Use of lean principals to improve flow of patients with fractured neck of femur--the HOPE study.

We describe the implementation of a care pathway for patients with fractured neck of femur (NOF) using Lean and Six Sigma principles. After introduction of the Lean pathway, 32 patients out a total of 86 (37%) with fractured NOF were admitted to the Trauma Ward within 4 hours of presentation to the hospital; prior to implementation this was 16 patients out of a total of 59 (27%). Post-Lean an earlier mean theatre start time of 8.40am was achieved, resulting in a 38 minute increase in daily theatre time. An additional 52 patients (12%) received surgery within 24 hours of admission, resulting in 1 night length of stay reduction. Lean methodology proved an effective method to guide change resulting in an improved journey for the patient and significant workflow gains.

Cyclosporin immunosuppression of sheep: pharmacokinetics and allograft survival.

A chronically immunosuppressed sheep model was established using a regimen of cyclosporin A (CsA; 2-3mg/kg twice daily) and ketoconazole (10mg/kg twice daily). Blood CsA concentrations reached a steady-state after 17 days of treatment. The clearance of CsA decreased from a mean (95% CI) of 9.47 (6.2-12.7)ml/min/kg after a single (first) dose (3mg/kg i.v.) to 1.62 (1.38-1.86)ml/min/kg after 18 days of CsA (3mg/kg i.v. twice daily) co-administration with ketoconazole. These data indicated that the combination of CsA and ketoconazole could be used to give stable high concentrations of CsA in the sheep. Using this regimen in the sheep, the long-term survival of skin allografts was monitored as an indicator of effective immunosuppression. CsA in blood was measured daily and CsA dose adjusted to various target concentration ranges. Provided that the trough concentration of blood CsA was maintained between 1500-2500 mg/l, long-term healthy skin allografts were maintained on the sheep without significant adverse effects on haematological or biochemical parameters.

The influence of live weight, live-weight change and diet on protein synthesis in the skin and skeletal muscle in young Merino sheep.

Wool growth is derived directly from protein synthesis in the skin of sheep, and is affected by the nutritional status of the animals. The present experiment examined both protein synthesis in the skin and muscle and wool growth in Merino lambs differing in live weight, intake and dietary protein source. The experiment was a 2(3) factorial design: twenty-four 5-month-old lambs initially weighing 33 kg (heavy) or 25 kg (light) were fed on a hay-based diet with either lupin seed or rapeseed meal as the major protein sources to maintain live weight (M) for 56 d, or were fed at 0.6 M for 28 d (period 1) followed by 28 d at 1.6 M (period 2). Fractional protein synthesis rates (FSR, % per d) in the skin and the m. longissimus dorsi on days 4 and 24 of period 1 and day 4 of period 2 were measured by means of a flooding dose of L-[ring-d5]phenylalanine, and wool growth on a skin patch over period 1 was also measured. The FSR ranged from 13.2 to 20.2% per d in the skin, higher than reported for other breeds, and 1.53-3.07% per d in the muscle. Sheep on the low intake (0.6 M) had significant reductions in FSR, protein content (g), protein synthesis (g/d) in the skin, and wool growth (g/d). The heavy lambs had similar FSR to the light lambs, but had a higher skin protein content and total protein synthesis per unit of skin area (100 cm2) and, therefore, grew more wool. The rapeseed-meal diet increased FSR and wool growth only in the light lambs over the short term. The protein deposited in wool over period 1 was 0.185 of the total protein synthesis in the skin, regardless of live weight, intake or diet, a result similar to other breeds. With the changes in dietary intake, protein synthesis in the skin and muscle responded differentially, with nutrient partitioning at sub-maintenance in favour of wool growth but at supra-maintenance, following a nutrient restriction, in favour of weight gain in young growing sheep.

Cyclosporine a immunosuppression in sheep with response enhancement by concomitant ketoconazole.

