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Hair cells in many nonmammalian vertebrates are regenerated by the mitotic division of supporting cell progenitors and the differentiation of the resulting progeny into new hair cells and supporting cells. Recent studies have shown that nonmitotic hair cell recovery after aminoglycoside-induced damage can also occur in the vestibular organs. Using hair cell and supporting cell immunocytochemical markers, we have used confocal and electron microscopy to examine the fate of damaged hair cells and the origin of immature hair cells after gentamicin treatment in mitotically blocked cultures of the bullfrog saccule. Extruding and fragmenting hair cells, which undergo apoptotic cell death, are replaced by scar formations. After losing their bundles, sublethally damaged hair cells remain in the sensory epithelium for prolonged periods, acquiring supporting cell-like morphology and immunoreactivity. These modes of damage appear to be mutually exclusive, implying that sublethally damaged hair cells repair their bundles. Transitional cells, coexpressing hair cell and supporting cell markers, are seen near scar formations created by the expansion of neighboring supporting cells. Most of these cells have morphology and immunoreactivity similar to that of sublethally damaged hair cells. Ultrastructural analysis also reveals that most immature hair cells had autophagic vacuoles, implying that they originated from damaged hair cells rather than supporting cells. Some transitional cells are supporting cells participating in scar formations. Supporting cells also decrease in number during hair cell recovery, supporting the conclusion that some supporting cells undergo phenotypic conversion into hair cells without an intervening mitotic event.

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Recent studies have suggested that myosin Ibeta mediates the adaptation of mechanoelectrical transduction in vestibular hair cells. An important prediction of this hypothesis is that myosin Ibeta should be found in the side insertional plaque, an osmiophilic hair bundle structure that anchors tip links and is thought to house the adaptation motor. To determine whether myosin Ibeta was situated properly to perform adaptation, we used immunofluorescence and immunoelectron microscopy with the monoclonal antibody mT2 to examine the distribution of myosin Ibeta in hair bundles of the bullfrog utricle. Although utricular hair cells differ in their rates and extent of adaptation [Baird RA (1994) Comparative transduction mechanisms of hair cells in the bullfrog utriculus. II. Sensitivity and response dynamics to hair bundle displacement. J Neurophysiol 71:685-705.], myosin Ibeta was present in all hair bundles, regardless of adaptation kinetics. Confirming that, nevertheless, it was positioned properly to mediate adaptation, myosin Ibeta was found at significantly higher levels in the side insertional plaque. Myosin Ibeta was also present at elevated levels at the second tip link anchor of a hair bundle, the tip insertional plaque, found at the tip of a stereocilium. These data support myosin Ibeta as the adaptation motor and are consistent with the suggestion that the motor serves to restore tension applied to transduction channels to an optimal level, albeit with different kinetics in different cell types.

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Earlier studies have demonstrated hair cell regeneration in the absence of cell proliferation, and suggested that supporting cells could phenotypically convert into hair cells following hair cell loss. Because calcium-binding proteins are involved in gene up-regulation, cell growth, and cell differentiation, we wished to determine if these proteins were up-regulated in scar formations and regenerating hair cells following gentamicin treatment. Calbindin and parvalbumin immunolabeling was examined in control or gentamicin-treated (GT) bullfrog saccular and utricular explants cultured for 3 days in amphibian culture medium or amphibian culture medium supplemented with aphidicolin, a blocker of nuclear DNA replication in eukaryotic cells. In control cultures, calbindin and parvalbumin immunolabeled the hair bundles and, less intensely, the cell bodies of mature hair cells. In GT or mitotically-blocked GT (MBGT) cultures, calbindin and parvalbumin immunolabeling was also seen in the hair bundles, cuticular plates, and cell bodies of hair cells with immature hair bundles. Thus, these antigens were useful markers for both normal and regenerating hair cells. Supporting cell immunolabeling was not seen in control cultures nor in the majority of supporting cells in GT cultures. In MBGT cultures, calbindin and parvalbumin immunolabeling was up-regulated in the cytosol of single supporting cells participating in scar formations and in supporting cells with hair cell-like characteristics. These data provide further evidence that non-mitotic hair cell regeneration in cultures can be accomplished by the conversion of supporting cells into hair cells.

