A case of barotrauma-induced pneumolabyrinth secondary to perilymphatic fistula.

We report the case of a 62-year-old woman who experienced pneumolabyrinth associated with a perilymphatic fistula. Her condition was diagnosed with the help of computed tomography, which detected the presence of an air bubble in the labyrinth, and middle ear exploration, which revealed that clear fluid was emanating from the round window niche in a manner consistent with the presence of a perilymphatic fistula. The niche was repaired with tragal perichondrium and bolstered with Gelfoam.

Sex, drugs, and HIV: does methadone maintenance reduce drug use and risky sexual behavior?

This study examined differences in drug use, sexual behavior, attitudes, and perceptions of vulnerability for AIDS between injection drug users who received methadone treatment in the previous 6 months and those who did not. Of the 123 participants assessed, 62 (50%) received methadone treatment. Methadone patients reported fewer sexual partners and greater use of condoms compared to nonmethadone patients. Methadone patients also reported fewer high-risk sexual partners than those not in treatment. Women reported more high-risk partners than men. Methadone patients reported drinking alcohol less, but smoking marijuana more than nonmethadone users. Methadone users had more positive beliefs about the efficacy of condoms for preventing AIDS and expressed less anger than nonmethadone users in situations related to condom usage. These findings have important implications for using methadone maintenance to reduce the dual risk for HIV in injection drug users.

The impact of the number of young adults on an inpatient psychiatric unit.

Age has been shown to contribute to aggression in inpatient settings. Studies that examine violence in inpatient settings have shown that younger patients have a higher tendency of aggressive behavior toward staff and other patients (Aquilina, 1991; Hillbrand, Foster, & Spitz, 1996; James, Fineberg, Shah, & Priest, 1990; Nijman, Allerti, Merckelbach, a Campo, & Rovelli, 1997; Owen, Tarantello, Jones, & Tennant, 1998).However, though younger age has been associated with higher rates of violence, no studies have been conducted to assess the impact of multiple young adults on the functioning of an inpatient unit. This study evaluates the effect of the number of young adults on unit functioning and whether young adults mix poorly with other age groups.

The effect of gelfilm in the prevention of fibrosis in the middle ear of the animal model.

HYPOTHESIS: Gelfilm offers protection against fibrosis in the middle ear when used in combination with Gelfoam. BACKGROUND: Gelfoam is used routinely as a support structure in the middle ear cleft when ossicular reconstruction and tympanic membrane grafts are performed. It has been recognized that fibrosis may occur in this setting if the middle ear mucosa is denuded. Materials have been used to protect the mucosa in an attempt to prevent scar bands, adhesions, and fibrosis and its potential detriment on hearing. These materials have included Teflon, Silastic, and Gelfilm. Concerns have arisen regarding this mode of therapy and its benefit. METHODS: This study looks at the effects of implanting Gelfoam independently and Gelfoam and Gelfilm concurrently in the bulla cavity of the Mongolian Gerbil. The temporal bones were harvested and evaluated histologically using hemotoxylin and eosin staining for fibrosis. RESULTS: Results demonstrated a decrease in the amount of fibrosis in the animals in which Gelfilm was used to protect the denuded mucosa. No evidence of fibroblast ingrowth or scar bands penetrating the Gelfilm was identified. CONCLUSION: These results suggest that Gelfoam can be used safely in the middle ear cleft to support ossicular prosthesis and tympanic membrane grafts when Gelfilm is used to protect denuded mucosa.

Osseointegrated implants in the head and neck cancer patient.

BACKGROUND: Osseointegrated implants allow patients with oromandibular defects to obtain complete or partial dentition via implant-assisted or implant-borne prostheses. Implants restore masticatory and occlusal function, improving oral intake and articulation. However, use of implants in head and neck cancer patients has been discouraged due to lack of data supporting their utility in these patients. This study attempts to establish the validity of using osseointegrated implants for dental restoration in head and neck cancer patients. METHODS: Six patients who underwent resection/reconstruction for head and neck cancer received osseointegrated implants. Integration was assessed clinically, radiographically, and mechanically at 4-8 months; oral intake, mastication, and articulation were evaluated 6-12 months after receiving the dental prosthesis. RESULTS: Osseointegration occurred in 92% (24/26) of the implants: 100% (14/14) in neomandibles and 83% (10/12) in native mandibles. One patient had implants (2/5) that failed to integrate. The remaining patients' implants were immobile, free of infection, with no osteoradionecrosis. These patients tolerated a regular diet and experienced weight gain and improved articulation. CONCLUSIONS: The advent of osseointegrated implants and their compatibility with native and neomandible allows the restoration of functional dentition in patients undergoing ablative surgery for head and neck cancer.

