molding. The control subjects (n = 10) were selected from a group that had undergone presurgical alveolar molding alone., Interventions: All subjects underwent presurgical orthopedic treatment until the age of approximately 4 months at which time the primary surgery was performed., Main Outcome Measure: The nasal shape following nasal molding should be more symmetrical than if molding had not been done., Results: The mean asymmetry index for the nasoalveolar molding group was 0.74, and the control group was 1.21. This difference was statistically significant (p < .05)., Conclusions: Presurgical nasoalveolar molding significantly increases the symmetry of the nose. The increase in symmetry is maintained long term into early childhood. The limitations of this study include (1) asymmetry alone is not an adequate shape result in most situations, (2) the children evaluated in this study were not fully grown, and (3) the control group was not age matched.

Anthropometry and clinical examination best evaluate the morphology of repaired cleft lip and nose. An original, accurate, and practical image analysis of the lip and nose, which takes advantage of the mathematic, geometric, and organizational capabilities of public domain NIH-Image software (http://rsb.info.nih.gov/nih-image/), has been developed and tested over the past 6 years. A modified structured physical examination form that complements this analysis is under study. Accuracy of NIH-Image-based anthropometry was compared with direct measurements of 22 linear distances on the lip and nose. Twenty-five sets of direct measurements were taken, prospectively, on 15 children with repaired cleft lip over a 6-year period. The results were submitted to regression analysis. Then, relevant lip and nasal tip aesthetics were evaluated by the measuring capabilities of NIH-Image to create a quantitative assessment tool. For each episode, 15 possible faults were weighted, according to aesthetics and deformity, to provide an adverse score. The sum of the 5 lip scores, 10 nose scores, and combination gave respective grades. The analysis was modified to stratify congenital deformity to relate severity of disease to outcome. This analysis was applied to digitized images of 19 consecutive children, immediately prior to repair of complete unilateral cleft lip and nose, at the time of palate repair, and annually from the age of 3 to 6 years. There were 19 NIH-Image-based measurements of the congenital deformity and 35 measurements of surgical results; four children had three sets of records, eight had two sets, and seven had one set Descriptive statistics were applied. Following 556 paired direct and computer-assisted measurements, exceptional linear correlation was shown with a Pearson R coefficient of 0.96. The best correlation was lines within the plane of the camera lens, with the average difference ranging between 0.025 and 0.997 mm. Visual inspection of frontal and submental photographs of excellent, good, and poor results substantiates the ability of this analysis to quantify and grade a spectrum of relevant cleft lip and nasal anatomy. For these 19 patients, there was a broad range of performance scores, approximating a normal distribution. The mean of the NIH-Image-based analysis scores, 16.91, was a (very) good grade. A single standard deviation of 6.88 extended up into excellent and down to fair. The congenital analysis indicated a range of deformity. Comparing deformity with outcome, simple regression analysis had a coefficient of determination (R2) of 0.223, indicative of a weak positive relationship. An accurate and practical morphologic computer-assisted outcome assessment of repaired cleft lip and nasal deformity has been developed. There is a weak direct correlation between severity of deformity and outcome. Testing in multiple clinics is warranted.

To evaluate the potential of the ex vivo bone marrow stromal cell (BMSC) system as a gene therapy for hemophilia A, we studied the in vitro expression of human factor VIII (hFVIII) in canine BMSCs following transfection with plasmid vectors and transduction with retroviral vectors. Vectors were composed of B domain-deleted forms of hFVIII that either retain or delete the proteolytic site at amino acid 1648. On transfection of BMSCs, vectors supported expression and secretion of similar levels of up to 386 mU/10(6) cells/24 hr, even though only 3-9% of the cells expressed hFVIII while 42-48% of transfected cells harbored plasmid vector. Much higher percentages (approximately 70%) of cells expressing hFVIII were achieved when BMSCs were transduced by retroviral vectors, resulting in expression and secretion as high as 1000-4000 mU/10(6) cells/24 hr. Western analysis demonstrated that the B domain-deleted forms possessing the proteolytic site were secreted predominantly as heavy and light chain heterodimers that resemble native forms found in plasma. In contrast, the hFVIII lacking the proteolytic site was expressed mostly as unprocessed, single heavy-light chains. Both hFVIII forms were correctly cleaved and activated by thrombin. The proteolyzed hFVIII form possessed > or = 93% normal biological activity while the unproteolyzed form possessed consistently less than 55% normal biological activity and was therefore considered less suitable for therapeutic application. These results demonstrate that the BMSC system has potential utility in gene therapy for hemophilia A and stress the importance of selecting the appropriate hFVIII structure for prospective clinical use.

