Cell autonomous regulation of multiple Dishevelled-dependent pathways by mammalian Nkd

Genetic studies have identified Drosophila Naked Cuticle (Nkd) as an antagonist of the canonical Wnt/beta-catenin signaling pathway, but its mechanism of action remains obscure [Zeng, W., Wharton, K. A., Jr., Mack, J. A., Wang, K., Gadbaw, M., et al. (2000) Nature (London) 403, 789--795]. Here we have cloned a cDNA encoding a mammalian homolog of Drosophila Nkd, mNkd, and demonstrated that mNkd interacts directly with Dishevelled. Dishevelled is an intracellular mediator of both the canonical Wnt pathway and planar cell polarity (PCP) pathway. Activation of the c-Jun-N-terminal kinase has been implicated in the PCP pathway. We showed that mNkd acts in a cell-autonomous manner not only to inhibit the canonical Wnt pathway but also to stimulate c-Jun-N-terminal kinase activity. Expression of mNkd disrupted convergent extension in Xenopus, consistent with a role for mNkd in the PCP pathway. These data suggest that mNkd may act as a switch to direct Dishevelled activity toward the PCP pathway, and away from the canonical Wnt pathway.

Increased mortality in adults with a history of juvenile rheumatoid arthritis: a population-based study

OBJECTIVE

To assess mortality in a population-based cohort of adults with a history of juvenile rheumatoid arthritis (JRA).

METHODS

The Rochester Epidemiology Project database was used to identify all cases of JRA diagnosed among Rochester, Minnesota residents under the age of 16 between January 1, 1960 and December 31, 1993. Fifty-seven patients in this cohort are now adults (ages 18-53 years, mean age 34.3 years), and this subgroup was contacted for a long-term followup study. The average length of followup from the time of diagnosis was 25.6 years.

RESULTS

Four deaths occurred in this cohort of 57 adults with a history of JRA. All 4 deceased patients had other autoimmune illnesses and died of complications of these diseases. The observed frequency of 4 deaths was significantly greater (P < 0.0026 by one-sample log-rank test) than the 1 death that would be expected among Minnesota whites of similar age and sex, and corresponds to a mortality rate of 0.27 deaths per 100 years of patient followup compared with an expected mortality rate of 0.068 deaths per 100 years of followup in the general population.

CONCLUSION

The results indicate a significant, unexpected increase in mortality in this population-based cohort of adults with a history of JRA in comparison with the rate in the general population. The deaths in this group were all associated with other autoimmune disorders, suggesting that special emphasis should be given to the diagnosis and treatment of other autoimmune diseases, including immunodeficiencies, in JRA patients. The frequency of deaths in this cohort suggests that JRA patients are at substantial risk for mortality, and highlights the need for longitudinal followup and care into adulthood.

Primary anaplastic large cell lymphoma of the lung: a clinicopathologic study of five patients

Primary anaplastic large-cell lymphoma is a rare malignancy in the lung. Anaplastic large-cell lymphoma characteristically involves the lymph nodes or skin, with few reports from other sites. We studied the clinical and pathologic features of five cases of anaplastic large-cell lymphoma limited to the lungs. The patients were three women and two men aged 27 to 66 years (mean, 44.6 y) The tumors ranged in size from 1.1 to 5 cm. All patients were CD 30 (Ki-1) positive and CD 15 (LeuM-1) negative. Epithelial membrane antigen immunoreactivity was seen in two patients. Epstein-Barr virus was not detected by immunohistochemistry (four patients tested) or by polymerase chain reaction studies (three patients tested). The immunophenotypes were T cell (n = 3) and null (n = 2). Gene rearrangement studies supported the immunophenotypic findings. One patient who had underlying HIV infection died of infectious complications. One patient died at 6 months. Two patients developed recurrent disease and are alive after 42 and 51 months of follow-up. The remaining patient is alive at 8 years of follow-up without evidence of disease. ALCL can mimic metastatic or primary carcinoma and should be considered in the differential diagnosis of large cell neoplasms of the lung.

Case studies in pathology from the National Museum of Health and Medicine, Armed Forces Institute of Pathology

The National Museum of Health and Medicine was founded as the Army Medical Museum during the American Civil War to document the effects of war wounds and disease on the human body. Since then, the Museum has created a collection of documented pathologic specimens that can be used to study the gross and microscopic appearance of disease conditions. The Museum's collections are a vital link to the past and the future of medical research and form a unique national medical repository that is used continuously for research, education, and exhibit purposes. Today, the Museum in association with its parent institution, the Armed Forces Institute of Pathology, provides access to over 130 years of documented medical specimens. These specimens allow the unique opportunity to re-examine historical classification systems and disease diagnoses. The case of subacute chronic osteomyelitis with cortical sequestration of Private J. Potter from the Civil War is presented here.

