Pityriasis rubra pilaris with acantholysis

Two patients developed a papulosquamous eruption in a widespread distribution which progressed with islands of sparing of uninvolved skin characteristic clinically of adult-onset pityriasis rubra pilaris (PRP). Biopsies from both patients showed multiple areas of nonfollicular and follicular suprabasilar and intra-epidermal acantholysis with minimal dyskeratosis. They also showed the usual histologic features of PRP with a thickened orthokeratosis and parakeratosis, a retained and sometimes thickened granular cell layer, and psoriasiform epidermal hyperplasia with a perivascular lymphohistiocytic infiltrate in the superficial dermis. Two previous patients with PRP have been reported with nonfollicular, focal acantholytic dyskeratosis and both were interpreted as most likely representing an incidental finding. We believe the acantholysis in these two cases is related to the disease process, and in our second patient, was helpful in establishing the diagnosis.

Glycolic acid modulation of collagen production in human skin fibroblast cultures in vitro

BACKGROUND

Glycolic acid has been used extensively for the treatment of photoaging and wrinkles. Suggestions have been made that glycolic acid may have specific dermal effects, although biochemical studies are limited.

OBJECTIVE

This study's purpose was to examine the effect of glycolic acid on the radioactively labeled collagen production in human skin fibroblasts in culture.

METHODS

Normal dermal fibroblasts were grown to semi-confluence and incubated in the presence of glycolic acid for 24 hours. Radioactive proline was added to the cultures. Using a specific amino acid assay, the amount of radioactive hydroxyproline was measured and was used as an accurate index of collagen production.

RESULTS

Results show that glycolic acid caused an elevated collage production in the fibroblasts.

CONCLUSION

These results demonstrate a specific stimulatory effect by the glycolic acid and could explain some of the positive benefits from the clinical use of glycolic acid.

Fibrinolytic abnormalities in two different cutaneous manifestations of venous disease

BACKGROUND

Chronic venous insufficiency may be associated with lipodermatosclerosis or atrophie blanche. Coagulation abnormalities may be related to these cutaneous disorders.

OBJECTIVE

Our purpose was to determine whether fibrinolytic abnormalities exist in patients with lipodermatosclerosis or atrophie blanche.

METHODS

A case control study of patients with venous disease and atrophie blanche or lipodermatosclerosis was performed. Plasma levels of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) in a resting and venous occluded state were measured.

RESULTS

Plasma levels of PAI-1 were different between the two groups of patients. The lipodermatosclerosis group had significantly higher levels of PAI-1 in both the resting and venous occluded states (p < 0.001). Patients with atrophie blanche had milder elevations of PAI-1 in the resting and venous occluded state (p = 0.06).

CONCLUSION

Fibrinolytic abnormalities are present in patients with venous disease. These abnormalities are different between patients with lipodermatosclerosis and patients with atrophie blanche.

A retrospective study of the investigation and management of muscle-invasive bladder cancer in the South West Region

OBJECTIVE

To evaluate the present management of muscle-invasive bladder cancer in the South West Region and to assess the workload resulting from the rationalization of treatment in specific centres.

METHODS

A retrospective survey was undertaken in all the hospitals in the South West Region, to assess the management of all patients presenting with muscle-invasive bladder cancer in the years 1989 and 1993. Data were collected from histopathology records and hospital in-patients' notes. The optimum standard of assessment and treatment were defined by a panel of specialists in urological tumours. The management of patients was compared against these defined standards.

RESULTS

A total of 186 and 199 patients in 1989 and 1993, respectively, were evaluated. When comparing their assessment against the defined standard, only 69% of patients in 1989 and 58% in 1993 had an intravenous urogram, with 7% and 4%, respectively, having no upper tract imaging (the remainder undergoing ultrasonography). Evidence from an examination under anaesthetic (EUA) was found for 80% of patients in 1989 and 84% of patients in 1993. Only 23% of patients in 1989 and 36% in 1993 were staged by either computed tomography or magnetic resonance imaging. In both 1989 and 1993, 54% of patients had definitive treatment, 31% had an endoscopic follow-up only and 15% had no treatment; there were no differences in age or co-morbidity among these groups. The median time elapsed between referral and diagnosis was 59 days (1989) and 52 days (1993), and the median delay to definitive treatment was 114 and 96 days, respectively.

CONCLUSION

There was insufficient upper tract imaging, poor clinical staging in the EUA and too few investigations for staging. The low rate of definitive treatment may be a consequence of the delays in management, allowing the tumour to progress, and suggesting the need for a more rapid assessment of haematuria.

