Laryngeal Histoplasmosis

Histoplasma capsulatum is an endemic fungus found in moist, fertile soil; in North America, it is most prevalent in the river valleys of the central United States. Most primary infections in the immunocompetent host are asymptomatic or are thought to be a flu-like illness. Disseminated histoplasmosis most commonly occurs in immunosuppressed patients. Histoplasmosis infection involving the larynx is an extremely rare manifestation. Here, we describe the case of an immunocompetent man with symptomatic, acute pulmonary histoplasmosis with laryngeal involvement who presented with a chief complaint of hoarseness. We also review the literature of immunocompetent patients with laryngeal histoplasmosis.

Congenital Duplication of the Thumb

Duplication or polydactyly of the thumb is among the most common congenital deformities that involve the hand. The purpose of this presentation is to review the Mayo Clinic experience with thumb duplication and to present preferred operative procedures to achieve the best clinical outcome and esthetic appearance for the hand. We propose that a combination or "best of parts", utilizing the components of both duplicates with retention of the ulnar duplicate as the base for reconstruction will provide the most functional clinical result. A clinical grading system and analysis of results from our personal experience during two different time frames provides the scientific support for our conclusions that combination procedures are preferred to simple excisions or to central joining of parts as in the Bilhaut-Cloquet procedure.

Improved limits on nu(e) emission from mu+ decay

We investigated mu(+) decays at rest produced at the ISIS beam stop target. Lepton flavor (LF) conservation has been tested by searching for nu(e) via the detection reaction p(nu(e),e(+))n. No nu(e) signal from LF violating mu(+) decays was identified. We extract upper limits of the branching ratio (BR) for the LF violating decay mu(+)-->e(+)+nu(e)+nu(-) compared to the standard model (SM) mu(+)-->e(+)+nu(e)+nu(mu) decay: BR<0.9(1.7) x 10(-3) (90% C.L.) depending on the spectral distribution of nu(e) characterized by the Michel parameter rho=0.75(0.0). These results improve earlier limits by one order of magnitude and restrict extensions of the SM in which nu(e) emission from mu(+) decay is allowed with considerable strength. The decay mu(+)-->e(+)+nu(e)+nu(mu) often proposed as a potential source for the nu(e) signal observed in the LSND experiment can be excluded.

14-day variant of the bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone regimen in advanced-stage Hodgkin's lymphoma: results of a pilot study of the German Hodgkin's Lymphoma Study Group

PURPOSE

This multicenter pilot study assessed the feasibility and efficacy of a time-intensified bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP) regimen given in 14-day intervals (BEACOPP-14) with granulocyte colony-stimulating factor (G-CSF) support in advanced Hodgkin's lymphoma.

PATIENTS AND METHODS

From July 1997 until March 2000, 94 patients with Hodgkin's lymphoma stage IIB, III, and IV were scheduled to receive eight cycles of BEACOPP-14. Consolidation radiotherapy was administered to regions with initial bulky disease or residual tumor after chemotherapy.

RESULTS

All patients were assessable for toxicity and treatment outcome. Eighty-six patients received the planned eight cycles of BEACOPP-14. Consolidation radiotherapy was given in 66 patients. Chemotherapy could generally be administered on schedule. Dose reductions varied among drugs but were generally low. Acute toxicity was moderate, with World Health Organization grade 3/4 leukopenia in 75%, thrombocytopenia in 23%, anemia in 65%, and infection in 12% of patients. A total of 88 patients (94%) achieved a complete remission. Four patients had progressive disease. At a median observation time of 34 months, five patients have relapsed, one patient developed a secondary non-Hodgkin's lymphoma, and three deaths were documented. The overall survival and freedom from treatment failure rates at 34 months were 97% (95% confidence interval [CI], 93% to 100%) and 90% (95% CI, 84% to 97%), respectively.

CONCLUSION

Acceleration of the BEACOPP baseline regimen by shortening cycle duration with G-CSF support is feasible and effective with moderate acute toxicity. On the basis of these results, the German Hodgkin's Lymphoma Study Group will compare the BEACOPP-14 regimen with BEACOPP-21 escalated in a prospective multicenter randomized trial.