The cost of disease eradication. Smallpox and bovine tuberculosis

Although eradication is the ideal approach to reduce the economic and human health costs of disease, there may be both short- and long-term consequences. A $300 million effort succeeded in completely eradicating smallpox in less than ten years. The campaign was effective because variola virus produced acute illness, had no carrier stage or non-human reservoirs, and had an effective vaccine that was used in combination with international surveillance and public education. Bovine tuberculosis was completely eradicated in many U.S. herds at a cost of $450 million over 50 years using a "test and slaughter" program combined with meat inspection. Mycobacterium bovis often does not produce acute disease, persists in the carrier stage, has multiple non-human reservoirs, and easily crosses species. No effective vaccine or centralized global surveillance or eradication programs currently exist. Control measures result in significant economic losses. Smallpox eradication had limited economic consequences but has left much of world's population highly susceptible to zoonotic orthopoxviruses and to the use of smallpox as a biologic weapon. The primary threat of M. bovis exists in wildlife that share watering holes or pasture land with domestic stock. In the developed world, surveillance can minimize risks, but one-third of the world's population lacks effective agricultural and food safety programs, leaving them at substantial risk for zoonotic infection by M. bovis.

Trichomoniasis in pregnant human immunodeficiency virus-infected and human immunodeficiency virus-uninfected congolese women: prevalence, risk factors, and association with low birth weight

OBJECTIVE

We sought to assess the prevalence of and risk factors for vaginal trichomoniasis in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected pregnant Congolese women and its relationship to pregnancy outcomes.

STUDY DESIGN

We performed a nested case-control study of 215 infected and 206 uninfected mothers who responded to questionnaires, underwent sexually transmitted disease testing (including culture for trichomoniasis shortly after delivery), and underwent assessment of infant outcomes. Maternal variables and birth outcomes were assessed according to presence or absence of trichomoniasis and human immunodeficiency virus.

RESULTS

Trichomoniasis was present in 18.6% of human immunodeficiency virus-positive and 10.2% of human immunodeficiency virus-negative women, respectively (odds ratio, 2.0; 95% confidence interval, 1.1-3.6), and was significantly associated with low birth weight (odds ratio, 2.4; 95% confidence interval, 1.2-4.5). In multivariate analyses trichomoniasis remained associated with low birth weight, and adjustments were made for other risk factors associated with low birth weight.

CONCLUSION

These findings suggest an association between trichomoniasis and low birth weight independent of human immunodeficiency virus infection and other risk factors. Further studies are needed to assess the impact of antenatal screening and treatment for trichomoniasis on pregnancy outcomes.

Pedal osteosarcoma in a donkey

An 18 1/2-year-old castrated male donkey with progressively worsening right forelimb lameness presented with a mass on the distal dorsal aspect of its P3 bone. Grossly, the firm, gritty mass was infiltrative, disrupted the contours of the overlying hoof wall, and had mottled and cavitated areas on cut surface. Histologically, the growth was composed of densely cellular sheets of mildly pleomorphic mesenchymal cells forming irregularly shaped islands of poorly mineralized osteoid. The neoplastic mass had patchy areas of necrosis. The diagnostic possibilities considered for this donkey's mass include osteosarcoma, osteoma, ossifying fibroma, and fibrous dysplasia. Careful consideration of the gross and histological characteristics of this donkey's mass support a diagnosis of osteosarcoma.

Pathology of human immunodeficiency virus infection: infectious conditions

Infection with the human immunodeficiency virus (HIV) and the subsequent derangement of host immunity place affected patients at risk for secondary infections. Some of the secondary pathogens occur with such frequency or are so rare in the non-immunosuppressed population that they have become part of the Centers for Disease Control and Prevention (CDC) classification for HIV/acquired immune deficiency syndrome (AIDS). Other infectious agents not yet included in the CDC definition are being reported in the HIV-infected population with increased frequency. General observations of the degree of immunosuppression associated with specific secondary infections have been useful in developing classification systems for HIV disease such as that of the CDC. However, the specific alterations in host immunity that promote infection with specific secondary pathogens are generally unknown. Geographic differences in the types and frequency of secondary infections also have been reported. Variation in strains of HIV, effect of malnutrition, lack of appropriate medical treatment, prevalence of virulent infectious diseases, and epidemiologic differences are possible contributing factors. Some infections that seemed likely to be closely associated with HIV infection have not occurred more frequently in HIV-infected patients. This review summarizes the histopathology of infectious conditions in the current CDC classification and highlights some conditions seen in HIV-infected individuals that are not currently HIV/AIDS-defining infections, yet may be seen by practicing pathologists.