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Hair cells in the bullfrog vestibular otolith organs were immunolabeled by monoclonal and polyclonal antisera against calbindin (CaB), calmodulin (CaM), calretinin (CaR), and parvalbumin (PA). S-100, previously shown to immunolabel striolar hair cells in fish vestibular organs, only weakly immunolabeled hair cells in the bullfrog vestibular otolith organs. Immunolabeling was not detected in supporting cells. With the exception of CaR, myelinated axons and unmyelinated nerve terminals were immunolabeled by all of the above antisera. Immunolabeling was seen in all saccular hair cells, although hair cells at the macular margins were immunolabeled more intensely for CaB, CaM, and PA than more centrally located hair cells. As the macula margins are known to be a growth zone, this labeling pattern suggests that marginal hair cells up-regulate their calcium-binding proteins during hair cell development. In the utriculus, immunolabeling for CaM and PA was generally restricted to striolar hair cells. CaR immunolabeling was restricted to the stereociliary array. Immunolabeling for other calcium-binding proteins was generally seen in both the cell body and hair bundles of hair cells, although this labeling was often localized to the stereociliary array and the apical portion of the cell body. CaM and PA immunolabeling in the stereociliary array in saccular and utricular striolar cells suggests a functional role for these proteins in mechanoelectric transduction and adaptation.

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Vestibular nerve afferents innervating the bullfrog utriculus differ in their response dynamics and sensitivity to natural stimulation. They also supply hair cells that differ markedly in hair bundle morphology. To examine the peripheral innervation patterns of individual utricular afferents more closely, afferent fibers were labeled by the extracellular injection of horseradish peroxidase (HRP) into the vestibular nerve after sectioning the vestibular nerve medial to Scarpa's ganglion to allow the degeneration of sympathetic and efferent fibers. The peripheral arborizations of individual afferents were then correlated with the diameters of their parent axons, the regions of the macula they innervate, and the number and type of hair cells they supply. The utriculus is divided by the striola, a narrow zone of distinctive morphology, into medial and lateral parts. Utricular afferents were classified as striolar or extrastriolar according to the epithelial entrance of their parent axons and the location of their terminal fields. In general, striolar afferents had thicker parent axons, fewer subepithelial bifurcations, larger terminal fields, and more synaptic endings than afferents in extrastriolar regions. Afferents in a juxtastriolar zone, immediately adjacent to the medial striola, had innervation patterns transitional between those in the striola and more peripheral parts of the medial extrastriola. Most afferents innervated only a single macular zone. The terminal fields of striolar afferents, with the notable exception of a few afferents with thin parent axons, were generally confined to one side of the striola. Hair cells in the bullfrog utriculus have previously been classified into four types based on hair bundle morphology (Lewis and Li: Brain Res. 83:35-50, 1975). Afferents in the extrastriolar and juxtastriolar zones largely or exclusively innervated Type B hair cells, the predominant hair cell type in the utricular macula. Striolar afferents supplied a mixture of four hair cell types, but largely contacted Type B and Type C hair cells, particularly on the outer rows of the medial striola. Afferents supplying more central striolar regions innervated fewer Type B and large numbers of Type E and Type F hair cells. Striolar afferents with thin parent axons largely supplied Type E hair cells with bulbed kinocilia in the innermost striolar rows.

