Traumatic subarachnoid-pleural fistula

BACKGROUND

Traumatic subarachnoid-pleural fistula is a very uncommon but important condition. Only 21 cases have been reported so far in the world literature.

METHODS

We encountered 2 cases of subarachnoid-pleural fistula, both in pediatric patients presenting without any neurologic deficit. Whereas our first patient presented with recurrent, rapidly filling clear pleural effusions with an obscure cause, posing a diagnostic problem for the pediatricians, the second patient had trauma to the pleura and dura mater by the sharp edge of Kirschner wire, with impending risk of injury to spinal cord and infection.

RESULTS

Surgical intervention was undertaken after we had a strong suspicion of subarachnoid-pleural fistula in both cases. A subarachnoid-pleural fistula was found at the level of the eleventh thoracic vertebra in the first patient and at the level of the eighth thoracic vertebra in the second patient. Autogenous tissues (mediastinal pleural flap and hammered intercostal muscle covered with methylcellulose) were used to repair the fistula. The subarachnoid space was decompressed with a lumbar drain in the second patient.

CONCLUSIONS

The diagnosis of subarachnoid-pleural fistula is difficult when it is not associated with any neurologic deficit. We found that a high degree of suspicion and early surgical intervention to repair the fistula are rewarding.

The t(X;1)(p11.2;q21.2) translocation in papillary renal cell carcinoma fuses a novel gene PRCC to the TFE3 transcription factor gene

The specific chromosomal translocation t(X;1)(p11.2;q21.2) has been observed in human papillary renal cell carcinomas. In this study we demonstrated that this translocation results in the fusion of a novel gene designated PRCC at 1q21.2 to the TFE3 gene at Xp11.2. TFE3 encodes a member of the basic helix-loop-helix (bHLH) family of transcription factors originally identified by its ability to bind to microE3 elements in the immunoglobin heavy chain intronic enhancer. The translocation is predicted to result in the fusion of the N-terminal region of the PRCC protein, which includes a proline-rich domain, to the entire TFE3 protein. Notably the generation of the chimaeric PRCC-TFE3 gene appears to be accompanied by complete loss of normal TFE3 transcripts. This work establishes that the disruption of transcriptional control by chromosomal translocation is important in the development of kidney carcinoma in addition to its previously established role in the aetiology of sarcomas and leukaemias.

Regulation of intracellular level of Na+, K+ and glycerol in Saccharomyces cerevisiae under osmotic stress

The intracellular level of Na+ and K+ ofS. cerevisiae strain AB1375 revealed that under KCl as well as sorbitol stress, the cationic level was comparable to the level under no stress conditions. On the other hand, there was a sharp drop in the intracellular K+ content and increase in the Na+ content on addition of NaCl to the medium. However, the total cationic level was close to that under control conditions. In addition to changes in the cationic level, an enhanced production and accumulation of glycerol were also observed under osmotic stress. A regulatory mechanism co-ordinating the intracellular concentration of glycerol as well as Na+, K+ content under osmotic stress conditions has been proposed.

Interphase fluorescence in situ hybridization and reverse transcription polymerase chain reaction as a diagnostic aid for synovial sarcoma

Identification of the t(X;18)(p11.2;q11.2) that is associated with a high proportion of synovial sarcoma can be a useful diagnostic aid. The translocation results in fusion of the SYT gene on chromosome 18 to either the SSX1 or the SSX2 gene, two homologous genes within Xp11.2. Two-color interphase fluorescence in situ hybridization and reverse transcription polymerase chain reaction were assessed as approaches to identify the rearrangement in well characterized cases. The presence of the translocation, and the specific chromosome X gene disrupted, were inferred from the configuration of signals from chromosome-specific centromere probes, paints, and markers flanking each gene in preparations of interphase nuclei. Rearrangement was found in two cell lines and eight of nine tumor samples, including analysis of five touch imprints. This was consistent with cytogenetic data in four cases and reverse transcription polymerase chain reaction analysis using primers known to amplify both SYT-SSX1 and SYT-SSX2 transcripts. The transcripts were distinguished by restriction with LspI and SmaI. Contrary to previous suggestions, there was no obvious correlation between histological subtype and involvement of the SSX1 or SSX2 gene. These approaches could also be applied to the identification of tumor-free margins and metastatic disease.

Reference ranges and sources of variability of CD4 counts in HIV-seronegative women and men

BACKGROUND

CD4 lymphocyte counts are used to monitor immune status in HIV disease. An understanding of the variability of CD4 counts which occurs in the absence of HIV infection is essential to their interpretation. The sources and degree of such variability have not been extensively studied.

