Variant chromophobe renal cell carcinoma

Separation of renal cell tumors into different prognostic groups is an imperative function of the diagnostic pathologist. Recently, chromophobe renal carcinoma has been described as a tumor that is morphologically distinct from conventional "clear cell" carcinoma and that has a low metastatic potential. Identification is based on routine light microscopic features and is confirmed by special stains, immunohistochemistry, and electron microscopy. We present a variant of chromophobe renal carcinoma that did not show the typical cytomorphologic features on light microscopy after formaldehyde fixation. After fixation in Solufix (a commercial fixative), these features were recognized and the diagnosis was confirmed. The tumor also showed an unusual form of calcification and psammoma body formation not previously recognized in chromophobe tumors. Molecular biological assessment was inconclusive, but excluded a chromosome 3p deletion usually found in conventional renal carcinoma. The use of a different primary fixative may provide a cost-effective screening tool to detect variant renal tumors and may have important prognostic implications.

Morphological features of Murray Valley encephalitis virus infection in the central nervous system of Swiss mice

We have examined the histological and ultrastructural features of CNS infection with Murray Valley encephalitis (MVE) virus in mice inoculated with a virulent parental strain (BH3479). Light microscopic examination revealed neuronal necrosis in the olfactory bulb and hippocampus of MVE-infected brains by 5 days post-infection (pi). Electron microscopy of these regions showed endoplasmic reticulum membrane proliferation, and tubular and spherical structures in the cisternae of the endoplasmic reticulum, Golgi complex and nuclear envelope. At seven to eight days pi, infected neurones exhibited chromatin condensation and extrusion, nuclear fragmentation, loss of segments of the nuclear envelope, reduced surface contact with adjacent cells and loss of cytoplasmic organelles. This cell injury was particularly noticeable in the proximal CA3 and distal CA1 regions of the hippocampus. The inflammatory cell profile consisted of macrophages, lymphocytes and especially neutrophils, and many of these inflammatory cells were apoptotic. High mortality rates in the BH3479-infected population of mice correlated with the intense polymorphonuclear and mononuclear leucocyte inflammatory infiltrate in the CNS.

Characterization of cytoplasmic secretory granules (PSG), in prostatic epithelium and their transformation-induced loss in dysplasia and adenocarcinoma

Cytoplasmic clarity is a histological feature of normal prostatic secretory cells, but in this study, tissue fixation in strong (>2.5%) glutaraldehyde dramatically altered cytological staining. Secretory cytoplasm appeared red and granular on routine stains because of myriad intensely staining eosinophilic granules (PSG). Immunostaining for prostate-specific antigen (PSA) and prostatic acid phosphatase (PAP) showed their exclusive localization to the PSG. Electron microscopy confirmed these findings and also showed that after fixation in many agents, including formaldehyde, PSG appeared empty, accounting for the artefactual "clear cell" appearance on light microscopy. PSG were most densely concentrated apically in a bud-shaped luminal compartment in which cytokeratin was selectively absent. Normal exocrine secretion was visualized as detachment of apocrine buds or their in situ disintegration. Distinctively in dysplasia and almost all carcinomas, PSG were rare to absent, and proteases were free in the cytoplasm, often concentrated beneath the apical membrane. The apocrine compartment was absent, with no observed secretory mechanism. Tumor cells had dark amphiphilic cytoplasm after all fixatives. This provided a reliable method of distinguishing malignant from benign glands in tissues fixed in strong glutaraldehyde. Clear cell carcinomas, whose cytoplasm mimicked routinely fixed normal secretory cells, surprisingly had almost no PSG. Instead, their "granules" were lipid-filled vacuoles reflecting a secretory pathway not seen in normal cells, dysplasia, or the common "dark cell" carcinomas. These observations may define two distinctive biological pathways of prostate cancer evolution and may facilitate diagnostic decisions on needle biopsy samples.

Pulmonary blood flow does not redistribute in dogs with reposition from supine to left lateral position

BACKGROUND

Recent studies have questioned the classical gravitational model of pulmonary perfusion. Because the lateral position is commonly used during surgery, the authors studied the redistribution of pulmonary blood flow in the left lateral decubitus position using a high spatial resolution technique.

METHODS

Distributions of pulmonary blood flow were measured using intravenously injected 15-microm diameter radioactive-labeled microspheres in eight halothane-anesthetized dogs, which were studied in the supine and left lateral decubitus positions in random order. Lungs flushed free of blood were air-dried at total lung capacity and sectioned into 1,498-2,396 (1.7 cm3) pieces per animal. Radioactivity was measured by a gamma counter, and signals were corrected for piece weight and normalized to mean flow.

RESULTS

Blood flow to the dependent left lung did not increase, and blood flow to the nondependent right lung did not decrease in the lateral position. The left lung received 39.3 +/-7.0% and 39.2+/-8.8% (mean +/- SD) of perfusion in the supine and left lateral positions, respectively. Detailed assessment of the spatial distributions of pulmonary blood flow revealed the lack of a gravitational gradient of blood flow in the lateral position. The distributions of blood flow did not differ in the supine and left lateral decubitus positions.

CONCLUSIONS

Perfusion to each lung did not change with movement from the supine to the left lateral position. These findings contradict the prediction of increased dependent lung and decreased nondependent lung blood flow based on the gravitational model. It was concluded that the distribution of blood flow in the lateral position in dogs is dominated by pulmonary vascular structure.