1. The pharmacokinetics of a single dose of Cyclosporine A (CsA) administered to sheep by intravenous (i.v.) route were examined. 2. Concomitant administration of ketoconazole was found to increase the area under the blood CsA concentration-time curve (AUC) and was effective when administered by the oral or intraperitoneal route. 3. The effects of CsA and ketoconazole on the immune system of sheep were also assessed. 4. A single dose of CsA 5 mg/kg resulted in abrogation of in vitro lymphocyte function manifest at 24 h after injection of CsA. Normal responsiveness recovered in 48-72 h. Numbers of T lymphocytes in peripheral blood were elevated transiently at 48 h although no other significant alteration in lymphocyte subsets was observed with this treatment. 5. Concomitant ketoconazole administration enhanced the CsA-induced suppression of in vitro lymphocyte responses. Blood levels of CsA (AUC values to 24 h) were significantly elevated with concomitant ketoconazole administration and depression of lymphocyte responses to mitogens were also significantly enhanced. An increase in the proportion of T4 positive cells in the blood was observed at 48 h and at 7 days after administration of CsA with ketoconazole. 6. These findings indicate that CsA effectively abrogates immunocompetence in the sheep and this immunosuppressive effect is enhanced by concomitant administration of ketoconazole.

Radiopharmaceutical therapy of 5T33 murine myeloma by sequential treatment with samarium-153 ethylenediaminetetramethylene phosphonate, melphalan, and bone marrow transplantation.

BACKGROUND: Total-body irradiation, followed by hematopoietic system rescue by bone marrow transplantation (BMT), has been found to improve the response of patients with multiple myeloma to treatment with melphalan. The problems of nonhematopoietic toxicity from whole-body irradiation might be circumvented by using a bone-seeking radiopharmaceutical, such as samarium-153 ethylenediaminetetramethylene phosphonate (153Sm-EDTMP), to ablate the bone marrow. PURPOSE: A mouse model system for multiple myeloma was used to evaluate the potential therapeutic efficacy of sequential therapy with 153Sm-EDTMP, melphalan, and BMT. METHODS: Female C57BL/KaLwRij mice were inoculated with 8 x 10(5) 5T33 murine myeloma cells. Treatment protocols were begun 3 or 10 days later, when the myeloma was either confined to bone marrow or disseminated in liver, spleen, and lymph nodes, simulating human multiple myeloma. 153Sm, a potent beta particle-emitting radioisotope of short half-life (46.7 hours), was linked to the bone-seeking chelate EDTMP. Animals in the first treatment group were each given 22.5 MBq 153Sm-EDTMP via the jugular vein (day 3 or 10), followed by 18.5 mg/kg melphalan (maximum tolerated dose) given intraperitoneally 5 days later (day 8 or 15) and syngeneic BMT another 2 days later (day 10 or 17). Survival in groups of six to 10 animals for each time series was compared with that in mice left untreated (control cohort), in mice treated with 153Sm-EDTMP alone (day 3 or 10), or in mice treated with melphalan alone (day 8 or 15). The hematopoietic systems of animals in the latter two treatment groups recovered full function, obviating the necessity of BMT. The end point was onset of paraparesis, at which time the animals were immediately killed by carbon dioxide asphyxiation. RESULTS: Median survival in untreated control animals was 23 days in those with localized disease and 24 days in those with disseminated myeloma. Treatment with 153Sm-EDTMP alone improved survival to a median of 29 days when commenced on day 3 and 30 days when begun on day 10. Melphalan treatment alone improved the median survival to 31 days for animals with localized myeloma and 34 days in animals with disseminated disease. Additional improvement in survival to a median of 42 days was achieved in animals treated 3 days after tumor inoculation with sequential 153Sm-EDTMP, melphalan, and BMT; median survival was 40 days using this regimen in animals with disseminated myeloma. CONCLUSIONS: Animals in all three treatment protocols survived longer than those left untreated after inoculation with myeloma cells (P < .001). Sequential treatment with 153Sm-EDTMP, melphalan, and BMT was significantly more effective than single-agent treatment (P < .01). No evidence of radiotoxicity was detected in nonhematopoietic organs. IMPLICATIONS: The survival advantage conferred by our sequential treatment protocol suggests its potential clinical usefulness in the treatment of multiple myeloma and other hematologic malignancies in humans.

