Importance of dose of type II collagen in suppression of collagen-induced arthritis by nasal tolerance

OBJECTIVE

To determine the influence of the dose of collagen given nasally on the induction of specific mucosal tolerance in collagen-induced arthritis.

METHODS

The severity of clinical arthritis induced in DBA/1 mice was studied after the nasal administration (before disease induction) of 1 of 4 doses (across a 2-log range) of bovine type II collagen (CII). Parameters of immunity included lymphocyte proliferation and cytokine production in vitro in response to antigen stimulation, and the production of anticollagen IgG antibody subclasses.

RESULTS

The 3 highest doses (20, 80, and 320 microg) ameliorated disease severity, whereas the lowest dose (5 microg) aggravated disease. These findings correlated well with antigen-specific T cell proliferation and cytokine and antibody production. T cell proliferation was suppressed by the higher doses of CII, whereas the low dose enhanced T cell proliferation, indicating it primed the T cells. Suppression of T cell proliferation could be overcome by the addition of exogenous interleukin-2 (IL-2) to these cultures. Decreased T cell proliferation was associated with suppression of both Th1 (interferon-gamma [IFNgamma]) and Th2 (IL-4) cytokines and all the subclasses of anticollagen IgG in mice receiving 20, 80, or 320 microg of collagen. Overall, the highest dose of collagen (320 microg) was less effective at suppressing the immune response and disease than the 20-microg or 80-microg doses. There was an increased production of antibodies of all IgG isotypes, and of the Th1-associated cytokines IFNgamma and IL-2, in animals that had received the lowest dose of 5 microg collagen nasally.

CONCLUSION

Nasal administration of antigens is effective in inducing tolerance and reducing disease severity, but the effects are dose dependent. Low doses can prime the immune system and aggravate disease; high doses may not suppress disease. Suppression of the immune response, which correlates with suppression of disease, is not obviously associated with a type I to type II T cell switch, but rather with an overall suppression of both forms of T cell response, with a potential role for anergy of T cells in this process.

Post-partum ovarian vein thrombosis

Post-partum ovarian vein thrombosis (POVT) is uncommon, but the true incidence is not known. Ninety per cent of cases present as right iliac fossa pain within 10 days of delivery. Anti-coagulation and intravenous antibiotics are the mainstay of treatment. We report three cases that were referred to our unit. These cases illustrate the difficulty in the clinical diagnosis of POVT and highlight the importance of its inclusion in the differential diagnoses of an acute abdomen in post-partum patients. POVT can be accurately diagnosed by appropriate noninvasive investigations and a laparotomy avoided.

Identification of candidate endothelial cell autoantigens in systemic lupus erythematosus using a molecular cloning strategy: a role for ribosomal P protein P0 as an endothelial cell autoantigen

OBJECTIVE

To attempt to characterize the diversity and nature of antigens recognized by anti-endothelial cell antibodies (AECA) in patients with systemic lupus erythematosus (SLE) using a molecular cloning strategy.

METHODS

AECA in sera of 15 SLE patients were measured by ELISA and Western blot analysis was used to examine the diversity of autoantigen targets in two clinically active patients. A human umbilical vein endothelial cell cDNA expression library was immunoscreened with sera from these two patients to identify their autoantigen targets. An anti-ribosomal P peptide antibody ELISA was used to assess the clinical significance of anti-ribosomal P protein antibodies in the sera of one patient.

RESULTS

Significantly higher AECA levels were found in five patients with active disease and nephritis than in five patients with clinically inactive disease. Sera from two clinically active patients were found to recognize distinct spectra of autoantigens. The candidate autoantigens that were identified included (1) endothelial cell-specific plasminogen activator inhibitor; (2) the classical lupus antigen, i.e. ribosomal P protein P0; and (3) proteins never before described as putative autoantigens in SLE, including ribosomal protein L6, elongation factor 1alpha, adenyl cyclase-associated protein, DNA replication licensing factor, profilin II and the novel proteins HEAPLA 1 and HEAPLA 2 (human endothelial associated putative lupus autoantigens 1 and 2). In one patient, antibodies against ribosomal P protein P0 were predominant and levels of these antibodies correlated with total AECA levels, anti-DNA antibody titres, overall clinical score and renal disease in a longitudinal study.

CONCLUSIONS

A panel of candidate endothelial autoantigens in SLE, which includes previously described autoantigens and novel targets, has been identified by a molecular cloning strategy. This novel molecular approach could also be applied to the identification of autoantigens in other autoimmune vascular diseases.