Cell polarity, phagocytosis and viral gene transfer in cultured human retinal pigment epithelial cells

PURPOSE

To investigate whether there is a difference in the expression of adenovirus transgenes in human retinal pigment epithelial cells when the vector was exposed to the apical or basal surface, the effect of transgene expression on rod outer segment (ROS) phagocytosis and finally, the role of phagocytosis in gene transfer to RPE cells, using the Royal College of Surgeons (RCS) rat.

METHODS

Monolayers of human retinal pigment epithelium (HRPE) or an RPE cell line (A407) had the apical or basal surfaces exposed to 10(7) pfu/ml of replication deficient adenovirus (Ad.RSV.betagal) carrying the beta-galactosidase marker gene, and the numbers of expressing cells were compared. Parallel cultures were infected and challenged with fluorescein-labelled bovine rod outer segments (FBROS). The fluorescence of infected versus uninfected cells was recorded for both challenged and unchallenged states, using fluorophotometric flow cytometry. Primary cultures of RCS rat RPE were established and the transgene uptake dynamics compared to control Long Evans rat RPE cells.

RESULTS

The expression of transgene in HRPE and A407 cell cultures was an order of magnitude greater when the vector was exposed apically (analysis of variance p < 0.05). There was no difference in the phagocytic capacity of Ad.RSV.betagal-infected and -noninfected cells when challenged with FBROS. There was also no difference in the number of cells expressing transgene, when compared to the RCS or Long Evans control rat RPE.

CONCLUSIONS

The surface of exposure in polarized retinal pigment epithelial cells affects the rate of uptake and expression of adenovirus. The defective ROS phagocytosis in RCS rat RPE cells did not lead to a decrease in transgene expression relative to the Long Evans control cells. Finally we have found that phagocytosis is not significantly altered with adenoviral transgene expression in this in vitro model.

Pax7 includes two polymorphic homeoboxes which contain rearrangements associated with differences in the ability to regenerate damaged skeletal muscle in adult mice

Pax7 is a paired-type homeobox gene which has previously been shown to play an important role in skeletal muscle formation. It is expressed in skeletal muscle of the limbs during embryogenesis and in adulthood. The aims of this study were firstly to determine the degree of polymorphism of Pax7 amongst inbred laboratory mice using Southern blotting and Pax7 regional specific sub-probes. Secondly, functional studies were performed on mice with each of the different structural forms of Pax7 to determine whether they were associated with differences in the ability to regenerate damaged skeletal muscle. Four different allelic forms of Pax7 have now been identified in laboratory mice indicating that the previously reported DNA sequence of Pax7 is not applicable to all laboratory mice. Hybridisation patterns of TaqI digested DNA representing each of the different Pax7 alleles with the Pax7 specific sub-probes suggested that in contrast to previous findings, Pax7 is associated with two highly polymorphic homeoboxes. The presence of two homeoboxes in BALB/c mice has been confirmed by DNA sequencing. Results of functional studies have also shown that the ability to regenerate damaged skeletal muscle in adult mice is strongly associated with the presence of a 0.15-kb TaqI fragment derived from one of the homeoboxes.

Influence of gender on in-hospital clinical and angiographic outcomes and on one-year follow-up in the New Approaches to Coronary Intervention (NACI) registry

Higher complication rates and lower success rates for treatment of women compared with men have been reported in prior studies of coronary angioplasty and in most early reports of outcome with new coronary interventional devices. In multivariate analysis this has been attributed largely to older age and other unfavorable clinical characteristics. These results are reflected in the current guidelines for coronary angioplasty. Women in prior studies have also had different distributions of vessel and lesion characteristics, but the influence of these differences on the outcome of new-device interventions have not been adequately evaluated. This article evaluates the influence of gender on clinical and angiographic characteristics, interventional procedure and complications, angiographic success, and clinical outcomes at hospital discharge and 1-year follow-up, as observed in the New Approaches to Coronary Intervention (NACI) registry. The NACI registry methodology has been reported in detail elsewhere in this supplement. This study focuses on the 90% of patients-975 women and 1,880 men-who had planned procedures with a single new device and also had angiographic core laboratory readings. Women compared with men were older, had more recent onset of coronary ischemic pain that was more severe and unstable, and had more frequent histories of other adverse clinical conditions. The distributions of several but not all angiographic characteristics before intervention were considered more favorable to angioplasty outcome in women. Differences were observed in device use and procedure staging. Angiographically determined average gain in lumen diameter after new-device intervention, with or without balloon angioplasty, was significantly less in women (1.38 mm) than in men (1.53 mm; p < 0.001); this 0.15 mm difference is consistent with the 0.16-mm smaller reference vessel lumen diameter of women. However, final percent diameter stenoses and TIMI flow and lesion compliance characteristics were similar. Among procedural complications, only treatment for hypotension, blood transfusion, and vascular repair occurred more often in women. More women than men were clinically unstable (2.1% vs 1.1%) or went directly to emergent coronary artery bypass graft surgery (CABG; 1.2% vs 0.6%) on leaving the interventional laboratory. However, in-hospital death (1.4% vs 1.1%), Q-wave myocardial infarction (MI) (0.9% vs 1.1%), and emergent CABG (1.5% vs 1.0%, for women and men, respectively) were not significantly different. Nonemergent CABG was more frequent in women (1.8% vs 0.9%; p < 0.05) and length of hospital stay after device intervention was longer (4.4 days vs 3.8 days in men; p < 0.01). In both univariate and multivariate analyses gender did not emerge as a significant variable in relation to the combined endpoint, death, Q-wave MI, or emergent CABG at hospital discharge. At 1-year follow-up more women than men reported improvement in angina (70% vs 62%) and fewer women than men had had repeat revascularization (32% vs 36%). Similar proportions were alive and free of angina, Q-wave MI and repeat revascularization (46% of women vs 45% of men). Although several procedure-related complications were more frequent in women than men after coronary interventions with new devices, no important disadvantages were observed for women in the rates of major clinical events at hospital discharge and at 1-year clinical follow-up. Additional studies are needed to evaluate the complex interplay of clinical, vessel, and lesion characteristics on success and complications of specific interventional techniques and to determine whether gender, per se, is a risk factor and whether gender specific interventional strategies may be beneficial.