A model of multiple myeloma: culture of 5T33 murine myeloma cells and evaluation of tumorigenicity in the C57BL/KaLwRij mouse.

The 5T33 multiple myeloma is one of a series of transplantable murine myelomas arising spontaneously in C57BL/KaLwRij mice. This study describes the establishment and characterisation of the 5T33 murine myeloma in vitro as a cultured cell line in terms of its morphology, growth rate, expression of paraprotein (IgG2b) and tumorigenicity in syngeneic animals. The 5T33 cell line has been in continuous culture for over 10 months and has achieved more than passage 34. In culture, 5T33 myeloma grows as single cells or in small clusters of loosely adherent cells on an adherent stromal cell layer. Maximum doubling time is approximately 25 h, and over 90% of the cells express cytoplasmic IgG2b paraprotein. The cultured 5T33 myeloma cells are highly tumorigenic in C57BL/KaLwRij mice with as few as 500 cells inducing paralysis and death as early as day 36 post-tumour inoculation. Kinetics of tumour development and detection of IgG2b paraprotein are dose dependent. Two weeks following intravenous inoculation of 5 x 10(5) cultured 5T33 myeloma cells, tumour cells were readily identified in the bone marrow. By 3 weeks post-tumour inoculation, 5T33 myeloma cells were found in various tissues throughout the animal. Studies are now underway to determine the sensitivity of this cell line to various therapeutic modalities.

Mouse cytomegalovirus infection induces antibodies which cross-react with virus and cardiac myosin: a model for the study of molecular mimicry in the pathogenesis of viral myocarditis.

Mouse cytomegalovirus (MCMV) infection induces persisting myocarditis in the susceptible BALB/c strain. Autoantibodies to cardiac myosin are produced in both susceptible BALB/c and resistant C57BL/6 mice following MCMV infection. These affinity-purified anti-cardiac myosin antibodies cross-react with MCMV protein(s). The polypeptides of CMV which share immunological cross-reactivity with the 200,000 MW polypeptide, the heavy chain of myosin, were viral polypeptides of 83,000, 94,000 and 116,000 MW recognized by BALB/c post-infection sera and polypeptides of 66,000 and 94,000 MW recognized by C57BL/6 post-infection sera. Passive transfer of anti-cardiac myosin antibodies from Day 56 post-infection sera of the BALB/c strain induced inflammation and necrosis of the myocardium of uninfected BALB/c recipients. This late immune sera contains autoantibodies specific for the cardiac isoform of myosin. Furthermore, immunization with cardiac myosin induced myocarditis and high titres of cardiac myosin antibodies in uninfected mice of the susceptible BALB/c strain only. However, antibodies to myosin elicited in cardiac myosin-immunized BALB/c mice did not cross-react with MCMV by ELISA. We suggest that virus infection may modulate the immune recognition of the common-epitope(s) shared between MCMV protein(s) and the heavy chain of myosin. Of particular interest is the possibility that molecular mimicry of CMV with cardiac myosin may contribute to the pathogenesis of autoimmune myocarditis following virus infection.

Murine anti-cytomegalovirus monoclonal antibodies with autoreactivity.