Psychosocial outcomes and health status of adults who have had juvenile rheumatoid arthritis: a controlled, population-based study

OBJECTIVE

The goal of this study was to evaluate the physical and psychosocial impact of juvenile rheumatoid arthritis (JRA) among a population-based cohort of adults who had the disease during childhood, compared with a control cohort of subjects with no history of JRA.

METHODS

The Rochester Epidemiology Project database was used to identify all cases of JRA (based on the American College of Rheumatology [formerly, the American Rheumatism Association] 1977 criteria) among Rochester, Minnesota residents first diagnosed between January 1, 1960 and December 31, 1993. Controls were age- and sex-matched to the cases as of the date of diagnosis of JRA. A pretested postal survey was mailed to all adult cases (whose date of birth was before December 31, 1975) and matched controls from the same population, to obtain information on socioeconomic issues and functional status (using the Health Assessment Questionnaire and the Health Status Questionnaire). The complete medical records of all cases and controls were reviewed to obtain information on demographics and clinical manifestations of JRA.

RESULTS

Of the 50 eligible cases, 44 (88%) responded to the survey. There were 102 age- and sex-matched controls (2-3 per case) who responded to the survey. Seventy-three percent of the cases had pauciarticular-onset JRA, 16% had polyarticular-onset JRA, and 11% had systemic-onset JRA. Average followup was 24.7 years and 24.5 years after the index date for cases and controls, respectively. Greater disability (P = 0.0002), more bodily pain (P = 0.0002), increased fatigue (P = 0.0112), poorer health perception (P = 0.0004), and decreased physical functioning (P = 0.0002) were reported by the cases compared with the controls. JRA cases reported significantly lower rates of employment (P = 0.015) and lower levels of exercise (P = 0.0002) than did controls. Level of educational achievement, annual income, health insurance status, and rate of pregnancy and childbirth were similar for both cases and controls.

CONCLUSION

Adults who have had JRA during childhood experience long-term physical and psychosocial impairment.

Pathology of human immunodeficiency virus infection: noninfectious conditions

Diagnostic anatomic pathologists play a crucial role in the battle against acquired immunodeficiency syndrome (AIDS). Not only are they intimately involved in the treatment of individual patients with human immunodeficiency virus (HIV) infection, but also they make important observations that result in the expansion of the scientific understanding of its pathogenesis. Pathologists studying tissue from patients with HIV infection should be familiar with the conditions to which these patients are susceptible. Although opportunistic infections are important causes of morbidity and mortality, noninfectious conditions frequently make substantial contributions to the disease course. Patients with HIV infection may be at increased risk for neoplastic disease. They do not, however, have an increased incidence of the most common tumors affecting the general population, such as breast, colon, and prostate carcinoma. Immunodeficiency results in increased susceptibility to malignant neoplasms, both by decreased immunologic response to abnormal cells and increased susceptibility to infection by viruses. All of the malignant neoplastic diseases that are Centers for Disease Control and Prevention (CDC) AIDS indicator conditions have been shown to have an association with a virus: Kaposi sarcoma (KS) with herpes hominis virus 8 (HHV-8), malignant lymphoma with Epstein-Barr virus (EBV), and cervical carcinoma with human papilloma virus (HPV). Patients with HIV infection also can develop reactive processes that are attributable to direct effects of HIV or immune system alterations. Such conditions include salivary gland cystic lymphoepithelial lesion, lymphadenopathy, lymphocytic interstitial pneumonitis, encephalopathy, enteropathy, nephropathy, hepatic conditions, dermatologic conditions and anemia.

Neuroimaging--autopsy correlations in AIDS

This article is a brief review of the radiologic-pathologic correlation of central nervous lesions occurring in patients with AIDS. The major discussions of the imaging appearance and radiologic differential diagnosis have been presented elsewhere in this issue. Our emphasis is on the gross pathologic correlations that are only possible with autopsy materials. We will illustrate the opportunistic neoplasms such as primary CNS lymphoma. This article also discusses the imaging and pathology of the common opportunistic infections. Toxoplasmosis, an obligate intracellular protozoan, is the most common CNS infection producing a mass lesion in AIDS. However, AIDS encephalitis, a direct infection of the brain by the HIV-1 virus itself, may actually be more prevalent. Other viral infections occurring in AIDS include progressive multifocal leukoencephalopathy. Fungal diseases infecting the central nervous system of AIDS patients include cryptococcus, aspergillosis, and mucormycosis. The primary purpose of this article is to demonstrate how the gross pathology correlates with the radiologic images.

