Bias and precision of estimated glomerular filtration rate in children

Determining true glomerular filtration rate (GFR) using an exogenous marker is time-consuming and cumbersome. Therefore, creatinine-based estimates of GFR are used. Recent papers using new population-specific/local parameters in their prediction equations, standardizing creatinine determination or adding other endogenous surrogate markers of GFR, like cystatin C, could demonstrate an improvement of bias inherent in the results of the prediction equations. Precision, however, is still poor. Currently, we have to accept a precision (as defined in the so-called Bland-Altman plot) of +/-20% in adults and +/-30-40% in children. This problem of poor precision/uncertainty is especially bothering in the higher, near normal GFR range. Caution should be exercised when applying prediction equations in individuals in need of an accurate GFR determination. In that case, a real clearance procedure has to be performed. In the long run, the true clearance procedure should be simplified using new exogenous GFR markers and developing new devices, allowing GFR measurements to be performed, for example, transcutaneously. Such a procedure would be more acceptable for both patients and physicians.

Plasma creatinine determination in mice and rats: An enzymatic method compares favorably with a high-performance liquid chromatography assay

The use of the colorimetric Jaffé method for the measurement of creatinine in mouse and rat plasma has been criticized as prior studies have shown a dramatic overestimation. We compared a colorimetric picric acid, an enzymatic, and a high-performance liquid chromatography (HPLC) method to assess their appropriateness for routine measurements of creatinine in plasma of healthy and diseased mice (n=61) and rats (n=56). For the colorimetric Jaffé method a pronounced overestimation is confirmed. Additionally the method showed interference with hemoglobin already in a very low, non-visible concentration range in rat plasma. The enzymatic measurement demonstrated a hemoglobin interference in mice, only when hemolysis was visible. The comparison between HPLC and the enzymatic measurement gave a good agreement between both methods in both species. Therefore the enzymatic method fulfills the requirements for a routine screening test for plasma creatinine in healthy as well as diseased mice and rats Kiover a broad concentration range.

[MDCT after balloon kyphoplasty: analysis of vertebral body architecture one year after treatment of osteoporotic fractures]

PURPOSE

To evaluate the value of MDCT in the monitoring of vertebral body architecture after balloon kyphoplasty and observe morphological changes of the vertebral body.

MATERIAL AND METHODS

During a period of 26 months, 66 osteoporotic fractures of the vertebral bodies were treated with percutanous balloon kyphoplasty. The height of the vertebral body, width of spinal space, sagittal indices, kyphosis und COBB angle, and cement leakage were evaluated by computed tomography before and after treatment and in a long-term follow up. Statistical analysis was performed by calculating quantitative constant parameters of descriptive key data. In addition, parametric and distribution-free procedures were performed for all questions.

RESULTS

After kyphoplasty, the treated vertebral bodies showed a significant gain in the height of the leading edge (0.15 cm; p < 0.0001) and in the central part of the vertebral body (0.17 cm; p < 0.0001). The height of the trailing edge did not change significantly. A corresponding gain in the sagittal index was found. The index remained stable during follow-up. Treated vertebral bodies as well as untreated references showed a comparable loss of height over the period of one year. The shape of the vertebral bodies remained stable. In comparison to these findings, treated vertebral bodies showed a reduced loss of height. A significant change in kyphosis und the COBB angle was noted. In total, pallacos leakage was detected in 71 % of cases.

CONCLUSION

MDCT is an accurate method for evaluating vertebral body architecture after treatment with balloon kyphoplasty. Morphological changes in the vertebral bodies, and complications such as pallacos leakage and progression of osteoprosis can be accurately documented. The significant increase in the vertebral body height after treatment is closely correlated with a gain in the sagittal index and reduced kyphosis and COBB angle.

Hereditary hemorrhagic telangiectasia: an update on clinical manifestations and diagnostic measures

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is an autosomal dominant disorder of the fibrovascular tissue. It is characterized by the classic triad of (muco-)cutaneous telangiectases, arteriovenous malformations with recurrent epistaxis and hemorrhages, and inheritance. A wide variety of clinical manifestations in HHT have been described. In more than 90% of the patients, nosebleeds are the first predominant symptom, therefore ENT physicians often play a key role as far as diagnosis and management of the disease are concerned. In spite of recent diagnostic and therapeutic progress, a cure for this often burdening and handicapping disease is still not available. Apart from affecting the nose, arteriovenous malformations (AVMs) may also affect the skin, lungs, brain, liver and gastrointestinal tract. The two known genes that are implicated in HHT are endoglin (ENG) located on chromosome 9q33-q34 and activin-receptor-like kinase (ALK1) located on chromosome 12q13. Mutations of ENG are observed in HHT type 1 with an incidence up to 40% for pulmonary AVMs, whereas mutations of ALK1 are observed in HHT type 2 with an incidence of only 14% for pulmonary AVMs, which clinically distinguishes these two types of mutation. The emphasis of this paper is mainly on the clinical manifestation, molecular genetics and diagnosis of HHT, taking account of current literature on HHT in order to better understand the complexity of the disease. Recent therapeutic options in the treatment of HHT have been omitted from this paper as they are subject of a following paper. HHT is more common than previously thought and shows a broad range of different clinical organ manifestations that can be sources of substantial morbidity and mortality, making HHT a continuing challenge for many sub-specialties where interdisciplinary diagnostic screening is mandatory in the management of the disease.