Certain murine monoclonal antibodies (mAb) raised against structural proteins of mouse cytomegalovirus (MCMV) display distinct patterns of multiple organ-autoreactivity in addition to their viral specificities. We analysed the autoreactivity of five such mAb by immunoperoxidase histochemistry, western immunoblot and enzyme-linked immunosorbent assay (ELISA). Four mAb recognized cellular autoantigens in the salivary gland, lung, heart, liver, kidney, ileum, striated muscle and brain, as detected by immunoperoxidase histochemistry. However, the mAb showed different specificities for nuclear, cytoplasmic and surface membrane antigens on various cell types in addition to common autoreactivities. Immunoblot analyses showed that some of the mAb recognized polypeptides of various molecular weights obtained from 100,000 g supernatants of normal BALB/c liver, brain, striated and cardiac muscle homogenates. Reactivity of the mAb with a 200,000 molecular weight (MW) polypeptide was similar to our previous finding of the reaction of late immune polyclonal sera with a 200,000 MW polypeptide, the heavy chain of myosin. The mAb reacted to the cardiac isoform of myosin as determined by ELISA and immunoblot. Reactivity of mAb with cardiac myosin, as detected by immunoblot, was removed by absorption with cardiac myosin and recovered in the eluate. However, cardiac myosin used in a competitive inhibition ELISA did not abrogate the reactivity of the mAb with MCMV antigens. These anti-MCMV mAb appear to be multispecific for both virus and self-antigens, including cardiac myosin, and possibly recognize these different antigens through partly similar or distinct antigen-binding sites.

Autoantibodies to cardiac myosin in mouse cytomegalovirus myocarditis.

Myocarditis accompanies sublethal mouse cytomegalovirus (MCMV) infection in susceptible BALB/c mice and persists beyond the acute phase of infection, in the absence of demonstrable virus antigen but in the continuing presence of autoantibodies to cardiac muscle. Heart tissue autoantibodies of the IgG class were first detected by ELISA in sera at Days 3-5 post-infection (PI) and persisted to Day 100, in two strains of MCMV-infected mice which are susceptible (BALB/c) and resistant (C57BL/10) to MCMV-induced myocarditis. Analysis by immunoblot showed that autoantibodies in early immune sera (Day 10) from both mouse strains reacted with the contractile proteins troponin, tropomyosin and myosin, as well as with other unidentified polypeptides within normal mouse organ homogenates. However, the dominant reactivity of late immune sera (Day 100) was to a 200,000 molecular weight (MW) polypeptide in muscle homogenates identified as the heavy chain of myosin. Autoantibodies reacting with the cardiac or striated muscle isoforms of myosin were assessed by ELISA in BALB/c and C57BL/10 mice. At Days 28, 56 and 100 PI only the susceptible BALB/c strain had high titres of autoantibodies reacting with the cardiac isoform of myosin. Increasing the virus dose given to C57BL/10 mice resulted in slight increases in titres of anti-myosin antibody; however, the peak antibody titres did not approach those of BALB/c mice and persisting myocarditis did not develop. Absorption experiments showed that cardiac myosin-specific antibodies were present in immune sera from susceptible BALB/c mice at Day 100 but not in resistant C57BL/10 mice by ELISA and immunoblot. These results demonstrate that autoimmunity to myosin is a prominent feature of the humoral autoimmune response following MCMV infection, and that there are differences both in fine isoform specificity and titre of anti-myosin antibodies between strains of mice that develop persisting myocarditis and strains that do not. Cardiac myosin-specific autoantibodies may play an immunopathogenic role in CMV-induced myocarditis.

Genetic control of mouse cytomegalovirus-induced myocarditis.

