Clinical expression and long-term outcomes of primary hyperoxaluria types 1 and 2

Primary hyperoxaluria, types 1 and 2, are rare disorders. Much of the information in the literature has been derived from case reports and data registries limited to patients requiring dialysis and/or transplantation. We present a single-center experience of 42 patients and 437 patient years of clinical experience with primary hyperoxaluria. Median age at onset of symptoms for patients with type 1 PH was 9 years, type 2 15.7 years. Sixty-four percent of the patients were less than 15 years of age at onset of symptoms. There was no correlation between urine oxalate excretion rates and age at onset of symptoms. Stone forming activity was greater in patients with type 1 PH than type 2. Ten patients presented initially with ESRD, and an additional seven developed ESRD during the course of follow-up. ESRD occurred in 54 percent of the patients with type 1 and 12 percent of patients with type 2 PH. Eight patients received nine renal allografts, five patients received combined kidney/liver transplants, and one patient received a hepatic allograft only. Ten of the transplanted patients were surviving at the time of the most recent follow up. Eight of them have functioning renal grafts and four have functioning hepatic grafts. There have been no deaths since 1988 among the 32 patients followed since that time. These data may suggest a broad range of clinical expression of primary hyperoxaluria. With current management strategies, outcomes are more favorable than has been reflected in previous literature.

Prophylactic chemoradiation of inguinofemoral lymph nodes in patients with locally extensive vulvar cancer

OBJECTIVE

Primary surgical resection of locally advanced squamous cancer of the vulva may compromise the integrity of important midline structures such as the anus, clitoris, urethra, and vagina. Chemoradiation (synchronous radiation and cytotoxic chemotherapy) has been used as alternative initial treatment which may serve as definitive management for some patients, or may reduce the scope and functional sequelae of subsequent surgery in others. Inguinofemoral node dissection is associated with substantial risk of both acute and late morbidity, prompting consideration of elective inclusion of groin nodes within the irradiated volume and deletion of subsequent groin surgery. Concern that disease relapse in the groins is potentially fatal suggested the prudence of formal outcome assessment of our recent experience with prophylactic treatment of clinically uninvolved groin nodes in the context of concurrent chemoradiation for locally advanced primary vulvar cancer.

METHODS

A review was conducted of 23 previously untreated patients with locally advanced squamous cancer of the vulva (2 T2, 20 T3, 1 T4) and clinically uninvolved groin nodes (1969 FIGO stages 14 N0, 4 N1, and 5 N2 with negative node biopsies) who were treated since 1987 with chemoradiation administered to a volume electively including bilateral inguinofemoral nodes. These patients did not undergo subsequent groin surgery.

RESULTS

With follow-up from 6 to 98 months (mean, 45.3 months; median, 42 months), no patient has failed in the prophylactically irradiated inguinofemoral nodes. No patient has developed lymphedema, vascular insufficiency, or neurological injury in a lower extremity, and no patient has experienced aseptic necrosis of a femur.

CONCLUSIONS

Elective irradiation of the groin nodes in the context of initial chemoradiation for locally advanced vulvar cancer is an effective therapy associated with acceptable acute toxicity and minimal late sequelae. It constitutes a sensible alternative to groin dissection in this patient population.

Detection of serologic neutralizing antibodies against HPV-11 in patients with condyloma acuminata and cervical dysplasia using an in vitro assay

This study was designed to investigate if neutralizing antibodies against HPV-11 are detectable in the serum of patients with condyloma acuminata (CA) or cervical intraepithelial neoplasia (CIN) using an in vitro infectivity assay for HPV-11. Purified HPV-11 virions were extracted from xenografted condyloma tissues implanted into athymic mice and used to infect cultured neonatal human foreskin keratinocytes (HFK) and an immortalized adult skin cell line (HaCaT). The presence of HPV-11-specific E1--E4 mRNA as detected by reverse transcriptase-polymerase chain reaction was indicative of early infection. Sera previously characterized for reactivity to HPV-11 and HPV-11 VLP (virus-like particles) by ELISA were tested for the ability to prevent HPV-11 in vitro infectivity. Neutralizing antibodies against HPV-11 were demonstrated when monoclonal antibodies or patient serum preincubated with HPV-11 virions prevented the infection of either of the two cell cultures, as shown by the absence of the E1--E4 mRNA transcript. Eleven (of 20) patients with CA were strongly ELISA reactive against HPV-11 virus-like particles. Five of these 11 patients also had detectable levels of neutralizing antibodies in their serum. It was also demonstrated that the neutralizing properties of the serum were titratable by endpoint dilution. None of 15 patients with CIN had detectable neutralizing antibodies against HPV-11. Neutralizing antibodies against HPV-11 can be detected in some patients with CA and the neutralizing effects of the patient sera can be titrated by endpoint dilution. The in vitro assay for the detection of neutralizing antibodies against HPV-11 may have utility for investigating the natural history of HPV infection and resolution, as well as assessing the efficacy of any putative HPV vaccine.