Pharmacological profile and toxicity of fluorescein-labelled sinistrin, a novel marker for GFR measurements

There is an evident and growing medical need for an accurate determination of kidney function for a broad spectrum of indications. The glomerular filtration rate (GFR) is the most accepted indicator of renal function. Due to difficulties in performing the test, GFR is currently determined rarely in clinical practice. A procedure for such GFR determination has to be safe, accurate and easy to handle. By using the new compound fluorescein isothiocyanate-sinistrin (FS) these requirements are met. The pharmacological profile and tolerability of FS, selected from among various newly synthesized, labelled compounds intended for use as GFR markers, was characterized in male Sprague-Dawley rats following i.v. application. Using the newly described fluorometric method, FS can be determined much more easily in serum and urine than with the established enzymatic method. After i.v. dosing, FS concentrations in serum declined rapidly in various experimental groups to a comparable extent (t (1/2), mean+/-SD: 22.4+/-8.3 to 26.2+/-5.4 min). Its increase after unilateral nephrectomy reflects the loss of filtration capacity. Comparable concentration-time curves of FS in serum measured fluorometrically and enzymatically suggest no relevant alteration of pharmacokinetic behaviour by the labelling. This notion is supported by the high urinary excretion rate and absence of biliary excretion. The higher sensitivity of the fluorometric method suggests a dose of FS of 100 mg in humans compared with 5 g of sinistrin or inulin. FS was well tolerated after single and multiple applications. On the basis of these results, the kinetics of FS are comparable with the gold standard inulin or sinistrin, but FS is superior in handling. Providing the data can be transferred from rat to human, determination of GFR using the new method should result in an improvement of acceptance by both physicians and patients.

Fluorescein-labeled sinistrin as marker of glomerular filtration rate

There is an obvious and growing medical need for an accurate and easy to handle determination of glomerular filtration rate (GFR) for a broad spectrum of indications. Newly synthesized fluorescein-isothiocyanate (FITC)-sinistrin (FS) with various degrees of labeling was selected by its physicochemical properties and good tolerability out of a number of dye-labeled compounds intended for use as GFR markers for characterization of its pharmacological profile. With respect to solubility FS is more convenient in handling compared to FITC-inulin (FI). Up to 100 mg ml(-1) of FS can be dissolved in aqueous solvents at room temperature, whereas FI can only be solubilized after warming up to 55 degrees C. This reveals a considerable advantage of FS over FI in preparation of galenical formulations for intended i.v. application. A fluorometric method was established to determine FS concentration in blood serum with a comparable accuracy to the established enzymatic method for polyfructosanes. Similar concentration time curves in blood serum of FS measured fluorometrically and enzymatically suggest no relevant change of pharmacokinetic behavior by dye labeling. This notion is supported by the rapid renal and missing of biliary excretion. On the basis of these results, FS is superior in handling to the available GFR markers and makes it highly interesting as a novel diagnostic drug.

[Localization of bleeding using 4-row detector-CT in patients with clinical signs of acute gastrointestinal hemorrhage]

PURPOSE

There is no gold-standard regarding the diagnostic work-up and therapy of an acute gastrointestinal (GI) hemorrhage. In most cases endoscopy provides the diagnosis but in a low percentage this modality is not feasible or negative. Purpose of this study was to evaluate the role of multi-phase Multi-Slice-Computertomography (MSCT) as a modality to diagnose and locate the site of acute GI hemorrhage in case of unfeasible or technically difficult endoscopy.

MATERIALS AND METHODS

58 patients, presenting with clinical signs of lower GI hemorrhage, were examined through a 24-month period. Preliminary endoscopy was either negative or unfeasible. Images were obtained with a four-detector row CT with an arterial (4 x 1 mm collimation, 0.8 mm increment, 1.25 mm slice width, 120 kV, 165 mAs) and portal venous series (4 x 2,5 mm collimation, 2 mm increment, 3 mm slice width, 120 kV, 165 mAs). Time interval between endoscopy and CT varied between 30 minutes and 3 hours. The results of the MSCT were correlated with clinical course and surgical or endoscopical treatment.

RESULTS

20 of the 58 patients (34 %) undergoing MSCT had a bleeding site identified, thus providing decisive information for the following intervention. In case of a following therapeutic intervention there was 100 % correlation regarding the bleeding site. In 38 of the 58 patients (66 %), a bleeding site was not identified by MSCT. Twenty of these 38 patients (53 %) were stable and required no further treatment. In 18 of these 38 patients further interventional therapy was required due to continuing hemorrhage and in all of those patients the bleeding site was detected by intervention.

CONCLUSION

Compared to other diagnostic methods MSCT is a fast, widely-available and low-risk technique for the localization of active GI hemorrhage. The clinical use seems to be justified since in more than one third of the patients, MSCT demonstrates the site of bleeding and provides decisive information for further interventional therapy. Concerning those patients, in whom MSCT is negative (38 out of 58 patients), only every second patient requires any additional diagnostic work-up.

[Whole-body MSCT of patients after polytrauma: abdominal injuries]

PURPOSE

The goal of this retrospective study was to evaluate the spectrum of abdominal injuries and the reliability of computed tomography-based diagnosis in patients after polytrauma.

MATERIAL AND METHODS

CT findings and clinical reports for 177 patients after polytrauma were evaluated with regard to abdominal injuries. Clinical patient reports at the time of discharge from the hospital were utilized as the standard of reference. Abdominal injuries resulting from an accident, frequent additional traumas and following therapeutic procedures were recorded. In the case of discrepancies in the reports, the CT scans were viewed retrospectively.

RESULTS

In 30 out of 177 patients, 42 abdominal injuries were detected. 69 % of the injuries were caused by traffic accidents while 31 % resulted from falls. Liver and spleen injuries were the most common. 50 % of the cases were treated surgically, and the other half of the cases underwent non-surgical conservative therapy. Massive chest traumas, pelvic injuries, cerebral traumas and injuries to extremities were commonly associated with abdominal injuries. Evaluation of the discrepancies in the clinical reports showed that injury to the pancreas and the small intestine were not successfully detected on CT, thus resulting in a false negative diagnosis. Early stages of organ parenchyma laceration were also initially misdiagnosed on CT.