Hypothermic ischaemia of the liver: a re-perfusion phenomenon

BACKGROUND

The effects of hypothermic injury to the liver were investigated on an isolated perfusion circuit by comparing porcine livers with varying degrees of preservation injury.

METHODS

A group of unstored livers (n = 5) were compared to livers stored in University of Wisconsin (UW) solution for 18 h (n = 5), and a group of livers stored in Hartmann's solution for 18 h (n = 5).

RESULTS

We observed that the degree of platelet sequestration was directly related to the severity of the preservation injury. After 2 h of isolated liver perfusion, the perfusate platelet count fell from 148 +/- 14 x 10(9)/L to 84 +/- 13 x 10(9)/L for control livers. In comparison for livers stored in UW solution, the platelet count fell from 173 +/- 43 x 10(9)/L to 61 +/- 14 x 10(9)/L representing a 64.8% fall, while for those stored in Hartmann's solution, an even more profound fall from 152 +/- 36 x 10(9)/L to 19 +/- 9 x 10(9)/L (87.5% fall) was observed. The difference between the UW-stored and Hartmann's-stored livers was significant (P < 0.05). However, using this model, the degree of leukocyte sequestration did not differentiate the groups. Both histological and ultrastructural examination of liver biopsies taken immediately following revascularization demonstrated that for mild degrees of preservation injury following hypothermic storage, changes occur to the sinusoidal lining cells well before changes to the parenchymal elements.

CONCLUSIONS

These findings substantiate the hypothesis that the primary injury associated with hypothermia involves the sinusoidal lining cells (non-parenchymal elements), that it is predominantly a reperfusion phenomenon and that efforts at improving preservation should therefore be targeted primarily at these cells and not the hepatocytes.

Initiation of impaired outer segment degradation in vivo using an antisense oligonucleotide

This paper describes the first successful in vivo application of antisense DNA technology to induce the accumulation of photoreceptor outer segment derived debris in the retina. An antisense oligonucleotide (CatSC), which was previously demonstrated to be an effective tool to induce debris accumulation in vitro, was injected into the vitreous of pigmented and non-pigmented rats. The animals were euthanased 7 days after the injections. The number of inclusions significantly increased in the RPE layer of Long Evans and RCS-rdy + rats injected with 66 ug of CatSC to 96.2 +/- 13.6 (SD) (p < 0.0003) and 204.2 +/- 39.3 (SD) (p < 0.0001), respectively. The difference between the number of phagosome-like inclusions present in control saline, 6.6 ug of CatSC or 66 ug of sense oligonucleotide (S1) injected animals was not statistically significant. There were no abnormalities observed in the inner layers of the retina but the accumulation of phagosome-like inclusions was accompanied by disorganisation in the apices of outer segments. The large number of inclusions found in CatSC treated animals showed the characteristics of phagosomes containing stacks of undigested photoreceptor outer segment membranes which suggest that the lysosomal digestion process was halted or at least slowed down by the antisense oligonucleotide.

Detection of mRNAs for urokinase-type plasminogen activator, its receptor, and type 1 inhibitor in giant cell tumors of bone with in situ hybridization

Although giant cell tumor of bone (GCT) is generally considered to be an uncommon benign neoplasm, it can pursue an aggressive course with local recurrence and metastasis. Attempts to predict the biological behavior of GCT with histopathological parameters, however, have not been successful. The urokinase-type plasminogen activation system has been implicated in tumor invasion and metastasis and abnormalities of the components of this system have been found in several malignancies. In this study we postulated that the urokinase-type plasminogen activation system associated with bone destruction and local invasion is present in GCT. We therefore evaluated the mRNA levels for urokinase-type plasminogen activator (u-PA), urokinase-type plasminogen activator receptor (u-PAR), and plasminogen activator inhibitor type 1 (PAI-1) by using Northern blot analysis and in situ hybridization in four cases of GCT and spindle-shaped mononuclear cells at the 35th passage from a GCT. Our results showed that giant cell tumors of bone contained variable levels of u-PA, u-PAR, and PAI-1 mRNA, respectively, 2.3, 1.4, and 3.2 kb in size. In situ hybridization showed that u-PA, u-PAR, and PAI-1 mRNA were expressed in both the mononuclear cells and the osteoclast-like giant cells; the signal for u-PA mRNA in the spindle-shaped mononuclear cells was more intense than that in the osteoclast-like multinuclear giant cells. Some spherical mononuclear cells (macrophage-like cells) expressed high levels of PAI-1 mRNA in comparison with the spindle-shaped mononuclear cells. In addition, the 35th passaged spindle-shaped mononuclear cells were used to study the gene expression of u-PA during cell proliferation. The results showed that the level of u-PA mRNA increases after adding 10% fetal calf serum to quiescent cells. The induction was maximal at 16 hours and remained high during 48 hours of treatment. In conclusion, even though osteoclast-like cells are ultimately responsible for the bone resorption of GCT, the mononuclear neoplastic cells of GCT may also be involved in degradation of the extracellular matrix during invasive growth by facilitating the urokinase plasminogen activation system. In addition, our observation of upregulation of u-PA mRNA in spindle-shaped mononuclear cells after serum stimulation indicated that u-PA production may be linked to tumor growth.

