Overall and site-specific risk of malignant melanoma associated with nevus counts at different body sites: a multicenter case-control study of the German Central Malignant-Melanoma Registry

A large number of benign melanocytic nevi is the major risk factor for malignant melanoma (MM). In a multicenter case-control study, the number of common (CN) and clinically atypical (AN) nevi were counted separately at individual sites in 278 melanoma patients and 278 age- and gender-matched non-melanoma controls. Relative risk (RR) adjusted for age and sex was calculated. In men as well as women, the number of CN on the legs was the best predictor of overall melanoma risk. In men, RR for developing MM when > or = 1 AN were present on the trunk was 4-fold (vs. none). In women, presence of AN on the arms increased RR 9.5-fold. For men and women combined, after adjusting for age and gender, the RR for developing MM on the trunk and on the legs was best predicted by counts of CN at the respective body region. However, high counts of CN on the arms were associated with high melanoma risk on the legs (somewhat lower on the trunk). For AN, no site-specificity of melanoma risk was found. Our data suggest that nevus counts of the legs are the best predictor of overall melanoma risk if total body nevus counts are not feasible. Although high counts of CN on the trunk and legs are associated with a higher risk of developing MM at the respective site than at another site, our data do not unequivocally support a direct site-specific melanoma risk.

Expression of p53 protein in malignant melanoma: clinicopathological and prognostic implications

In the present study, we investigated the expression of the tumour suppressor protein p53 in 113 primary and 43 metastatic malignant melanomas by immunohistochemistry, and correlated the findings with clinicopathological parameters such as histological melanoma subtype, thickness of primary melanomas (Breslow thickness) and patient outcome. In primary melanomas, the polyclonal anti-p53 antibody CM-1 detected immunoreactivity in 70% of the lesions, predominantly in the cytoplasm. Signals were observed in this cellular compartment in 57% of the melanomas, whereas in 32% nuclear p53 over-expression was detected. Immunohistochemistry, using the monoclonal antibody DO-1, revealed lower staining frequencies. However, both antibodies showed congruent results in approximately 80% of the cases. Overall, immunoreactivity was observed in 73% of superficial spreading melanomas, but only in 52% of lentigo maligna melanomas. This difference (P < 0.001) was mainly due to a lower frequency of cytoplasmic immunoreactivity (P < 0.002). There was no difference with respect to cytoplasmic and nuclear immunoreactivity between thin (< 1 mm thickness) and thicker primary melanomas. Staining frequencies detected in metastatic lesions seemed to be lower than in primary tumours. In 103 primary melanomas, follow-up data for at least 5 years were available. In 71% (54 of 76) of the primary melanomas which did not recur, and in 78% (21 of 27) of tumours with subsequent metastases, p53 over-expression was detected by CM-1. However, this difference was not statistically significant. The results of the present study indicate that immunoreactivity to anti-p53 antibodies is a common observation in malignant melanomas, with staining signals predominantly found in the cytoplasm of cells.(ABSTRACT TRUNCATED AT 250 WORDS)

A defined region of loss of heterozygosity at 11q23 in cutaneous malignant melanoma

Karyotypic and molecular data indicate that genetic alterations of the long arm of chromosome 11 (11q) may be involved in malignant melanoma. To test this we analyzed 5 polymorphic microsatellite repeats on 11q using a PCR-based assay for loss of heterozygosity in normal and tumor tissues from 24 individuals with cutaneous malignant melanoma of various stages. Our findings indicate that a tumor suppressor gene that plays a role in malignant melanoma is located on the long arm of chromosome 11, likely within a 51 cM region at 11q23. Its loss appears to be a late event in tumor progression and may serve as an indicator for a less favorable clinical outcome.