Titration of HPV-11 infectivity and antibody neutralization can be measured in vitro

Human papillomavirus type 11 (HPV-11), produced from the athymic mouse xenograft system, was shown to infect cultured neonatal human foreskin keratinocytes and the HaCaT keratinocyte cell line in vitro. Infection was documented by the appearance of HPV-11-specific spliced mRNA, detected by reverse transcriptase-polymerase chain reaction. Purified HPV-11 virions at concentrations of approximately 10(7) particles/ml could successfully evoke infection in this system. Infection was completely abrogated by preincubation of the HPV-11 inoculum with mouse anti-HPV-11 monoclonal antibodies, experimentally immunized animal sera, or sera of human patients with HPV infection. Concurrent detection of cellular mRNA for the beta-actin gene, also by reverse transcriptase-polymerase chain reaction, provided an internal control confirming RNA recovery and successful reverse transcriptase-polymerase chain reaction. Using this approach, it was possible to determine semiquantitative titers for test solutions of HPV-11-neutralizing antibodies. The in vitro system for HPV-11 infectivity and neutralization may be useful in the study of the immune response to HPV-11 infection or immunization in patients.

Results of long-term treatment with orthophosphate and pyridoxine in patients with primary hyperoxaluria

BACKGROUND

The prognosis for patients with primary hyperoxaluria has been ominous, with the expectation of renal failure, poor results with transplantation, and early death.

METHODS

We studied the long-term effects of orthophosphate and pyridoxine therapy in 25 patients with primary hyperoxaluria who were treated for an average of 10 years (range, 0.3 to 26). Their mean age at the start of treatment was 12 years (median, 6; range, 0.5 to 32). We also studied the effect of orthophosphate and pyridoxine on urinary supersaturation with calcium oxalate, crystal inhibition using a seeded growth system, and crystal formation using scanning electron microscopy in 12 patients during three-day stays in the clinical research center.

RESULTS

The mean (+/- SD) glomerular filtration rate at the start of treatment was 91 +/- 26 ml per minute per 1.73 m2. The median decline in glomerular filtration rates was 1.4 ml per minute per 1.73 m2 of body-surface area per year. The actuarial survival free of end-stage renal disease was 96, 89, 74, and 74 percent of 5, 10, 15, and 20 years, respectively. Treatment with orthophosphate and pyridoxine reduced urinary supersaturation with calcium oxalate from 8.3 +/- 3.0 to 2.1 +/- 1.7 kJ per mole at 38 degrees C (P < 0.001), increased the inhibition of calcium oxalate formation from 63 +/- 11 to 108 +/- 10 inhibitor units per 24 hours (P < 0.001), and improved the crystalluria score from 2.6 +/- 0.3 to 0.6 +/- 0.1 (P < 0.001).

CONCLUSIONS

Treatment of patients with primary hyperoxaluria with orthophosphate and pyridoxine decreases urinary calcium oxalate crystallization and appears to preserve renal function.

Molecular evidence that the myxozoan protists are metazoans

The evolutionary origins of the protistan phylum, Myxozoa, have long been questioned. Although these obligate parasites are like protozoans in many features, several aspects of their ontogeny and morphology have implied a closer relationship to metazoan lineages. Phylogenetic analyses of 18S ribosomal RNA sequences from myxozoans and other eukaryotes, with the use of parsimony, distance, and maximum-likelihood methods, support the hypothesis that myxozoans are closely related to the bilateral animals. These results suggest that the Myxozoa, long considered an assemblage of protozoans, should be considered a metazoan phylum.

Cloning and characterization of bys1, a temperature-dependent cDNA specific to the yeast phase of the pathogenic dimorphic fungus Blastomyces dermatitidis

The pathogenic dimorphic fungal organism Blastomyces dermatitidis exists as a budding yeast at 37 degrees C and as a mycelium at 25 degrees C. While the conversion of one morphological phase of B. dermatitidis to another has long been known to be a thermally dependent process, little of the accompanying biochemical or genetic events controlling the phase transition has been elucidated. Using differential cDNA library screening, we have identified one transcript, bys1, in B. dermatitidis that is expressed at very high levels in the yeast phase but whose levels diminish rapidly when yeast cells are transferred to 25 degrees C to promote conversion to the mycelial phase. Although the 0.95-kb bys1 transcript is absent in B. dermatitidis mycelia maintained at 25 degrees C, transfer of mycelial cultures to 37 degrees C results in the reappearance of bys1 within 12 h. bys1 codes for a protein of 18.6 kDa that contains multiple putative phosphorylation sites, a hydrophobic N terminus, and two 34-amino-acid domains with similarly spaced nine-amino-acid degenerative repeating motifs. Although the nature of the thermal dependency of bys1 expression and the function of the bys1 protein are unknown, the strong expression of this transcript specifically in the yeast phase of B. dermatitidis may prove to be very useful in the development of more specific and sensitive diagnostic methods for blastomycosis.