Detection and possible functions of a cysteine protease involved in digestion of rod outer segments by retinal pigment epithelial cells

PURPOSE

To investigate the presence and role of a recently cloned cysteine protease (cathepsin S) in the digestion of rod outer segments (ROS) by cultured retinal pigment epithelial (RPE) cells.

METHODS

RPE cell cultures were established from eye bank donor eyes. Total RNA was extracted from freshly harvested cultures, and after reverse transcription, the cDNA was subjected to polymerase chain reaction (PCR). Cathepsin S (Cat S) mRNA translation was inhibited by antisense oligonucleotides, and the effect of inhibition on the accumulation of fluorescent debris was examined. The activity of cysteine and aspartic proteases in ROS-challenged RPE cell cultures was inhibited by leupeptin and pepstatin, respectively. The accumulation of autofluorescent debris within RPE cells was measured by a fluorophotometric flow cytometer. The presence of phagosomes in antisense DNA-inhibited and control cultures was demonstrated by electron microscopy.

RESULTS

The expression of Cat S in RPE cells was demonstrated by RNA-PCR. Using antisense oligonucleotide-mediated-specific inhibition of Cat S, a significant ROS-derived increase in autofluorescence was detected within the RPE cells when they were compared with the unchallenged control cultures and cultures in the presence of ROS and sense oligonucleotides. Electron microscopy demonstrated the presence of a large number of phagosomes that enveloped structures similar to ROS. The accumulation of autofluorescent debris was also demonstrated in cysteine protease-inhibited, ROS-challenged RPE cultures, but it was not detected with aspartic protease inhibition.

CONCLUSIONS

The expression of Cat S in RPE cells and the accumulation of an autofluorescent debris in cultures in which cysteine proteases or Cat S activity is inhibited suggest a key role for this enzyme, either in the ROS digestion process or in the activation of cathepsin D, the major lysosomal enzyme present in RPE cells.

Gene expression of transforming growth factor-beta 1 and its type II receptor in giant cell tumors of bone. Possible involvement in osteoclast-like cell migration

Giant cell tumor of bone (GCT) is a relatively rare skeletal neoplasm characterized by multinuclear giant cells (osteoclast-like cells) scattered in a mass of mononuclear cells. The currently favored hypothesis for the origin of cells within GCT is that the multinuclear giant cells are reactive osteoclasts, whereas the truly neoplastic cells are the major component of the mononuclear population. However, the pathological significance and the precise relationship of tumor cells and osteoclast-like cells in GCT have not been fully established. In this study, we evaluated two GCTs for the presence of transforming growth factor-beta 1 (TGF-beta 1) and TGF-beta type II receptor gene transcripts and attempted to establish a possible role for TGF-beta 1 in the interaction between tumor cells and osteoclast-like cells. By using in situ hybridization and Northern blot analysis, we have demonstrated that TGF-beta 1 mRNA transcript is consistently detected in both tumor mononuclear cells and osteoclast-like cells, whereas TGF-beta type II receptor gene transcript is only present in osteoclast-like cells. Moreover, isolated rat osteoclasts were tested for their ability to migrate in response to GCT-conditioned medium (GCTCM) in an in vitro chemotactic assay. Our results showed that GCTCM stimulates the migration of osteoclasts in a dose-dependent manner. Interestingly, only osteoclasts containing less than three nuclei can migrate through 12-mu pore filters. Addition of monoclonal antibody against TGF-beta significantly reduced but did not abolish the chemotactic activity of GCTCM. Moreover, TGF-beta type II receptor mRNA has been demonstrated in the normal rat osteoclasts and may be involved in the chemotactic action of TGF-beta 1. We concluded that TGF-beta 1, possibly in concert with other cytokines, is involved in the recruitment of osteoclast-like cells in GCT by acting in an autocrine or paracrine fashion.

Dying in palliative care units and in hospital: a comparison of the quality of life of terminal cancer patients

A comparison of the quality of life of terminal cancer patients in two palliative care units with that of those in a general hospital is reported here. Quality of life was considered as a multidimensional concept. It was assessed for the 182 patients by applying content analysis scales to transcripts of their responses to part of a standardized interview. A personal construct model of dying provided the specific hypotheses about differences in quality of life. Patients in specialized palliative care units were, as predicted, found to differ from those dying in hospital, showing less indirectly expressed anger but more positive feelings. They also reported more anxiety about death but less anxiety about isolation and general anxiety, and fewer influential and nonspecified shared relationships. Against prediction, the patients in the two specialized units were also found to differ from each other, those in the smaller unit showing more directly expressed anger and helplessness than those in the larger unit.

Baseline characteristics and therapeutic goals in the New Approaches to Coronary Intervention (NACI) registry

BACKGROUND

The New Approaches to Coronary Intervention (NACI) voluntary registry was designed to study the use, safety, and efficacy of new percutaneous transluminal interventional devices including directional coronary atherectomy, the transluminal extraction catheter, the rotablator, the Palmaz-Schatz stent, the Gianturco-Roubin stent, the Advanced Interventional Systems (AIS) laser, and the spectranetics laser.