Prospects for use of recombinant BPI in the treatment of gram-negative bacterial infections

The bactericidal/permeability-increasing protein (BPI), a potent cytotoxin specific for Gram-negative bacteria and an endotoxin-neutralizing agent, is a major component of the antimicrobial arsenal of mammalian polymorphonuclear leukocytes. The antibacterial and endotoxin-neutralizing activities of the N-terminal portion (approximately 25 kDa) of BPI are at least equal to those of the holoprotein (approximately 50 kDa). Recombinant N-terminal fragments of BPI are antibacterial and inhibit host cell responses to endotoxin in whole blood ex vivo and in animal experiments. BPI administered to both animals and man is apparently nontoxic and nonimmunogenic and acts synergistically with some antibiotics. Thus, the prospects for the therapeutic use of bioactive BPI fragments in serious Gram-negative bacterial infections are highly encouraging.

Antibacterial proteins of granulocytes differ in interaction with endotoxin. Comparison of bactericidal/permeability-increasing protein, p15s, and defensins

Bactericidal/permeability-increasing protein (BPI), antibacterial 15-kDa protein isoforms (p15s), and defensins (neutrophil peptides or NPs) are granule-associated antibacterial proteins of polymorphonuclear leukocytes (PMN) that have both direct and synergistic growth inhibitory activity against Gram-negative bacteria. In this study, we have compared in vitro the abilities of these antibacterial proteins, alone and in combination, to inhibit the endotoxic activity of isolated LPS and whole bacteria. All three proteins blocked endotoxin activity in: 1) the Limulus amoebocyte lysate assay, 2) priming of PMN for enhanced arachidonate release, and 3) stimulating leukocyte oxidase activity in 1% blood. However, the proteins differ markedly in both relative potency (BPI &gt; p15s = NP1) in the presence of the plasma LPS-binding protein and in the range of LPS chemotypes that can be inhibited. BPI potently neutralizes LPS of any chemotype, but p15s and defensins are less active against long-chain (S-type) LPS. In whole blood ex vivo, the p15s and NP1 are approximately 1000-fold less potent than BPI, but at subinhibitory doses act in synergy with BPI to inhibit the TNF-inducing activity of a serum-resistant encapsulated strain of Escherichia coli (K1/r). The anti-endotoxic effects of p15 and NP1 against E. coli K1/r in whole blood appear secondary to growth arrest, because, in marked contrast to BPI, they are not evident against nonviable bacteria (pretreated with antibiotic) nor isolated LPS. Thus, BPI stands out for its ability to inhibit isolated or bacterial LPS under physiologic conditions. However, p15s and defensins may also contribute to suppression of endotoxic signaling by Gram-negative bacteria via synergistic (with BPI) growth inhibition upon extracellular release of these proteins from PMN during inflammation.

Antibacterial proteins of granulocytes differ in interaction with endotoxin. Comparison of bactericidal/permeability-increasing protein, p15s, and defensins

Bactericidal/permeability-increasing protein (BPI), antibacterial 15-kDa protein isoforms (p15s), and defensins (neutrophil peptides or NPs) are granule-associated antibacterial proteins of polymorphonuclear leukocytes (PMN) that have both direct and synergistic growth inhibitory activity against Gram-negative bacteria. In this study, we have compared in vitro the abilities of these antibacterial proteins, alone and in combination, to inhibit the endotoxic activity of isolated LPS and whole bacteria. All three proteins blocked endotoxin activity in: 1) the Limulus amoebocyte lysate assay, 2) priming of PMN for enhanced arachidonate release, and 3) stimulating leukocyte oxidase activity in 1% blood. However, the proteins differ markedly in both relative potency (BPI >> p15s = NP1) in the presence of the plasma LPS-binding protein and in the range of LPS chemotypes that can be inhibited. BPI potently neutralizes LPS of any chemotype, but p15s and defensins are less active against long-chain (S-type) LPS. In whole blood ex vivo, the p15s and NP1 are approximately 1000-fold less potent than BPI, but at subinhibitory doses act in synergy with BPI to inhibit the TNF-inducing activity of a serum-resistant encapsulated strain of Escherichia coli (K1/r). The anti-endotoxic effects of p15 and NP1 against E. coli K1/r in whole blood appear secondary to growth arrest, because, in marked contrast to BPI, they are not evident against nonviable bacteria (pretreated with antibiotic) nor isolated LPS. Thus, BPI stands out for its ability to inhibit isolated or bacterial LPS under physiologic conditions. However, p15s and defensins may also contribute to suppression of endotoxic signaling by Gram-negative bacteria via synergistic (with BPI) growth inhibition upon extracellular release of these proteins from PMN during inflammation.

