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The pathogeneses of parathyroid disease in patients with uremia and nonfamilial primary parathyroid hyperplasia are poorly understood. Because of multigland involvement, it has been assumed that these common diseases predominantly involve polyclonal (non-neoplastic) cellular proliferations, but an overall assessment of their clonality has not been done. We examined the clonality of these hyperplastic parathyroid tumors using X-chromosome inactivation analysis with the M27 beta (DXS255) DNA polymorphism and by searching for monoclonal allelic losses at M27 beta and at loci on chromosome band 11q13. Fully 7 of 11 informative hemodialysis patients (64%) with uremic refractory hyperparathyroidism harbored at least one monoclonal parathyroid tumor (with a minimum of 12 of their 19 available glands being monoclonal). Tumor monoclonality was demonstrable in 6 of 16 informative patients (38%) with primary parathyroid hyperplasia. Histopathologic categories of nodular versus generalized hyperplasia were not useful predictors of clonal status. These observations indicate that monoclonal parathyroid neoplasms are common in patients with uremic refractory hyperparathyroidism and also develop in a substantial group of patients with sporadic primary parathyroid hyperplasia, thereby changing our concept of the pathogenesis of these diseases. Neoplastic transformation of preexisting polyclonal hyperplasia, apparently due in large part to genes not yet implicated in parathyroid tumorigenesis and possibly including a novel X-chromosome tumor suppressor gene, is likely to play a central role in these disorders.

Study design: A case report of Neisseria sicca/subflava discitis in a healthy elderly female. Objective: To report a rare case, which is usually seen exclusively in children. Setting: Stoke on Trent, England. Method: Case report, a 65-year-old female with a 6 month history of back and bilateral leg pain. X-rays showed collapse of L4/5 disc. No neurological deficit. Magnetic resonance imaging supported the clinical suspicion of discitis. Percutaneous biopsy followed 2 weeks later by open biopsy with bilateral root decompression was performed. Culture of L4/5 disc tissue produced Neisseria sicca/subflava. The patient was treated with a 4-week course of intravenous amoxycillin. Follow-up at 3 months confirmed clinical resolution of original symptoms. Conclusion: Any organism cultured from biopsy needs to be interpreted within the context of the clinical case. If clinical suspicion is high, further weight must be added to the finding of unusual or environmental organisms and culture of a repeat aspirate or biopsy may clarify the significance.

We obtained intervertebral discs with cartilage endplates and underlying cancellous bone at operation from patients with degenerative disc disease and then used immunohistochemical techniques to localise the nerves and nerve endings in the specimens. We used antibodies for the ubiquitous neuronal protein gene product 9.5 (PGP 9.5). Immunoreactivity to neuropeptide Y was used to identify autonomic nerves and calcitonin gene-related peptide (CGRP) and substance P to identify sensory nerves. Blood vessels were identified by immunoreactivity with platelet-endothelial cell-adhesion molecule (CD31; PECAM). In a control group with no known history of chronic back pain, nerve fibres immunoreactive to PGP 9.5 and neuropeptide Y were most closely related to blood vessels, with occasional substance P and CGRP immunoreactivity. In patients with severe back pain and markedly reduced disc height, proliferation of blood vessels and accompanying nerve fibres was observed in the endplate region and underlying vertebral bodies. Many of these nerves were immunoreactive to substance P or CGRP, and in addition, substance P- and CGRP-immunoreactive nociceptors were seen unrelated to blood vessels. Quantification by image analysis showed a marked increase in CGRP-containing sensory nerve fibres compared with normal control subjects. We speculate that a chemotactic response to products of disc breakdown is responsible for the proliferation of vascularity and CGRP-containing sensory nerves found in the endplate region and vertebral body adjacent to degenerate discs. The neuropeptides substance P and CGRP have potent vasodilatory as well as pain-transmitting effects. The increase in sensory nerve endings suggests increase in blood flow, perhaps as an attempt to augment the nutrition of the degenerate disc. The increase in the density of sensory nerves, and the presence of endplate cartilage defects, strongly suggest that the endplates and vertebral bodies are sources of pain; this may explain the severe pain on movement experienced by some patients with degenerative disc disease.

The causes of gastrointestinal hemorrhage in children were detailed in 1964 by Spencer. We investigated the causes of gastrointestinal hemorrhage in 165 children seen at our institution over a 13-year period. The most common causes of gastrointestinal hemorrhage in the hospitalized patients were necrotizing enterocolitis (44%), anal fissures (23%), and guaiac-positive stools of unknown cause (16%). The mortality rate was 5.4%. Necrotizing enterocolitis was the most common cause of death. Only 16 patients required surgery. Gastrointestinal hemorrhage is an infrequent cause of mortality and morbidity in hospitalized pediatric patients.