Midfacial hypoplasia following primary cleft lip repair is a common clinical correlate. Recent experimental work has suggested that increased lip pressure following an undermined lip repair may contribute to midfacial growth inhibition. Soft-tissue expansion has been used to generate additional soft tissue for reconstruction in the cranial region. The use of this technique in the labial region may allow lip repair to be performed with less tension (pressure) and thus facilitate midfacial growth. To test this hypothesis, 40 4-week-old rabbits were randomly divided into four groups. Two groups had surgically created lip and alveolar defects. Ipsilateral labial tissue expanders were placed in all four groups. One cleft and one normal group underwent expansion. The other two groups served as a control. The expanders were removed at 4 weeks, and an undermined lip repair was performed in both cleft groups. Findings revealed that soft-tissue expansion increased labial surface area significantly by approximately 96% (p < 0.001). Labial soft-tissue expansion alone had no effect on midfacial growth during the observation period. In contrast, cleft animals undergoing tissue expansion exhibited significantly reduced (p < 0.05) postoperative lip pressure and increased midfacial growth compared with cleft animals without expansion through 36 weeks of age. Results suggest that preoperative tissue expansion reduced postoperative lip pressure and improved midfacial growth in a rabbit cleft lip model.

Canine bone marrow stromal cells (BMSCs), transduced ex vivo with retroviral vectors, expressed and secreted biologically active human and canine coagulation factor IX (hFIX and cFIX) in vitro, and on autologous reinfusion expressed hFIX into the circulation of normal (nonhemophiliac) dogs. Human FIX, when expressed in vitro by BMSCs of two dogs at 1.22 and 1.39 microg/10(6) cells/24 hr in medium supplemented with vitamin K, respectively, exhibited 28.1 and 27.3% normal biological activity as determined on the basis of a one-stage clotting assay. BMSCs of two additional dogs expressed 1.54 and 4.81 microg of cFIX/10(6) cells/24 hr in vitamin K-supplemented medium and the expressed cFIX possessed 58.4 and 32.9% normal activity, respectively. Between 2.33 and 3.35 x 10(8) transduced BMSCs, expressing 1.22 and 2.61 microg of hFIX/10(6) cells/24 hr or 3.24 and 7.82 microg of cFIX/10(6) cells/24 hr were reintroduced into the four donor dogs by intravenous infusion. Human FIX was detected in plasma for 7 or 12 days after BMSC reinfusion, with peak levels of 85.8 and 233.0 ng/ml observed at 2 days. Canine anti-hFIX antibodies, which were detected as early as 2-4 days after reinfusion of BMSCs expressing hFIX, may have masked potentially longer duration expression in vivo. Peak plasma levels of hFIX represented 2.1 and 5.8% normal human hFIX levels. When adjusted for percent normal one-stage clotting activity determined in vitro, these levels represented 0.6 and 1.6% normal human hFIX activity levels. Thus, we have demonstrated that retroviral vector-modified BMSCs can deliver human therapeutic levels of hFIX to the circulation of dogs.