Failure of orally administered dipyridamole to enhance the antineoplastic activity of fluorouracil in combination with leucovorin in patients with advanced colorectal cancer: a prospective randomized trial

PURPOSE

A randomized trial was performed to investigate the ability of the nucleoside transport inhibitor dipyridamole (DP) to enhance the antitumor activity of fluorouracil (5-FU)/leucovorin (folinic acid [FA]).

PATIENTS AND METHODS

One hundred eighty-one untreated patients with advanced colorectal cancer were randomized to receive 5-FU 600 mg/m2 plus FA 300 mg/m2 on days 2 to 4 with or without DP 75 mg orally three times daily on days 1 to 5. Cycles were repeated every 3 weeks. Only patients with documented tumor progression before therapy were eligible. 5-FU pharmacokinetics using high-performance liquid chromatography (HPLC) were assessed in 11 nonrandomized patients receiving paired cycles with or without DP.

RESULTS

One hundred seventy-four patients were assessable for toxicity and response. There was no significant difference in toxicity, except DP-related headache in 24% of patients. An objective response rate of 15% (one complete response [CR] and 13 partial responses [PRs]) for 5-FU/FA and 13% (two CRs and nine PRs) for 5-FU/FA/DP was observed. The dose-intensity of 5-FU delivered was significantly higher (1.09- to 1.16-fold) for the DP-containing arm. Pharmacokinetic parameters of 5-FU did not differ significantly, except for a prolonged half-life (t1/2) induced by DP. The median time to progression (P = .8) and the median survival time (11.6 months for 5-FU/FA v 9.3 months for 5-FU/FA/DP; P = .14, log-rank test) were not different between treatment arms.

CONCLUSION

Orally administered DP did not improve the antineoplastic activity of 5-FU/FA in patients with advanced colorectal cancer when used at this dose and schedule. The observed increase in 5-FU dose-intensity for FU/FA/DP was not clinically relevant.

Transcriptional activation of the follicle-stimulating hormone beta-subunit gene by activin

Activin markedly stimulates FSH beta messenger RNA (mRNA) levels in rat pituitary cells. Nonetheless, the molecular mechanisms through which activin enhances FSH beta gene expression are not clear. To assess the role of transcriptional activation in activin stimulation, we first transfected two -2300FSH beta Luc constructs into primary pituitary cells and treated them with activin in plated culture and perifusion. Basal expression of the constructs was low, and no activin response was observed. These results suggested that additional FSH beta sequences are required for basal expression or that the effects of activin are not transcriptional. An alternative approach for measuring transcriptional responses was developed based upon changes in the levels of FSH beta primary transcripts (FSH beta-PT; newly transcribed mRNAs that still contain the first intron) after activin (3 ng/ml) stimulation of perifused rat pituitary cells. An increase in FSH beta-PT was observed after 30 min of activin stimulation, preceding the first observable rise in mature FSH beta mRNA. Levels of FSH beta-PT peaked between 1-2 h, then fell to a lower level (28% of maximal) at 4 h, which was maintained through 10 h of activin stimulation (36% of maximal at 10 h). Mature FSH beta mRNA levels peaked between 2-4 h, which is after the increase in FSH beta-PT, and fell more gradually between 4-10 h of stimulation (56% of maximal at 10 h). Unstimulated levels of mature mRNA and FSH beta-PT did not vary significantly over the course of the experiments. Cotreatment with the transcriptional inhibitor actinomycin-D (2 microM) blocked activin stimulation of both FSH beta-PT and FSH beta mRNA, confirming the transcriptional basis for these events. In summary, we have documented rapid and sequential increases in FSH beta-PT and mature FSH beta mRNAs after activin stimulation, which are prevented by transcriptional blockade. These data provide evidence that the increase in FSH beta mRNA levels after activin treatment are at least partly due to transcriptional activation of the FSH beta gene.