Minimal residual disease detection in acute promyelocytic leukemia by reverse-transcriptase PCR: evaluation of PML-RAR alpha and RAR alpha-PML assessment in patients who ultimately relapse

RT-PCR assays used to detect acute promyelocytic leukemia (APL) are generally considered less sensitive than those for other hematological malignancies, such as CGL. Most patients with APL express del(17q)-derived RAR alpha-PML transcripts as well as the putative leukemogenic PML-RAR alpha associated with add(15q). We have found that a nested RT-PCR for RAR alpha-PML affords greater sensitivity than that for PML-RAR alpha, particularly in patients with the commonest breakpoint pattern. Therefore, we have evaluated both assays in parallel to monitor a group of 12 de novo APL patients who relapsed despite treatment with both all-trans retinoic acid (ATRA) and chemotherapy. 5' (bcr 3) breakpoints in PML were over represented among the group and three patients had complex cytogenetic abnormalities suggesting both factors may increase the risk of relapse. The RAR alpha-PML assay changed the PCR status of two patients in morphological remission; in both cases disease contamination of bone marrow harvest specimens was detected. Although parallel assessment of PML-RAR alpha and RAR alpha-PML can enhance minimal residual disease detection in APL, this study demonstrates that treatment strategies involving determination of PCR status post-consolidation, even using RAR alpha-PML in addition to the more conventional PML-RAR alpha assay will fail to identify all patients at risk of relapse. Whether the duration of PCR positivity is a helpful prognostic indicator in those patients who ultimately become PCR negative is being addressed by

The solution structure of the RING finger domain from the acute promyelocytic leukaemia proto-oncoprotein PML

Acute promyelocytic leukaemia (APL) has been ascribed to a chromosomal translocation event which results in a fusion protein comprising the PML protein and the retinoic acid receptor alpha. PML is normally a component of a nuclear multiprotein complex (termed ND10, Kr bodies, nuclear bodies, PML oncogenic domains or PODs) which is disrupted in the APL disease state. PML contains a number of characterized motifs including a Zn2+ binding domain called the RING or C3HC4 finger. Here we describe the solution structure of the PML RING finger as solved by 1H NMR methods at physiological pH with r.m.s. deviations for backbone atoms of 0.88 and 1.39 A for all atoms. Additional biophysical studies including CD and optical spectroscopy, show that the PML RING finger requires Zn2+ for autonomous folding and that cysteines are used in metal ligation. A comparison of the structure with the previously solved equine herpes virus IE110 RING finger, shows significant differences suggesting that the RING motif is structurally diverse. The role of the RING domain in PML nuclear body formation was tested in vivo, by using site-directed mutagenesis and immunofluorescence on transiently transfected NIH 3T3 cells. Independently mutating two pairs of cysteines in each of the Zn2+ binding sites prevents PML nuclear body formation, suggesting that a fully folded RING domain is necessary for this process. These results suggest that the PML RING domain is probably involved in protein-protein interactions, a feature which may be common to other RING finger domains.

A case of acute monocytic leukemia with t(11;17) involving a rearrangement of MLL-1 and a region proximal to the RARA gene

A case of acute monocytic leukemia with t(11;17)(123;q11-21) arising in a 4-month-old boy is described. The breakpoint on chromosome 11 could be mapped to an 8-kb BamHI fragment within the MLL-1 gene, as seen in the majority of infant leukemias. In situ hybridization with cosmid probes allowed us to map the breakpoint on 17q proximal to the RARA gene, while Southern and Northern analyses showed that the gene was not disrupted by the translocation.

Molecular analysis of simple variant translocations in acute promyelocytic leukemia

The primary cytogenetic abnormality in acute promyelocytic leukemia (APL; FAB M3) is a reciprocal translocation, t(15;17)(q22;q12), which serves to fuse the PML gene on chromosome 15 to the retinoic acid receptor alpha (RARA) gene on chromosome 17. A PML-RARA fusion message transcribed from the der(15) is thought to mediate leukemogenesis. Two APL patients with simple variants of this translocation, t(3;15)(q21;q22) and t(X;15)(p11;q22), have previously been reported who lack cytogenetic involvement of chromosome 17, although their breakpoint positions on chromosome 15 still suggest the involvement of the PML gene. Here we report on a combined analysis by molecular genetics and in situ hybridization of these two patients, in which we wanted to determine whether the PML gene has alternative fusion partners or whether cryptic rearrangement of the RARA locus has occurred instead. A cryptic involvement of RARA was demonstrated in both patients by a combination of Southern analysis, reverse transcription coupled to PCR (RT-PCR), and fluorescence in situ hybridization. The results indicate an absolute requirement for the rearrangement of the RARA gene in the pathogenesis of APL and underline the importance of RARA during normal myeloid differentiation.