Objective: The adduction moment at the knee during gait is the primary determinant of medial-to-lateral load distribution. If the adduction moment contributes to progression of osteoarthritis (OA), then patients with advanced medial tibiofemoral OA should have higher adduction moments. The present study was undertaken to investigate the hypothesis that the adduction moment normalized for weight and height is associated with medial tibiofemoral OA disease severity after controlling for age, sex, and pain level, and to examine the correlation of serum hyaluronan (HA) level with disease severity and with the adduction moment in a subset of patients., Methods: Fifty-four patients with medial tibiofemoral OA underwent gait analysis and radiographic evaluation. Disease severity was assessed using the Kellgren-Lawrence (K-L) grade and medial joint space width. In a subset of 23 patients with available sera, HA was quantified by sandwich enzyme-linked immunosorbent assay. Pearson correlations, a random effects model, and multivariate regression models were used., Results: The adduction moment correlated with the K-L grade in the left and right knees (r = 0.68 and r = 0.60, respectively), and with joint space width in the left and right knees (r = -0.45 and r = -0.47, respectively). The relationship persisted after controlling for age, sex, and severity of pain. The partial correlation between K-L grade and adduction moment was 0.71 in the left knees and 0.61 in the right knees. For every 1.0-unit increase in adduction moment, there was a 0.63-mm decrease in joint space width. In the subset of patients in whom serum HA levels were measured, HA levels correlated with medial joint space width (r = -0.55), but not with the adduction moment., Conclusion: There is a significant relationship between the adduction moment and OA disease severity. Serum HA levels correlate with joint space width but not with the adduction moment. Longitudinal studies will be necessary to determine the contribution of the adduction moment, and its contribution in conjunction with metabolic markers, to progression of medial tibiofemoral OA.

Functional adaptations in knee kinematics and kinetics during level walking in 30 patients with unilateral anterior cruciate ligament deficiency and 30 healthy control subjects were studied. To examine the impact of time after injury on the functional adaptations, patients were placed into three time interval groups: early, intermediate, and chronic. The patients with anterior cruciate ligament deficiency had significantly decreased external knee flexion moments (balanced by net quadriceps contraction) and significantly increased external knee extension moments (balanced by net knee flexors contraction) as compared with the control subjects. As time after the injury increased, changes in the sagittal plane knee moments were more pronounced. A significant linear relationship (positive correlation) was found between the midstance knee flexion moment and the corresponding knee flexion angle. The patients with anterior cruciate deficiency had a greater knee flexion angle when generating a comparable midstance knee flexion moment as compared to the control subjects. The identification of gait adaptations over time provides additional information on the natural history of anterior cruciate ligament deficiency and may have implications regarding conservative rehabilitation, evaluation of outcomes, progression of meniscal injury, and the development of degenerative arthritis of the knee.

The ex vivo establishment, expansion, transduction, and reintroduction of autologous bone marrow stromal cells offers a potential efficacious system for somatic cell gene therapy. It is likely that any ex vivo system will require the use of large numbers of cells which express high levels of transgene products. We present a method for routine expansion of canine bone marrow stromal cells, established from initial 10-20 ml marrow aspirates, to greater than 10(9) cells. This high level expansion of cell cultures uses the stimulatory effect of acidic fibroblast growth factor (aFGF) and heparin. In the absence of these factors, stromal cell cultures grow actively for only 1 to 2 passages, become flattened in morphology, and expand to only 10(8) cells. In the presence of heparin (5 U/ml), aFGF exerts its effect over a wide range of concentrations (0.1-10 ng/ml) in a dose-dependent manner. The stimulatory effect is dependent on the presence of both aFGF and heparin. Immunocytochemical and cytochemical analyses phenotypically characterize these stromal cells as bone marrow stromal myofibroblasts. Stromal cells grown in the presence of aFGF and heparin grow actively and maintain a fibroblast-like morphology for a number of passages, transduce efficiently with a human growth hormone (hGH) expression vector, and express and secrete high levels of hGH. Human marrow stromal cells were also established and expanded by the same culture method. This culture method should be of great value in somatic cell gene therapy for the delivery of secreted gene products to the plasma of large mammals.