Malignant proliferating trichilemmal cyst

We report a case of a metastasizing proliferating trichilemmal cyst. A 78-year-old man had multiple common and two proliferating trichilemmal cysts, one of which showed malignant transformation as evidenced by lymph node metastases. Despite surgical removal of the malignant tumor, extensive metastatic disease rapidly occurred. This case exemplifies the difficulties in diagnosis and treatment of these rare tumors and their unpredictable course.

Extracellular accumulation of potently microbicidal bactericidal/permeability-increasing protein and p15s in an evolving sterile rabbit peritoneal inflammatory exudate

To what extent the host defense role of granule-associated antibacterial proteins and peptides of PMN includes extracellular action has not been established. To address this question, we have analyzed the antibacterial activity of cell-free (ascitic) fluid (AF) obtained from glycogen-induced sterile inflammatory rabbit peritoneal exudates in which > 95% of the accumulating cells are PMN. AF, but not plasma collected in parallel, exhibits potent activity toward serum-resistant Gram-negative and Gram-positive bacteria. Total and specific antibacterial activity of AF increases during the first 12 h after injection of glycogen in parallel with the influx of PMN. At maximum, > 99% of 10(7) encapsulated Escherichia coli and Staphylococcus aureus are killed in 30 min/ml of AF. Neutralizing antibodies against the bactericidal/permeability-increasing protein (BPI) of PMN abolishes activity of AF toward encapsulated E. coli but has no effect on activity vs staphylococci. However, BPI alone (approximately 1 microgram/ml in AF) can only account for < or = 20% of AF activity toward E. coli. AF also contains 15 kD PMN proteins (p15s) that act in synergy with BPI. Purified BPI and p15s, in amounts present in AF, reconstitute the growth-inhibitory activity of AF toward encapsulated E. coli. These findings show for the first time an extracellular function of endogenous BPI, providing, together with the p15s, a potent microbicidal system toward Gram-negative bacteria resistant to plasma-derived proteins and phagocytes in inflammatory exudates.

The construction and characterization of colanic acid deficient mutants in an extraintestinal isolate of Escherichia coli (O4/K54/H5)

Extraintestinal strains of Escherichia coli possess a variety of virulence factors that enable them to cause disease. These strains express a group 2 capsular polysaccharide which is important in the pathogenic process. Extraintestinal strains evaluated to date are also capable of producing the group 1 capsular polysaccharide colanic acid. The blood isolate CP9 (O4/K54/H5) constitutively produces the group 2, K54 capsule but can be induced to produce colanic acid. In this report we assess whether colanic acid contributes to the pathogenesis of this extraintestinal pathogen. CP9 and its derivatives that are deficient in their ability to produce colanic acid (TR94), the K54 group 2 capsule +/- colanic acid (CP9.137, TR1374) and the O4 specific antigen +/- colanic acid (CP921,CP925) were used to test whether the group 1 capsule colanic acid conferred protection against the bactericidal effects of serum and recombinant bactericidal/permeability-increasing protein (rBPI-23) in vitro. Additionally, CP9, CP9.137 and TR94 were evaluated in the rat granuloma pouch, an in vivo model for localized infection, and by intraperitoneal inoculation into mice, a systemic infection model. In summary, the inability of CP9 to produce colanic acid in the presence or absence of its K54 and O4 antigens had no effect on its ability to survive these host defenses in vitro and did not affect its virulence in these two in vivo models of infection.

Roles of estrogen, progesterone, and gonadotropin-releasing hormone (GnRH) in the control of pituitary GnRH receptor gene expression at the time of the preovulatory gonadotropin surges