Expression of folylpolyglutamyl synthetase predicts poor response to methotrexate therapy in patients with rheumatoid arthritis

OBJECTIVE

The enzyme folylpolyglutamyl synthetase (FPGS) is involved in the resistance to methotrexate in tumor cell lines. The aim of the present study was to determine the impact of FPGS mRNA expression on resistance to methotrexate therapy in patients with rheumatoid arthritis (RA).

METHODS

We determined the expression of FPGS mRNA using the Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) in 141 patients with RA. All patients received methotrexate therapy. The primary outcome measures were disease activity as determined by a disease activity score (DAS) and response to therapy.

RESULTS

Seventy-eight of 141 patients (55%) showed expression of FPGS mRNA. FPGS mRNA expression was not associated with age, sex, disease duration, white blood cell count, erythrocyte sedimentation rate, C-reactive protein (CRP), number of swollen joints, number of painful joints, and combined therapy with other disease-modifying antirheumatic drugs (DMARDs) or additional corticosteroids. The response rate to methotrexate therapy was 44% for the total study population. Patients without FPGS mRNA expression showed a significantly higher response rate than patients with FPGS mRNA expression (57% versus 33%; p = 0.005). Multivariate logistic regression analysis revealed that female sex (p = 0.009) and FPGS mRNA expression (p = 0.004) were independent predictive factors for failure to achieve a response to methotrexate therapy.

CONCLUSION

FPGS mRNA expression is an independent predictive factor associated with poor response to methotrexate therapy in RA patients.

Prognostic factors in Hodgkin's lymphoma

Risk-adapted treatment strategies have constituted a major issue since the beginning of clinical research into Hodgkin's disease (HD). Various prognostic factors have been identified and several of those considered for staging procedures, resulting in strictly stage-dependent treatment recommendations for patients suffering from HD. These factors may be subdivided in host-related (e.g. age, sex) and tumour-related (e.g. number of tumour cells, growth characteristics, spread of tumour cells, resistance to apoptosis) factors. Owing to the striking improvement of the overall prognosis in HD patients it may be difficult to identify novel prognostic factors analysing the minority of patients with a fatal outcome. However, especially in advanced-stage disease, improved treatment results were achieved by the introduction of more aggressive treatment regimens, resulting in an increased toxicity rate. Thus, partially in contrast to earlier work in this field, future prognostic factors are needed for identification of those patients that have a good prognosis and might be susceptible to overtreatment. During the Fifth International Symposium on Hodgkin's Lymphoma, promising results on several new prognostic markers were presented. Furthermore, a joint effort to design new studies on large, well characterised patient groups has been initiated.

Genetic instability in Hodgkin's lymphoma

Genetic instability is a characteristic feature of the malignant Hodgkin and Reed-Sternberg (HRS) cells in classical Hodgkin's lymphoma and the lymphocytic and histiocytic (L&H) cells in lymphocyte predominant Hodgkin's lymphoma. Genetic instability can be classified into four major categories: distinct DNA mutations (microsatellite instability); numerical aberrations (chromosomal instability); structural aberrations (translocation instability); and gains and losses of chromosomal regions. In Hodgkin's lymphoma (HL), HRS cells and L&H cells show somatically mutated clonally rearranged immunoglobulin genes, thus characterizing these cells genetically as germinal center B cells. These cells furthermore show mutations of oncogenes and tumor suppressor genes in some cases (p53, IkappaBalpha, CD95/Fas). They do not, however, display microsatellite instability, as they have a proficient mismatch repair machinery. In contrast, HRS and L&H cells frequently harbor recurrent but not specific numerical and structural aberrations as detected by classical cytogenetics and fluorescence in situ hybridization analysis. Results from molecular genetic studies using comparative genomic hybridization and allelotyping (LOH) indicate typical genetic patterns in HL with gains and losses of distinct chromosomal regions. In some instances, candidate genes possibly involved in the malignant transformation of HRS cells and L&H cells have been characterized (JAK2, c-REL, MDM2). In summary, using molecular genetics it might be possible in the near future to elucidate some of the complex genetic instabilities observed in HL.