Chemostratigraphy of predominantly siliciclastic Neoproterozoic successions: a case study of the Pocatello Formation and Lower Brigham Group, Idaho, USA

Isotopic chemostratigraphy has proven successful in the correlation of carbonate-rich Neoproterozoic successions. In successions dominated by siliciclastic rocks, chemostratigraphy can be problematic, but if thin carbonates punctuate siliciclastic strata, useful isotopic data may be obtained. The upper Pocatello Formation and lower Brigham Group of southeastern Idaho provide an opportunity to assess the potential and limitations of isotopic chemostratigraphy in overwhelmingly siliciclastic successions. The 5000 m thick succession consists predominantly of siliciclastic lithologies, with only three intervals that contain thin intercalated carbonates. Its depositional age is only broadly constrained by existing biostratigraphic, sequence stratigraphic and geochronometric data. The lowermost carbonates include a cap dolomite atop diamictites and volcanic rocks of the Pocatello Formation. The delta 13C values of these carbonates are distintly negative (-5 to -3), similar to carbonates that overlie Neoproterozoic glaciogenic rocks worldwide. Stratigraphically higher carbonates record a major positive delta 13C excursion to values as high as +8.8 within the carbonate member of the Caddy Canyon Quartzite. The magnitude of this excusion is consistent with post-Sturtian secular variation recorded elsewhere in the North American Cordillera, Australia, Svalbard, Brazil and Nambia, and exceeds the magnitude of any post-Varanger delta 13C excursion documented to date. In most samples, Sr-isotopic abundances have been altered by diagenesis and greenschist facies metamorphism, but a least-altered value of approximately 0.7076 supports a post-Sturtian and pre-Marinoan/Varanger age for upper Pocatello and lower Brigham rocks that lie above the Pocatello diamictite. Thus, even though available chemostratigraphic data are limited, they corroborate correlations of Pocatello Formation diamictites and overlying units with Sturtian glaciogenic rocks and immediately post-Sturtian successions in western North America and elsewhere.

Dietary management of urolithiasis

Within the United States, 5% to 15% of the population will have a symptomatic episode of a stone within the urinary tract by the age of 70. At least 50% of these individuals will have recurrent stone formation if left untreated. The composition of urine from which these stones are formed and in which they grow is, in part, dependent on diet, including fluid intake. The volume of urine is an important determinant of solute concentration. Ionic strength, pH, and the concentration of the major ionic species present in urine determine the level of saturation for any crystal system that could be precipitating. There are many conditions that can be complicated by the formation of calculi within the urinary tract. Identifying the dietary factors that are contributing to the problem and correcting these abnormalities are the foundations for good medical management. This review identifies dietary components that need to be considered in the management of affected patients and considers specific medical problems that may be especially influenced by diet and fluid intake.

Long-term prognosis in primary hyperoxaluria type II (L-glyceric aciduria)

Primary hyperoxaluria type II (PH-II) or L-glyceric aciduria was first reported by Williams and Smith in 1968 (N Engl J Med 278:233-239, 1968). Deficiencies of D-glycerate dehydrogenase and glyoxylate reductase activity in patients with this disorder leads to increases in urinary oxalate and glycerate excretion. Clinically, PH-II presents in a similar fashion to the more common variant of the disorder, PH-I, with symptoms of calcium oxalate nephrolithiasis. To date, 16 patients with PH-II have been described, and information regarding follow-up is available in only three. We review these reports and present five additional patients from three families, four of whom have been followed closely for more than 20 years. The favorable long-term outcome of our patients over 110 patient-years, as determined by renal function testing and radiographic evaluation, suggests that PH-II may have a more favorable prognosis when compared with the natural history of PH-I. Systematic screening of all PH patients in our practice led to the discovery of five of 30 with PH-II, thus suggesting that this subset population may be more common than originally suspected.

T-type and L-type calcium currents in freshly dispersed human uterine smooth muscle cells

OBJECTIVE

Our purpose was to characterize the types of voltage-activated calcium currents that are found in human uterine myocytes and to determine the effects of magnesium and nifedipine on these currents.