Pituitary GnRH receptor (GnRH-R) messenger RNA (mRNA) levels are regulated dynamically during the rat estrous cycle. GnRH-R mRNA levels increase 3-fold on the morning of proestrus and remain elevated throughout the gonadotropin surges, after which they decline rapidly. Because the day of proestrus is characterized by complex changes in the steroidal milieu and increased release of hypothalamic peptides such as GnRH, a series of in vivo steroid replacement and in vitro perifusion studies was used to assess the relative contributions of estrogen (E), progesterone (P), and GnRH to the induction and decline of GnRH-R gene expression during the gonadotropin surges. Steroid replacement studies in ovariectomized (OVX) E-primed rats demonstrated that GnRH-R mRNA levels were elevated before and during the E-induced LH surge (1000-1800 h). Receptor mRNA levels declined after the peak of the LH surge and were significantly lower by 2000 h. Pentobarbital treatment, which inhibits hypothalamic input and the LH surge, prevented the gonadotropin surge-associated increase in GnRH-R mRNA levels in E-primed OVX rats. Although GnRH-R mRNA levels did not change throughout the day of experiments in OVX unprimed rats, treatment with pentobarbital significantly reduced GnRH-R mRNA expression in these animals. P treatment of E-primed OVX rats had no significant effect on GnRH-R mRNA expression during the LH surge, but significantly reduced mRNA levels immediately after the LH surge (2000 h). Data from in vitro perifusion experiments using either metestrous or proestrous pituitary glands demonstrated that pulsatile GnRH up-regulates the expression of its own receptor mRNA at both estrous cycle stages. Based on these results, we conclude that enhanced GnRH-R mRNA expression observed on the day of proestrus is largely due to the actions of E, exerted indirectly via hypothalamic routes (presumably through enhanced GnRH secretion). Furthermore, preovulatory P secretion may account for the rapid decline in GnRH-R mRNA levels observed on the evening of proestrus.

Mutation and expression of TP53 in malignant melanomas

Mutations of the TP53 gene are the most common genetic alterations in human malignancies. Overexpression of the p53 protein has been reported in high frequencies in all types of skin cancer. To determine the role of TP53 in the pathogenesis of malignant melanoma, we investigated the expression of p53 in 12 cell lines and 145 primary and metastatic lesions by immunohistochemistry. Overexpression of p53 was predominantly detected in the cytoplasm of the cells in 96 (66%) tumor and 12 (93%) cell lines. In contrast to findings in other tumor types, in melanomas immunoreactive cells were found in clusters or as scattered single cells. In primary melanomas, the frequency of p53 overexpression did not correlate with tumor thickness. Nucleotide sequencing of TP53 genes of 24 melanoma tumors/cell lines demonstrated point mutations in seven samples, all coding for mutant p53 protein species. The frequency of TP53 alterations of 20%-30% is lower than in other skin tumor types. Notably, immunohistochemistry was not a suitable method to distinguish overexpression of wild-type p53 from mutant species, since cell lines/tumors with TP53 mutations did not show distinctive staining patterns. The mutation pattern in six out of seven lesions was similar to that caused by ultraviolet light damage. This finding may be regarded a further indication for a pathogenetic role of UV light damage in at least a subgroup of malignant melanomas.

Homologous desensitization of gonadotropin-releasing hormone (GnRH)-stimulated luteinizing hormone secretion in vitro occurs within the duration of an endogenous GnRH pulse

A pulsatile GnRH signal is required for the maintenance of LH and FSH secretion. Studies in animals and in perifused pituitary cells have shown that continuous exposure to GnRH leads to decreased gonadotropin secretion and a blunted secretory response to subsequent pulses of GnRH, a process referred to as homologous desensitization. In the current study, we demonstrate that the duration of continuous GnRH exposure required to desensitize the gonadotrope in vitro is less than the durations of most in vivo GnRH pulses. Perifused male rat pituitary cells were tested with 20-sec pulses of 100 nM GnRH at 5-min intervals before, immediately upon termination of, and after GnRH infusions of varying concentration and duration. Desensitization in response to a GnRH infusion was calculated as the decrease in the LH response to the pulse of GnRH immediately after the infusion (Dsn pulse) compared to the mean LH response to GnRH pulses before and after the infusion. Gonadotropes were completely desensitized after a 2-min infusion of 10 nM GnRH (P < 0.05), the shortest duration tested. Endogenous GnRH pulses, by contrast, average more than 5 min in length. When the duration of GnRH infusion was held constant at 4 min, a concentration response for GnRH-induced desensitization was observed. Gonadotropes were desensitized by GnRH concentrations as low as 1 nM (P < 0.05), and maximal desensitization was observed with 5 nM GnRH. To determine the recovery period for GnRH-induced desensitization, a second series of experiments was performed. Experiments were conducted as described above, except the cells were perifused with medium that did not contain GnRH (recovery) for varying periods between the GnRH infusion and the Dsn pulse. A small response (16% of control) to the Dsn pulse of GnRH was observed after 1 min of recovery, and the response was not different from the control value (P > 0.05) after a 3-min recovery period. This recovery period is consistent with the ability to respond to endogenous GnRH pulses, which rarely exceed two per h. We conclude that GnRH-induced secretory desensitization and recovery occur within endogenous GnRH pulse durations and interpulse intervals, respectively. These data raise the possibility that homologous desensitization occurs under some in vivo conditions, providing an unexpected mechanism for physiological regulation of gonadotropin secretion.