A case study: development of a bioassay for IL-1ra

The IL-1ra bioassay was overhauled in 1993 at Synergen, Inc. The team included bioassay specialists and two pre-clinical statisticians. We began by focusing on the technical aspects, optimizing the number of cells per well, altering the staining procedure, and checking incubation times. We then proceeded to revise the layout of the dose-response curves on the 96-well plates and included an internal control as well as a standard. Finally, we reconfigured the statistical modelling procedure to model each plate as a whole using a 9-parameter logistic curve. When the work was concluded, the precision (%CV) had improved from 44% to 10%, while the retest rate was reduced from 20-30% to less than 5%.

Preclinical evaluation of the antiproliferative potential of STI571 in Hodgkin's disease

STI571 is a selective tyrosine kinase inhibitor with proven therapeutic potential in malignancies expressing c-kit. A strong c-kit and stem cell factor expression was detected in the Hodgkin and Reed Sternberg cell line L1236, but not in 20 primary cases of classical Hodgkin's disease. Proliferation of L1236 cells was neither affected by addition of stem cell factor nor by neutralising anti-stem cell factor antibodies or STI571. Results suggest that patients with Hodgkin's disease may not benefit from therapy with STI571.

The identification and development of specific monoclonal antibodies to squamous cell carcinoma

We have developed specific monoclonal antibodies to immunogenic glycoproteins expressed selectively on the cell membrane of squamous cell malignancies. These proteins serve to act as tumor markers that characterize this malignancy; there has be no evidence of cross reactivity to normal epithelial cells. Analysis of patterns of expression reveals that those membrane proteins identified by monoclonals AD7 and 5C6 appear early in cellular transformation to malignancy. At such a time, immunohistochemical recognition is seen in the presence of genotypic alterations, yet phenotypic changes may not be apparent. Of additional interest is that these monoclonal antibodies exhibit strong ADCC allowing the tumor proteins to not only serve as a marker of malignancy but as a target for therapeutic destruction.

Whole-body positron emission tomography using 18F-fluorodeoxyglucose for initial staging of patients with Hodgkin's disease

An accurate initial staging of patients with Hodgkin's disease (HD) is important for the evaluation of clinical stage and risk factors, which are crucial for the choice of an appropriate treatment. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is useful for detecting active tumor tissue in patients with lymphoproliferative diseases and may contribute to conventional staging methods in patients with HD. Twenty-two patients who presented with newly diagnosed HD underwent conventional staging methods including computed tomography (CT) as well as FDG PET. Lesions apparent in FDG PET and CT were correlated to each other. Seventy-seven lesions were observed either in PET or CT or in both. In 48 (62%) lesions PET and CT were both positive. In 20 (26%) sites, PET was positive and CT negative. Of 22 patients (18%) 4 were upstaged due to these positive PET findings, and as a result one patient received a different therapeutic regimen. PET failed to detect nine (12%) CT-positive sites in six patients. Statistically, these data are reflected by a sensitivity for PET and CT of 88% and 74%, respectively. Specificity of both imaging modalities was 100%. PET can contribute valuable information as an additional staging examination and led to an upstaging in some patients with primary HD. However, PET should not be used as the only imaging modality as it failed to detect CT-positive, active tumor regions in some cases.

Long-term adverse effects on dentition in children with poor-risk neuroblastoma treated with high-dose chemotherapy and autologous stem cell transplantation with or without total body irradiation