STUDY DESIGN

Electrophysiologic experiments were performed on freshly isolated human uterine smooth muscle cells by means of the nystatin modification of the whole-cell patch clamp technique.

RESULTS

Two types of voltage-activated calcium currents that are similar to the T-type and L-type calcium currents observed in cardiac myocytes were identified in freshly dispersed, pregnant human uterine myocytes. Magnesium at 8 mmol/L reduced uterine myocyte T-type currents by 68% +/- 17% but did not reduce L-type currents. Nifedipine at 10(-6) mol/L blocked the L-type currents but had no effect on T-type currents.

CONCLUSION

Freshly isolated human uterine smooth muscle cells exhibit subtypes of calcium currents that are analogous to those found in cardiac myocytes. The uterine myocyte T-type current may be primarily involved with action potential transmission and the L-type current primarily with increasing intracellular free calcium by bulk calcium transport. The differing physiologic effects of magnesium and nifedipine on the calcium current subtypes suggest that for the treatment of preterm labor the primary effect of magnesium therapy is to decrease the frequency of contractions and of nifedipine the strength.

In vitro HPV-11 infection of human foreskin

Study of the infectious process of human papillomavirus type 11 (HPV-11) has been facilitated by the discovery that HPV-11-infected neonatal human foreskin epithelium can proliferate as xenografts into condyloma-like growths within athymic nude mice. Here we describe detection of HPV-11 infection of neonatal human foreskin-derived keratinocytes, infected and cultured entirely in vitro, by use of the polymerase chain reaction and primers straddling the splice donor/acceptor site of the most prevalent early gene HPV-11 transcript (E1 increase E4). Expression of the E1 increase E4 HPV-11 mRNA is abrogated by 60 degrees C heat inactivation of the inoculum. HPV-11-infected foreskin explants continue to produce the E1 increase E4 mRNA for up to 5 weeks in culture, and second-passage keratinocytes derived from infected explant outgrowths continue to produce the E1 increase E4 mRNA. The in vitro system described here provides a new way to study HPV-11 infection and may be useful in evaluating early events of infection.

Urinary oxalate and glycolate excretion patterns in the first year of life: a longitudinal study

To determine the range of normal values, we studied urinary excretion of oxalate and glycolate prospectively and longitudinally in a cohort of 30 healthy term infants. Random urine samples were obtained at 2 days, 2 weeks, and 2, 4, 6, and 9 months of age. The results had a log-normal distribution. The mean oxalate/creatinine ratio, as determined by the oxalate oxidase method, was 0.08 (in milligrams of oxalate to milligrams of creatinine) with a normalized range of 0.02 to 0.31. The mean ratio when oxalates were measured by using the Olthuis assay was 0.13 (range 0.03 to 0.53). The mean glycolate/creatinine ratio was 0.07 (range 0.02 to 0.26). These values did not correlate with increasing age. The oxalate/creatinine ratios were higher in formula-fed infants than in those who were fed human milk (0.14 +/- 0.16 vs 0.08 +/- 0.04; p < 0.01).

Condylomata acuminata. Roles of different techniques of laser vaporization

Eighty-four women with acuminate warts of the external genital tract were treated with two methods of laser vaporization. Patients were classified by lesion number and volume (1+, 2+, 3+). Thirty-three patients had only the lesions vaporized, whereas 51 had individual lesions vaporized followed by the "brushing" technique applied to the surrounding mucosa. Postoperative discomfort and pain were worse in those patients who had the brushing technique. The results were assessed colposcopically six to eight weeks postoperatively. Regardless of the method of laser vaporization, the majority of patients with extensive disease (2+ or 3+) had persistent lesions, although reduced in number in most instances. Patients with relatively few lesions (1+) had complete elimination of the warts whether or not brushing was employed. Based upon this study, reducing the burden of acuminate warts before laser vaporization is recommended.

Retroperitoneal fibrosis as a cause of hypertension in an aviator: a case report

The authors describe a case report of a previously healthy rotary-wing aviator who developed hypertension of unknown etiology. His 30 pack/year smoking history and hypercholesterolemia (ranging from 224-268) were significant. The initial evaluation revealed an elevated creatinine of 1.7 (normal to 1.5). Right-sided hydronephrosis was noted on ultrasound and the right kidney was poorly visualized on IVP. A subsequent retrograde cystoureterogram confirmed the hydronephrosis and demonstrated a distal calculus and stenosis, findings which were compatible with retroperitoneal fibrosis (RPF). This diagnosis was confirmed at surgery and the patient's ureters were freed. Following surgery, return of normal kidney function and satisfactory recovery, this aviator returned to full flying duty. A review of RPF is included.