Evaluation of a nurse-led continence service in the south-west of Glasgow, Scotland.

This paper reports the results of a pilot study of a nurse-led continence promotion service in both the community and a local nursing home. Telephone and written referrals were made to the service from 28 primary care teams in Glasgow, Scotland. In the nursing home all patients were assessed and an appropriate management plan implemented. A full assessment was carried out in all community patients, including an appraisal of contributory factors, urinalysis and diaries of food and drink intake. A management plan suited to the patient was then implemented. Patients' levels of incontinence in both arms of the study were assessed objectively using the Lagro-Janssen method. The cost incurred in both arms of the study were measured. There was a 69% improvement in the level of incontinence in the community group compared with 30% in the residents wing and 13% in the hospital wing. The savings in the nursing home amounted to Pounds 4152 in the residents' wing and Pounds 1959 in the hospital wing. In summary, a nurse dedicated to urinary incontinence in the community allows improved management, a greater level of awareness and results in resource savings, whilst increasing patient accessibility to a service.

Metabolic activation, DNA adducts, and H-ras mutations in human neoplastic and non-neoplastic laryngeal tissue.

Metabolic activation, DNA adducts, and H-ras mutations were examined in human laryngeal tissue (n = 16) from both smoker and non/ex-smoker patients with laryngeal cancer. DNA adducts detected by 32P-postlabelling were evident only in smokers (n = 13); in fact, smoking cessation for as little as 10 months resulted in no DNA adducts detected (n = 3). Total DNA adduct levels in these samples were significantly correlated with levels of cytochromes P-4502C and 1A1 in laryngeal microsomes. Moreover, the P-4501A1 levels represent the highest yet found in human tissues. In contrast, laryngeal microsomes did not have detectable P-4501A2 activity, while laryngeal cytosols showed appreciable N-acetyltransferase activity for p-aminobenzoic acid (NAT1) but not sulfamethazine (NAT2). DNA was extracted from laryngeal specimens and amplified by PCR. Nylon filter dot or slot blots were hybridized with 32P-labelled probes for codons 12, 13, and 61 of the H-ras gene. Sixty percent of specimens demonstrated mutations in either codon 12, 13, or 61; a single common and specific mutation was a Gln-->Glu transversion in codon 61. This mutation appeared in 5 laryngeal specimens, all from smokers. These results implicate cigarette smoke components, bioactivated by CYP1A1 and/or CYP2C, in DNA adduct formation. These results also demonstrate a probable smoking-related H-ras Gln-->Glu transversion in codon 61.

Properties of IgA-binding receptors on murine T cells: relative importance of Fc alpha R, beta-galactosyltransferase and anti-secretory component reactive proteins (ASCP).

Murine T cells and T-cell lines express receptors for the Fc of IgA (Fc alpha R); however, their molecular properties remain to be elucidated. In the present study, we examined three candidate molecules for IgA-binding receptors including Fc alpha R, beta-galactosyltransferase (beta-GT) and anti-secretory component (SC) reactive proteins (ASCP) expressed on T cells which might participate in the binding of different molecular forms of IgA. T-cell lines derived from CD4+ T cells of mouse Peyer's patches (PP) (designated PPT 4-6 and PPT 4-16) and from cloned PP T helper (Th) cell lines (ThHA1 #9 and #10) bound both monomeric and dimeric IgA (mIgA and dIgA), while the fusion partners (BW 5147 and R1.1) did not. In contrast, both Fc alpha R+ and Fc alpha R- cell lines bound to high molecular weight polymeric or aggregated IgA (pIgA). All cell lines reacted with a monoclonal anti-beta-GT (MoAb) and beta-GT enzyme activity was associated with the cell lysates and membrane fractions of all cells tested. The anti-beta-GT MoAb stained a 47-kDa band on immunoblots which was identical to that seen with native enzyme. mRNA analysis with beta-GT cDNA showed that all cell lines constitutively produced enzyme-specific mRNA. Both Fc alpha R+ T cells and Fc alpha R- control cell lines showed cell surface specific beta-GT activity. This is the first study which shows that mouse T cells produce beta-GT. However, Fc alpha R and beta-GT appear to be separate receptors, because Fc alpha R+ T cells bound mIgA and dIgA, and this treatment did not affect staining with biotinylated anti-beta-GT MoAb. Further, preincubation of the Fc alpha R+ cells with anti-beta-GT MoAb did not block mIgA binding. However, the anti-beta-GT MoAb partially blocked binding of pIgA to both Fc alpha R+ and Fc alpha R- T cells, suggesting that beta-GT may be a receptor for pIgA. Others have shown that T cells may bind IgA through a receptor serologically related to SC. We found that antibodies both to human SC and to rat SC specifically bound to both Fc alpha R+ and Fc alpha R- T cells. Further, a 72-kDa band was detected when cell membrane fractions were analysed with these antisera (ASCP) by solid phase immunoisolation technique and immunoblot analysis. The ASCP is not an IgA-binding receptor, since anti-SC did not block either mIgA or pIgA binding.(ABSTRACT TRUNCATED AT 400 WORDS)