Canine bone marrow stromal cells were expanded to numbers in excess of 10(9) cells from the initial 10-20 ml of marrow aspirates and transfected to express high levels of human growth hormone (hGH) in vitro. Ex vivo-modified marrow stromal cells were used in a gene therapy model system for the systemic delivery of transgene products in dogs. Adherent bone marrow stromal cell cultures, established and expanded from iliac crest marrow aspirates from each of 8 dogs, were transfected with a hGH gene plasmid expression vector and shown to express from 0.54-3.84 micrograms/10(6) cells per 24 hr hGH in vitro. The transfected plasmid vector does not possess a eukaryotic origin of replication nor does it possess sequences required for efficient integration into the host cell genome. As such, expression was expected to be transient. Transfected cells were autologously reintroduced into each dog by either infusion into a foreleg vein or directly into iliac crest marrow. In two cases, the stromal cells were cryopreserved following transfection, and subsequently thawed and infused. In one case, the expanded stromal cells were first cryopreserved, and then thawed, recultured, transfected, and infused. Reintroduced cell numbers ranged from 2.2 x 10(7) to 2.6 x 10(9), with total hGH expression capacities ranging from 62 to 1,400 micrograms/24 hr. Plasma of each of the dogs contained detectable hGH for a mean of 3.1 days (SD +/- 0.8 day) ranging from 2 to 5 days following reinfusion of cells. Peak plasma levels ranged from 0.10 to 1.76 ng/ml. Similar hGH expression values, based upon total expression capacity of the cells infused and dog body weight, were obtained for all dogs. Vector-modified stromal cells were detectable, by polymerase chain reaction (PCR) analysis, in the peripheral circulation following reinfusion in all 4 dogs analyzed. In 3 of the dogs, modified stromal cells were detected for 8.5-15 weeks. In addition, modified stromal cells were detected in iliac crest marrow of 2 dogs for 9 and 13 weeks, respectively, following reinfusion. In another experiment, cultured bone marrow stromal cells were transfected with a human factor IX (hFIX) plasmid vector. Modified cells (5.57 x 10(8)), with a total hFIX expression capacity of 281 micrograms/24 hr, were reinfused, resulting in detectable hFIX in plasma continuously for 9 days with a peak level of 8 ng/ml on day 1. These results demonstrate that the ex vivo bone marrow stromal cell system is a potentially powerful method by which to deliver secreted transgene product to the systemic circulation of large animals.

The effect of co-integration of the entire beta-lactoglobulin (BLG) gene or matrix attachment region (MAR) sequences on the expression of various BLG/ human serum albumin (HSA) gene constructs was tested in transgenic mice. These former sequences were chosen because of their reported ability to insulate transgenes from the neighboring host genomic DNA sequences and/or to provide a more permissive transcriptional environment. When introduced alone, a cDNA-based BLG/HSA construct was expressed in 60% of transgenic strains and HSA was secreted at levels up to 0.3 mg/ml into the milk. Upon co-integration with either the entire BLG gene or MAR element, HSA RNA and protein expression were completely abrogated. While the co-integrated BLG gene suppressed the proportion of expresser strains carrying cDNA as well as genomic BLG/HSA constructs, the MAR element only exerted its negative effect on the cDNA-based BLG/HSA construct. In transgenics expressing both HSA and BLG, the tissue specificity and developmental patterns of BLG expression were altered and resembled the less stringent pattern of the BLG/HSA expression. These results demonstrate that rescue of transgene expression through co-integration with BLG or MAR sequences do not apply universally.

The management of infants with bilateral coronal synostosis and resultant brachyturricephaly poses a significant therapeutic challenge. The application of total calvarial reconstruction to the treatment of this problem has represented a major recent innovation that has substantially improved the cosmetic results in this patient population. However, rigid fixation of the reconstructed calvaria is often required to maintain the correction achieved and to provide protection for the underlying brain. The requirement of extensive fixation constitutes a significant disadvantage for the use of this procedure in infants and young children. In this report, the authors describe an approach to the treatment of this problem that incorporates a series of tongue-in-groove osteotomies to provide increased stability to advancements of both the frontal and occipital regions in conjunction with cranial height reduction, while minimizing the need for metallic fixation. With this approach, the reconstructed skull is sturdy enough to resist the compressive force applied by the weight of the child's head immediately after surgery, but retains the ability to expand progressively. The authors have found the cosmetic results to be extremely gratifying. In this article they present their experience with this technique in seven children.