OBJECTIVES

To establish reference ranges for CD4 counts in HIV-seronegative women and heterosexual men attending a genitourinary medicine (GUM) clinic, and to identify possible differences according to gender and cigarette smoking and, in women, any effect of the menstrual cycle, oral contraceptive use and cigarette smoking.

DESIGN

Female and heterosexual male patients attending a GUM clinic and requesting an HIV-antibody test were recruited prospectively. Results from an earlier study of CD4 counts in homosexual men were available for comparison.

METHODS

Lymphocyte subpopulation analysis on whole blood by flow cytometry.

RESULTS

The absolute CD4 count and percentage of CD4 cells (CD4%) were significantly higher in women (n = 195) than heterosexual men (n = 91) [difference between the means 111 x 106/1 (95% CI 41, 180) and 3.1% (1.30, 4.88)]. The absolute CD4 count and CD4% were also significantly higher in smokers (n = 143) than non-smokers (n = 140) [difference 143 (79, 207) and 2.1% (0.43, 3.81)]. Reference ranges for absolute CD4 counts (geometric mean +/- 2SD) were calculated on log transformed data as follows; female smokers 490-1610, female non-smokers 430-1350, heterosexual male smokers 380-1600, heterosexual male non-smokers 330-1280. Among other variables examined, combined oral contraceptive pill use was associated with a trend towards a lower absolute CD4 count. Changes were seen in CD4% with the menstrual cycle. CD4 counts and CD4% did not differ significantly between heterosexual men and homosexual men (n = 45).

CONCLUSION

There is a significant gender and smoking effect on CD4 counts. The effects of oral contraceptive use and the menstrual cycle warrant further investigation.

Fusion of the EWS gene to CHN, a member of the steroid/thyroid receptor gene superfamily, in a human myxoid chondrosarcoma

The specific chromosomal translocation t(9;22)(q22-31;q11-12) has been observed in the myxoid variant of human chondrosarcoma. In agreement with this observation we report that the EWS gene located at chromosome band 22q12 becomes fused to CHN, a member of the steroid/thyroid receptor gene superfamily located at 9q22-31, in a skeletal myxoid chondrosarcoma. CHN appears to be the human homologue of the rat gene NOR1, which was recently identified as a sequence overexpressed in rat brain cells undergoing apoptosis. Our results also indicate that the chimaeric EWS-CHN gene encodes a EWS-CHN fusion protein in which the C-terminal RNA-binding domain of EWS is replaced by the entire CHN protein, comprising a long N-terminal domain, a central DNA binding domain and a C-terminal ligand-binding/dimerisation domain.

c-Src regulates the simultaneous rearrangement of actin cytoskeleton, p190RhoGAP, and p120RasGAP following epidermal growth factor stimulation

Analysis of C3H10T1/2 murine fibroblasts overexpressing wild type and dominant negative variants of c-Src has demonstrated a requirement for c-Src in EGF-induced mitogenesis. Correlating with the ability of c-Src variants to potentiate or inhibit EGF-dependent DNA synthesis is the phosphotyrosine content of multiple cellular proteins, including p190-RhoGAP, a protein thought to regulate growth factor-induced actin cytoskeleton remodeling by modulating the activity of the small GTP binding protein, Rho. Because the in vivo phosphotyrosine content of p190 varies with the level of active c-Src and not with EGF treatment, p190 is considered to be a preferred substrate of c-Src. To determine whether tyrosyl phosphorylation of p190 (by c-Src) could influence EGF-dependent actin remodeling, we used conventional and confocal immunofluorescence microscopy to examine the intracellular distribution of p190, actin, and p120RasGAP in EGF-stimulated or unstimulated 10T1/2 Neo control cells and cells that stably overexpress wild-type (K+) or kinase-defective (K-) c-Src. We found that in all cell lines, EGF induced a rapid and transient condensation of p190 and RasGAP into cytoplasmic, arclike structures. However, in K+ cells the rate of appearance and number of cells exhibiting arcs increased when compared with control cells. Conversely, K- cells exhibited delayed arc formation and a reduction in number of cells forming arcs. EGF-induced actin stress fiber disassembly and reassembly occurred with the same kinetics and frequency as did p190 and RasGAP rearrangements in all three cell lines. These results, together with the documented Rho-GAP activity intrinsic to p190 and the ability of Rho to modulate actin stress fiber formation, suggest that c-Src regulates EGF-dependent actin cytoskeleton reorganization through phosphorylation of p190.