Patient-controlled analgesia and postoperative urinary retention after open appendectomy

We retrospectively studied 279 patients who had undergone uncomplicated open appendectomy for acute appendicitis to determine risk factors for postoperative urinary retention. The gender of the patients, the operating time and the amount of fluid given perioperatively had no influence on the occurrence of retention. The amount of analgesic agent administered postoperatively and the age of the patient were significantly associated with urinary retention (p = 0.01 and p < 0.0001, respectively, after adjustment for potential confounding factors). The use of meperidine hydrochloride as compared with morphine and of patient-controlled analgesia as compared with intramuscular delivery were initially found to be significantly related to retention (p = 0.014 and p < 0.0001, respectively). After the effects of the age of the patient, the drug type and the amount of fluid and analgesic agent administered were controlled for, patient-controlled analgesia remained significantly associated with retention (p < 0.0001), whereas the type of drug given was no longer significant after controlling for potential confounding factors. Because we found that urinary retention was 13 times more likely to occur in the patients who had patient-controlled analgesia, we recommend that the use of this form of analgesia delivery be avoided after open appendectomy.

Microcystic adnexal carcinoma: in vitro growth characteristics and effect on stromal collagen production

BACKGROUND

Microcystic adnexal carcinoma (MAC) is a locally aggressive cutaneous neoplasm, which is characterized by follicular and sweat gland differentiation and a stroma of dense collagen.

METHODS

MAC cells were studied and characterized in vitro through phase microscopy and proliferation assays. Additionally, to delineate a possible role of soluble mediators in bringing about the dense stromal collagen seen in association with these tumors, the effect of conditioned media derived from the tumor cells on the level of collagen production by normal fibroblasts was examined.

RESULTS

A significant morphologic difference between the MAC cells and normal keratinocytes was not noted. Proliferation assays demonstrated a significantly slower rate of growth of the MAC cells in comparison to controls. Media conditioned by MAC cells did not induce an increase in collagen synthesis by cultured fibroblasts, but rather, there appeared to be an inhibitory effect on the level of collagen synthesis.

CONCLUSIONS

The increased stromal collagen seen in MAC histologically is not the result of growth factors or cytokines produced by the MAC cells.

Yeast artificial chromosomes for the molecular analysis of the familial polyposis APC gene region

Two yeast artificial chromosomes (YACs) spanning a total distance of 1.1 megabase pairs of DNA around the MCC (for mutated in colorectal carcinoma) and APC (for adenomatous polyposis coli) genes at 5q21 have been isolated and characterized. Starting from the MCC gene, a strategy was undertaken to identify constitutional submicroscopic deletions in familial adenomatous polyposis patients that might considerably narrow down the position of the APC gene. To this end, YACs identified by the MCC gene were screened across a chromosome 5-specific cosmid library to provide a source of DNA probes for genomic scanning. The cosmids isolated from these experiments were used to screen a panel of somatic cell hybrids containing chromosome 5 segregated from patients suspected to carry putative interstitial deletions. This screening approach led to the confirmation of a small heterozygous deletion in a polyposis patient that overlaps one of the two isolated YACs. This YAC has been shown to contain the entire APC gene, in addition to a significant portion of DNA flanking the 5' end of the gene, and should therefore prove a valuable resource for functional studies by transfer to colorectal tumor-derived cell lines.

Using a Full-depth Wound Drainage System to Decrease Wound Infection Rates in the Morbidly Obese

The morbidly obese surgical patient is at increased risk for wound complications due to mechanical stresses from a deep and heavy subcutaneous tissue layer that create dead spaces in which hematomas and seromas can form. To drain the full depth of this layer, we revised an existing wound drainage system using cut segments of a Davol drain and added a Velcro binder to minimize lateral stress on the wound. We used the full-depth drain for all 384 morbidly obese patients who underwent vertical banded gastroplasty during a 10-year period. No patient developed a wound infection in the hospital; however, three patients had wound abscesses one month postoperatively, an infection rate of 0.78%. We believe that the drain system was an important factor in producing the low infection rate.

Mycotic aortic aneurysm infected by Clostridium septicum--a case history

The authors describe a sixty-seven-year-old hypertensive, diabetic man with a mycotic abdominal aortic aneurysm infected with Clostridium septicum. The patient had colonic polyps but no malignant disease. They could find only one other report of a mycotic aneurysm infected with C. septicum. In that case, as in most other cases of C. septicum bacteremia, the patient had gastrointestinal cancer. Their case suggests that treatment for a clostridial infection should be considered in patients with known gastrointestinal disease, signs and symptoms of sepsis, and abdominal pain. Conversely, patients known to have a C. septicum infection should be evaluated for gastrointestinal lesions.