METHODS

To date, more than 3800 consecutive patients treated for the first time with a new device at 41 centers have been entered into the registry. Complete detailed information about the patient, lesions, device characteristics, reasons for device selection, and procedural data, such as adjunctive use of conventional balloon angioplasty (PTCA), was available for the first 2835 patients.

RESULTS

The registry shows that 88% of the 3233 attempts with a new device were intended as a definitive treatment of target lesions, frequently in combination with adjunctive PTCA. The remaining 12% of attempts with a new device were unplanned, prompted by unexpected complications, unsuccessful attempts, or suboptimal results with PTCA. Although there was some overlap in the indications for selecting a given interventional device, the variation from device to device was sufficiently large to caution users against any direct comparison of either safety or efficacy between devices without careful attention to the differences in baseline patient and lesion characteristics, treatment plans, and the circumstances of device use.

CONCLUSION

This report provides the first comprehensive overview of how new interventional devices are currently being used in the treatment of coronary artery lesions at the 41 centers participating in the NACI registry.

Evidence for a viral aetiology of Jembrana disease in Bali cattle

Jembrana disease is an acute infectious disease of Bali cattle (Bos javanicus) in Indonesia. High titres of the infectious agent are present in plasma during the febrile phase of the disease. The size of the agent determined by membrane filtration was between 50 and 100 nm, indicating it is a virus and not a rickettsia as previously proposed. Spherical virus-like particles of 75 to 130 nm diameter with a smooth membrane and frequently with an eccentric nucleoid were detected by electron microscopy in plasma from infected animals. The virus replicated in mononuclear cell cultures of peripheral blood origin but not in other cell cultures. The virus and the associated disease have characteristics consistent with viruses in the family Retroviridae.

One-year results of the Thrombolysis in Myocardial Infarction investigation (TIMI) Phase II Trial

BACKGROUND

The Thrombolysis in Myocardial Infarction (TIMI) Phase II Trial randomized 3,339 patients to either an invasive (INV, n = 1,681) or a conservative (CON, n = 1,658) strategy after intravenous recombinant tissue-type plasminogen activator (rt-PA) for acute myocardial infarction.

METHODS AND RESULTS

The patients assigned to the INV strategy routinely underwent cardiac catheterization, and when anatomically appropriate, percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting 18-48 hours after infarction. CON patients had these procedures only in response to the occurrence of spontaneous or provoked ischemia. One-year follow-up data are available in 3,316 patients (99.3%). The primary trial end point, death and nonfatal reinfarction, occurred in 14.7% of INV patients and in 15.2% of CON patients (p = NS). When analyzed individually, there was no difference (p = NS) in death (INV, 6.9%; CON, 7.4%) or recurrent infarction (INV, 9.4%; CON, 9.8%) between the two groups. Anginal status at 1 year was also similar. Cardiac catheterization and PTCA were performed more often in INV (98.0% and 61.2%, respectively) compared with CON (45.2% and 20.5%, respectively) patients. At 1 year, the cumulative number of patients who underwent coronary bypass surgery (INV, 17.5%; CON, 17.3%) was similar in the two groups.

CONCLUSIONS

The INV and CON strategies resulted in similar favorable outcomes at 1 year of follow-up. In particular, the rates of mortality and reinfarction were not different and were impressively low in both groups. One possible advantage of the INV strategy was detected in subgroup analyses. In patients with a history of myocardial infarction, the data are suggestive that 1-year mortality was lower in INV patients (10.3%) than in CON patients (17.0%) (p = 0.03).

The NACI Registry: an instrument for the evaluation of new approaches to coronary intervention. The NACI Investigators

The New Approaches to Coronary Intervention (NACI) Registry was developed to collect in-depth data about patients whose coronary artery lesions are being treated with new interventional techniques such as atherectomy, stents, and laser devices. The NACI Registry database distinguishes among several possible "modes" for device use, such as preparatory, planned definitive, and bailout use. Common definitions are used for data collection across all devices, and device-specific forms are used to record procedural details. NACI's unique modular form design facilitates thorough data collection, even for the most complex treatment scenarios. The database structure allows for data analysis at the patient, procedure, lesion, and device levels, as required to perform in-depth analyses of the immediate and long-term success of new devices. Once adequate knowledge of basic device performance has been collected, the Registry structure can also allow expeditious planning and performance of randomized trials comparing a new device to conventional PTCA.

Analysis of possible triggers of acute myocardial infarction (the MILIS study)

Recent documentation of a circadian variation in acute myocardial infarction (AMI) suggests that AMI is not a random event, but may frequently result from identifiable triggering activities. The possible triggers reported by 849 patients enrolled in the Multicenter Investigation of Limitation of Infarct Size were analyzed. Possible triggers were identified by 48.5% of the population; the most common were emotional upset (18.4%) and moderate physical activity (14.1%). Multiple possible triggers were reported by 13% of the population. Younger patients, men and those without diabetes mellitus were more likely to report a possible trigger than were older patients, women and those with diabetes. The likelihood of reporting a trigger was not affected by infarct size. This study suggests that potentially identifiable triggers may play an important role in AMI. Because potential triggering activities are common in persons with coronary artery disease, yet infrequently result in AMI, further studies are needed to identify (1) the circumstances in which a potential trigger may cause an event, (2) the specific nature of potential triggering activites, (3) the frequency of such activities in individuals who do not develop AMI and (4) the presence or absence of identifiable triggers in various subgroups of patients with infarction.