Fusion of SYT to two genes, SSX1 and SSX2, encoding proteins with homology to the Kruppel-associated box in human synovial sarcoma

We demonstrate that the cytogenetically defined translocation t(X;18)(p11.2;q11.2) found in human synovial sarcoma results in the fusion of the chromosome 18 SYT gene to either of two distinct genes, SSX1 or SSX2, at Xp11.2. The SSX1 and SSX2 genes encode closely related proteins (81% identity) of 188 amino acids that are rich in charged amino acids. The N-terminal portion of each SSX protein exhibits homology to the Kruppel-associated box (KRAB), a transcriptional repressor domain previously found only in Kruppel-type zinc finger proteins. PCR analysis demonstrates the presence of SYT-SSX1 or SYT-SSX2 fusion transcripts in 29 of 32 of the synovial sarcomas examined, indicating that the detection of these hybrid transcripts by PCR may represent a very useful diagnostic method. Sequence analysis has demonstrated heterogeneity in the fusion transcripts with the formation of two distinct SYT-SSX1 fusion junctions and two distinct SYT-SSX2 fusion junctions.

Fusion of the EWS gene to a DNA segment from 9q22-31 in a human myxoid chondrosarcoma

Southern blot analyses revealed a rearrangement of the EWS gene in a skeletal human myxoid chondrosarcoma. Interphase fluorescence in situ hybridization (FISH) studies, using cosmid clones F7 and G9 that flank the EWS locus on 22q12, confirmed the presence of this EWS gene abnormality. Cloning the rearranged EWS DNA fragment and mapping by FISH demonstrated that the EWS gene is joined to DNA sequences localised in 9q22-31. These findings are consistent with previous cytogenetic reports of a recurrent t(9;22)(q22-31;q11-12) in the myxoid variant of chondrosarcoma and reveal involvement of the EWS gene in a fourth type of human sarcoma.

The human SB1.8 gene (DXS423E) encodes a putative chromosome segregation protein conserved in lower eukaryotes and prokaryotes

We report that the human gene SB1.8 (DXS423E) encodes a protein of 1233 amino acids that is highly homologous (30% identity) to the essential yeast protein SMC1 which is required for the segregation of chromosomes at mitosis. Both SB1.8 and SMC1 contain an N-terminal NTP binding site, a central coiled-coil region and a C-terminal helix-loop-helix domain, and have structural features in common with the force generating proteins myosin and kinesin. SB1.8 also exhibits regions of homology and overall structural similarity to the prokaryote (Mycoplasma hyorhinis) protein 115p. Thus SB1.8 and SMC1 are members of a highly conserved and ubiquitous family of proteins that appear to have a fundamental role in cell division. In addition we show that SB1.8 (DXS423E) maps to a cosmid contig that lies centromeric to the OATL2 locus at chromosome Xp11.2.

Mapping the X chromosome breakpoint in two papillary renal cell carcinoma cell lines with a t(X;1)(p11.2;q21.2) and the first report of a female case

A t(X;1)(p11.2;q21.2) has been reported in cases of papillary renal cell tumors arising in males. In this study two cell lines derived from this tumor type have been used to indicate the breakpoint region on the X chromosome. Both cell lines have the translocation in addition to other rearrangements and one is derived from the first female case to be reported with the t(X;1)(p11.2;q21.2). Fluorescence in situ hybridization (FISH) has been used to position YACs belonging to contigs in the Xp11.2 region relative to the breakpoint. When considered together with detailed mapping information from the Xp11.2 region the position of the breakpoint in both cell lines was suggested as follows: Xpter-->Xp11.23-OATL1-GATA1-WAS-TFE3-SY P-t(X;1)-DXS255-CLCN5-DXS146-OATL2- Xp11.22-->Xcen. The breakpoint was determined to lie in an uncloned region between SYP and a YAC called FTDM/1 which extends 1 Mb distal to DXS255. These results are contrary to the conclusion from previous FISH studies that the breakpoint was near the OATL2 locus, but are consistent with, and considerably refine, the position that had been established by molecular analysis.

Patterns of practice analysis for acute myocardial infarction

OBJECTIVE

To assess the level of use of acetylsalicylic acid (ASA), beta-blockers and thrombolytic therapy--proven efficacious therapies in the management of acute myocardial infarction (AMI)--in contemporary patients admitted with AMI, and to assess the role of contraindications and other patient-specific factors in the use or nonuse of these treatments.