CONCLUSION

Contrast-enhanced whole-body MSCT is a reliable and rapid method for diagnosing abdominal injuries in patients after polytrauma. Only very few patterns of injury are not detected on CT. The appearance of fluid collection in the abdomen is an indicator of possible parenchyma injury and requires further evaluation in cases of clinically suspected organ trauma.

Efficacy and immunogenicity of novel erythropoietic agents and conventional rhEPO in rats with renal insufficiency

Recombinant human erythropoietin (rhEPO) is used to treat anemia in chronic renal insufficiency. Erythropoietin (EPO) immunogenicity can lead to EPO-resistant anemia. Conjugating proteins with polyethylene glycol (PEG) can prolong elimination half-life and diminish protein immunogenicity. We investigated the efficacy of new erythropoietic agents, synthesized by single (Ro 50-3821) and multiple (MIX) integrations of PEG and succinimidyl butanoic acid with rhEPO, in rats with chronic renal insufficiency. Sprague-Dawley rats with surgically induced renal insufficiency received Ro 50-3821 or MIX subcutaneously (s.c.) over 4-12 weeks compared to rhEPO and NaCl. Hemoglobin and antibody levels served as primary efficacy and safety variables. Dosing intervals and dose-response characteristics were investigated. Ro 50-3821 (2.5 microg/kg once weekly) increased hemoglobin levels by 7 g/dl after 4 weeks compared to 1 g/dl in NaCl controls (P<0.05). MIX (2.5 microg/kg once weekly) and rhEPO (0.25 microg/kg three times weekly) increased hemoglobin levels by 3 g/dl. Ro 50-3821 administered for 12 weeks (0.75 microg/kg once weekly) increased hemoglobin levels (from 13 to 19 g/dl) more effectively than rhEPO (0.75 microg/kg once weekly, decline from 13 to 11 g/dl, P<0.05). No antibodies against Ro 50-3821 were detected after 12 weeks of treatment. Antibodies against rhEPO were seen in 69% of animals (P<0.00001). Ro 50-3821 increased hemoglobin levels with once weekly s.c. dosing. Multiple pegylated EPO is less effective. In rats, rhEPO failed to increase hemoglobin levels with once weekly long-term dosing. Antibody formation following rhEPO may explain this finding. Therefore, Ro 50-3821 may provide important clinical advantages compared to unpegylated EPO. It can be administered in longer dosing intervals and has a lower risk of unfavorable immunological responses.

Estriol induced squamous metaplasia on the nasal mucosa in patients with hereditary hemorrhagic telangiectasia

BACKGROUND

The aim of this study was to evaluate by light and electron microscopy the effect of topical estriol on the nasal mucosa in patients with hereditary hemorrhagic telangiectasia (HHT).

METHODS

Twelve patients were instructed to apply twice daily 0.1% estriol as a nose ointment over a period of 12 months. Written consent was obtained from each patient, allowing biopsy specimens of the nasal mucosa to be taken prior to and 3, 6 and 12 months after estriol application.

RESULTS

Metaplastic change of the nasal mucosa was observed 6 months after topical estriol application. The former ciliated columnar epithelium changed into a keratinizing squamous epithelium. The effect was reversible after discontinuation of estriol application.

CONCLUSIONS

For the first time, we could outline the effect of topical estriol on the nasal mucosa. These histomorphological findings, and the fact that estriol is a low-potency metabolite of estradiol, make estriol a valuable agent in the treatment of HHT patients.

Cross-sectional imaging combined with 3D-MR angiography (3D-MRA): diagnostic tool for preoperative vascular assessment of head and neck tumors

BACKGROUND

Head and neck cancer accounts for 5% of all malignancies worldwide. The presence of lymph node metastases and vascular infiltration influence patient outcome. This prospective study describes the preoperative morphologic assessment of the vascular status of patients with head and neck tumors by means of high spatial resolution and extended coverage of the arterial and venous system reaching from the supra-aortic region to the skull base.

PATIENTS AND METHODS

Cross-sectional imaging combined with contrast-enhanced 3D-maximum intensity projection MR angiography (3D-MRA) was applied using a dedicated head and neck coil with a 4-channel panorama array system interface to assess vascular involvement in patients with suspected head and neck cancer. 32 patients underwent preoperative assessment by magnetic resonance imaging (MRI). The results were then correlated with surgical and histological findings.

RESULTS

3 of the 32 patients (9%) demonstrated involvement of the arterial system. In 2 of these 3 cases, MRA correctly predicted the arterial status, while in 1 case it gave a false negative result. 11 of the 32 patients (34%) presented with involvement of the venous system. 10 cases showed complete concordance between the findings of the MR venography and the intraoperative status, while in 1 case a false negative result was produced.

CONCLUSION

In patients with suspected head and neck tumors, 3D-MRA in combination with cross sectional imaging is a valuable diagnostic tool for the detection of vascular involvement.

[Is imaging possible for otosclerosis? Characteristics of the disease and a survey of the clinical relevance of imaging]

Otosclerosis is a localized progressive disease of bone remodeling within the otic capsule of the human temporal bone. Histomorphologically, active cochlea otosclerosis (otospongiosis) is diagnosed in the presence of foci of demineralization in the otic capsule. The clinical symptoms of otosclerosis are associated with mixed and sensorineural hearing loss. With recent technological advances, diagnostic imaging of the inner ear is becoming more and more important in the evaluation of diseases affecting the cochlea. Studies could demonstrate that otosclerosis has a characteristic appearance on high-resolution computed tomography (HRCT), producing a distinctive pericochlear hypodense double ring. Its appearance on MRI is not as readily appreciated, producing a ring of intermediate signals in the pericochlear and perilabyrinthine regions on T1-weighted images, demonstrating mild to moderate enhancement after gadolinium administration. The ethiology and pathophysiology of otosclerosis are described and a review of the literature is given to illustrate the clinical relevance of imaging in otosclerosis.