Regulation of mucosal responses by CD4+ T lymphocytes: effects of anti-L3T4 treatment on the gastrointestinal immune system.

The role of CD4+ T cells in the gastrointestinal (GI) immune system in vivo was studied in mice selectively depleted of this subset by treatment with monoclonal anti-L3T4 (GK1.5) mAb. Treatment of young BALB/c mice with weekly injections of anti-L3T4 mAb resulted in a selective depletion of CD4+ T cells in both IgA effector (lamina propria regions of the intestine; LP) and inductive (Peyer's patch; PP) sites. However, levels of CD3+CD4-CD8+ and CD4-CD8- (double negative) T cells remained constant or increased. When sections of small intestine were assessed for the isotype of Ig-containing cells, normal mice contained predominantly IgA plasma cells with small numbers of IgM and IgG plasma cells while anti-L3T4 treatment dramatically reduced the numbers of IgA plasma cells. When numbers of IgA-producing cells were assessed by the isotype-specific ELISPOT assay, the LPL of anti-L3T4 mAb-treated mice showed an 80% reduction in the number of IgA spot-forming cells. The effect of anti-L3T4 mAb treatment on IgA inductive sites was also studied and this treatment reduced the overall size of PP as well as the germinal centers in this tissue. Although anti-L3T4 treatment depleted CD3+CD4+ T cells in PP, the relative frequency of surface IgA-positive (slgA+) B cells in this tissue did not change. These results show that repeated injection of anti-L3T4 mAb results in a CD4+ T cell deficiency in both IgA inductive (PP) and effector (LP) sites. The depletion of CD4+ T cells resulted in reductions in the numbers of mature IgA plasma cells present in the LP of gut-associated tissues, and reduced the overall size of PP including germinal centers, but did not affect the frequency of sIgA+ B cells in this IgA inductive site.

Porphyromonas gingivalis-specific serum IgG and IgA antibodies originate from immunoglobulin-secreting cells in inflamed gingiva.

Patients with adult periodontitis (AP) exhibit elevated serum antibody levels to Porphyromonas (Bacteroides) gingivalis; however, it is not known whether these antibodies originate from plasma cells in the local disease site or from peripheral lymphoid tissues. We studied the isotype and subclass levels and origin of antibodies to P. gingivalis fimbriae, since elevated serum anti-fimbriae responses were seen when compared with sera of healthy controls. IgG anti-fibriae titres were dominant and the subclass response was IgG3 much greater than IgG1 greater than IgG2 much greater than IgG4; however, some IgA anti-fimbriae antibodies were also seen. The IgA subclass fimbriae-specific response was mainly IgA1; however, significant IgA2 anti-fimbrae antibodies were seen. We also assessed numbers of anti-fimbriae antibody producing cells from peripheral blood mononuclear cells (PMBC) and from either healthy or inflamed gingiva of AP subjects. Gingival mononuclear cells (GMC) of AP patients exhibited high numbers of immunoglobulin-producing (spot-forming) cells (SFC) including fimbriae-specific antibody secreting cells in a pattern of IgG greater than IgA greater than greater than greater than IgM. However, low numbers of SFC were seen in GMC from healthy gingiva; further, no anti-fimbriae SFC responses were noted in healthy GMC. Although no fimbriae-specific immunoglobulin-producing cells were seen in PBMC, low numbers of antigen-specific SFC were found in pokeweed mitogen-triggered PBMC from AP subjects. Treatment of AP patients for plaque and surgical removal of inflamed gingiva resulted in significant reductions in serum anti-fimbriae responses. These studies show that AP patients exhibit brisk serum IgG and IgA subclass anti-fimbriae antibodies, whose origin appear to be the plasma cells present in the localized inflamed tissues.