Local staging of Wilms' tumor--computerized tomography correlation with histological findings

PURPOSE

The aim of this study was to assess the accuracy of computed tomography (CT) in the local staging of Wilms' tumor.

METHODS

Twenty-six patients with unilateral, nonmetastatic Wilms' tumors were accrued over the period of 1990 through 1997. Preoperative CT staging was performed before surgical biopsy or excision. The abdominal CT images were reviewed and staged for local disease according to National Wilms' Tumour Study (NWTS) Group Staging V as either intrarenal disease (Stage I), local extrarenal extension amenable to complete local excision (Stage II), or advanced local disease (Stage III). Patients with metastatic (Stage IV) and bilateral disease (Stage V) were excluded from our study. Results were compared to histological findings.

RESULTS

CT scan correctly staged 10 of 26 cases (38%) of Wilms' tumor. CT scan overstaged 12 of 16 (75%) localized renal disease (Stage I) and local extension (Stage II) tumors, and understaged 4 of 10 (40%) localized spread (Stage III) tumors.

CONCLUSIONS

CT scan appears to have poor correlation to histological staging. Therefore, basing therapy solely on radiological imaging may lead to some patients receiving more intense therapy than necessary, whereas others do not receive sufficient therapeutic regimens. Histological assessment of the excised mass should remain the standard for staging Wilms' tumors.

Presentation of low anorectal malformations beyond the neonatal period

OBJECTIVE

Anorectal malformations are usually diagnosed at birth, but some patients have presented to this institution beyond the early newborn period without recognition of their anorectal malformations. To quantify the extent of this problem, we undertook a review of all patients presenting to this hospital with anorectal malformations.

METHODS

We reviewed all new cases of anorectal malformations treated at British Columbia's Children's Hospital during the past 11 years. We looked specifically at the time of diagnosis, patient age, sex and mode of presentation, the type of anorectal malformations, and any associated anomalies.

RESULTS

One hundred twenty new cases of anorectal malformations were seen here, of whom, 15 patients (9 girls and 6 boys) presented beyond the early newborn period. Of these, 1 male infant was diagnosed at 2 weeks of age and another girl at 14 years of age. The remaining 13 presented between 3 and 11 months of age because of increasing constipation, usually associated with the introduction of solid foods. All had low anorectal malformations. Nine patients had at least 1 other feature of the VACTERL complex.

CONCLUSIONS

Most anorectal malformations are identified at birth, but a significant number of the milder lesions may not be recognized until later. Therefore, this condition must be considered in older infants and children presenting with constipation, particularly if they also have cardiac or genitourinary anomalies. constipation, imperforate anus, VACTERL.

Breast cancer in a 6-year-old child

A 6-year-old girl presented for a second opinion with a 1-year history of an enlarging soft tissue mass just lateral to the right areola. She had been seen by a pediatric surgeon elsewhere who reassured the parents that the lesion was benign. Ultrasound scan showed a 1.5- x 1.5-cm cystic structure adjacent to the right breast bud. Excisional biopsy results showed secretory ductal adenocarcinoma. Modified radical mastectomy with axillary node dissection was performed. All 11 nodes were negative for metastatic disease. She is now disease free 3 years after diagnosis. Estrogen-progesterone receptors were negative, as was screening for BCR 1 and 2. This is the first report of cytogenetics showing an abnormal cell line with a reciprocal translocation between 12p and 15q. Although breast cancer is extremely rare in children, a history of a painless, enlarging, firm breast mass should raise concern about possible neoplastic disease. Cystic appearance on ultrasound scan caused by the pseudocapsule around the tumor may be a marker for secretory carcinoma. Histological evaluation of all suspicious masses should be obtained. Because of the risk of local recurrence and axillary metastases, the authors recommend modified radical mastectomy with axillary node dissection for children with secretory carcinoma of the breast.

Life-threatening gastrointestinal hemorrhage due to juvenile polyposis

A 14-yr-old, previously healthy boy presented with massive lower GI hemorrhage. After the routine endoscopic and radiological evaluation, laparotomy and intraoperative colonoscopy revealed multiple polyps in the colon. A hemicolectomy was performed because of the severity of hemorrhage. A diagnosis of juvenile polyposis was made based upon histological findings and the family history. This is an extremely unusual presentation of juvenile polyposis and has been reported only once before. The clinical features, diagnosis, and therapeutic options for juvenile polyposis are discussed. Juvenile polyposis, although a rare condition in the pediatric population, should be considered in the differential diagnosis of life-threatening GI hemorrhage.