Direct fluorometric analysis of a newly synthesised fluorescein-labelled marker for glomerular filtration rate

There is an obvious and growing medical need for an accurate determination of kidney function in the diagnosis and management of renal diseases. The glomerular filtration rate (GFR) is the accepted gold standard measurement of kidney function. Several approaches to estimate the GFR are available, but most of them are inconvenient and, therefore, of limited acceptance. A new method of quantification with fluorescein-isothiocyanate (FITC) sinistrin (FS), a novel GFR marker, has been evaluated. The method is based on the fluorescence label of FS and can be performed with a standard fluorometer. To control the interference of protein with the fluorescence signal, a calibration function was developed. The accuracy of the fluorometric method established is comparable to the so-called "gold standard" of enzymatic determination of polyfructosan. Moreover, FS is easy to handle and requires low-cost instruments. Our results demonstrate the potential of the direct fluorometric analysis of the new FITC-labelled marker of being a precise, simple, rapid and cost-effective method for diagnosing disturbed kidney function and monitoring its treatment efficacy. The dramatic decrease in analytical effort will result in a significantly higher acceptability of GFR determination.

Plasma level and tissue expression of angiogenic factors in patients with hereditary hemorrhagic telangiectasia

The value of angiogenic factors interleukin-8 (IL-8) and vascular endothelial growth factor (VEGF) was determined in patients with hereditary hemorrhagic telangiectasia (HHT) to evaluate their role in HHT pathogenesis. IL-8 and VEGF were measured in plasma of 41 HHT patients and healthy controls by ELISA technique. In both groups, the IL-8 and VEGF tissue expression in cryostat sections of the nasal mucosa were then compared. VEGF plasma levels were significantly increased in HHT patients compared to healthy controls. In contrast, the IL-8 plasma levels in both groups did not show any significant difference. Compared to healthy controls, HHT tissue samples showed a weak IL-8 staining, whereas the VEGF staining was very strong. The plasma levels of VEGF and IL-8 could not be correlated to the patients' clinicopathological findings. Additionally to the angiogenic pro-inflammatory cytokine IL-8, the angiogenic factor VEGF seems to play a major role in HHT pathogenesis.

Diagnostic evaluation of magnetic resonance imaging with turbo inversion recovery sequence in head and neck tumors

The clinical outcome of patients with head and neck cancer depends on many factors such as tumor size, metastatic involvement and angioarchitecture of the tumor. The correct staging of tumor extension, presence of cervical lymph node metastases and evaluation of vascular infiltration are essential diagnostic steps before treatment. The aim of this study was to evaluate the accuracy of turbo inversion recovery magnitude (TIRM) magnetic resonance imaging (MRI) in the diagnosis of head and neck tumors with special attention to tumor size and tumor spread according to the current TNM classification. TIRM sequence with short T1 relaxation and long TE (echo time) improves imaging contrast because of the increased T1-weighting and the inherent fat suppression. In a prospective clinical study, 32 patients underwent preoperative MRI. Diagnosis was confirmed histologically in all cases. Scanning was performed on a 1.0-T unit applying TIRM as well as T1- and T2-weighted turbo spin echo (TSE) sequences. In all sequences, tumor size was overestimated due to reactive inflammatory changes surrounding the tumor tissue. The least overestimation was documented on TIRM and post-contrast T1 TSE. The highest values of relative tumor signal intensities were obtained in TIRM (3.5+/-0.9) and T2 TSE (3.5+/-0.8) followed by post-contrast T1 TSE (1.6+/-0.7) and pre-contrast T1 TSE (1.2+/-0.3). Due to the inherent fat suppression, tumor delineation was most obvious in TIRM. In patients with suspected cancer of the head and neck, TIRM should be considered as a standard and a diagnostically relevant sequence in the MRI staging protocol.

Antibody binding regions on human nerve growth factor identified by homolog- and alanine-scanning mutagenesis

The binding specificities of a panel of mouse monoclonal antibodies (MAbs) to human nerve growth factor (hNGF) were determined by epitope mapping using chimeric and point mutants of NGF. Subsequently, the MAbs were used to probe NGF structure-function relationships. Six MAbs, which recognize distinct or partially overlapping regions of hNGF, were evaluated for their ability to block the binding of hNGF to the TrkA and p75 NGF receptors in various in vitro assays, which included blocking of TrkA autophosphorylation and blocking of NGF-dependent survival of dorsal root ganglion sensory neurons. Three MAbs (911,912,938) were potent blockers of all activities. Potent blocking of p75 binding occurs only with MAb 909, which recognizes an NGF region identified by mutagenesis as important for NGF-p75 binding. These results are consistent with recently proposed models of binding regions involved in NGF-TrkA and NGF-p75 interactions generated through mutagenic analysis and structure determination of the NGF-TrkA complex. These studies provide insight to the epitope specificities and potency of MAbs that would be useful for physiological NGF blocking studies.