Long-term follow-up of coronary angioplasty: the 1977-1981 National Heart, Lung, and Blood Institute registry

Between September 1977 and September 1981, 1587 consecutive patients underwent a first coronary angioplasty (PTCA) at 16 clinical centres. After excluding patients with prior coronary bypass surgery (CABG) and left main or minimal vessel disease, 1390 were available for in-hospital and long-term follow-up. Mean duration of follow-up was 5.9 years (range 0-9.0 years). PTCA was successful (all attempted lesions reduced greater than or equal to 20%) in 882 patients (63.4%) and, overall, 624 patients (44.9%) had complete (COREV) and 766 (55.1%) incomplete (INCOREV) revascularization or a failed PtCA. In-hospital events included death in 0.7%, myocardial infarction (MI) in 5.0% and CABG in 24.0% of patients. Patients with COREV had significantly lower rates of these events than the INCOREV group. At 6 years, mortality in all registry patients was 6.5% and MI rate 15.0%; CABG was performed after the initial hospitalization in 15.5% of patients and repeat PTCA in 19.1%. All events, except repeated PTCA, were less frequent in the COREV than the INCOREV group. Among patients with a successful first PTCA, cumulative 6-year mortality was 5.8% and incidence of MI 10.8%; 16.9% underwent CABG and 24.7% repeat PTCA during follow-up. CABG was slightly more frequent in INCOREV than COREV patients with successful PTCA, but all other events were similar in the two groups, suggesting that INCOREV 'by intent' has a good prognosis. In patients with INCOREV, mortality and incidence of MI were higher during follow-up for patients with multivessel rather than single vessel disease. However, the incidence of CABG and repeat PTCA was similar in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Research collaboration

The complexity and cost of cardiovascular medical care dictate research to deliver high quality and cost-conscious cardiovascular care. This goal is aided by modeling medical decision making. To be useful, the modeling must be based on real data so that the results can serve as a guide to actual practice. It is suggested that a registry of randomized clinical trials and larger data bases in cardiovascular disease and health care delivery be established. The registry would be a resource for those desiring to model decision making. The registry would contain key words allowing retrieval by modelers accessing the registry and would contain contact information for consideration of possible collaborative work. The initiation of such a registry should contain plans for its evaluation to determine whether the registry itself is a cost-effective tool to encourage the needed research.

The effect of diabetes mellitus on prognosis and serial left ventricular function after acute myocardial infarction: contribution of both coronary disease and diastolic left ventricular dysfunction to the adverse prognosis. The MILIS Study Group

Patients with diabetes mellitus experience a more adverse outcome after acute myocardial infarction compared with nondiabetic patients, although the mechanisms responsible for these findings are not clear. From the Multicenter Investigation of the Limitation of Infarct Size (MILIS) study, the course of acute infarction in 85 diabetic patients was compared with that in 415 nondiabetic patients, all of whom had serial assessments of left ventricular function. The diabetic patients experienced a more complicated in-hospital and postdischarge course than did the nondiabetic patients, including a higher incidence of postinfarction angina, infarct extension, heart failure and death, despite the development of a smaller infarct size and similar levels of left ventricular ejection fraction. Although diabetic patients had a worse profile of cardiovascular risk factors at the time of the index infarction, the increased incidence of adverse outcomes among them persisted despite adjustment for these baseline imbalances. Diabetic women had a poor baseline risk profile compared with the other groups categorized by gender and diabetic status, and experienced an almost twofold increase in cardiac mortality despite development of the smallest infarct size during the index event. The duration of diabetes and the use of insulin at the time of the index infarction were associated with a better in-hospital mortality rate, but the duration of diabetes did not exert a major influence on the outcome of the diabetic patients. The factors responsible for the increased incidence of adverse outcomes among diabetic patients may be related to an acceleration of the atherosclerotic process, diastolic left ventricular dysfunction associated with diabetic cardiomyopathy or other unidentified unfavorable processes.

Morning increase in onset of ischemic stroke

The time of onset of ischemic stroke was determined for 1,167 of 1,273 patients during the collection of data by four academic hospital centers between June 30, 1983, and June 30, 1986. More strokes occurred in awake patients from 10:00 AM to noon than during any other 2-hour interval. The incidence of stroke onset declined steadily during the remainder of the day and early evening. The onset of stroke is least likely to occur in the late evening, before midnight.

Pericarditis in acute myocardial infarction: characterization and clinical significance

To determine the significance of pericarditis following acute myocardial infarction, the hospital course and 12-month follow-up were analyzed in 703 patients enrolled in the Multicenter Investigation of the Limitation of Infarct Size (MILIS). Pericarditis, defined by the detection of a pericardial rub, occurred in 20% of the patients (n = 141) and was more likely to follow Q wave than non-Q wave infarction (25% vs 9%, p less than 0.001). Patients with pericarditis experienced more serious myocardial damage compared to those without pericarditis, as evidenced by a larger infarct size (25 +/- 1 vs 17 +/- 1 MB-CK gm-Eq/m2, p less than 0.001), a lower admission left ventricular ejection fraction (42 +/- 1% vs 48 +/- 1%, p less than 0.001), and a higher incidence of congestive heart failure (47% vs 26%, p less than 0.001) and atrial tachyarrhythmias (16% vs 10%, p less than 0.05). When patients were classified by the presence of Q or non-Q wave infarction, these differences persisted although statistical significance was not always achieved due to smaller sample size. Mortality at 12-month follow-up for patients with pericarditis was 18% compared with 12% for patients without pericarditis (p = 0.055). This mortality difference could be accounted for in part by the lower ventricular ejection fraction in patients with pericarditis (p = 0.20 after adjustment).