Beyond cost: 'responsible purchasing' of managed care by employers

We explore the extent of "responsible purchasing" by employers--the degree to which employers collect and use nonfinancial information in selecting and managing employee health plans. Most firms believe that they have some responsibility for assessing the quality of the health plans they offer. Some pay attention to plan characteristics such as the ability to provide adequate access to providers and services and scores on enrollee satisfaction surveys. A more limited but still notable number of firms take specific actions based on responsible purchasing information. Because of countervailing pressures, however, it is not clear whether or not the firms most involved in responsible purchasing are signaling a developing trend.

Fibromatoses: clinical and pathological features suggestive of recurrence

BACKGROUND/PURPOSE

Fibromatoses represent a spectrum of nonneoplastic spindle cell tumors frequently identified in childhood. Although they may be locally aggressive, they do not metastasize. The authors have reviewed their experience of these lesions in an attempt to identify clinical and pathological features suggestive of recurrence.

METHODS

Clinical records and pathological specimens from 55 cases of fibromatosis diagnosed and treated at British Columbia's Children's Hospital from 1982 to 1995 were reviewed.

RESULTS

Thirty boys and 25 girls with ages ranging from 1 month to 14 years were identified. Eighteen tumors (33%) were congenital. Diagnoses were as follows: musculoaponeurotic fibromatosis (n = 27), infantile myofibromatosis (n = 10), Dupuytren-type fibromatosis (n = 7), fibromatosis colli (n = 7), and digital fibroma (n = 4). Clinical follow-up showed a survival rate of 98%. The single mortality occurred in an infant born with an intraabdominal visceral myofibromatosis, which proved unresectable. Fifteen cases recurred (27%), and nine cases (16%) of infantile myofibromatosis spontaneously regressed. All remaining cases were controlled successfully by surgical resection.

CONCLUSIONS

Clinical features suggestive of recurrence included (1) presentation at greater than 5 years of age, (2) extremity location of disease, and (3) incomplete surgical resection. Pathological features suggestive of recurrence were (1) microscopic evidence of tumor at resection margins, (2) mitotic index of 5 or more per 10 high-power fields, and (3) areas of necrosis and inflammation within the tumor.

Neutropenic enteropathy: a 10-year review

PURPOSE

With the advent of more aggressive chemotherapy, the incidence of neutropenic enteropathy is increasing. This review was performed to (1) determine which children are affected, (2) identify predisposing factors, and (3) assess efficacy of treatment.

METHODS

A 10-year (1988 to 1997) review identified 33 children who had 38 episodes of neutropenic enteropathy. Each presented with fever, abdominal pain, and chemotherapy-induced neutropenia. All were treated with fluid resuscitation, bowel rest, and broad-spectrum antibiotics. Surgical intervention was reserved for children with bowel perforation.

RESULTS

Neutropenic enteropathy occurred in 24 children with hematologic malignancies and nine with solid tumors. This disease developed in three children after bone marrow transplantation for leukemia. All five patients in whom recurrent episodes developed were receiving chemotherapy for Burkitt's lymphoma. Cytosine arabinoside and VP16 were the most commonly implicated chemotherapeutic agents. Four children required laparotomy and right hemicolectomy, and all survived. Overall survival was 94%.

CONCLUSIONS

Although previously described in children receiving chemotherapy for hematologic malignancies, neutropenic enteropathy also occurs in children who have solid tumors and after bone marrow transplantation. The use of cytosine arabinoside and VP16 may predispose patients to this disease. Children receiving chemotherapy for Burkitt's lymphoma are at increased risk for recurrent episodes. Excellent survival rate was attained with supportive care being used as the primary treatment modality.