DESIGN

The demographics and treatment course of patients admitted with a diagnosis of AMI were reviewed. Specifically targeted therapies were ASA, beta-blockers and thrombolytic therapy. Rates of use were calculated as 'gross utilization' (overall use) and 'adjusted utilization' (accounting for late presentation to hospital, initially equivocal diagnosis or contraindications).

SETTING

Tertiary care hospital in suburban Vancouver, British Columbia.

PATIENTS

A total of 372 consecutive patients admitted to Royal Columbian Hospital between September 1, 1990 and September 1, 1991.

INTERVENTIONS

None.

MAIN RESULTS

Gross utilization of ASA, beta-blockers and thrombolytic therapy was 71, 31 and 21%, respectively. The adjusted utilization rates for early (6 h or less) treatment with ASA was 66%; with early beta-blockers, it was 18% and was 100% for thrombolytic therapy. Adjusted late (more than 6 h, to hospital discharge) use of ASA and beta-blockers was 84 and 57%, respectively.

CONCLUSIONS

With the exception of thrombolytic therapy, proven efficacious medical therapies for AMI appear underused at the study hospital. Ongoing educational efforts and continuing patterns of practice analyses are needed.

Identification of novel genes, SYT and SSX, involved in the t(X;18)(p11.2;q11.2) translocation found in human synovial sarcoma

Human synovial sarcomas contain a recurrent and specific chromosomal translocation t(X;18)(p11.2;q11.2). By screening a synovial sarcoma cDNA library with a yeast artificial chromosome spanning the X chromosome breakpoint, we have identified a hybrid transcript that contains 5' sequences (designated SYT) mapping to chromosome 18 and 3' sequences (designated SSX) mapping to chromosome X. An SYT probe detected genomic rearrangements in 10/13 synovial sarcomas. Sequencing of cDNA clones shows that the normal SYT gene encodes a protein rich in glutamine, proline and glycine, and indicates that in synovial sarcoma rearrangement of the SYT gene results in the formation of an SYT-SSX fusion protein. Both SYT and SSX failed to exhibit significant homology to known gene sequences.

Identification of variability of ribosomal DNA spacer from Pseudomonas soil isolates

The polymerase chain reaction was used to amplify the spacer region located between the 16S and 23S ribosomal RNA genes of strains of Pseudomonas fluorescens and Pseudomonas putida isolated from peat bog, canola field, or arctic plants. Some of spacer region of four of the P. fluorescens strains examined, strains 64-3, 63-28, QP5, and R17-FP2, was about 515 base pairs (bp) in length, and contained the genes for tRNA(Ile) and tRNA(Ala). The DNA sequences of two strains from canola, 64-3 and 63-28, differed at only two positions. The sequences of the peat bog strains QP5 and R17-FP2 were identical. However, differences were noted between the DNA sequence common to the pair of strains 64-3 and 63-28 and the corresponding common sequence for strains QP5 and R17-FP2. These differences were mainly concentrated in two DNA segments of 10 and 19 bp, respectively. A probe for the 19-bp variable segment that occurs in the ribosomal spacer of strains QP5 and R17-FP2 recognized total DNA from these two strains, but not DNA from other bacteria of different origins. These results suggest the existence of a limited degree of variability within the 16S-23S ribosomal DNA spacer region, and that this variability may be useful to the recognition of particular Pseudomonas strains from environmental samples.

Abnormalities of the p53 MDM2 and DCC genes in human leiomyosarcomas

In this study we have screened a series of 29 primary leiomyosarcomas for abnormalities of both the p53 gene and the MDM2 gene, which encodes a p53-associated protein. SSCP (single-strand conformation polymorphism) analysis and direct sequencing of polymerase chain reaction (PCR)-amplified DNA were used to establish that 6/29 tumours possessed point mutations of the p53 gene. Using a monoclonal antibody that recognises the p53 protein in immunohistochemical staining experiments, we observed overexpression of the p53 protein in five of the six tumours containing point mutations in the p53 gene. Southern analysis of tumour DNA revealed that 2/29 tumours demonstrated amplification of the MDM2 gene. When considered together, these results indicate that alterations in both the p53 gene and MDM2 gene are important in the development of a significant minority of leiomyosarcomas. In addition, we have demonstrated a significant association between the presence of abnormalities of the p53 gene or MDM2 genes in leiomyosarcomas and a more advanced clinicopathological stage (P = 0.03). We have also examined the role of the DCC tumour-suppressor gene in the development of human soft-tissue tumours in a variety of histological types. Except for evidence of a rearrangement in a single leiomyosarcoma cell line, SK-UT-1, we have found no direct evidence to support a role for mutation of the gene in the development of human soft-tissue tumours.