Importance of interleukin-8 in the development of reexpansion lung injury in rabbits

Reexpansion of a collapsed lung induces increased microvascular permeability leading to reexpansion pulmonary edema (REPE). This study was designed to prove the hypothesis that local overproduction of interleukin-8 (IL-8) induces inflammatory cell accumulation which leads to the induction of REPE. Initially, we examined the detailed characteristics of a rabbit model of REPE in association with IL-8 production and its mRNA expression. The lung tissue to plasma ratio of radiolabeled albumin (T/P ratio), the lung wet to dry ratio, and bronchoalveolar lavage (BAL) neutrophil counts were significantly increased in the reexpanded lung. IL-8 concentrations and mRNA expression were significantly increased in the reexpanded lung homogenate. Immunohistochemically, alveolar macrophages (AMs) and epithelial cells in the reexpanded lung and AMs in the collapsed lung were positive for IL-8. Second, we examined the effect of pretreatment with a specific monoclonal anti-IL-8 antibody (Ab) or control IgG on the development of REPE. The T/P ratio and BAL neutrophil counts were conspicuously decreased by pretreatment with anti-IL-8 Ab, but not with control IgG. On a histopathological study, lung injury and leukocyte infiltration were attenuated by the pretreatment with anti-IL-8 Ab. In conclusion, IL-8 production is enhanced in the reexpanded lung, and contributes to the development of REPE. The pretreatment with anti-IL-8 antibody may be useful as a novel protective therapy for this disease.

Evaluation of breath-hold contrast-enhanced 3D magnetic resonance angiography technique for imaging visceral abdominal arteries and veins

RATIONALE AND OBJECTIVES

To evaluate the diagnostic value of breath-hold contrast-enhanced 3D magnetic resonance angiography (MRA) for assessment of the visceral abdominal arteries and veins in patients with suspected abdominal neoplasms.

METHODS

Twenty-one patients underwent MR imaging on a 1.5 T unit using a body phased-array coil. MRA was performed with a 3D-FLASH sequence (TR 3.8 ms, TE 1.3 ms, flip angle 25 degrees, acquisition time 20 seconds), 8 to 12 seconds after an intravenous bolus injection of Gd-DTPA. The acquisition delay between the arterial and the portal venous phase was 12 seconds. The image quality and the degree of vascular involvement were evaluated using coronal source images and maximum intensity projection reconstructions. Diagnosis was confirmed by surgery/histology.

RESULTS

Image quality was optimal in more than 85% of the patients (19/21 arterial phase and 17/21 portal venous phase). MRA correctly predicted vascular status in 20 of 21 patients (95%), with complete concordance between MRA results and surgical findings. In one patient with chronic pancreatitis, MRA demonstrated a false-positive finding that could not be confirmed surgically. CONCLUSIONS. Breath-hold contrast-enhanced 3D-MRA is a valuable technique for assessing visceral abdominal arteries and veins.

Pancreatic cancer: value of dual-phase helical CT in assessing resectability

PURPOSE

To evaluate the use of dual-phase helical computed tomography (CT) (with or without CT angiography) to assess resectability in patients suspected to have pancreatic cancer.

MATERIALS AND METHODS

Tumor resectability was prospectively evaluated in 89 patients who later underwent surgery for suspected pancreatic cancer. Helical CT scans were obtained in the vascular phase and a phase of maximal hepatic enhancement. CT angiograms were produced with multiprojection volume reconstruction and maximum-intensity projection. CT results were correlated with surgical and histopathologic results.

RESULTS

Helical CT allowed detection of pancreatic cancer in 74 of 76 cases (97%). There were six false-positive results (positive predictive value, 92%). For prediction of irresectability, helical CT had an accuracy of 91%, negative predictive value of 79%, and sensitivity of 91%. Helical CT allowed detection of liver metastases in 21 of 28 cases (75%), nodal involvement in 13 of 24 cases (54%), and vascular invasion in 35 of 40 cases (88%). CT angiography demonstrated 30 of the 35 cases of vascular invasion detected with helical CT (86%).

CONCLUSION

Use of dual-phase helical CT improves prediction of resectability in patients with pancreatic cancer. CT angiography cannot show all of the findings seen on helical scans.

[Bolus tracking and NaCl bolus in biphasic spiral CT of the abdomen]

PURPOSE

To optimise injection parameters in helical CT of the abdomen with individual bolus tracking and subsequent NaCl bolus injection. To investigate the effect of bolus tracking on image quality in the abdomen.

METHODS

Patients were randomised into three examination protocols and underwent biphasic helical CT (Hi-Speed Advantage, GE). The effect of NaCl bolus on duration of aortic enhancement was investigated. Contrast enhancement in parenchyma and vessels was examined. The influence of body mass index, injection flow and contrast material volume on enhancement was evaluated.

RESULTS

Subsequent injection of NaCl provided significant extension of contrast enhancement in the aorta. Optimal image quality for pancreas and abdominal arteries was achieved in the arterial phase and for liver, spleen, kidneys and abdominal veins in the portal venous phase. Body mass index, injection flow and contrast material volume showed a significant influence on the time intervals resulting from bolus tracking.

CONCLUSION

Individual bolus tracking with subsequent injection of 20 ml NaCl bolus optimises intravenous contrast application.

[Radiotherapy in advanced osseous destruction in chronic myeloid leukemia. A case report]

PURPOSE

Chronic myelocytic leukemia is a disease of myeloproliferative disorder. In chronic myelocytic leukemia occasionally myelosarcomas occur as defined tumors which can cause localized symptoms. We report a case of successful palliative radiotherapy.

PATIENT AND METHODS

A 44-year-old patient with total destruction of the left humerus caused by myelosarcoma of the bone in chronic myelocytic leukemia was treated with percutaneous megavoltage radiotherapy, the total applied dose was 40 Gy. After radiotherapy the patient was free of pain. The tumorous swelling of soft tissue subsided completely, there was total formation of callus in the affected humerus and the patient could be mobilized.

CONCLUSIONS

This case report confirms the high effectiveness of palliative radiotherapy even in advanced cases of myelosarcomas which has been described in literature.