Two new beta-lactoglobulin (BLG)/human serum albumin (HSA) hybrid gene vectors were constructed and tested for expression in COS-7 cells and in transgenic mice. The HSA sequences were inserted between the second and sixth BLG exons. Transient transfection experiments with these vectors as well as a series of additional vectors with either the BLG 5'- or 3'- intragenic sequences revealed that sequences within BLG exon 1/intron 1/exon 2 abrogated BLG- directed HSA expression in vitro, regardless of the presence of HSA introns or the origin of the 3' polyadenylation signal. In contrast, the same BLG expression cassette enabled the efficient expression of HSA cDNA or minigene in the mammary gland of transgenic mice with subsequent secretion of the corresponding protein into the milk of 56 and 82%, respectively of the mouse strains at levels up to 0.3 mg/ml. Previous attempts to express HSA cDNA inserted into exon 1 of the BLG gene had failed [Shani,M., Barash,I., Nathan,M., Ricca,G., Searfoss,G.H., Dekel,I., Faerman,A., Givol,D. and Hurwitz,D.R. (1992) Transgenic Res. 1, 195- 208]. The new BLG expression cassette conferred more stringent tissue specific expression than previously described BLG/HSA constructs [Barash,I, Faerman,A., Ratovitsky,T, Puzis,R., Nathan,M., Hurwitz,D.R. and Shani, M. (1994) Transgenic Res. 3, 141-151]. However, it was not able to insulate the transgenes from the surrounding host DNA sequences and did not result in copy number dependent expression in transgenics. Together, the in vitro and in vivo results suggest both positive and negative regulatory elements within the BLG intragenic sequences evaluated. The new BLG construct represents an extremely valuable vector for the efficient expression of cDNAs in the mammary gland of transgenic animals.

The Sure-Closure device, designed for wound closure, harnesses the viscoelastic properties of the skin. It has been used in clinical studies in the past. We have evaluated the role of this device in complex wound problems and compared it to closure achieved by conventional wound closure methods such as skin grafts and flaps. A total of 40 patients with multiple wound etiologies were examined. We used the device under local and general anesthesia. In addition, we performed cost analysis on the use of the device and compared this to traditional methods. We found a cost reduction trend associated with the Sure-Closure method (p < .05). All of the 24 patients in whom the device was used to close the wounds had complete primary closure. The device is also easy to use. When used for delayed stretching, as in some of our patients, the compliance rate was high.

Forty years after its introduction by McNeil and Burston, presurgical orthopedics remains a controversial subject. Although the more extravagant claims for the technique have been dismissed, assessment of its proper place in cleft rehabilitation has been hampered by the poor design of early studies. Furthermore, although the principles of presurgical orthopedics are derived from the venerable tradition of reducing cleft width to facilitate reconstructive surgery, almost all research has focused on matters of dental alignment, cross bites, and maxillary arch form. Not one research paper has ever been published investigating the possible benefits to cleft surgery resulting from presurgical orthopedic treatment. Although it is now generally accepted that presurgical orthopedics does not give significant orthodontic benefits, there are still numerous opinions indicating that presurgical orthopedics does facilitate primary reconstructive surgery for cleft lip and palate. Furthermore, presurgical alignment of the maxillary skeletal base is considered essential to some of the new techniques of primary rhinoplasty.

We compared the developmental pattern of expression of the sheep beta-lactoglobulin (BLG), the chimeric BLG/human serum albumin (HSA), and the endogenous murine beta-casein genes in the mammary gland of virgin, pregnant and lactating transgenic mice, both at the RNA (expression) and protein (synthesis and secretion) levels. The BLG and casein genes were expressed at very low levels in virgin animals and during early stages of pregnancy. The increase in the expression of these genes started at the second half of pregnancy and reached a peak between the end of pregnancy and day 10 of lactation. The accumulation of their RNA coincided with that of the corresponding proteins, indicating a transcriptional control of expression of these genes. The expression and secretion patterns of the endogenous casein gene in transgenic and nontransgenic mice were indistinguishable. The hybrid BLG/HSA gene constructs displayed distinct patterns of expression in virgin animals and at early stage of pregnancy, from that of the BLG transgene or the endogenous mouse milk protein gene. High levels of expression (17-60% of that on day 18 of pregnancy) were detected in the mammary gland of virgin animals. At day 5 of pregnancy there was a dramatic decrease in HSA synthesis and secretion in all transgenic strains tested. The down-regulation, revealed by immunoprecipitation and immunohistochemical studies, demonstrated that at that stage of pregnancy only 10-18% of ductal structures contained HSA expressing cells in contrast to the majority of ducts expressing HSA in virgin animals. These morphological studies also demonstrated that the down-regulation in HSA synthesis and secretion was correlated with the transition from ducts comprised of a single layer of epithelial cells (characteristic of the virgin state) to ducts composed of multilayers of such cells. In two of the three transgenic strains tested, the down-regulation at the protein level was associated with a similar decrease in HSA transcripts. In the exceptional strain no. 23, HSA transcripts continued accumulating even at this stage. The differences in the control of expression at the RNA level between these transgenic strains were also confirmed by in situ hybridization. Our results suggest the involvement of at least two regulatory mechanisms effective at early stages of gestation in the control of expression/secretion of the HSA transgene targeted for expression in the mammary gland by the BLG milk protein promoter. These putative mechanisms may play key roles in the interplay between normal mammogenesis and lactogenesis.(ABSTRACT TRUNCATED AT 400 WORDS)