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1. Hair cells in whole-mount in vitro preparations of the utricular macula of the bullfrog (Rana catesbeiana) were selected according to their macular location and hair bundle morphology. The sensitivity and response dynamics of selected hair cells to natural stimulation were examined by recording their voltage responses to step and sinusoidal hair bundle displacements applied to their longest stereocilia. 2. The voltage responses of 31 hair cells to sinusoidal hair bundle displacements were characterized by their gains and phases, taken with respect to peak hair bundle displacement. The gains of Type B and Type C cells at both 0.5 and 5.0 Hz were markedly lower than those of Type F and Type E cells. Phases, with the exception of Type C cells, lagged hair bundle displacement at 0.5 Hz. Type C cells had phase leads of 25-40 degrees. At 5.0 Hz, response phases in all cells were phase lagged with respect to those at 0.5 Hz. Type C cells had larger gains and smaller phase leads at 5.0 Hz than at 0.5 Hz, suggesting the presence of low-frequency adaptation. 3. Displacement-response curves, derived from the voltage responses to 5.0-Hz sinusoids, were sigmoidal in shape and asymmetrical, with the depolarizing response having a greater magnitude and saturating less abruptly than the hyperpolarizing response. When normalized to their largest displacement the linear ranges of these curves varied from < 0.5 to 1.25 microns and were largest in Type B and smallest in Type F and Type E cells. Sensitivity, defined as the slope of the normalized displacement-response curve, was inversely correlated with linear range. 4. The contribution of geometric factors associated with the hair bundle to linear range and sensitivity were predicted from realistic models of utricular hair bundles created using morphological data obtained from light and electron microscopy. Three factors, including 1) the inverse ratio of the lengths of the kinocilium and longest stereocilia, representing the lever arm between kinociliary and stereociliary displacement; 2) tip link extension/linear displacement, largely a function of stereociliary height and separation; and 3) stereociliary number, an estimate of the number of transduction channels, were considered in this analysis. The first of these factors was quantitatively more important than the latter two factors and their total contribution was largest in Type B and Type C cells. Theoretical models were also used to calculate the relation between rotary and linear displacement.(ABSTRACT TRUNCATED AT 400 WORDS)

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1. Hair cells in whole-mount in vitro preparations of the utricular macula of the bullfrog (Rana catesbeiana) were selected according to their macular location and hair bundle morphology. The voltage responses of selected hair cells to intracellular current steps and sinusoids in the frequency range of 0.5-200 Hz were studied with conventional intracellular recordings. 2. The utricular macula is divided into medial and lateral parts by the striola, a 75- to 100-microns zone that runs for nearly the entire length of the sensory macula near its lateral border. The striola is distinguished from flanking extrastriolar regions by the elevated height of its apical surface and the wider spacing of its hair cells. A line dividing hair cells of opposing polarities, located near the lateral border of the striola, separates it into medial and lateral parts. On average, the striola consists of five to seven medial and two to three lateral rows of hair cells. 3. Utricular hair cells were classified into four types on the basis of hair bundle morphology. Type B cells, the predominant hair cell type in the utricular macula, are small cells with short sterocilia and kinocilia 2-6 times as long as their longest stereocilia. These hair cells were found throughout the extrastriola and, more rarely, in the striolar region. Three other hair cell types were restricted to the striolar region. Type C cells, found primarily in the outer striolar rows, resemble enlarged versions of Type B hair cells. Type F cells have kinocilia approximately equal in length to their longest stereocilia and are restricted to the middle striolar rows. Type E cells, found only in the innermost striolar rows, have short kinocilia with prominent kinociliary bulbs. 4. The resting potential of 99 hair cells was -58.0 +/- 7.6 (SD) mV and did not vary significantly for hair cells in differing macular locations or with differing hair bundle morphology. The RN of hair cells, measured from the voltage response to current steps, varied from 200 to > 2,000 M omega and was not well correlated with cell size. On average, Type B cells had the highest RN, followed by Type F, Type E, and Type C cells. When normalized to their surface area, the membrane resistance of hair cells ranged from < 1,000 to > 10,000 k omega.cm2. The input capacitance of hair cells ranged from < 3 to > 15 pA, corresponding on average to a membrane capacitance of 0.8 +/- 0.2 pA/cm2.(ABSTRACT TRUNCATED AT 400 WORDS)