Characterization of Gas6, a member of the superfamily of G domain-containing proteins, as a ligand for Rse and Axl

Rse, Ax1, and c-Mer comprise a family of cell adhesion molecule-related tyrosine kinase receptors. Human Gas6 was recently shown to act as a ligand for both human Rse (Godowski et al., 1995) and human Ax1 (Varnum et al., 1995). Gas6 contains an NH2-terminal Gla domain followed by four epidermal growth factor-like repeats and tandem globular (G) domains. The G domains are related to those found in sex hormone-binding globulin and to those utilized by laminin and agrin for binding to the dystroglycan complex. A series of Gas6 variants were tested for their ability to bind to Rse and Ax1. The Gla domain and epidermal growth factor-like repeats were not required for receptor binding, as deletion variants of Gas6 which lacked these domains bound to the extracellular domains of both Rse and Axl. A deletion variant of Gas6 containing just the G domain region was shown to activate Rse phosphorylation. These results provide evidence that G domains can act as signaling molecules by activating transmembrane receptor tyrosine kinases. Furthermore, they provide a structural link between the activation of cell adhesion related receptors and the control of cell growth and differentiation by the G domain-containing superfamily of proteins.

Inhibition of insulin receptor phosphorylation by PC-1 is not mediated by the hydrolysis of adenosine triphosphate or the generation of adenosine

Individuals with insulin resistance show increased levels of PC-1 expression in skeletal muscle and fibroblasts, and in transfected cell lines that overexpress PC-1 there is a reduction in the insulin-stimulated insulin receptor tyrosine phosphorylation. As PC-1 is a type II transmembrane protein with extracellular phosphodiesterase and pyrophosphatase activity, increased expression of PC-1 at the cell surface will decrease extracellular adenosine triphosphate levels and increase extracellular adenosine levels. Consequently it is possible that PC-1-mediated insulin resistance could be caused either by a decrease in adenosine triphosphate or an indirect increase in adenosine levels. We have tested this hypothesis and find that the PC-1-mediated inhibition of insulin-stimulated insulin receptor autophosphorylation is not altered by agents that alter the level or action of adenosine. Further, a mutated PC-1 with a single amino acid change that abolishes the phosphodiesterase and pyrophosphatase activities is still able to inhibit insulin-stimulated insulin receptor phosphorylation. The results of these experiments indicate that the phosphodiesterase activity of PC-1 is not involved in the inhibition of insulin receptor autophosphorylation.

Interleukin-8 is a major component of pleural liquid chemotactic activity in a rabbit model of endotoxin pleurisy

Gram-negative endotoxin induces production of the potent chemotactic factor interleukin-8 (IL-8) in vitro; however, the importance of IL-8 in endotoxin-induced inflammation in vivo is unknown. We asked whether IL-8 is an important contributor to chemotactic activity in acute inflammatory liquids formed in response to endotoxin, and, if present, what concentrations of IL-8 antigen are generated. For these studies, we cloned and expressed rabbit recombinant IL-8 (rrIL-8), developed specific anti-rabbit IL-8 monoclonal antibodies (mAb), and then used these reagents to develop assays to detect rabbit IL-8 bioactivity and measure rabbit IL-8 antigen. Escherichia coli endotoxin (20 ng/ml, n = 4, or 2,000 ng/ml, n = 4) was instilled into the pleural space of eight rabbits for 6 h. Rabbit IL-8 bioactivity in the endotoxin pleurisy samples was assayed by measuring the migration of rabbit neutrophils toward the pleural liquid under two different conditions: 1) after addition of an anti-IL-8 neutralizing mAb and 2) after desensitization of the neutrophils to rrIL-8. Addition of the anti-IL-8 mAb decreased neutrophil migration toward the pleural liquid by 65 +/- 13 and 75 +/- 22% (mean +/- SE, after 20 and 2,000 ng/ml endotoxin, respectively; P < 0.01 compared with a control mAb). Desensitization of neutrophils to rrIL-8 decreased their migration toward the pleural liquid by 72 +/- 5% (P = 0.03, compared with exposure of neutrophils to buffer alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Production of the RANTES chemokine in delayed-type hypersensitivity reactions: involvement of macrophages and endothelial cells

To understand the selective accumulation of memory T helper lymphocytes and of macrophages in delayed-type hypersensitivity (DTH) granulomas, we studied the in situ production of RANTES, a chemokine initially characterized on the basis of its in vitro chemotactic properties for each of these cell populations. RANTES gene expression was studied by in situ hybridization in 15 human lymph nodes presenting typical DTH lesions related to either sarcoidosis or tuberculosis. A positive signal was detected in all cases. Labeling was specific for the DTH lesions, as very few if any positive cells were detected in the normal residual lymphoid tissue surrounding them or in reactive lymph nodes involved in a B lymphocyte response. RANTES gene expression was associated with the production of the protein, which was detected by immunochemistry in DTH lymph nodes. The morphological characteristics and distribution of positive cells in in situ hybridization and immunochemical experiments indicated that macrophages and endothelial cells, two cell populations not previously reported to produce RANTES, contributed to its production in DTH reactions. The ability of macrophages and endothelial cells to produce RANTES was confirmed by in vitro studies with alveolar macrophages and umbilical vein endothelial cells. In view of the chemotactic properties of RANTES for a limited range of cell populations, these results suggest that RANTES production in DTH granulomas may play a role in the selective accumulation of macrophages and memory T helper lymphocytes characterizing this type of cell-mediated immune reaction, and that macrophages and endothelial cells are involved in this production.