A new series of expression vectors, each comprised of the beta-lactoglobulin (BLG) promoter driving one of a variety of human serum albumin (HSA) minigenes or the entire gene, were evaluated for their ability to direct expression of HSA in vitro in COS tissue culture cells and into the milk of transgenic mice. Vectors directed a hierarchy of expression levels in vitro, dependent upon the specific complement of HSA introns included. HSA introns acted in a synergistic manner. In addition, minigenes comprised of specific subsets of introns were more efficacious than the entire HSA gene with all of its introns. Transgenic mice expressed as much as 10 mg ml-1 of HSA in their milk. Vectors comprised of specific intron subsets directed levels at 1 mg ml-1 or greater in the milk of 20% of generated transgenics. A statistical correlation between the expression level trend in vitro with the trend of expression in vivo (% which express) at detectable levels (p = 0.0015) and at the level of greater than 0.1 mg ml-1 (p = 0.0156) was demonstrated. A weak correlation existed (p = 0.0526) at in vivo levels of 1 mg ml-1 or greater. These new vectors are expected to direct the production of high levels of HSA in the milk of a large percentage of generated transgenic dairy animals.

Use of a three-dimensional CT scan as an adjunct for planning chest-wall and breast reconstruction in Poland's syndrome is presented with follow-up MRI with three-dimensional reformation to demonstrate the results of the implant reconstruction. The imaging techniques are capable of accurately portraying the three-dimensional tissue deficit and asymmetry. This imaging may assist in the choice of muscle transposition flaps and reconstructive technique.

The clinical and radiographic results of 9 consecutive vascularized full-thickness cranial bone grafts to the midface are examined for a period of 3 to 8 years. Satisfactory contour was maintained throughout the follow-up in 5 patients with severe congenital facial deformities. Axial computerized tomography revealed complete survival of a trilaminar bone graft in each case. The complications were limited to a small area of alopecia in the midportion of one temporal scar. This relatively tedious harvest of bone is indicated for severe congenital malar and maxillary midface hypoplasia beginning at 4 years of age.

We produced transgenic mice carrying the native sheep beta-lactoglobulin (BLG) or fusion genes composed of the BLG promoter and human serum albumin (HSA) minigenes. BLG was expressed exclusively in the mammary glands of the virgin and lactating transgenic mice evaluated. In contrast, transgenic females carrying the BLG/HSA fusion constructs also expressed the HSA RNA ectopically in skeletal muscle, kidney, brain, spleen, salivary gland and skin. Ectopic expression of HSA RNA was detected only in strains that express the transgene in the mammary gland. There was no obvious correlation between the level of the HSA RNA expressed in the mammary gland and that found ectopically. In three transgenic strains analysed, the expression of HSA RNA in kidney and skeletal muscle increased during pregnancy and lactation, whereas in the brain HSA expression decreased during lactation in one of the strains. HSA protein was synthesized in skeletal muscle and skin of strain #23 and its level was higher in lactating mice compared with virgin mice. Expression of HSA was also analysed in males and was found to be more stringently controlled than in females of the same strains. In situ hybridization analyses localized the expressed transgene in the skin, kidney, brain and salivary glands of various transgenic strains. Distinct strain-specific and cell-type specific HSA expression patterns were observed in the skin. This is in contrast to the exclusive expression of the HSA transgene in epithelial cells surrounding the alveoli of the mammary gland. Taken together, these results suggest that the absence of sufficient mammary-specific regulatory elements in the BLG promoter sequences and/or the juxtaposition of the BLG promoter with the HSA coding sequences leads to novel tissue- and cell-specific expression in ectopic tissues of transgenic mice.