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Surface glycoconjugates of hair cells and supporting cells in the vestibular endorgans of the bullfrog were identified using biotinylated lectins with different carbohydrate specificities. Lectin binding in hair cells was consistent with the presence of glucose and mannose (CON A), galactose (RCA-I), N-acetylglucosamine (WGA), N-acetylgalactosamine (VVA), but not fucose (UEA-I) residues. Hair cells in the bullfrog sacculus, unlike those in the utriculus and semicircular canals, did not strain for N-acetylglucosamine (WGA) or N-acetylgalactosamine (VVA). By contrast, WGA and, to a lesser extent, VVA, differentially stained utricular and semicircular canal hair cells, labeling hair cells located in peripheral, but not central, regions. In mammals, WGA uniformly labeled Type I hair cells while labeling, as in the bullfrog, Type II hair cells only in peripheral regions. These regional variations were retained after enzymatic digestion. We conclude that vestibular hair cells differ in their surface glycoconjugates and that differences in lectin binding patterns can be used to identify hair cell types and to infer the epithelial origin of isolated vestibular hair cells.

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Adult bullfrog were given single intraotic injections of the aminoglycoside antibiotic gentamicin sulfate and sacrificed at postinjection times ranging from 0.5 to 9 days. The saccular and utricular maculae of normal and injected animals were examined in wholemount and cross-section. Intraotic 200 microM gentamicin concentrations resulted in the uniform destruction of the hair bundles and, at later times, the cell bodies of saccular hair cells. In the utriculus, striolar hair cells were selectively damaged while extrastriolar hair cells were relatively unaffected. Regenerating hair cells, identified in sectioned material by their small cell bodies and short, well-formed hair bundles, were seen in the saccular and utricular maculae as early as 24-48 h postinjection. Immature versions of mature hair cell types in both otolith organs were recognized by the presence or absence of a bulbed kinocilia and the relative lengths of their kinocilia and longest stereocilia. Utricular hair cell types with kinocilia longer than their longest stereocilia were observed at earlier than hair cell types with shorter kinocilia. In the sacculus, the hair bundles of gentamicin-treated animals, even at 9 days postinjection, were significantly smaller than those of normal animals. The hair bundles of utricular hair cells, on the other hand, reached full maturity within the same time period.

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1. Nerve fibers supplying the utricular macula of the chinchilla were labeled by extracellular injection of horseradish peroxidase into the vestibular nerve. The peripheral terminations of individual fibers were reconstructed and related to the regions of the end organ they innervated and to the sizes of their parent axons. 2. The macula is divided into medial and lateral parts by the striola, a narrow zone that runs for almost the entire length of the sensory epithelium. The striola can be distinguished from the extrastriolar regions to either side of it by the wider spacing of its hair cells. Calyx endings in the striola have especially thick walls, and, unlike similar endings in the extrastriola, many of them innervate more than one hair cell. The striola occupies 10% of the sensory epithelium; the lateral extrastriola, 50%; and the medial extrastriola, 40%. 3. The utricular nerve penetrates the bony labyrinth anterior to the end organ. Axons reaching the anterior part of the sensory epithelium run directly through the connective tissue stroma. Those supplying more posterior regions first enter a fiber layer located at the bottom of the stroma. Approximately one-third of the axons bifurcate below the epithelium, usually within 5-20 microns of the basement membrane. Bifurcations are more common in fibers destined for the extrastriola than for the striola. 4. Both calyx and bouton endings were labeled. Calyces can be simple or complex. Simple calyces innervate individual hair cells, whereas complex calyces supply 2-4 adjacent hair cells. Complex endings are more heavily concentrated in the striola than in the extrastriola. Simple calyces and boutons are found in all parts of the epithelium. Calyces emerge from the parent axon or one of its thick branches. Boutons, whether en passant or terminal, are located on thin collaterals. 5. Fibers can be classified into calyx, bouton, or dimorphic categories. The first type only has calyx endings; the second, only bouton endings; and the third, both kinds of endings. Calyx units make up 6% of the labeled fibers, bouton units less than 2%, and dimorphic units greater than 92%. The three fiber types differ in the macular zones they supply and in the diameters of their parent axons. Calyx units were restricted to the striola. The few bouton units were found in the extrastriola.(ABSTRACT TRUNCATED AT 400 WORDS)