Neutralization of IL-8 inhibits neutrophil influx in a rabbit model of endotoxin-induced pleurisy

Although the potent neutrophil chemotaxin, IL-8, is a known product of endotoxin-stimulated cells in vitro, the contribution of IL-8 to neutrophil recruitment in Gram-negative endotoxin inflammation in vivo is unknown. To determine whether neutralization of IL-8 would decrease endotoxin-induced neutrophil influx, we generated neutralizing mAbs to rabbit rIL-8 for use in our rabbit model of endotoxin-induced pleurisy. One mAb, ARIL8.2, specifically inhibited both rabbit rIL-8-induced chemotactic activity and activation of the rabbit IL-8 receptor transfected in 293 cells. Anesthetized rabbits with in-dwelling pleural catheters received either neutralizing mAb (ARIL8.2; 1 mg/kg) or irrelevant isotype-matched mAb (anti-HIV gp120) i.v. 1 h before as well as intrapleurally (20 micrograms/ml) at the time of intrapleural instillation of Escherichia coli endotoxin (200 ng bilaterally). ARIL8.2 blocked 77% of endotoxin-induced neutrophil influx (21 +/- 2 (SE) x 10(6) (ARIL8.2) vs 91 +/- 15 x 10(6) (anti-gp120) (p &lt; 0.0001)). By Western analysis, a band corresponding to rabbit IL-8 was detected in the pleural liquid of rabbits in both groups. By ELISA, however, the concentration of free, unbound IL-8 in the pleural liquid was significantly less in the ARIL8.2 group than in the anti-gp120 group for at least 4 h, confirming that ARIL8.2 bound the IL-8 generated in vivo during that time. We conclude that neutralization of IL-8 profoundly inhibits neutrophil recruitment in endotoxin-induced pleurisy indicating that IL-8 is a major chemotactic factor in this model of acute inflammation.

Neutralization of IL-8 inhibits neutrophil influx in a rabbit model of endotoxin-induced pleurisy

Although the potent neutrophil chemotaxin, IL-8, is a known product of endotoxin-stimulated cells in vitro, the contribution of IL-8 to neutrophil recruitment in Gram-negative endotoxin inflammation in vivo is unknown. To determine whether neutralization of IL-8 would decrease endotoxin-induced neutrophil influx, we generated neutralizing mAbs to rabbit rIL-8 for use in our rabbit model of endotoxin-induced pleurisy. One mAb, ARIL8.2, specifically inhibited both rabbit rIL-8-induced chemotactic activity and activation of the rabbit IL-8 receptor transfected in 293 cells. Anesthetized rabbits with in-dwelling pleural catheters received either neutralizing mAb (ARIL8.2; 1 mg/kg) or irrelevant isotype-matched mAb (anti-HIV gp120) i.v. 1 h before as well as intrapleurally (20 micrograms/ml) at the time of intrapleural instillation of Escherichia coli endotoxin (200 ng bilaterally). ARIL8.2 blocked 77% of endotoxin-induced neutrophil influx (21 +/- 2 (SE) x 10(6) (ARIL8.2) vs 91 +/- 15 x 10(6) (anti-gp120) (p < 0.0001)). By Western analysis, a band corresponding to rabbit IL-8 was detected in the pleural liquid of rabbits in both groups. By ELISA, however, the concentration of free, unbound IL-8 in the pleural liquid was significantly less in the ARIL8.2 group than in the anti-gp120 group for at least 4 h, confirming that ARIL8.2 bound the IL-8 generated in vivo during that time. We conclude that neutralization of IL-8 profoundly inhibits neutrophil recruitment in endotoxin-induced pleurisy indicating that IL-8 is a major chemotactic factor in this model of acute inflammation.

Quantitative two-site enzyme-linked immunosorbent assays for inhibin A, activin A and activin B

We have developed three specific enzyme-linked immunosorbent assay (ELISA) formats which quantitate inhibin A in conditioned media and serum. The assays are sensitive in a range 0.078-5.0 ng/ml and have been characterized in terms of cross-reactivity to inhibin related proteins. The CK:CK assay format recognizes inhibin A, inhibin B and inhibin-related molecules, while the 9A9:CK assay format recognizes inhibin A and inhibin A precursors, but not free alpha-subunit. The 11B5:CK assay appears to recognize only mature 32 kDa inhibin A. Additionally, we have developed separate, specific ELISA formats which quantitate activin A and activin B. The assays have a range of 0.2-50 ng/ml and 0.4-50 ng/ml for activin A and recombinant activin B, respectively. These assays are presently being used to examine the concentration of inhibin A, activin A and activin B in clinical serum samples.

Expression of the cytokine RANTES in human rheumatoid synovial fibroblasts. Differential regulation of RANTES and interleukin-8 genes by inflammatory cytokines

A chronic inflammatory disease may be characterized by an accumulation of activated leukocytes at the site of inflammation. Since the chemokine RANTES may play an active role in recruiting leukocytes into inflammatory sites, we investigated the ability of cultured human synovial fibroblasts isolated from patients suffering from rheumatoid arthritis to produce this chemokine and compared its regulation to that of the closely related chemokine gene, interleukin-8 (IL-8). In unstimulated synovial fibroblasts, the expression of mRNA for both chemokines was undetectable, but was increased in both a time- and dose-dependent manner upon stimulation with the monokines tumor necrosis factor alpha (TNF alpha) and interleukin-1 beta (IL-1 beta). Preincubation of the cells with cycloheximide "superinduced" the level of IL-8 mRNA stimulated by TNF alpha and IL-1 beta and RANTES mRNA stimulated by IL-1 beta, but decreased the expression of RANTES mRNA in response to TNF alpha. In addition, differential regulation of these genes was noted when synovial fibroblasts were stimulated with a combination of cytokines. IL-4 down-regulated and IFN gamma enhanced the TNF alpha- and IL-1 beta-induced increase in RANTES mRNA, whereas the induction of IL-8 mRNA by TNF alpha or IL-1 beta was inhibited by IFN gamma and augmented by IL-4. Moreover, a combination of TNF alpha and IL-1 beta synergistically induced IL-8 mRNA expression, whereas under the same conditions, the level of expression of RANTES mRNA was less than that induced by TNF alpha alone. These observations were also reflected at the level of chemokine secretion. These studies demonstrate that by expressing the chemokines RANTES and IL-8, synovial fibroblasts may participate in the ongoing inflammatory process in rheumatoid arthritis. In addition, the observation that these chemokine genes are differentially regulated, depending upon the presence of different cytokines, indicates that the type of cellular infiltrate and the progress of the inflammatory disease is likely to depend on the relative levels of stimulatory and inhibitory cytokines.

