Pulmonary embolism after hip or knee replacement: postoperative changes on pulmonary scintigrams in asymptomatic patients

Serial pulmonary imaging has proved to be effective in the evaluation of patients undergoing total joint arthroplasty. A clinical dilemma arises in asymptomatic patients whose postoperative pulmonary images differ from the preoperative images. The authors prospectively evaluated 403 patients with serial imaging to determine the significance of changed postoperative images in asymptomatic patients undergoing total hip or knee arthroplasty. Twenty-two (5.5%) patients had significant changes on postoperative images. Seventeen were asymptomatic; all but one underwent pulmonary angiography. Documented pulmonary emboli were demonstrated in 100% of patients whose postoperative images changed to indicate a high probability of pulmonary embolism, 71% whose images changed to a moderate probability, and 0% whose images changed to indeterminate probability. Overall, pulmonary emboli occurred in 76% of all asymptomatic patients with significantly change postoperative images. Asymptomatic pulmonary embolism is a significant occurrence after total hip or knee repair, and a changed lung scan with appropriate clinical evaluation is an accurate indicator of pulmonary emboli in asymptomatic postarthroplasty patients.     

Regulation of expression of interleukin 2 receptors upon triggering of the TCR-CD3 complex on human T lymphocytes

Monoclonal antibodies reactive with CD3 molecular complex can induce antigen-associated early biochemical changes in purified, monocyte-depleted resting T cell populations and synergize with interleukin 2 (IL2) in the induction of T-cell proliferation. Interleukin 2 mediates its effects via two receptor molecules of apparent 70-75 kD (p70/p75) and 50-55 kD (p50/55) molecular weights respectively. Using radioactive IL2 and bi-functional cross-linking chemistry, we are able to determine that incubation of purified, monocyte-depleted, resting T cells with anti-CD3 (OKT3) antibody induces a significant and selective increase in the expression of p70/75 IL2 receptors from their low constitutively expressed levels. This event occurs in the complete absence of cellular proliferation. Although IL2 also causes the upregulation of p70/75 molecules, it is the synergistic action of both antibody and lymphokine which is needed for the induction of significant amounts of the p50/55 IL2 receptors and the concomitant cellular proliferation. The effect of anti-CD3 on p70/75 receptor expression is specific, as determined by the inability of a non-related (anti-CD2) monoclonal antibody of the same subclass (IgG2a) to induce a similar effect. The Ca++ ionophore ionomycin, under conditions that cause significant intracellular Ca++ influx cannot by itself mediate upregulation of IL2 receptor expression in T cells. Since anti-CD3 itself can induce intracellular Ca++ increase in purified T cells, the finding with the ionophore suggests that the intracellular Ca++ accumulation alone cannot account for the IL2 receptor molecular events described here. Addition of PMA induces both p70/75 and p50/55 IL2 receptor upregulation, as well as IL2-dependent proliferation. Although resting T cells constitutively express p70/75 receptors, under our experimental conditions and with the concentration of IL2 used, these molecules cannot transduce the lymphokine signal efficiently. Thus, in a physiologic context, a simple interpretation of our data could be that upon interaction of the TCR/CD3 with antigen a selective upregulation of p70/75 IL2 receptors renders them competent of not only binding the lymphokine, but also transducing its signal. The latter event leads to the expression of p50/55 receptors and subsequent proliferation. Whether an increase in the numbers of these receptors is all that is needed or additional events are necessary merits further investigation.     

Osteomyelitis: detection with US

To evaluate the role of ultrasound (US) in the detection of osteomyelitis, the authors prospectively studied 48 patients clinically suspected of having osteomyelitis. A sonographic diagnosis was made if fluid was seen directly in contact with bone, without intervening soft tissues. Twelve of the 48 patients were subsequently found to have osteomyelitis. In 10 of them, US demonstrated abnormal fluid adjacent to the bone. This fluid was thought to represent an inflammatory exudate dissecting in a subperiosteal and/or extraperiosteal location. Eight of the 48 patients had soft-tissue fluid collections. The rest of the patients either had no abnormalities or had cellulitis. The authors conclude that US can be useful in the detection of osteomyelitis.     

Studies on the mechanism of bacterial resistance to complement-mediated killing. II. C8 and C9 release C5b67 from the surface of salmonella minnesota S218 because the terminal complex does not insert into the bacterial outer membrane

The mechanism for consumption of terminal complement components and release of bound components from the surface of serum-resistant salmonella minnesota S218 was studied. Consumption of C8 and C9 by S218 occurred through interaction with C5b67 on the bacterial surface because C8 and C9 were consumed when added to S218 organisms previously incubated in C8-deficient serum and washed to remove all C5b67 on the bacterial surface because C8 and C9 were consumed when added to S218 organisms previously incubated in C8- deficient serum and washed to remove al but cell bound C5b67. Rapid release of (125)I C5 and (125)I C7 from the membrane of S218 was dependent on binding of C8 because (125)I C5 and (125)I C7 deposition in C8D serum was stable and was twofold higher in C8D than in PNHA, and addition of purified C8 or C8 and C9 to S218 previously incubated in C8D serum caused rapid release of (125)I C5 and (125)I C7 from the organism. Analysis by sucrose density gradient ultracentrifugation of the fluid phase from the reaction of S218 and 10 percent PNHS revealed a peak consistent with SC5b-9, in which the C9:C7 ratio was 3.3:1, but the NaDOC extracted bound C5b-9 complex sedimented as a broad peak with C9:C7 of less than 1.2:1. Progressive elution of C5b67 and C5b-9 from S218 but not serum-sensitive S. minnesota Re595 was observed with incubation in buffers of increasing ionic strength. Greater than 90 percent of the bound counts of (125)I C5 or (125)I C9 were released from S218 by incubation in 0.1 percent trypsin, but only 57 percent of (125)I C9 were released by treatment of Re595 with trypsin. These results are consistent with the concept that C5b-9 forms on the surface of the serum-sensitive S. minnesota S218 in normal human serum, but the formed complex is released and is not bactericidal for S218 because it fails to insert into hydrophobic outer membrane domains.