Epidemiological use of rectal proliferation measures

Measures of rectal mucosal proliferation have been developed and used in research clinical settings, but their utility for larger-scale epidemiological studies remains uncertain. We assessed the suitability of bromodeoxyuridine (BrdUrd) and proliferating cell nuclear antigen (PCNA)-labeling indices (LIs) in the setting of a multicenter clinical trial of adenoma recurrence. Subjects at participating practices were asked to permit biopsy of normal rectal mucosa during a colonoscopy scheduled for other reasons. PCNA and BrdUrd labeling was performed, and corresponding LIs were computed. In general, subjects were willing to undergo biopsy during their scheduled procedures; less than 10% refused. Specimen preparation for PCNA was acceptable; the mean number of scorable crypts (+/- SE) was 12.99 +/- 0.37. Preparation for BrdUrd labeling was less successful, with a higher proportion of unscorable specimens and a lower mean number of scorable crypts. Among the 54 specimens with both LIs computed, the LI for PCNA was modestly higher than that for BrdUrd LI (4.1 +/- 0.2 and 3.7 +/- 0.2 respectively; P = 0.03). The rank order correlation between the two indices was 0.38). There was variation across centers in the PCNA LIs but few differences according to number of crypts scored. Measurement of rectal mucosal proliferation is feasible among endoscopy patients in large studies if PCNA is used; BrdUrd seems more difficult. The relationship between these two labels requires further study.

Carcinoma of the prostate gland: MR imaging with pelvic phased-array coils versus integrated endorectal--pelvic phased-array coils

PURPOSE

To compare the performance of pelvic phased-array (PPA) coils and integrated endorectal PPA coils in evaluation of local extent of prostate cancer.

MATERIALS AND METHODS

Seventy-one men underwent magnetic resonance (MR) imaging within 3 weeks of radical prostatectomy. MR findings of tumor, extracapsular extension, seminal vesicle invasion, nodal involvement, and stage were compared with step-sectioned (3-4-mm intervals) whole-mounted pathologic specimens. Prospective consensus versus single-reader interpretation (kappa statistics) and PPA versus integrated endorectal PPA coils (McNemar test) were compared, and a rating scale of 1-6 was developed for analysis of receiver operating characteristics. Statistical significance was calculated at delta = .05.

RESULTS

Comparison between consensus and single-reader image interpretation showed positive but poor agreement (kappa = .38) and no statistical significance. Staging accuracy was better (difference approached significance) for integrated endorectal PPA coils (77%) than for PPA coils (68%).

CONCLUSION

The integrated endorectal PPA coil is better for evaluation of local prostatic cancer than is the PPA coil.