Mouse cytomegalovirus (MCMV) infection of mice induced myocarditis, characterized by a mononuclear cell infiltrate with associated necrosis of myofibres. Myocarditis was observed in parallel with viral inclusion-bearing cells in the heart during the acute phase of the infection. Myocarditis also persisted after the acute phase when viral antigens were no longer detectable by immunoperoxidase histochemistry and infectious virus could not be cultivated from various organs. The influence of host genetic factors on the development of cytomegalovirus-induced myocarditis was investigated using H-2 congenic and recombinant inbred mouse strains. Analysis of congenic variants with C57BL/10 and BALB/c backgrounds and the A/J strain revealed that genes linked to the H-2 complex influenced susceptibility to peak levels of MCMV-induced myocarditis seen 7 and 10 days post-infection. In addition, non-H-2 genes of the BALB/c background were important in determining the severity of myocarditis. Analysis of the strain distribution pattern of the CXB recombinant inbred series did not disclose the identity of the BALB/c non-H-2-linked allele conferring susceptibility to MCMV-induced myocarditis. The level of myocarditis seen in the F1 hybrid between the high-responder BALB/c and low-responder C57BL/6 strains suggested dominant inheritance. The amount of viral replication in the major target organs did not correlate with the severity of myocarditis. In conclusion, at least two genes, one mapping to the H-2 complex and another non-H-2-linked gene, influenced the development of myocarditis in MCMV-infected mice.

Purtscher's retinopathy and fat embolism.

A 19-year-old woman who sustained multiple trauma but no head injury developed fulminant fat embolism syndrome (FES). Her neurological deterioration was associated with cerebral oedema and the concomitant Purtscher's type retinopathy. We suggest that the pathogenesis of the retinopathy and of the cerebral oedema are the same and that Purtscher's retinopathy and retinopathy of the FES are indistinguishable.

The role of T cells in mouse cytomegalovirus myocarditis.

BALB/c mice infected with murine cytomegalovirus (MCMV) developed myocarditis. Athymic nu/nu mice infected with the virus did not develop myocarditis, in contrast to heterozygous T-cell competent nu/+mice. MCMV-infected BALB/c mice given cyclosporin A(CsA) a drug which inhibits the activation of T cells, showed a delay in the development of myocarditis relative to CsA-untreated mice infected with MCMV. However, BALB/c mice infected with MCMV, regardless of CsA treatment, developed both anti-MCMV antibodies and autoantibodies. Nu/nu mice infected with MCMV did not produce the anti-MCMV antibody response or the multiple autoantibody response which was observed in nu/+ MCMV-infected mice. Both nu/nu and CsA-treated animals displayed greater organ distribution of viral antigen than control MCMV-infected animals. These results suggest that the presence of a thymus is required for both the development of myocarditis and the multiple autoantibody response, which includes autoantibodies to cardiac muscle, and that CsA immunosuppression does not abrogate either myocarditis or the antibody response in mice following MCMV infection.

Orbital fibrous histiocytoma in an infant.

A rare case of fibrous histiocytoma in an infant is described. The tumour appeared to arise in the medial orbit, invading the ethmoid and maxillary sinuses. Surgical and medical management, and the subsequent clinical course in a 11 year follow-up period are described. Histogenesis of this primary mesenchymal tumour is discussed.

Multiple autoantibodies following cytomegalovirus infection: virus distribution and specificity of autoantibodies.

Multiple autoantibodies were found in the sera of BALB/c, C57BL/10 and C3H mice following mouse cytomegalovirus (MCMV) infection. The complex pattern of intra-organ, intratissue and intracellular reactivity observed by immunoperoxidase histochemistry suggested that many autoantibodies of varying specificities were elicited. This evidence from immunoperoxidase histochemistry was confirmed by immunoblot, where autoantibodies binding to polypeptides of a variety of sizes and tissues of origin were observed. In addition to these central findings, the tissue and organ distribution of MCMV in three mouse strains of differing genetic resistance were described. No correlation was found between the distribution of virus and the tissue and organ specificity of the autoantibodies produced following infection. Inflammatory responses accompanied MCMV infection in a number of tissues. In BALB/c mice, myocarditis and salivary gland inflammation were evident at Day 56 post-infection in the absence of MCMV, but in the presence of autoantibodies to cardiac muscle and salivary duct epithelium. This model for virus-induced autoimmunity can be applied to studies of the relationship between virus infection, autoimmunity and disease.

Developmental glaucoma in oculocutaneous albinism.