Mouse IgA Fc receptor on CD3+ T cells. Molecular forms of IgA that bind to a 38-kDa Fc alpha R protein and development of an anti-Fc alpha R antisera.

Previous studies have shown that splenic T cells from mice that bear IgA myelomas, as well as certain T cell lines, express receptors for the Fc of IgA, and are termed Fc alpha R. In this study, we have isolated and characterized two CD3+ T cell lines derived by fusion of murine Peyer's patch (PP) CD4+ T cells with the BW 5147 lymphoma cell line. These cell lines, designated PPT4-6 and PPT4-16, were shown to bind monomeric or dimeric IgA, whereas the fusion partner did not bind either form of IgA. However, polymeric IgA (m.w. 600,000) bound equally well to all three cell lines. Similar results were also obtained with two known Fc alpha R+ T cell lines, ThHA1 nos. 9 and 10. Immunoprecipitation studies with IgA on PPT4-16 and ThHA1 no. 9 have shown that IgA binds to a 38-kDa protein. A rabbit antiserum was prepared to a 38-kDa fraction of Fc alpha R+ T cell membranes, and heterophilic antibody was removed from the antiserum by adsorption with mouse thymocytes, BW 5147 and R1.1 lymphoma. The antiserum bound to both PPT4-16 and ThHA1 no. 9 as well as to other Fc alpha R+ T cells, but did not bind to thymocytes or to the T lymphomas R1.1 or BW 5147. The antiserum appeared specific for the Fc alpha R, because it failed to block binding of anti-CD3 (145 2C11) or other surface molecule-specific antibodies. Further, competitive inhibition studies with IgA and anti-Fc alpha R (38 kDa) showed that preincubation of Fc alpha R+ T cells with the anti-38-kDa protein completely eliminated IgA binding, whereas IgA partially blocked the binding of the anti-Fc alpha R antibodies to the cell membrane. Immunoisolation with the anti-Fc alpha R antibody of radioiodinated cell membrane proteins from Fc alpha R+ T cells, but not from Fc alpha R- cells, gave a distinct band at 38 kDa. To further test the specificity of this antiserum, we have isolated T cells from spleens of IgA-myeloma bearing mice, and tested the phenotype and IgA binding. A subset consisting of 15 to 20% of CD3+, CD8+ T cells was found that bound monomeric or dimeric IgA. Further, the anti-Fc alpha R antiserum also recognized this CD8+ T cell subset, and preincubation of the cells with antibody resulted in their failure to bind IgA. Our results indicate that the Fc alpha R on T cell lines derived from PP is a 38-kDa protein.(ABSTRACT TRUNCATED AT 400 WORDS)

Bacteroides-specific IgG and IgA subclass antibody-secreting cells isolated from chronically inflamed gingival tissues.

The emergence of cells that produce IgG and IgA subclass antibodies to Bacteroides gingivalis (Porphyromonas gingivalis) fimbriae and lipopolysaccharide (LPS) antigens was examined in mononuclear cells isolated from inflamed gingiva of different stages (slight, moderate or advanced) of adult periodontitis (AP). Antigen-specific IgM, IgG (including IgG1, IgG2, IgG3 and IgG4) and IgA (including IgA1 and IgA2) producing cells were enumerated by the ELISPOT assay and were compared with total Ig-producing cells of each isotype or subclass. In advanced AP, the B. gingivalis fimbriae-specific IgG- and IgA-secreting cells represented 5% of total IgG- or IgA-secreting cells, while those from the moderate stage comprised approximately 1% of these two isotypes. Cells producing antibody specific for B. gingivalis LPS were observed at frequencies of 0.1% and 0.4% for IgG and IgA cells, respectively in the advanced stage. When IgG subclasses were analysed in moderate AP, the anti-fimbriae subclass responses were largely IgG1 (60%), followed by IgG2 (20%), IgG3 (10%) and IgG4 (10%). Fimbriae-specific IgG subclass responses were elevated in the advanced stage of AP, and IgG4 (40%) and IgG1 (30%) were dominant, followed by IgG3 (20%) and IgG2 (10%). IgA1 cells predominated in both the moderate and advanced stages, however a relative increase in IgA2 cells occurred in advanced AP. Mononuclear cells isolated from gingiva of AP patients did not contain cells producing antibody to antigens such as Escherichia coli K235 LPS, cholera toxin or the hapten dinitrophenyl coupled to bovine serum albumin. These results show that local IgG and IgA subclass responses occur to a protein antigen of a major periodontal disease (PD)-associated pathogen, B. gingivalis, and the increase in IgG4 and IgA2 responses may be associated with host protection.