Radiation-related ulcers of the chest wall provide a great challenge to reconstructive surgeons because of the necessity of protecting the underlying vital structures and the difficulty in repairing irradiated tissues. To evaluate the efficacy of treatment, 24 patients who underwent reconstruction of radiation related ulcers of the chest wall were retrospectively reviewed. A variety of muscle and musculocutaneous flaps as well as omentum and microvascular tissue transfers were used to reconstruct these defects. The defects in the chest wall arose from spontaneous breakdown of irradiated tissue, tumor recurrence, or nonhealing after surgical procedures performed in the irradiated field. Our treatment protocol consisted of aggressive debridement of all affected tissues including skeletal tissues when necessary. The application of a tension free closure using a flap was then performed. Skeletal support was provided in three reconstructions. There were no mortalities, the morbidity rate was 29% (six minor, one major complication), and the mean hospital stay was 10.9 days. None of the patients required prolonged ventilator support. In all but 2 patients, who were left with small chronic granulating nonhealing wounds, complete wound healing was achieved. We conclude that chest wall reconstruction of radiation-related ulcers can be achieved with minimal morbidity in an acceptable period of inpatient hospital care using a variety of vascularized tissue transfers.

Transgenic mice were produced, carrying hybrid genes comprised of the ovine beta-lactoglobulin (BLG) milk protein gene promoter and human serum albumin (HSA) coding sequences. In situ hybridization revealed high levels of BLG/HSA hybrid mRNA, confined to the epithelial cells of the lactating mammary gland with a several hundred fold lower concentration in virgin mammary glands. During the first 24 h in culture, exceptionally high levels of HSA were secreted from explants of virgin mice, independent of hormonal control. HSA secretion was reduced considerably during subsequent days in culture and became dependent on the presence of insulin, hydrocortisone and prolactin. This temporal and hormonal pattern of regulation of HSA was different than that found for the secretion of caseins. In contrast to the vast difference in the mRNA content, the amount of HSA secreted from explants derived from lactating mice during the first 24 h in culture was only 2- to 5-fold higher than that found with explants from virgin transgenic mice, suggesting post-transcriptional control of HSA synthesis. The high-level synthesis and secretion of HSA in mammary explants of lactating mice was also dependent on the presence of insulin, hydrocortisone and prolactin. This study confirms previous suggestion that mammary explants from virgin transgenics may serve as a powerful tool for screening the potential of transgenic animals to secrete foreign proteins in their milk.

Various agents are able to stimulate the EGF receptor protein tyrosine kinase in the absence of ligand binding. To characterize their mechanism of action, we investigated their effects on the kinase activity of the intracellular domain of the EGF receptor (EGFR-IC). EGFR-IC (67 kDa) lacking the extracellular domain and transmembrane segment of the EGF receptor, but retaining kinase and autophosphorylation domains, was produced and purified as a soluble, cytoplasmic protein from Sf9 insect cells infected with a recombinant baculovirus. EGFR-IC was able to undergo autophosphorylation in a manner similar to full-length EGFR. Synthetic substrate peptides showed similar affinity to EGFR-IC as to the full-length receptor. The activity of the EGFR-IC was found to be dependent on divalent cations, Mn2+ being a more potent activator than Mg2+. Agents capable of aggregating the kinase by direct interaction (cross-linking antibodies, polycations) or through altering the surrounding solvent structure and thereby decreasing protein solubility [ammonium sulfate, poly(ethylene glycol), 2-methyl-2,4-pentanediol] activated the kinase in a manner which correlated with their ability to precipitate the EGFR intracellular domain. The widely different chemical nature of these agents suggests that they do not act by direct interaction with specific allosteric regulatory sites, but rather by facilitating the interactions between kinase molecules. These results support the hypothesis that full-length receptor aggregation itself, induced by ligand binding to the extracellular domain, results in intracellular domain interactions and the activation of kinase activity.