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1. Extracellular recording techniques were used in the chinchilla to study the discharge properties of utricular afferents, including their discharge regularity, background discharge, and responses to both externally applied galvanic currents and centrifugal forces. 2. A normalized coefficient of variation (CV*), independent of discharge rate, was used to classify units as regularly (CV* less than 0.10), intermediate (0.10 less than or equal to CV* less than or equal to 0.20), or irregularly discharging (CV* greater than 0.20). In some circumstances, it was useful to recognize a group of very regularly discharging afferents (CV* less than 0.05). The CV* ranged from less than 0.020 to greater than 0.60. Regular units outnumbered irregular units by an approximate 3:1 ratio. The distribution of CV*s was bimodal: there was a major peak at CV* = 0.03 and a minor peak at CV* = 0.3. 3. Background rates were measured with the head in a horizontal position. Those of regular units usually fell between 40 and 80 spikes/s (mean: 54 spikes/s); those of irregular units were more broadly distributed (mean: 47 spikes/s). 4. Units were categorized in terms of the tilt directions resulting in increased discharge. There is a broad distribution of excitatory tilt directions with some units excited by ipsilateral rolls, others by contralateral rolls, some by nose-up pitches, and still others by nose-down pitches. In the chinchilla, there are almost equal numbers of units excited by ipsilateral or contralateral tilts. This is in contrast to previous findings in the cat and squirrel monkey, where the former units predominant by a 3:1 ratio. The difference can be related to the fact that the medial zone of the macula, where units excited by ipsilateral tilts reside, makes up a smaller proportion of the sensory epithelium in the chinchilla than in the monkey. 5. Galvanic sensitivity (beta *) and discharge regularity (CV*) were related by a power law, beta* = (CV*), with an exponent, b = 0.70. 6. Responses to sinusoidal centrifugal forces in the frequency range, f, between DC and 2 Hz were characterized by their gains (gf) and phases (phi f), taken with respect to peak linear force. Response linearity was studied by varying the amplitude of a 0.1-Hz sinusoid from 0.05 to 0.4 g. Nonlinear distortion was small (approximately 10%), as was the variation of gain (+/- 10%) and phase (+/- 5 degrees) with amplitude. 7. Response dynamics vary with discharge regularity. Very regular units are tonic. Their gains are typically 50 spikes.s-1/g and almost constant (+/- 10%) over the entire frequency range. Phases hover near zero with small (5 degrees) phase leads at low frequencies and slightly larger (10 degrees) phase lags at high frequencies. Irregular units are more phasic.(ABSTRACT TRUNCATED AT 400 WORDS)