The t(X;18)(p11.2;q11.2) translocation found in human synovial sarcomas involves two distinct loci on the X chromosome

A high proportion of synovial sarcomas contain the reciprocal translocation t(X;18)(p11.2;q11.2). We have previously localized the breakpoint on the X chromosome between the X chromosome marker DXS255 and an ornithine aminotransferase (OAT) pseudogene region designated OATL2. Subsequently by fluorescence in situ hybridization (FISH) we provided evidence that YACs corresponding to the OATL2 locus spanned the break-point. In order to confirm the position of this breakpoint cosmids corresponding to the OATL2 region were isolated. Most of these cosmids mapped to four cosmid contigs designated C1-C4. Analysis of two contigs, C1- and C4, using FISH established that in four of six synovial sarcomas examined the breakpoint occurs between these two contigs: C1 lies distal to the break-point while C4 is proximal. In contrast we provide evidence that the breakpoint in the remaining two tumours mapped to a second pseudogene region called OATL1 that is telomeric to the OATL2 locus. This heterogeneity of the breakpoint position on the X chromosome explains why in previous mapping studies there have been discrepancies between the results obtained by different laboratories.

Induction of osteopontin mRNA expression during activation of murine NK cells

Osteopontin (OPN) is an extracellular phosphorylated glycoprotein expressed in bone, kidney, nervous tissue, bone marrow, and granulated metrial gland (GMG) cells in murine decidua. We recently demonstrated that GMG cells are differentiated natural killer (NK) lineage cells that share phenotypic, functional, and morphologic characteristics with adherent interleukin-2 (IL-2)-activated NK cells. We now show that conditions that induce resting splenic NK cells to develop into adherent, activated cells induce the expression of opn mRNA. Nonstimulated NK cells did not express opn mRNA detectable by Northern analysis. However, expression was evident by day 1-2 of culture of NK cells with IL-2, increased to high levels by day 4, and was maintained at high levels thereafter. Thus, expression of mRNA for OPN, a secreted protein associated with cell adhesion, embryonic development, tissue remodeling, and immune regulation, is up-regulated during the activation of NK cells.

Hamster monoclonal antibodies to murine natural killer cells

To further the study of natural killer (NK) cells we have produced hamster monoclonal antibodies (MAbs) with reactivities to mouse NK cells. MAbs 4A2 and 3C2 were obtained by fusing spleen cells from Syrian hamsters immunized with IL-2-activated NK cells with Fox-NY myeloma cells. 4A2 antigen was expressed by bone marrow (BM)-derived IL-2-responsive NK cell precursors, by mature NK cells of the BM, and by a highly lytic subset of splenic NK cells, in addition to IL-2-activated NK cells. 3C2 antigen was also expressed by BM-derived NK cell precursors, by mature NK cells in the BM, at low levels by splenic NK cells, and at high levels by IL-2-activated NK cells. These MAbs are likely to provide useful reagents for the study of the life history and functional significance of NK cells.

Thrombolysis in acute myocardial infarction. The implementation of thrombolytic therapy in a coronary care unit in 1992

In order to describe the execution of thrombolytic therapy in acute myocardial infarction (AMI) in a coronary care unit, case records of 427 admissions in 1992 due to definite or possible AMI were reviewed: 32% received thrombolytic therapy while 68% did not because of contraindications, delayed admission, advanced age or nondiagnostic ECG changes. Among cases otherwise eligible for thrombolytic therapy according to the instructions of the department, 32% did not receive thrombolytic treatment solely because of nondiagnostic ECG changes. There is an obvious need for implementation of improved early diagnostic tools in the decision-making of thrombolysis as for instance newer, sensitive biochemical markers and continuous vectocardiography.

Home administration of intravenous antibiotics to children with cystic fibrosis

In examining the home administration of intravenous antibiotics to children with cystic fibrosis, this article concentrates on the role and responsibilities of the nurse in the support and education of the parents and children.

Help at hand for nurse placement

After reading about the problems encountered by Annette Millage in her quest to further her children's nurse training (Information exchange, October 7), I suggest that anybody in a similar position may obtain help by contacting the Nurse Teachers Group of the British Association of British Paediatric Nurses.

Is the cervical spine clear? Undetected cervical fractures diagnosed only at autopsy

Undetected cervical-spine injuries are a nemesis to both trauma surgeons and emergency physicians. Radiographic protocols have been developed to avoid missing cervical-spine fractures but are not fail-safe. Three case reports of occult cervical fractures documented at autopsy in the face of normal cervical-spine radiographs and computerized tomography scans are presented.