Active replication of HIV-1 at the lymphoepithelial surface of the tonsil

Cells that are infected with HIV-1 were visualized at the mucosal surface of the nasopharyngeal and palatine tonsils in 14 specimens from patients with CD4+ T-cell counts of 200 to 900/microliter and 2- to 10-year histories of HIV-1 infection. Most of the cells with intracellular HIV-1 protein were small but multinucleated. The majority of these syncytia could be double labeled for HIV-1 RNA and a dendritic cell marker S100. In the palatine tonsil, the infected cells were not found in the stratified squamous epithelium that is adjacent to the pharynx. Instead, the S100+ infected syncytia were localized to the surface of tonsil invaginations or crypts. This mucosa, termed lymphoepithelium, contains antigen-transporting M cells that lie above regions where S100+ dendritic cells are juxtaposed with CD4+ lymphocytes. Likewise, infected cells were found in lymphoepithelium and not respiratory epithelium of nasopharyngeal tonsils or adenoids. We propose that lymphoepithelia, the histological term that describes the specialized regions where antigens access mucosa-associated lymphoid tissue, are sites where HIV-1 replication can be enhanced in syncytia derived from dendritic cells.

Prevention of acute emesis in cancer patients following high-dose cisplatin with the combination of oral dolasetron and dexamethasone

PURPOSE

Dolasetron is a 5-HT3 antagonist antiemetic with active oral and intravenous formulations. The effects of this class are enhanced when combined with dexamethasone. This study tested the ability of the combination of oral dolasetron 200 mg and oral dexamethasone 20 mg to prevent acute emesis in cancer patients receiving initial cisplatin at doses > or = 70 mg/m2. Additionally, patients were randomly assigned to receive a second dosage of the regimen 16 hours later to improve control of acute symptoms.

PATIENTS AND METHODS

A total of 75 patients were entered, with 38 randomized to the two-dose regimen. Thirty-five percent were women and 77% had lung cancer.

RESULTS

Overall, the regimen prevented acute vomiting in 76% (95% confidence interval, 65% to 85%), including 74% of 35 patients who received cisplatin at doses > or = 100 mg/m2. There was no observed difference in emesis prevention between the one-dose (76%) and two-dose (76%) regimens (95% confidence interval for the difference, -20% to 19%). The median time to the onset of emesis was 19 hours for the one-dose regimen and 17 hours for the two-dose regimen in those patients with emesis. Headache occurred in 11% who received one dose and 16% who received two doses.

CONCLUSION

The combination of oral dolasetron 200 mg and dexamethasone 20 mg given only once prevented acute emesis in 76% of patients who received cisplatin > or = 70 mg/m2. Administration of a second dose of the regimen did not improve the observed prevention rate or delay the time to emesis. This one-dose oral regimen has comparable or better effectiveness than reported results of intravenous combination regimens in preventing cisplatin-induced vomiting and merits further study and use.

Using research for successful Medicare and Medicaid risk marketing

Medicare/Medicaid risk marketing is a vital business challenge, one that countless managed care organizations are facing right now. Early entry into new markets and aggressive participation in existing markets are essential to meet competitive pressures. Health plans intent on success in government risk programs should conduct research to learn the medical needs, wants, and desires of older persons in the geographic area they serve. Original, market-specific research yields critical marketing and clinical data that can be used to improve care and member satisfaction along with customer loyalty and retention.

Microsporidium-associated sinusitis

Two cases of biopsy-proven Microsporidium-associated chronic sinusitis in HIV-seropositive patients are presented. Spores of Septata intestinalis were identified by light microscopy and confirmed by electron microscopy in each case. Both patients displayed severe deficiencies of nasal mucosa CD4-positive cells, demonstrated by immunohistochemical methods. Only two other cases of Septata intestinalis-associated sinusitis have been reported previously. Our observations agree with the theory that functional defects in local mucosal immunity may partially explain the acquisition of opportunistic mucosal infections in many HIV-seropositive patients.

The epidemiology of morphea (localized scleroderma) in Olmsted County 1960-1993

OBJECTIVE

To determine the incidence, prevalence, survival rates, clinical manifestations, and longterm outcome of patients with morphea (localized scleroderma) and its subtypes over a 33 year period in Olmsted County, Minnesota.

METHODS

We used the unique data resources of the Rochester Epidemiology Project to review all Olmsted County medical records with any potential diagnosis consistent with morphea (including plaque, generalized, bullous, linear, and deep entities) from 1960 through 1993.