Retention of the host's Descemet's membrane is an unusual complication of penetrating keratoplasty. The membrane may opacify and even threaten the health of the transplant. Following creation of a central opening with the Nd:YAG laser in such a case, visual acuity improved from counts fingers at 5 ft to 20/100.

Cystic lesions of the mesentery, omentum, and retroperitoneum are rare; from 1956 to 1990, 22 patients had operative treatment for such lesions at our institution. They ranged in age from 1 month to 14 years; 75% were younger than 5 years. All had either an acute abdomen or, more commonly, a silent abdominal mass. In all cases, the histologic diagnosis was lymphangioma. Abdominal ultrasonography was done in all cases after 1977 except for two patients who had an acute abdomen requiring emergency exploration. A cystic abdominal mass was diagnosed in 94% of these cases, but the correct diagnosis of lymphangioma was made prior to surgery in only 24%. Mesenteric cysts are most common in the small bowel mesentery. Omental cysts usually occur singly and are easily resected, but multiple cysts predominate in the mesentery and retroperitoneum. Complete resection was accomplished in 82% of our cases. Two patients required partial bowel resection, and four had partial excision with marsupialization of the cysts. With a mean follow-up of 23 months, we have had three recurrences, but none necessitated reexploration. Extra-abdominal lesions, mainly cutaneous lymphangiomas, developed in two cases. Prognosis is good after surgical excision, but long-term follow-up is advisable because of the possibility of recurrence, even during adulthood.

Human FcR for IgG can be divided into three classes (Fc gamma RI, II, and III) based on their structure and reactivity with mAb. Fc gamma RII can be further subdivided into two categories based on functional and biochemical assays. These two Fc gamma RII subtypes were initially recognized by the failure of T cells from 40% of individuals to proliferate in response to mAb Leu 4 (mouse IgG1, anti-CD3), a response that requires the binding of the Fc region of the Leu 4 mAb to Fc gamma RII on monocyte accessory cells. Inas-much as mouse IgG1, does not bind efficiently to the nonresponder form of Fc gamma RII, mAb Leu 4 is unable to induce proliferation in these individuals. IEF data on Fc gamma RII from Leu 4 responder and nonresponder individuals suggested that the structural gene for Fc gamma RII consisted of two allelic forms R (responder) and N (nonresponder) producing the phenotypes RR, RN, and NN. Thus, exclusive expression of the nonresponder allele in monocytes of "nonresponder" individuals, appeared to be responsible for the lack of proliferation observed. In cooperation with the IVth International Conference on Human Leukocyte Differentiation Antigens, we analyzed CDw32 mAb to determine if they could distinguish the responder and nonresponder forms of Fc gamma RII. We report that mAb 41H16 binds preferentially to the responder allotypic form of Fc gamma RII expressed on human monocytes. When quantitative flow cytometry is used to measure the binding of both mAb 41H16 (responder Fc gamma RII) and mAb IV.3 (all myeloid cell Fc gamma RII), we are able to subdivide the responder population into homozygous and heterozygous responders. In addition, mAb 41H16 blocks the binding of mAb IV.3 to monocytes and inhibits proliferation when added to cells before addition of mAb Leu 4. We also show that polymorphonuclear leukocytes and platelets have the same allotypic differences in the binding of 41H16 as do monocytes. However, a subset of lymphocytes (previously shown to be B cells) expresses the 41H16 epitope with no evidence for donor to donor variability.

One hundred fifty-four patients with renovascular injuries were analyzed to gain insight into the mortality, morbidity and indications for immediate nephrectomy versus arterial revascularization. Arterial revascularization is seldom indicated in patients with a normal contralateral kidney who have multiple associated injuries, hilar injuries, long segmental arterial injuries or prolonged renal ischemia. An attempt at renal artery revascularization is justified with bilateral injuries, when only one kidney is present or when a solitary artery injury can be repaired by simple lateral arteriorrhaphy.

Human monocytes, pulmonary alveolar macrophages (PAMs) and spleen macrophages were concentrated by immobilization on cold insoluble globulins. These cell preparations were 90 +/- 3%, 95 +/- 1% and 83 +/- 3% esterase rich, respectively, 87 +/- 4%, 95 +/- 3% and 66 +/- 11% phagocytic and 78 +/- 3%, 79 +/- 9% and 68 +/- 5% reactive with OKM1 monoclonal antibody. Spleen macrophages differed from the other two cell preparations in that significantly fewer reacted with 61D3 or 63D2 monoclonal antibodies. Monocytes and PAMs promoted the mixed leucocyte response by autologous lymphocytes when added at low concentrations, but suppressed this response at high concentrations. Spleen macrophages only promoted the mixed leucocyte reaction but were required in much higher numbers than either monocytes or PAMs for optimal promotion. Likewise, the added presence of monocytes or PAMs in high numbers suppressed Ig synthesis stimulated with pokeweed mitogen, while spleen macrophages were not suppressive in this system. This study shows that the distribution of macrophages that differ in their regulatory effects upon lymphocyte responses varies in different tissues. The human spleen is deficient in macrophage related suppression.