Differential diagnosis of keratoacanthomas and squamous cell carcinomas: diagnostic value of DNA image cytometry and p53 expression

DNA-cytometry and immunohistochemistry with the anti-p53 antibody DO-1 was performed in 24 keratoacanthomas (KA) and 21 squamous cell carcinomas (SCC) (13 well-differentiated, 8 moderately differentiated) to establish the possible value of these methods for the differential diagnosis of both epithelial tumors. Aneuploidy was detected in 1 (4%) KA and 12 (57%) SCC (p < 0.05). In the latter tumors, histologic grade was associated with an abnormal DNA-content. Six (46%) well and 6 (75%) moderately differentiated SCC were shown to be aneuploid. Over-expression of p53 protein was found in 16 (76%) SCC and 14 (66%) KA (p > 0.05; not significant). However, quantification of p53 expression by evaluating both the intensity of immunostaining and the number of cells with over-expression by means of an immunoreactivity score (IRS) showed significant differences (p < 0.05). There was no correlation of p53 over-expression and aneuploidy in the tumors examined. The analysis of ploidy and immunostaining with anti-p53 antibodies may give useful additional information regarding the differential diagnosis of SCC and KA, if only aneuploidy or a high IRS are considered.

Sternal wound infection: our experience with 200 cases

More than 200 patients with sternal wound infections have been treated in the Plastic Surgery Department of our Medical Center over the years 1984-1993. Most of these were referrals from other hospitals. In recent years, the cases have become more severe, partially due to the fact that cardiac surgeons tend to operate older and sicker patients more readily than they previously did. 80% of these were post coronary bypass surgery, and the others heart and heart-lung transplants, repair of congenital heart anomalies, valve replacements etc. Several of the cases were cardiac surgery re-do's. Risk factors for developing this complication, such as diabetes, obesity, technical errors of sternal incision, prolonged intubation, the use of aortic balloon, etc. will be discussed. Many of our earlier patients had chronic fistulae following conservative therapy with old treatment modalities. In recent years, patients are usually referred at the acute stage. Most patients undergo removal of sternum and ribs. Previously, reconstruction included mainly transfer of the rectus ahdominis muscle, whereas lately the pectoralis muscles is utilized. Omentum was used in only one case. The importance of pre-operative imaging procedures has been thoroughly studied in our series. Especially important is the definition of the extent of the infection, and localization of foreign bodies causing chronic infections, such as suture material, epicardial electrodes etc. A change in infectants has also been noticed. In the first half of the study period, Pseudomonas aeruginosa comprised at least 40%.(ABSTRACT TRUNCATED AT 250 WORDS)

Shame, guilt, and depression in men and women in recovery from addiction

Men and women in recovery from addiction were compared on levels of depression and self-conscious affect including proneness to shame, guilt, externalization, detachment, and pride. The sample consisted of 130 subjects (88 men and 42 women; mean age 33.04), 90 of whom were active participants in a 12-step recovery program, and 40 of whom were in a residential treatment community. Subjects completed The Beck Depression Inventory and The Test of Self-Conscious Affect. Significant differences between the sexes were found for proneness to shame, detachment, and depression. Women were significantly higher on shame and depression; men were significantly higher on detachment. The subjects were compared to subjects who were not chemically dependent. It was found that these recovering drug-addicted subjects scored significantly higher in proneness to shame and externalization and significantly lower on proneness to guilt. Treatment implications of proneness to shame in the drug-addicted population, and particularly in women, are discussed. The use of confrontational drug treatment strategies may be contraindicated.

Structural determinants of the action against Escherichia coli of a human inflammatory fluid phospholipase A2 in concert with polymorphonuclear leukocytes