Role of ultrasound in medical management of patients with renal stone disease

Eighty-three patients with radiographically opaque renal stones were evaluated prospectively with ultrasound and compared to KUB (kidneys, ureters, bladder) with tomograms (KUB/T) to further define the use of ultrasound in the evaluation of renal calculi. The presence or absence and the size, number, and location of stones were analyzed and correlated for each modality. Ultrasound detected the presence of renal stones in 77 of 83 (93%) patients. However, all of the stones were detected on ultrasound in only 60% of these patients. Thirty percent (80 of 269) of the papillary-calyceal stones seen on KUB/T were missed on US; 66% of the stones missed measured 2 mm or less. Although ultrasound can be used for detection of intrarenal stones, KUB/T is a more accurate imaging examination for determination of size and number of small stones.

Synchronous radiation and cytotoxic chemotherapy for locally advanced or recurrent squamous cancer of the vulva

Between July 1987 and September 1991 a program of external beam radiation and synchronous, radiopotentiating chemotherapy was employed to treat 25 women with locoregionally advanced or locoregionally recurrent squamous cancer of the vulva. Of 18 previously untreated patients, 1 was Stage II, 10 were Stage III, 6 were Stage IVA, and 1 was Stage IVB. Reasons for patient referral for nonsurgical management included the presence of initially unresectable disease (5 patients), disease extent which would have necessitated partial or total exenteration if treated surgically (9 patients), disease extent predictive of inadequate surgical margins (less than 1 cm gross margin) if treated by less than exenterative surgery (8 patients), and severe comorbid illness precluding surgical management (3 patients). Complete clinical response was obtained in 16 of 18 previously untreated patients (89%) and in 4 of 7 patients with recurrent disease following vulvar surgery (57%). Of 20 patients achieving a complete clinical response, 3 patients have relapsed within the irradiated volume at 11, 38, and 48 months following completion of treatment. Fourteen patients remain alive and continuously cancer free from 2-52 months after completion of treatment (median follow-up 24 months). This experience suggests that initial management with radiation and chemotherapy may offer some patients with locally advanced squamous cancer of the vulva an alternative to exenterative surgery and may hold curative potential for some patients with surgically unresectable or medically inoperable disease.

Management of neutropenic enterocolitis in the patient with cancer

Neutropenic enterocolitis is a life-threatening condition often seen in patients experiencing prolonged periods of neutropenia from conditions such as leukemia and lymphoma and from aggressive chemotherapy regimens. Its exact pathologic process remains unclear; however, it has been proposed that direct cytotoxic damage occurs to the bowel mucosa with subsequent microbial invasion complicated by the lack of adequate neutrophil response. The damage may progress to bowel perforation and septic shock. Early recognition and management by healthcare team members are crucial for the improved prognosis of these individuals. Controversy continues to exist concerning management options and the timing of these interventions. This article outlines nursing and medical management of the patient with neutropenic enterocolitis.

Adenocarcinoma-reactive human monoclonal antibody MS2B6 defines an antigen in simple glandular epithelium

A human monoclonal antibody (MAb), MS2B6, produced from splenocytes isolated from a patient with advanced papillary serous cystadenocarcinoma of the ovary, defines a unique human tumor-associated antigen. This antigen, EA2B6 (epithelial antigen 2B6), is expressed in a tissue-restricted manner on cultured and fresh human adenocarcinomas and some normal glandular epithelial tissues. EA2B6 is a 38-48 kD protein antigen that co-fractionates with the nuclear matrix-intermediate filament scaffold of simple glandular epithelial tissues. EA2B6 is a molecule with restricted solubility, and in vitro antigen-antibody binding is dependent on the antigen being presented on a solid support. To determine if EA2B6 is a cytokeratin, competition studies were undertaken with several cytokeratin-specific murine monoclonal antibodies. None of these antibodies inhibited the binding of human MAb MS2B6 to partially purified EA2B6. Less than 1% of HT29 colon adenocarcinoma cells and fresh ovarian adenocarcinoma ascites cells express EA2B6 on their surface. The majority of EA2B6 is intracellular. Because of the restricted tissue distribution of this antigen and stability of the antibody, we believe MS2B6 is a good candidate for MAb-mediated diagnosis and therapy of human adenocarcinomas.

Formation of a vagina at the time of exenteration

The formation of an artificial vagina at the time of exenteration has been described. Femoral gluteal flaps forming a tube suspended to the iliopectineal ligament appeared to give the most satisfactory results.