A case of oculocutaneous albinism is described in which bilateral Axenfeld's anomaly co-exists. Progressive elevation of intraocular pressure required treatment and this complication has not been reported. Different hypotheses regarding the co-existence of these conditions are reviewed.

The relationship between liver-specific lipoprotein and the hepatocyte plasma membrane.

Liver-specific lipoprotein (LSP) has been the subject of intense investigation as a candidate target antigen in chronic active hepatitis. Fundamental to the interest in LSP has been the belief that it is an antigen complex of hepatocyte plasma membrane origin. In this study the physical, biochemical and antigenic relationships between LSP and isolated hepatocyte plasma membrane (HPM) were investigated. Electron microscopic examination of LSP showed it to be devoid of plasmalemma sheets that were abundant in HPM. The plasma membrane marker enzyme 5'-nucleotidase was enriched 11-fold in HPM relative to liver homogenate, whereas the enzyme activity in LSP was 17% of that found in liver homogenate and only 1.5% of that found in HPM. The antigenic relationship between LSP and HPM was assessed using sera from rabbits immunized with either mouse LSP or mouse HPM. By filtration ELISA, antibody to LSP reacted poorly with entrapped HPM, relative to antibody to mouse HPM. Antisera to LSP and HPM were both effectively absorbed by the immunizing antigen, however antibody to LSP was not absorbed with HPM, and minimal cross-absorption of HPM antibody with LSP was found. By immunoblot of SDS-PAGE separated LSP and HPM, it was shown that antigenic cross-reactivity between LSP and HPM at the polypeptide level was rare. By immunofluorescence, antibody to LSP failed to react with the surface of viable mouse hepatocytes, whereas antibody to HPM showed linear fluorescence. The data show that the two preparations, LSP and HPM, are dissimilar antigen complexes. HPM may be a more appropriate preparation for the study of autoimmune liver disease than LSP.

Thymus-dependence of autoantibody responses to liver specific lipoprotein in the mouse.

Proposed mechanisms for the induction of autoantibodies to liver specific lipoprotein (LSP) assume that the autoantibody response is T-dependent. This hypothesis was tested in the athymic nude mouse. Athymic homozygote (nu/nu) nude mice and appropriate control mouse strains were immunized with rabbit or human LSP and infected with murine cytomegalovirus (MCMV) in an attempt to induce autoantibodies to LSP. Antibodies to LSP were measured by passive haemagglutination and by an enzyme linked immunosorbent assay. Nude mice did not produce antibodies to either foreign LSP species or autoantibodies to mouse LSP when immunized with either rabbit or human LSP. Control heterozygote (nu/+) mice and C57BL/6J mice produced antibody to foreign LSP and autoantibody to mouse LSP when immunized with xenogeneic LSP. Athymic nu/nu mice also failed to produce autoantibody to mouse LSP following infection with MCMV, in contrast to control nu/+ and C57BL/6J mice which produced LSP autoantibody after infection with MCMV. It is concluded that the autoantibody response to LSP is T-dependent.

Importance of Tenon's capsule in squint surgery.

A procedure for dealing with Tenon's capsule in squint surgery on the horizontal muscles, which preserves intact the relations of the various expansions of Tenon's capsule, distorts and damages them as little as possible and replaces Tenon's capsule as an intact layer over the muscle at the end of surgery is outlined. It depends on adequate fixation and the avoidance of damage to and distortion of Tenon's capsule by the use of muscle hooks to 'fish' for the muscle. It is claimed that this method produces less fibrosis around the muscle post-operatively and allows a better final result.

Laser treatment in diabetic retinopathy.

During the past 2 years, 44 patients (71 eyes) had pan-retinal photocoagulation by argon gas laser for proliferative diabetic retinopathy. All except 9 eyes benefitted from the treatment, peripheral and disc vessels showing regression. Many of the patients needed, or will need, further laser treatment. The main complications of treatment were slight or moderate constriction of the visual field, poor night vision and macular oedema.