RESULTS

We screened 1030 medical records and identified 82 (59 female; 23 male) cases of morphea first diagnosed between 1960 and 1993. All cases were followed until death or migration from Olmsted County, a total of 754 person-years of observation. The annual age and sex adjusted incidence rate per 100,000 population was 2.7 (95% confidence interval 2.1, 3.3). The incidence rate increased significantly over the 33 years (p = 0.0037) on an average of 3.6% per year. The prevalence (estimated using cumulative incidence) at 80 years of age was about 2/1000. 50% of the patients had a cutaneous softening or evidence of disease resolution by 3.8 years' duration. The shortest active disease duration was found in the plaque group (50% resolution or skin softening by 2.7 years) compared to 5.5 years in the deep group. Arthralgias, synovitis, uveitis, and joint contractures were more frequent in the linear and deep categories. Although 9 patients (11%) developed some disease related disability over the followup period, this was common (44%) in the deep group. No case of morphea developed severe internal organ involvement and none progressed to systemic sclerosis. The survival rate was not significantly different from the general population (p = 0.409).

CONCLUSION

Morphea, and its subtypes, are more common than previously recognized, and can lead to important disability.

Localized forms of scleroderma, including morphea, linear scleroderma, and eosinophilic fasciitis

Under the term localized scleroderma a spectrum of conditions is classified, ranging from localized plaques of morphea of cosmetic importance only, to deep lesions of linear scleroderma and eosinophilic fasciitis, which can result in considerable morbidity. The etiology is unknown; environmental, infectious, and autoimmune causes have been proposed. In the past year, a revised classification of morphea has been presented. Additional information relating to pathogenesis, laboratory studies, and associated manifestations is reviewed.

Juvenile rheumatoid arthritis in Rochester, Minnesota 1960-1993. Is the epidemiology changing?

OBJECTIVE

To examine trends in the incidence and prevalence of juvenile rheumatoid arthritis (JRA) in Rochester, Minnesota, over 33 years.

METHODS

The diagnostic retrieval system of the Rochester Epidemiology Project was utilized to screen medical records of all Rochester residents with any potential diagnoses of JRA from 1978 to 1993 (based on the American College of Rheumatology 1977 revised criteria). In addition, all cases of JRA from our previously identified cohort from 1960-1979 were verified, and the 2 data sets were combined, resulting in an incidence cohort spanning 33 years (1960-1993).

RESULTS

Of the 1,240 medical records screened, we identified 65 cases of JRA diagnosed between 1960 and 1993 (48 females, 17 males). The average followup for cases was 12.7 years (range 0-34 years) for a total of 833 person-years of observation. A bimodal distribution of age at diagnosis was observed, with peaks between 0 and 4 years and 9 and 15 years. Seventy-two percent of patients had pauciarticular-onset, 17% had polyarticular-onset, and 11% had systemic-onset disease. Progression of pauciarticular to polyarticular disease occurred in 11% of the cases. The overall age- and sex-adjusted incidence rate was 11.7 per 100,000 population (95% confidence intervals 8.7, 14.8). The incidence rate per 100,000 population was 15.0, 14.1, and 7.8 for the time periods 1960-1969, 1970-1979, and 1980-1993, respectively (P = 0.024). A 3-year, centered, moving average, which was used to display time trends in incidence, suggested a cyclical pattern, with incidence peaks in 1967, 1975, and 1987.

CONCLUSION

An overall decrease in the incidence rate over the last decade was observed, most marked in the pauciarticular- and systemic-onset subtypes. This decrease, along with the observed cyclical pattern, suggest that environmental factors may influence disease frequency.

Replication of HIV-1 in dendritic cell-derived syncytia at the mucosal surface of the adenoid

Human immunodeficiency virus-type 1 (HIV-1) replicates actively in infected individuals, yet cells with intracellular depots of viral protein are observed only infrequently. Many cells expressing the HIV-1 Gag protein were detected at the surface of the nasopharyngeal tonsil or adenoid. This infected mucosal surface contained T cells and dendritic cells, two cell types that together support HIV-1 replication in culture. The infected cells were multinucleated syncytia and expressed the S100 and p55 dendritic cell markers. Eleven of the 13 specimens analyzed were from donors who did not have symptoms of acquired immunodeficiency syndrome (AIDS). The interaction of dendritic cells and T cells in mucosa may support HIV-1 replication, even in subclinical stages of infection.

Takayasu's arteritis presenting with unilateral digital clubbing

Unilateral clubbing has been associated with local vascular lesions of the arm, axilla, and thoracic outlet and with hemiplegia. We describe a patient with Takayasu's arteritis, a disease that affects the aorta and its major branches, who presented with unilateral digital clubbing. A review of the literature on unilateral clubbing is included.