Human synovial tissues have been assayed for the production of cartilage degrading activity (CDA). This activity is thought to be homologous with catabolin/interleukin 1 (IL1) produced by porcine synovium and leucocytes and by human leucocytes. The CDA of 26 rheumatoid (RA) and 41 non-rheumatoid synovia was measured on a dry weight basis. The rheumatoid synovia showed a threefold increase in activity over the non-rheumatoid, but there was no significant overall difference on a deoxyribonucleic acid (DNA) basis. The rheumatoid synovia appeared to consist of two populations; in over half the samples CDA was not related to cellularity, but eight patients had a high CDA and a high cellularity.

Cellular requirements for induction of primary proliferative responses by human T cells to trinitrophenylated autologous stimulators have been characterized. Substantial proliferative responses were observed with each of the Ia+ stimulator populations tested. Nevertheless, major differences in the hapten specificity of such responses were observed. Thus purified macrophages/monocytes (M phi) when TNP-modified induced responses that were relatively modest in absolute magnitude, but were highly hapten specific. This reflected the very limited capacity of purified M phi to induce proliferation when unmodified, i.e., an autologous mixed leukocyte response (AMLR). In contrast, unmodified M phi-depleted B plus null cells were potent stimulators of AMLR, but hapten modification did not significantly enhance the responses induced by these cells. Moreover, when M phi were added to B plus null cell stimulators AMLR responses were reduced and, with TNP-modified stimulators, hapten-specific responses were restored. The data thus suggest that M phi may have important roles in induction of primary T cell responses to conventional antigens but function largely as regulators rather than stimulators of AMLR. Finally, we have introduced a novel antigen-presenting cell population, the irradiated Ia+ TNP-specific cloned T cell. The possibility that such cells may utilize autostimulatory positive feedback circuits for activation of naive T cells and in interactions between subpopulations of hapten-reactive T cells is discussed.

To investigate mechanisms by which antigen, macrophages, and interleukin 2 (IL2) participate in the induction of secondary T-cell proliferative responses, trinitrophenyl (TNP) was presented in three distinct modes: (i) TNP-modified peripheral blood mononuclear cells (TNP-PBMC), (ii) TNP-PBMC cell sonicates, and (iii) TNP-ovalbumin (TNP-OVA). Stimulators were depleted of Mac-120+ macrophages using Mac-120 monoclonal antibody plus complement. TNP-Mac-120 macrophages stimulated primed T cells nearly as well as TNP-unfractionated macrophages (which were about 40% Mac-120+). In contrast, although greater than 70% DR+, Mac-120- macrophages plus either TNP-OVA or TNP-PBMC sonicate elicited minimal responses compared to unfractionated macrophages plus antigen. After 21-28 days of in vitro priming, macrophage-depleted T cells were not stimulated to proliferate by either IL2 alone or sonicates alone. IL2 plus TNP-PBMC sonicates, however, stimulated significant proliferation. Furthermore, this response was considerably greater than that to IL2 plus either TNP-T cell sonicates or TNP-mouse spleen sonicates. Thus, the Mac-120+ macrophage population may have an important antigen-presenting and/or accessory function in the stimulation of primed T cells by soluble or particulate antigen, although it is unnecessary for responses to intact TNP-Ia+ PBMC. In addition, the data suggest that Ia+ sonicates alone may suffice for induction of IL2 responsiveness, but not for endogenous IL2 production and subsequent proliferation by primed T cells.

Coronary artery disease due to atherosclerosis takes the lives of approximately 550,000 Americans each year--an enormous toll. Put in economic terms, the cost to the United States alone has been estimated to exceed 60 billion dollars annually. We have found that well-resolved proton (1H) NMR spectra can be obtained from human atheroma (fatty plaque), despite its macroscopic solid appearance. The fraction of the total spectral intensity corresponding to the sharp 1H NMR signals is temperature dependent and approaches unity at body temperature (37 degrees C). Studies of the total lipids extracted from atheroma and cholesteryl esters were conducted to identify the chemical and physical origin of the spectral signature. The samples were characterized through assignment of their chemical shifts and by measurement of their T1 and T2 relaxation times as a function of magnetic field strength. The results suggest that the relatively sharp 1H NMR signals from human atheroma (excluding water) are due to a mixture of cholesteryl esters, whose liquid-crystalline to isotropic fluid phase transition is near body temperature. Preliminary applications to NMR imaging of human atheroma are reported, which demonstrate early fatty plaque formation within the wall of the aorta. These findings offer a basis for noninvasive imaging by NMR to monitor early and potentially reversible stages of human atherogenesis.