Effects of stocking density and concentrate supplementation of grazing dairy cows on milk production, composition and processing characteristics

The effects on milk composition and processing characteristics of varying grass supply by changing stocking density and of offering a concentrate supplement were investigated. The experiment was conducted over 28 weeks of the lactation (April-October) using 48 spring-calved Friesian-Holstein cows. Three herds each of 16 cows were offered a restricted grass supply, a standard grass supply and a standard grass supply with a supplement of 3 kg concentrate/d. Treatment groups were grazed separately with a residence time of 3 d/paddock. Milk production, composition and processing characteristics such as renneting properties, ethanol stability and plasmin activity were measured weekly. Increasing stocking density above the standard system resulted in significant reductions in milk fat and protein yields, the concentrations of total protein, casein and whey proteins, and a deterioration in most processing characteristics. Imposing concentrate supplementation on the standard system increased total protein, casein and whey protein concentrations but generally did not improve processing characteristics except for ethanol stability. These results suggest that the standard grass supply in a rotational grazing paddock system can support efficient production of quality milk, and concentrate supplementation will not improve processing characteristics when an adequate supply of good quality herbage is available.

Elevation of conjugated cis-9, trans-11-octadecadienoic acid in bovine milk because of dietary supplementation

Cows on pasture were fed full fat soybeans (toasted, flaked, and pelleted) or ground full fat rapeseeds to investigate effects on cis-9, trans-11-octadecadienoic acid in milk. Three herds of 16 cows each that were on pasture were fed 3.1 kg/d of unmolassed beet pulp (control), 3.0 kg/d of rapeseed concentrate, or 3.1 kg/d of a soybean supplement. The concentration of cis-9, trans-11-octadecadienoic acid in the milk of cows fed the rapeseed and soybean supplements was significantly higher than in the milk of cows fed the control diet during the feeding trial. Over the trial, the cis-9, trans-11-octadecadienoic acid concentration in the milk of individual cows varied from 6.8 to 25.7 mg/g of fat in the control herd, from 10.6 to 33.5 mg/g of fat in the herd fed the rapeseed concentrate, and from 8.8 to 30.5 mg/g of fat in the herd fed the soybean supplement. The concentration of cis-9, cis-12-octadecadienoic acid, the substrate for cis-9, trans-11-octadecadienoic acid synthesis in the rumen, was 4.9 g/100 g of fatty acid methyl esters in the milk fat of cows fed the soybean supplement, 2.5 g/100 g of fatty acid methyl esters in the milk fat of cows fed the rapeseed concentrate, and 2.3 g/100 g of fatty acid methyl esters in the milk fat of the control cows. Milk yield and milk constituent yields were not affected by supplementation of either full fat soybeans or rapeseeds compared with controls, but milk protein concentration was significantly reduced by both oilseed supplements.

Increased condom use among teenage males, 1988-1995: the role of attitudes

CONTEXT

Understanding whether and to what degree changes in young men's attitudes explain increases in condom use over time can be useful in developing more effective disease prevention strategies.

METHODS

Data from the 1988 and the 1995 National Survey of Adolescent Males are used to determine changes in attitudes toward condoms, pregnancy prevention and HIV and AIDS. Two-limit tobit models are employed to investigate the association between these attitudes and condom-use behavior and to examine how this relationship may have changed over time.

RESULTS

Between 1988 and 1995, young men's attitudes toward partner appreciation of condom use, condom-use embarrassment and pleasure reduction from condom use all changed in a direction suggestive of more consistent condom use. However, attitudes related to pregnancy prevention and AIDS avoidance changed in a direction suggestive of less-consistent condom use. Changes over time in the strength of the relationship between three attitude measures (masculinity, pleasure reduction and partner appreciation) and condom use also were predictive of lower levels of condom-use consistency. Only the strength of the relationship between condom-use embarrassment and consistent condom use changed in a direction corresponding to observed increases in rates of condom use among young men.

CONCLUSIONS

Many of the significant changes in young males' attitudes toward condoms do not explain the increase in consistent condom use among adolescent males that occurred between 1988 and 1995. However increasing male contraceptive responsibility and emphasizing the risks and consequences of contracting HIV appear to be viable routes for policymakers to explore. Efforts particularly need to be targeted toward Hispanics.