Electrode site preparation techniques: a follow-up study

A posttest-only control group design was used to study the effect of electrode site preparation techniques on reducing electrical potential across a pair of disposable skin electrodes. One hundred twenty healthy volunteers were randomly assigned into one control and three treatment groups of 30 subjects each. The three treatments were One Step Skin Prep used once, ECG Prep Pad used five times, and ECG Prep Pad used once. To control for handedness, the skin preparation site was randomly assigned to either the left or right forearm. One-tailed paired t-test analyses were used to compare differences between treatment arms and control arms within each group (p less than 0.05). Skin preparation done by using One Step Skin Prep or the ECG Prep Pads used once significantly decreased skin potentials by 2.3 mV and 3.3 mV respectively. There was no significant difference in the control group and the group in which ECG Prep Pads were used five times. These findings extend the knowledge of techniques available to reduce the amount of noise (electrical potential) in physiologic measurement using skin electrodes.

An empirical study of proxy consent for elderly persons

To investigate empirical assumptions about substituted judgment, three treatment decision scenarios were presented to 43 competent elderly persons and 115 persons related to them. Related subjects who were explicitly asked to make a substituted judgment came significantly closer to the elderly person's preferences than those who were asked to make their best recommendation (p = .005-.067, depending on index used). These results support the use of a substituted judgment approach to proxy decision makers; other results suggest some limitations of durable powers of attorney.

Practical applications of a monoclonal antibody (NDOG2) against placental alkaline phosphatase in ovarian cancer

A monoclonal antibody (NDOG2) against placental alkaline phosphatase (PLAP) in ovarian cancer has been used in three ways by the Bristol University Department of Obstetrics & Gynaecology. First, in an indirect immunoperoxidase technique, NDOG2 demonstrated positive standing in 64% of 56 ovarian carcinomas as well as in 25% of 44 benign tumours. The majority of these positive tumours were serous cystadenocarcinomas or serous cystadenomas and there was considerable variation in the expression of this antigen from tumour to tumour. NDOG2 was also used as the basis of two serum assays and, when labelled with 123-iodine (123I), in radioimmunoscintigraphy (RIS) to monitor patients' response to therapy. The first serum assay measures the enzymic activity of PLAP and the second recognizes the antigenicity of the molecules. Assay 2 proved more useful in that it predicted the course of the disease in 45% of patients followed up, whereas Assay 1 was only of use in 25% of cases. RIS proved to be a useful imaging technique and was at least as sensitive as conventional imaging techniques. The common causes of false-positive and false-negative results are described.

Placental alkaline phosphatase in benign and malignant endometrium

The presence of placental alkaline phosphatase has been demonstrated immunohistochemically using a monoclonal antibody, in frozen sections of human endometrium. The enzyme is present in glandular epithelium, but is found most commonly in the surface epithelial layer throughout the menstrual cycle. It has also been demonstrated in malignant endometrial epithelium in eight out of twelve patients.

Radionuclide imaging of ovarian tumours with 123I-labelled monoclonal antibody (NDOG2) directed against placental alkaline phosphatase

A radiolabelled monoclonal antibody (NDOG2) directed against placental alkaline phosphatase (PLAP) was used in the radio-immunodetection of ovarian carcinoma. Tumour deposits were successfully visualized in 11 of 15 patients and the abnormalities demonstrated were classified as focal or diffuse. Of the 11 patients, eight showed focal abnormalities alone and three had a diffuse abnormality, of which two also showed a focal abnormality. False-positive results may occur not only due to uptake of 123I by gut mucosa and an inadequately blocked thyroid gland but also from activity in an incompletely emptied bladder. A false-negative result occurred due to high background activity in the liver masking a known, discrete tumour deposit.

Simple clinical method of measuring gastric emptying of solid meals

The radioisotope techniques used for the measurement of gastric emptying of solid meals in man require complex and expensive scintiscanners of cameras. We have evaluated a simple technique which uses a fixed scintillation detector and compared the results with those obtained from a gamma camera. The rates and patterns of gastric emptying recorded by the two methods correlated well in both healthy volunteers (mean r= 0.95) and patients with duodenal ulcer (mean r =0.89). The scintillation detector provides a reliable and inexpensive method for measurement of gastric emptying of solid meals.

Distribution of R plasmids among the O-antigen types of Escherichia coli isolated from human and animal sources

The O-antigen types of 600 independently isolated Escherichia coli strains from human feces have been determined, and the types have been related to the antibiotic resistance patterns of the strains. The relative abundance of each O-antigen type differed in the susceptible and resistant series of strains. The majority (86%) of the resistant strains carried R plasmids. Resistant E. coli (20.3%) were found associated with O-antigen types 8, 9 and 101, whereas the susceptible strains covered a wide range of O-antigen types. Examination of 174 resistant strains isolated from calf feces also showed a prevalence of O-antigen types 8, 9, 101 (24.1%), and it seems probable that strains expressing these three O-antigen types commonly carry R plasmids in the alimentary tracts of man and calves. The number of strains not typeable with the O sera available were similar in the human (12.5%) and the calf (11.5%) series. There are no grounds for distinguishing "human" from "calf" E. coli on the basis of their O-antigen reactions.