Extracellular 14-kDa phospholipases A2 (PLA2) in inflammatory exudates can contribute to bacterial phospholipid (PL) degradation during phagocytosis of Escherichia coli by polymorphonuclear leukocytes (PMN) and are highly active toward E. coli treated with the bactericidal/permeability-increasing protein (BPI) purified from PMN. PLA2 activity toward BPI-treated E. coli varies greatly among members of this conserved family of enzymes and apparently depends on a cluster of basic residues in a variable surface region near the NH2 terminus for recognition of this biological target (Weiss, J., Wright, G.W., Bekkers, A.C.A.P.A., van den Bergh, C.J., and Verheij, H.M. (1991) J. Biol. Chem. 266, 4162-4167). We have examined by site-specific mutagenesis of a recombinant PLA2 that is identical to an enzyme in human synovial fluid (containing His-6, Arg-7, Lys-10, and Lys-15 and a global net charge of +15) the role of basic residues in this region in PLA2 action against PLA-deficient (pldA-) E. coli. Substitution of Ser for Arg-7 +/- Gln for Lys-15 caused, respectively, about a 10- and 25-fold reduction in BPI-dependent PLA2 binding and activity to E. coli, but had no effect on hydrolysis of PL of autoclaved E. coli or dispersions of purified PL. PL degradation during phagocytosis was increased after pretreatment of E. coli (or PMN) with wild-type PLA2 followed by removal of unbound PLA2. Thus, the PLA2 binds to cells before phagocytosis followed by internalization of the enzyme along with E. coli and intracellular action. Mutant (e.g. R7S +/- K15Q) PLA2 show the same BPI-independent binding to E. coli as the wild-type enzyme but 10-30-fold reduced activity during phagocytosis, reflecting lower intracellular activity of these enzymes. Thus, structural determinants first implicated in PLA2 action toward E. coli treated with purified BPI apparently are also important in the intracellular action of PLA2 during phagocytosis by PMN.

Determinants of the inhibitory action of purified 14-kDa phospholipases A2 on cell-free prothrombinase complex

It has been suggested (Kini, R. R., and Evans, H. J. (1987) J. Biol. Chem. 262, 14402-14407) that the anticoagulant activity of members of the 14-kDa phospholipase A2 (PLA2) family depends on the presence of basic residues within a variable surface region (residues 54-77) distinct from both the conserved catalytic machinery and surface sites mediating the antibacterial action of these enzymes (see Weiss, J., Inada, M., Elsbach, P., and Crowl, R. M. (1994) J. Biol. Chem. 269, 26331-26337). To further define the determinants of the anticoagulant activity of PLA2, we have analyzed the inhibitory effects of purified native and recombinant PLA2 on cell-free prothrombinase. Both native and recombinant wild-type pig pancreas (net charge -1) and human "secretory" PLA2 (net charge +15) produced similar dose-dependent inhibition of prothrombinase activity that was significantly less potent than a toxic PLA2 purified from snake venom. Site-specific mutations that either increased or decreased PLA2 activity toward bactericidal/permeability-increasing protein-treated Escherichia coli by up to 50-fold had no effect on antiprothrombinase activity. In contrast, substitution of Arg for Asp-59/Gly for Ser-60 in the pig PLA2 increased antiprothrombinase activity by 5-10-fold without affecting catalytic activity toward a range of phospholipid substrates or antibacterial activity. Comparison of antiprothrombinase activity of catalytically active and inactive forms of the PLA2 and under a range of phospholipid conditions revealed that the potent antiprothrombinase activity of native toxic venom PLA2 and of the D59R.S60G mutant pancreatic PLA2 reflect combined catalytic and noncatalytic actions, the latter apparently dependent on basic residues at discrete surface sites in the enzyme.

[Our experience with diagnosis, evaluation and treatment of poststernotomy sternal wound infections]

During 1984-1992 162 patients with post-sternotomy sternal wound infections were treated. Between 0.4-5% of these undergoing sternotomy suffer from this complication which carries a mortality of about 50% when treated by conventional, nonsurgical methods. 80% of our patients had undergone aortocoronary bypass surgery and 11% valve replacement. Major risk factors identified for postoperative infection were prolonged mechanical ventilation, prolonged extracorporeal bypass, smoking, diabetes, obesity and chronic lung disease. Of 152 patients who underwent surgery, 35 had recurrent infections, especially during the first years of the study. 10 were managed by conservative methods. Reconstruction of the chest wall was performed in 125, using pectoralis major flaps (74 cases), rectus abdominis muscle flaps (53), myocutaneous flaps (5) and omental flap (1). Our series demonstrates the importance of a comprehensive, multi-disciplinary approach in evaluating and stabilizing these often critically ill patients. Computed tomography together with sinography have proven to be of major importance in diagnosing the location and extent of sternal wound infections. Strict adherence to antibiotic protocols, radical debridement of infected bone and soft tissues and subsequent reconstruction with muscle flaps has enabled us to reduce recurrent infection and improve morbidity and mortality rates.