Cellular analysis of functional mononuclear cells from chronically inflamed gingival tissue.

Functional mononuclear cells from chronically inflamed gingiva of different stages of adult periodontitis (AP) were isolated by using a novel enzymatic dissociation method and extensively characterized at the single cell level. Fresh tissues obtained following surgery were cut into 1-2 mm3 pieces, washed free of residual blood cells and dissociated with the neutral protease enzyme Dispase. Mononuclear cells were then obtained by separation on a mini-Ficoll-Hypaque gradient. This procedure yields an average of 2 x 10(6) cells/400 mg of tissue. The viability of unfractionated cells immediately after enzymatic dissociation was greater than 94%, and after Ficoll-Hypaque gradient separation this was greater than 99%. The relative percentages of lymphocytes, plasma cells, monocytes (MN)/macrophages (M phi) and granulocytes were determined on cytospin preparations by Wright's-Giemsa staining. Cell differential analysis showed that lymphocytes and MN/M phi predominated at all stages of disease, while the frequency of plasma cells increased with the severity of disease. Numbers of plasma cells specific for IgG, IgA, or IgM were determined by immunofluorescence using fluoresceinated anti-heavy chain specific antibodies. The majority of Ig-containing cells were of the IgG isotype, followed by significant numbers of IgA and few IgM-positive cells. IgG, IgA, and IgM secreting cells were also determined by the ELISPOT assay. Total numbers of spot forming cells (SFC) were measured in both the moderate and advanced stages of disease, and the major SFC isotype was IgG followed by IgA; essentially no IgM SFC were detected. Furthermore, higher numbers of IgG and IgA SFC were noted in the advanced stage when compared with the moderate stage of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of human IgG and IgA subclass antibody-secreting cells from localized chronic inflammatory tissue.

The chronic inflammatory diseases in humans have been intensively investigated, however the immune mechanisms underlying diseases such as rheumatoid arthritis (RA), inflammatory bowel disease, and periodontal disease (PD) remain elusive. In this study, we have analyzed the distribution of IgM, IgG, and IgA secreting cells with emphasis on the IgG and IgA subclasses among mononuclear cell populations isolated from gingiva at different stages of PD. Surgically removed tissues were treated with Dispase to gently dissociate cells and the Ficoll-Hypaque gradient centrifugation was used to enrich for viable mononuclear cells rich in lymphocytes, macrophages, and plasma cells. The total numbers of plasma cells increased with the severity of disease. Immunofluorescence analysis showed that most Ig-containing cells were of the IgG isotype; however, significant numbers of IgA-positive cells but few IgM-positive cells were seen. This isolation procedure allowed analysis, at the single cell level, of the distribution of IgG and IgA subclasses of antibody-secreting cells with monoclonal antibodies to human IgG and IgA subclasses. For this, we selected four monoclonal anti-IgG subclass (anti-gamma 1, -gamma 2, -gamma 3, and -gamma 4) antibodies with no subclass cross reactivity for use in the enzyme-linked immunospot assay. Analysis of slight, moderate, and advanced stages of PD showed a progressive increase in spotforming cells (SFC) numbers, and the major isotype of SFC was IgG followed by IgA. The major IgG subclass SFC seen was IgG1 followed by IgG2 whereas similar numbers of IgG3 and IgG4 SFC were observed, a pattern also seen with cells from synovium of RA patients and in mitogen-triggered spleen and PBMC. In terms of the IgA subclass distribution, IgA1 predominated in moderate stages, whereas a selective increase in IgA2 SFC were seen in the more advanced stage of PD. These results show that significant numbers of viable plasma cells/Ig-secreting cells can be isolated from inflamed gingival tissues. Further, careful analysis has shown that IgG subclass responses in gingiva are similar to those found in synovia of RA subjects, and in stimulated PBMC and spleen. However, it should be noted that the number of IgG4- and IgA2-secreting cells increased in the advanced stage of PD.

Can audit improve patient care? Effects of studying use of digoxin in general practice.

A survey of monitoring of digoxin treatment in five practices examined the indications for prescribing digoxin, its long term use, and how its use could be monitored. These data were used to generate a protocol for monitoring treatment with digoxin in general practice. The findings of the survey and the protocol were distributed to and discussed with all the partners in the practices participating in the study. One year later similar analysis showed that record keeping (recording of pulse rate and rhythm) had improved significantly in the group of principals carrying out the audit but not in other principals in these practices. Audit may change only the auditors.