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1. The relation between the discharge properties of utricular afferents and their peripheral innervation patterns was studied in the chinchilla by the use of intra-axonal labeling techniques. Fifty-three physiologically characterized units were injected with horseradish peroxidase (HRP) or lucifer yellow CH (LY) and their labeled processes were traced to the utricular macula. For most labeled neurons, the discharge regularity, background discharge, and sensitivity to externally applied galvanic currents were determined, as were the gain (g2 Hz) and phase (phi 2 Hz) of the response to 2-Hz sinusoidal linear forces. Terminal fields were reconstructed and fibers were classified as calyx (n = 13) or dimorphic units (n = 40). No bouton units were recovered. Calyx units were confined to the striola. Dimorphic units were located in the striola (n = 8), the juxtastriola (n = 7), or the peripheral extrastriola (n = 25). 2. To determine whether the intra-axonal sample was representative, the physiological properties of labeled utricular units were compared with those of a larger sample of extracellularly recorded units. A comparison was also made between the morphology of intra-axonally labeled units and those labeled by the extracellular injection of HRP into the vestibular nerve. Most of the discrepancies between the intra-axonal and either extracellular sample can be explained by assuming that small-diameter fibers are underrepresented in the former sample. Dimorphic fibers labeled intra-axonally had more bouton endings and larger terminal trees than did those labeled extracellularly. The latter differences may reflect a sampling bias in the extracellular material. 3. Calyx units were irregularly discharging. The discharge regularity of dimorphic units was related to their macular locations. Only 1/8 dimorphic units in the striola was regularly discharging. The ratio increases to 3/7 in the juxtastriola and to 23/25 in the peripheral extrastriola. Among dimorphic units, there is a tendency for irregularly discharging afferents to have fewer bouton endings. The trend is far from perfect because it is possible to pick a subsample of dimorphic units that have similar numbers of boutons and, yet, have discharge patterns that range from regular to irregular. 4. Published morphological polarization maps can be used to predict the excitatory tilt directions of a unit from its macular location. Predictions were confirmed in 39/41 labeled afferents. 5. The galvanic sensitivity (beta *) of an afferent, irrespective of its peripheral innervation pattern or its epithelial location, was strongly correlated with a normalized coefficient of variation (CV*).(ABSTRACT TRUNCATED AT 400 WORDS)

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1. Afferent fibers supplying the horizontal and superior semicircular canals of the chinchilla were labeled by extracellular injections of horseradish peroxidase (HRP) into the vestibular nerve. The arborizations of labeled fibers within the sensory epithelium were reconstructed from serial sections of the crista. 2. The sensory epithelium of the crista can be divided into central, intermediate, and peripheral zones of approximately equal areas. The three zones can be distinguished in normal material by the density of hair cells and by the morphology of calyx endings. 3. Labeled fibers supply either the canalicular or the utricular side of the crista. Axons seldom bifurcate below the basement membrane and they begin dividing into their terminal arborizations almost immediately upon entering the sensory epithelium. The arborizations are compact, seldom extending more than 50 micron from the parent axon. 4. Both calyx and bouton endings were labeled. Calyces can be simple or complex. Simple calyces innervate individual hair cells, whereas complex calyces supply two to three adjacent hair cells. Complex calyces are commonly found only in the central zone. Simple calyces and boutons are located in all regions of the epithelium. Calyces emerge from the parent axon or one of its thick branches. Boutons, whether en passant or terminal, are always located on thin processes. 5. Fibers were classified as calyx, bouton, or dimorphic. The first type only has calyx endings, the second only has bouton endings, and the third has both kinds of endings. Dimorphic units make up some 70% of the labeled fibers, bouton units some 20%, and calyx units some 10%. The three fiber types differ in the diameters of their parent axons and in the regions of the crista they supply. Axon diameters are largest for calyx units and smallest for bouton units. Calyx units are concentrated in the central zone of the crista, whereas bouton units are largely confined to the peripheral zone. Dimorphic units are seen throughout the sensory epithelium. 6. Calyx units are almost always unbranched and end as simple calyces or, less often, as complex calyces. The terminal arbors of bouton units consist of fine processes containing 15-80 endings. Dimorphic units vary in complexity from fibers with a single calyx and a few boutons to those with one to four calyces and more than 50 boutons. 7. The results emphasize the importance of dimorphic units, which were the most numerous type of afferent fiber labeled in this study and were the only units found to innervate all regions of the sensory epithelium.(ABSTRACT TRUNCATED AT 400 WORDS)