Effect of amount of dietary supplement and source of protein on milk production, ruminal fermentation, and nutrient flows in dairy cows

An experiment with a multiple Latin square design using 36 midlactation Friesian cows was carried out to determine the effect of fish meal or soybean meal in a supplement fed at two amounts (3.5 or 7 kg/d) with grass silage. The diets were also fed to four ruminally and duodenally cannulated cows to determine digestibility, ruminal fermentation, and nutrient flows. Dry matter intake, milk production, milk constituent yields, and concentrations of protein and lactose were significantly increased by the supplements when provided at 7 kg/d. The supplement containing fish meal increased milk production, protein and lactose yields, and milk protein concentration, but the increases were smaller than those obtained by increasing the amount of supplement fed. Neither the type nor the amount of supplement fed affected digestibility of dry matter or organic matter, and few significant effects on ruminal fermentation were observed. Supplements fed at the higher allowance significantly increased the flow of dry matter, organic matter, all nitrogenous components, and amino acids to the duodenum. The supplement containing fish meal significantly increased the duodenal flow of nonammonia nonmicrobial N and some amino acids. Results indicated that an increase in the concentration of supplement in the diet is more effective in increasing milk production, protein concentration and yield, and flow of amino acids to the duodenum than is increasing the concentration of ruminally undegradable protein in the supplement.

Cougar attacks on children: injury patterns and treatment

PURPOSE

Cougar attacks on humans appear to be on the rise. A review of all attacks on children was performed to determine the method of attack and injury patterns so that a treatment regimen as well as possible preventative measures could be determined.

METHODS

A review of all attacks, including attacks on children, was performed, including three recent attacks treated at our institution. Situation, adult supervision, patient age, injuries recorded, survival, and mode of attack, if known, were reviewed.

RESULTS

There were 50 documented attacks on children with a 25% fatality rate. Most children were not alone at the time of the attack (92%), and in many instances adult supervision was present or nearby. Severe head and neck lacerations along with puncture wounds were the most common injury. Examples of typical cervical injuries include a nonfatal vertebral artery injury, phrenic nerve injury, a fatal internal carotid artery injury, and a fatal cervical spine injury. The cougar was rabid in two cases. Pasteurella resulted in late infections in two patients.

CONCLUSIONS

Based on the pattern of injuries, the authors recommend aggressive evaluation for occult cervical injuries as well as surgical debridement. Antibiotics should cover oropharyngeal flora including Pasteurella multocida. Rabies prophylaxis is indicated. Adult supervision in wilderness areas is not necessarily protective.

Effect of altering the daily herbage allowance to cows in mid lactation on the composition, ripening and functionality of low-moisture, part-skim Mozzarella cheese

Milk was collected from three spring-calving herds, on different daily herbage allowances (DHA) of perennial rye-grass (16, 20 or 24 kg dry matter (DM)/cow for a 17 week period. On five occasions, at weekly intervals in the middle of the period, the three different milks were converted into low-moisture part-skim Mozzarella cheese. Increasing the DHA resulted in significant increases in the concentrations of protein in the cheesemilk (P < 0.05) and cheese whey (P < 0.02). The moisture-adjusted cheese yield increased significantly (P < 0.01) on raising the DHA from 16 to 24 kg grass DM/cow. DHA had no significant effects on any of the gross compositional values of the cheese (although moisture and fat-in-DM levels tended to decrease and increase respectively with increasing DHA). The hardness of the uncooked cheese and functionality of cooked cheese (i.e. melt time, flowability, stretch and viscosity) were not significantly influenced by DHA over the 115 d ripening period at 4 degrees C.

Ectopic expression of Bcl-2, but not Bcl-xL rescues Ramos B cells from Fas-mediated apoptosis

The human Burkitt lymphoma Ramos B cell line can be induced to undergo apoptosis in response to a variety of different agents, including calcium ionophores, anti-immunoglobulin (Ig) and macromolecular synthesis inhibitors. In addition, following up-regulation of the Fas (CD95) surface receptor by CD40 ligation, these cells also become susceptible to apoptosis induction by Fas ligation. We have previously shown that protection from calcium ionophore- and macromolecular synthesis inhibitor-induced apoptosis by CD40 ligation is associated with a rapid up-regulation of Bcl-xL followed by a more moderate and delayed up-regulation of Bcl-2. We show here that overexpression of Bcl-xL, like Bcl-2, protects Ramos cells from apoptosis induction in response to calcium ionophore, anti-Ig and macromolecular synthesis inhibition. However, in contrast to Bcl-2, ectopic overexpression of Bcl-xL does not rescue from Fas-mediated apoptosis. Thus, in Ramos B cells, the Fas apoptotic pathway exhibits differential sensitivity to inhibition by Bcl-2 family members. These findings also suggest that CD40 signaling provides a switch which renders the cells susceptible to Fas-ligand mediated apoptosis through up-regulation of Fas whilst affording protection from anti-Ig-induced apoptosis through up-regulation of Bcl-xL.