Characterization of the human basophil response to cytokines, growth factors, and histamine releasing factors of the intercrine/chemokine family

We have tested the histamine releasing properties and priming abilities of a wide range of recombinant or purified cytokines and growth factors on the basophils of 20 subjects (10 atopic and 10 nonatopic). We found that monocyte chemotactic and activating factor/monocyte chemoattractant protein-1 (MCAF/MCP-1), RANTES, human macrophage inflammatory protein-1 alpha and human inflammatory protein-1 beta, Connective tissue activating peptide III and Neutrophil Activating Peptide-2 (NAP-2) cause histamine release from basophils and are all members of the intercrine/chemokine family. MCAF/MCP-1 was as potent as anti-IgE or C5a and it is clearly the major contributor to histamine releasing factor activity. RANTES was the second major histamine releasing factor among the positive cytokines. Both MCAF/MCP-1 and RANTES are present in conditioned mononuclear cell media and can be separated using Mono Q anion exchange chromatography. We also demonstrated that RANTES has unusual chromatographic properties in spite of its isoelectric point of &gt; 9.0 because it is largely found in peak-2 of the Mono Q column rather than peak-1 in which intercrines such as MCAF/MCP-1, IL-8, and connective tissue activating peptide III are found. All other cytokines and growth factors tested were negative, with the exception of IL-3, which caused histamine release in a subpopulation of subjects, and also primed basophils for release by anti-IgE. Other basophil primers for anti-IgE-dependent histamine release were IL-5, mast cell growth factor (c-kit ligand), and insulin-like growth factor II. Using specific neutralizing antibodies we have shown that MCAF/MCP-1, RANTES, and IL-3 contribute significantly to the activity found in mononuclear cell culture supernatants. Granulocyte-macrophage-CSF, IP-10, I-309, IL-7, IL-8, IL-9, IL-10, IL-11, IgE-binding factor, TNF-alpha, TGF-beta 1, fibroblast growth factor, epidermal growth factor, and endothelial cell growth factor were negative for direct histamine release and as primers of basophils. Our results indicate that cytokines belonging to the intercrine/chemokine family are major constituents of the activity known as "histamine releasing factor" found in MNC supernatants.

Characterization of the human basophil response to cytokines, growth factors, and histamine releasing factors of the intercrine/chemokine family

We have tested the histamine releasing properties and priming abilities of a wide range of recombinant or purified cytokines and growth factors on the basophils of 20 subjects (10 atopic and 10 nonatopic). We found that monocyte chemotactic and activating factor/monocyte chemoattractant protein-1 (MCAF/MCP-1), RANTES, human macrophage inflammatory protein-1 alpha and human inflammatory protein-1 beta, Connective tissue activating peptide III and Neutrophil Activating Peptide-2 (NAP-2) cause histamine release from basophils and are all members of the intercrine/chemokine family. MCAF/MCP-1 was as potent as anti-IgE or C5a and it is clearly the major contributor to histamine releasing factor activity. RANTES was the second major histamine releasing factor among the positive cytokines. Both MCAF/MCP-1 and RANTES are present in conditioned mononuclear cell media and can be separated using Mono Q anion exchange chromatography. We also demonstrated that RANTES has unusual chromatographic properties in spite of its isoelectric point of > 9.0 because it is largely found in peak-2 of the Mono Q column rather than peak-1 in which intercrines such as MCAF/MCP-1, IL-8, and connective tissue activating peptide III are found. All other cytokines and growth factors tested were negative, with the exception of IL-3, which caused histamine release in a subpopulation of subjects, and also primed basophils for release by anti-IgE. Other basophil primers for anti-IgE-dependent histamine release were IL-5, mast cell growth factor (c-kit ligand), and insulin-like growth factor II. Using specific neutralizing antibodies we have shown that MCAF/MCP-1, RANTES, and IL-3 contribute significantly to the activity found in mononuclear cell culture supernatants. Granulocyte-macrophage-CSF, IP-10, I-309, IL-7, IL-8, IL-9, IL-10, IL-11, IgE-binding factor, TNF-alpha, TGF-beta 1, fibroblast growth factor, epidermal growth factor, and endothelial cell growth factor were negative for direct histamine release and as primers of basophils. Our results indicate that cytokines belonging to the intercrine/chemokine family are major constituents of the activity known as "histamine releasing factor" found in MNC supernatants.

Tumour necrosis factor alpha restores granulomas and induces parasite egg-laying in schistosome-infected SCID mice

Schistosomiasis (bilharzia) is a parasitic disease caused by several species of schistosome worms (blood flukes). The key pathogenic event in this disease is the formation of granulomas around schistosome eggs trapped in portal venules of the liver. Granulomas are a distinctive form of chronic inflammation characterized by localized aggregation of activated macrophages around an inciting stimulus. Each granuloma evolves to form a fibrous scar; in schistosomiasis, the result is widespread hepatic fibrosis and portal hypertension. To identify the specific immune signal molecules necessary for granuloma formation, we studied schistosome infections in severe combined immunodeficient (SCID) mice, which have normal macrophages but lack functional B or T lymphocytes. Here we report that the immunoregulatory cytokine tumour necrosis factor alpha is necessary and sufficient to reconstitute granuloma formation in schistosome-infected SCID mice. Moreover, we find that the parasitic worms require tumour necrosis factor alpha for egg-laying and for excretion of eggs from the host. The implication of this latter result is that the parasite has adapted so successfully to its host that it uses a host-derived immunoregulatory protein as a signal for replication and transmission.