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1. The relation between the response properties of semicircular canal afferents and their peripheral innervation patterns was studied by the use of intra-axonal labeling techniques. Fifty physiologically characterized units were injected with horseradish peroxidase (HRP) or Lucifer yellow CH (LY) and their processes were traced to the crista. The resting discharge, discharge regularity, and responses to both externally applied galvanic currents and sinusoidal head rotations were determined for most neurons. Terminal fields were reconstructed and, as in the preceding paper, the fibers were classified as calyx, bouton, or dimorphic units. 2. To determine if the intra-axonal sample was representative, the physiological properties of the labeled units were compared with those of a sample of extracellularly recorded units. A comparison was also made between the morphology of the intra-axonal units and those labeled by extracellular injection of HRP into the vestibular nerve Most of the discrepancies between the intra-axonal and the two extracellular samples can be explained by assuming that small-diameter fibers are underrepresented in the former sample. 3. A normalized coefficient of variation (CV*), independent of discharge rate, was used to classify units as regular, intermediate, or irregular. The CV* ranged from 0.020 to 0.60. Regular units (CV* less than or equal to 0.10) outnumbered irregular units (CV* greater than or equal to 0.20) by an approximately 3:1 ratio and had higher resting discharges. 4. Calyx units were invariably irregular. The one recovered bouton unit was regular. The discharge regularity of dimorphic units was related to their epithelial location, with those found in the periphery of the crista having a more regular discharge than those located more centrally. Dimorphic units, even those with quite similar morphology, can differ in their discharge regularity. Calyx and dimorphic units, which differ in their morphology, can both be irregular. These observations imply that discharge regularity is not determined by the branching pattern of a fiber or the number and types of hair cells it contacts. 5. The galvanic sensitivity (beta*) of an afferent, irrespective of its peripheral innervation pattern, was strongly correlated with CV*. This is consistent with the notion that discharge regularity and galvanic sensitivity are causally related, both being determined by postspike recovery mechanisms of the afferent nerve terminal.(ABSTRACT TRUNCATED AT 400 WORDS)

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The results in twenty-four patients who were treated for a distal fibular fracture and disruption of the deltoid ligament were studied, using subjective, objective, and radiographic criteria, over a period of at least two years. Nineteen (90 per cent) of the twenty-one patients who were treated without repair of the deltoid ligament had a good or excellent result. All but two of these patients were unrestricted in the ability to walk and run and had no pain during the activities of daily living. No patient had instability of the ankle. At follow-up, the range of motion of the ankle was within 15 degrees of that of the uninjured ankle in 90 per cent of the patients. Only one ankle had radiographic evidence of narrowing of the joint space. The three patients in whom the deltoid ligament was repaired did not have as good a result as the twenty-one patients in whom it was not, but this group was too small to permit valid comparisons. We concluded that exploration of the medial side of the ankle and repair of the deltoid ligament are not necessary unless reduction of the lateral malleolus fails to reduce the talus within the ankle mortise.

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Lacerations of the profundus tendon distal to the superficialis insertion can be treated by advancement of the proximal cut end of the tendon to its insertion. In the English-language literature, limits cited for the distance a profundus tendon can be safely advanced vary from 0.75 to 2.5 cm and appear to be based on clinical impressions. Our cadaver model suggested the degree of tendon advancement tolerable was 1 cm. A delicate balance exists in the profundus tendon system, and this should be considered when surgical advancement is contemplated.

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External fixation was used to treat femoral shaft fractures in nine spinal cord injury (SCI) patients. One patient died of unrelated causes during fracture treatment. Of the remaining eight patients, seven healed their fractures. Two complications, one superficial pin-track drainage and one fracture comminution, occurred in the nine patients. Neither complication adversely affected the patient's final result. In patients with acute spinal cord injury, external fixation should be considered for the treatment of closed femoral shaft fractures with marked comminution, and for open femoral shaft fractures with significant contamination or soft tissue loss. In the chronic SCI patient, external fixation of a femoral shaft fracture may increase the patient's level of independence and mobility during fracture healing, and may permit a more rapid return to the patient's pre-fracture functional level.

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