Chemo- and radiotherapy may have injurious effects on developing teeth. In this long-term follow-up study among poor-risk neuroblastoma (NBL) survivors our aims were: (1) to assess both the type and extent of the side-effects of the anticancer treatment on tooth development; and (2) to develop an index for expressing total damage to the permanent dentition. We studied the dental development from panoramic radiographs (PRG) of 18 long-term survivors treated under the age of 6 years with high-dose (HD) chemotherapy and autologous stem cell transplantation (ASCT) for poor-risk NBL. The myeloablative therapy was either HD chemotherapy and fractionated total body irradiation (TBI) of 10-12 Gy (TBI group, n = 10) or HD chemotherapy only (non-TBI group, n = 8). A defect index (DeI) was developed to describe the damage to the permanent dentition. The DeI was also tested in 18 healthy adolescents. All NBL patients had disturbances in dental development including short roots, arrested root development, microdontia and tooth aplasia. After TBI, 9/10 patients had very severe root defects, in contrast to none in the non-TBI group. All children in the TBI group had 2-12 (mean 6.6) missing permanent teeth, while 2/5 in the non-TBI group (3/8 excluded due to young age) had two and four missing permanent teeth, respectively. Microdontia was found at equal frequency in both groups. The mean value of the DeI was 70.0 (range 28-117) in the TBI group, 15.2 (range 4-34) in the non-TBI group (P<0.001, Mann-Whitney U test) and 1.8 (range 0-15) in healthy adolescents. Disturbances in dental development may compromise occlusal function in poor-risk NBL patients after ASCT, especially when TBI is included in the conditioning regimen. Long-term dental follow-up and rehabilitation is required.

Gubernacular development in Müllerian inhibiting substance receptor-deficient mice

OBJECTIVE

To determine, in mice with disrupted Müllerian inhibiting substance (MIS) receptor genes, whether MIS affects gubernacular development; MIS causes Müllerian duct regression and is proposed to be involved in the first stage of testicular descent, because gubernacular development is abnormal in humans with persistent Müllerian duct syndrome.

MATERIALS AND METHODS

Ten wild-type, 11 heterozygotic and 12 homozygotic mice for MIS receptor mutations were killed at 17.5 or 18.5 days after conception or at birth, to provide serial sagittal sections of the pelvis. The amount of cremaster muscle, mitotic bodies in the gubernacular bulb, and gubernacular size were quantified by computer analysis (four mice/group).

RESULTS

Müllerian ducts were present in the homozygous mutants, partially present in the heterozygotes and absent in the wild-type controls. All mice had descended testes. The cremaster muscle was significantly less developed in homozygous mutants than in wild-type controls (P < 0.001) and heterozygotes (P < 0.01) at birth. The mitotic index between the gubernacula of all groups was indistinguishable. There was no statistical difference in gubernacular area amongst the groups. Poor cremaster muscle development in homozygous mutants gave the muscle a loose mesenchymal appearance.

CONCLUSIONS

Although there was an observable effect on cremaster muscle development in these mutant mice, gubernacular development and testicular descent were otherwise normal, and thus there must be other reasons for the observed differences in humans with persistent Müllerian duct syndrome.

Dental diseases and loss of teeth in a group of Finnish alcoholics: a radiological study

A total of 85 Finnish alcohol-dependent subjects and 53 controls were studied with panoramic radiography. The aim was to study the possible associations between prolonged alcohol consumption and dental health. The mean number of teeth, caries lesions, endodontic treatments, periapical lesions, marginal bone loss, and periodontal infrabony pockets was studied. The subjects met the diagnostic criteria of alcohol dependence as set out in DSM-IV and ICD-10. The control group comprised social drinking volunteers with an AUDIT score < or =8. For the final results the subjects were divided into groups on the basis of sex and age. The social backgrounds of the subjects were similar, except for employment and smoking. The results show significantly fewer teeth and more caries in the alcoholic group. There was a tendency for the alcoholics <45 years of age to have more endodontically treated teeth than the controls, but no difference in the number of periapical lesions in endodontically treated teeth was found. Horizontal bone loss and the presence of calculus were more frequent in alcoholic men than in alcoholic women. Significantly more horizontal bone loss was observed in the group of alcoholic nonsmokers than in nonalcoholic nonsmokers. In the nonsmoking groups alcoholics had significantly more periodontal destruction than the nonsmoking controls. We conclude that radiological dental health among individuals dependent on alcohol is weakened by more caries, more horizontal bone loss, and more numerous vertical infrabony pockets than social drinkers.