High-risk subgroups of patients with non-Q wave myocardial infarction based on direction and severity of ST segment deviation

To determine the significance of the direction of ST segment deviation on admission of patients who evolved non-Q wave myocardial infarction (MI), 97 patients with initial ST segment depression were compared to 207 patients with initial ST segment elevation. Patients with ST segment depression developed smaller infarcts than those with ST segment elevation (creatine kinase MB isoenzyme 8.2 vs 13.3 gmEq/m2, p less than 0.002), but had a lower left ventricular ejection fraction on admission (44% vs 51%, p less than 0.001), more in-hospital complications, and a higher cumulative 1-year mortality (29% vs 11%, p less than 0.001) that could be accounted for by an excess of adverse baseline characteristics. Although a severity index (combining magnitude and extent of the initial ST segment deviation) was not useful for discriminating prognosis of patients with non-Q wave MI who presented with ST segment depression, it was useful in identifying a subgroup of patients with ST segment elevation with an adverse prognosis. The poor outcome of patients with non-Q wave MI presenting with either ST segment depression or severe ST segment elevation on admission suggests that patients in these subgroups should receive close surveillance and should possibly be considered for aggressive therapy.

The Thrombolysis in Myocardial Infarction (TIMI) phase II pilot study: tissue plasminogen activator followed by percutaneous transluminal coronary angioplasty

The Thrombolysis in Myocardial Infarction (TIMI) Study Group is investigating whether percutaneous transluminal coronary angioplasty or intravenous beta-receptor blockers, or both, are useful adjuncts to recombinant tissue-type plasminogen activator (rt-PA) in the treatment of patients with acute myocardial infarction (TIMI II study). A total of 317 patients with acute myocardial infarction were treated an average of 2.7 hours after the onset of chest pain during the course of a nonrandomized pilot investigation with 150 mg of rt-PA given over 6 hours. This dose of rt-PA resulted in a high rate of infarct-related coronary artery patency (82 and 87% of patients catheterized an average of either 1 or 32 hours after entry, respectively) and a low 21 day mortality rate of 4.4%. Coronary angioplasty was performed successfully in greater than 90% of patients with appropriate anatomy and in greater than 50% of those treated with rt-PA. In 75 patients treated within 2 hours of the onset of chest pain only 2 (2.7%) were dead by 6 weeks. However, five cases of intracranial hemorrhage were noted, and the rt-PA dose was subsequently reduced to 100 mg given over 6 hours. The TIMI II design and the results of the TIMI II pilot study are discussed.

The neurotoxicity of high-dose cytosine arabinoside is age-related

Fifteen patients with acute myeloid leukaemia were given a total of 17 courses of high-dose cytosine arabinoside (Ara-C). The median age of the patients was 37 years. Four patients developed severe irreversible neurotoxicity, three developed mild to moderate, reversible neurotoxicity, whereas eight patients had no toxicity. Of five patients over the age of 55 years given high dose Ara-C, four developed severe, irreversible neurotoxicity, but there were no severe episodes in nine patients aged 55 years or less. (P less than 0.01). At a dose of 3 g/m2 given intravenously every 12 hours for 3 days, three cases of severe irreversible neurotoxicity were noted in elderly patients. Neurotoxicity at this total dose has previously been considered unusual. Administration of high dose Ara-C at total doses of 18 g/m2 and over carries a risk of severe irreversible cerebellar toxicity that increases with age.

Prognosis after cardiac arrest due to ventricular tachycardia or ventricular fibrillation associated with acute myocardial infarction (the MILIS Study). Multicenter Investigation of the Limitation of Infarct Size

Previous studies have reached conflicting conclusions about whether cardiac arrest due to ventricular tachycardia (VT) or ventricular fibrillation (VF) in acute myocardial infarction (AMI) is of long-term prognostic significance. The mortality rate in 849 patients with confirmed AMI was analyzed. The mortality rate during the initial hospitalization was higher for patients in whom VT/VF occurred (27% vs 7%, p less than 0.001). The in-hospital mortality rate for patients with primary VT/VF, that is, VT/VF occurring in the absence of hypotension or heart failure, was similar to that of patients who did not have VT/VF (8% vs 7%, difference not significant), whereas the rate for patients with secondary VT/VF was significantly greater than that for patients with no VT/VF (51% vs 7%, p less than 0.001). The timing of occurrence of VT/VF also influenced mortality: Patients in whom VT/VF occurred more than 72 hours after admission had a higher in-hospital mortality rate than did patients in whom it occurred within 72 hours (57% vs 20%, p less than 0.05). All cases of primary VT/VF occurred within the first 72 hours of admission. The long-term mortality rate for hospital survivors was not significantly different for patients who had had VT/VF during acute infarction compared with those who had not (19% vs 21%) (mean follow-up 32 months). Thus, cardiac arrest due to ventricular tachyarrhythmia was associated with a higher in-hospital mortality rate but was not a prognostic factor among hospital survivors. Patients resuscitated from primary VT/VF, which characteristically occurs early after AMI, do not have an adverse prognosis.

Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly black women

Controversy has arisen concerning whether gender influences the prognosis after myocardial infarction. Although some studies have shown there to be no difference between the sexes, most have indicated a worse prognosis for women, attributing this to differences in baseline characteristics. It has been further suggested that black women have a particularly poor prognosis after infarction. To determine the contribution of gender and race to the course of infarction, 816 patients with confirmed myocardial infarction who were enrolled in the Multicenter Investigation of the Limitation of Infarct Size (MILIS) were analyzed. Of those patients, 226 were women and 590 were men, 142 were black and 674 were white. The cumulative mortality rate at 48 months was 36% for women versus 21% for men (p less than 0.001, mean follow-up 32 months). The cumulative mortality rate by race was 34% for blacks versus 24% for whites (p less than 0.005). Both women and blacks exhibited more baseline characteristics predictive of mortality than did their male or white counterparts. It was possible to account for the greater mortality rate of blacks by identifiable baseline variables; however, even after adjustment, the mortality rate for women remained significantly higher (p less than 0.002). The poorer prognosis for women was influenced by a particularly high mortality rate among black women (48%); the mortality rate for white women was 32%, for black men 23% and for white men 21%. The mortality for black women was significantly greater than that of the other subgroups. Thus, findings in the MILIS population indicate that the prognosis after myocardial infarction is worse for women, particularly black women.

In vitro antibody-mediated macrophage activity on Breinlia macropi microfilariae. II. Ultrastructural and video recording investigations of adherence and cytotoxicity

Video recordings and ultrastructural studies have revealed an intricate sequence of antibody-mediated cytotoxic activity by quokka peritoneal macrophages on Breinlia macropi microfilariae. The microfilaricidal activity was effected by at least two types of macrophages measuring 17 micrometers and 8 micrometers in diameter respectively. The relatively large macrophages were responsible for trapping, encircling and eventually degrading the highly motile microfilariae in a sequence of events in which the participating macrophages may interdigitate. The smaller macrophages adhered transiently to a number of adjacent sites on the surface of a trapped microfilaria, resulting in a series of damaged spots. This activity of the small macrophages was interpreted as responsible for killing the microfilaria. Thus the microfilaricidal activity was interpreted to be accomplished by the co-operative functions of the relatively large and small macrophages.

IgD multiple myeloma. A case report

A patient with a fracture of the left femur was investigated for suspected multiple myeloma. Serum total proteins, protein electrophoresis, and immunoglobulin G, A and M levels were within normal limits. Bence Jones proteinuria of the lambda type was present. Subsequent investigations revealed the presence of IgD myeloma.

Circadian variation in the frequency of onset of acute myocardial infarction

To determine whether the onset of myocardial infarction occurs randomly throughout the day, we analyzed the time of onset of pain in 2999 patients admitted with myocardial infarction. A marked circadian rhythm in the frequency of onset was detected, with a peak from 6 a.m. to noon (P less than 0.01). In 703 of the patients, the time of the first elevation in the plasma creatine kinase MB (CK-MB) level could be used to time the onset of myocardial infarction objectively. CK-MB-estimated timing confirmed the existence of a circadian rhythm, with a three-fold increase in the frequency of onset of myocardial infarction at peak (9 a.m.) as compared with trough (11 p.m.) periods. The circadian rhythm was not detected in patients receiving beta-adrenergic blocking agents before myocardial infarction but was present in those not receiving such therapy. If coronary arteries become vulnerable to occlusion when the intima covering an atherosclerotic plaque is disrupted, the circadian timing of myocardial infarction may result from a variation in the tendency to thrombosis. If the rhythmic processes that drive the circadian rhythm of myocardial-infarction onset can be identified, their modification may delay or prevent the occurrence of infarction.

Preparation of interstitial lung cells by enzymatic digestion of tissue slices: preliminary characterization by morphology and performance in functional assays

A technique is reported here for the quantitative extraction of live cells from the lung interstitium; it involves the incubation of slices of perfused lung in a mixture containing optimal concentrations of collagenase, DNAse, and fetal calf serum, followed by the simultaneous recovery and fractionation of cells released from the tissue matrix on a six-step discontinuous percoll gradient. Yields in the order of 10(8) viable cells per gram of lung were routinely achieved with tissues from rat, mouse and guinea-pig. Preliminary characterization of these cells has been performed in the rat by histological techniques (Giemsa staining, transmission electron microscopy), cytochemistry (acid phosphatase, esterase, peroxidase), by the capacity to bind monoclonal antibodies directed at lymphocyte surface markers, and by a range of functional tests. The cells comprised, on average, 32% macrophages, 44% lymphocytes (T and B cells and large granular lymphocytes), with small numbers of eosinophils, mast cells and epithelial cells. Transmission electron microscopy revealed minimal ultrastructural damage to extracted cells, with such functions as phagocytosis, FcR activity, mitogen responsiveness, antigen presentation, and NK-cell activity, being readily demonstrable. In addition, these activities segregated into defined areas of the six-step density gradient.

Unusual presentation of multiple myeloma. A report of 2 cases

The diagnosis of multiple myeloma (overt plasma cell dyscrasia) is usually not considered in patients under 30 years of age. Furthermore, multiple myeloma with coexistent megaloblastic and iron deficiency anaemia is very uncommon. Within 6 months we encountered 2 patients under 30 years of age who had multiple myeloma, one with advanced secondary amyloidosis and the other with severe megaloblastic and iron deficiency anaemia.

Biclonal gammopathy. A case report

The presence of two or more monoclonal proteins in serum due to the malignant proliferation of more than one clone of B lymphocytes is uncommon. A patient with raised levels of both immunoglobulin G and M is presented and some clinical and laboratory features are shown.