Genetic polymorphism of inosine triphosphate pyrophosphatase is a determinant of mercaptopurine metabolism and toxicity during treatment for acute lymphoblastic leukemia

The influence of genetic polymorphism in inosine triphosphate pyrophosphatase (ITPA) on thiopurine-induced adverse events has not been investigated in the context of combination chemotherapy for acute lymphoblastic leukemia (ALL). This study investigated the effects of a common ITPA variant allele (rs41320251) on mercaptopurine metabolism and toxicity during treatment of children with ALL. Significantly higher concentrations of methyl mercaptopurine nucleotides were found in patients with the nonfunctional ITPA allele. Moreover, there was a significantly higher probability of severe febrile neutropenia in patients with a variant ITPA allele among patients whose dose of mercaptopurine had been adjusted for TPMT genotype. In a cohort of patients whose mercaptopurine dose was not adjusted for TPMT phenotype, the TPMT genotype had a greater effect than the ITPA genotype. In conclusion, genetic polymorphism of ITPA is a significant determinant of mercaptopurine metabolism and of severe febrile neutropenia, after combination chemotherapy for ALL in which mercaptopurine doses are individualized on the basis of TPMT genotype.

Care without coverage: is there a relationship between insurance and ED care?

The Institute of Medicine (IOM) has concluded that differences in care exist for hospitalized patients on the basis of insurance; we attempted to determine if these differences begin in the emergency department (ED). We retrospectively studied high-acuity adult visits to one ED over 6 months, utilizing electronic databases. Uninsured patients were more often younger, male, and non-white (n = 3899 visits; 468 uninsured, 3431 insured). Fewer uninsured patients were admitted (9.8% vs. 27.2% insured; p < 0.001). Comparing patients by admission status, there was no evidence of difference for most measures, excepting radiographic studies (admitted patients: 78.3% uninsured vs. 90.5% insured, p = 0.007; treated-and-released patients: 62.3% uninsured vs. 69.4% insured, p = 0.004). In a subset of trauma patients for whom acuity could be evaluated with Injury Severity Scores (ISS), admission rates were similar. In this pilot study of high-acuity patients, there was limited evidence of differences in most measures of ED-based patient care on the basis of insurance status.

Prediction of persistent vaginal intraepithelial neoplasia in previously hysterectomized women by high-risk HPV DNA detection

AIM

To estimate the incidence and latency of Vaginal Intraepithelial Neoplasia (VAIN) in women previously hysterectomized for benign/malign pathology and to evaluate the role of high risk HPVs in the prediction of persistent or recurrent disease.

SUBJECTS AND METHODS

830 women with prior hysterectomy for benign/malign pathologies followed by cytological scraping and vaginal colposcopy. Forty-four patients presented VAIN lesions confirmed by histopathological diagnosis. HPV DNA test was performed at the time of diagnosis. Patients were treated by Laser CO(2) vaporization and underwent follow-up by cytology, colposcopy for a mean period of 3 years. HPV DNA test was performed at 6 months after treatment and every years. Persistent or relapsed disease was confirmed by histopathology.

RESULTS

Incidence of VAIN in women hysterectomized for benign pathologies did not differ significantly from the malign group. VAIN degree was more severe in the hysterectomized patients with cervical malignancy and subsequently radiated respect to non-radiated patients. The HPV DNA test at 6 months after VAIN treatment showed fifteen positive cases: twelve HPV 16 (80%) and three HPV 18 (20%). In five cases HPV DNA test was positive with a persistent negative cytological smear during the years. Positivity to high-risk HPV (either 16 or 18) was significantly higher in the patients with relapse to VAIN (10/44, p<0.002).

CONCLUSIONS

We suggest to include HPV DNA test in addition to cytology in the follow-up of patients previously treated for VAIN, in order to predict VAIN persistence or progression in vaginal carcinoma before cytology becomes abnormal.

Modelling predictions of cancer deaths in Northern Ireland

BACKGROUND

An ageing population has service planners concerned about future levels of disease which are age dependent. Predictions of mortality for colorectal, lung and breast cancers, which account for 30% of cancer cases and 40% of cancers deaths, were calculated for 2010 and 2015, based on trends in death rates and the predicted change in the demography of the Northern Ireland population.

METHODS

The U.S. National Cancer Institute's "Joinpoint" program was used to check for structural breaks in the time series of cancer death rates from 1984 to 2004. The prediction models applied to the data allowed variations in trends across age groups to be taken into account. A linear model was used for increasing or constant trends and a log linear model was used where the trend was decreasing. The models assume the number of deaths in each stratum, defined by age-sex and time-period, is Poisson distributed, with the average value determined by a log or linear function.

RESULTS

Recent trends in rates of cancers studied were downwards except for female lung. Predictions include decreased colorectal cancer deaths in females and lung cancer deaths in males. In females, lung cancer deaths are predicted to more than double by the year 2015 (473 deaths), based on the 1984 level. Colorectal death rates in males are predicted to drop, but the number of deaths will increase by more than 10%, due to demographic change. Numbers of breast cancer deaths are likely to rise slightly, despite falling age standardised death rates, due to an ageing population.

CONCLUSIONS

This work has provided estimates of early future trends, useful to service planners, and highlights the need for tobacco control, to reduce numbers of lung cancer deaths in females. The recently announced control of environmental tobacco legislation is one welcome development which should reduce lung cancer mortality in Northern Ireland.

Viscoelasticity Modeling of the Prostate Region Using Vibro-elastography

We present an ultrasound vibro-elastography system designed to acquire viscoelastic properties of the prostate and peri-prostatic tissue. An excitation stage imparts low-frequency (<20 Hz), limited amplitude (< +/- 2 mm), broadband vibratory motion to an endorectal transducer, along a radial/transversal direction. The induced tissue motion is estimated from ultrasound radio-frequency data and is used to estimate the mechanical frequency response of tissue to the excitation at different spatial locations. This can be used to determine the spatial distribution of various mechanical parameters of tissue, such as stiffness and viscosity. Phantom and in-vivo images are presented. The results obtained demonstrate high phantom and tissue linearity and high signal-to-noise ratio.

Genome-wide approach to identify risk factors for therapy-related myeloid leukemia

Using a target gene approach, only a few host genetic risk factors for treatment-related myeloid leukemia (t-ML) have been defined. Gene expression microarrays allow for a more genome-wide approach to assess possible genetic risk factors for t-ML. We assessed gene expression profiles (n=12 625 probe sets) in diagnostic acute lymphoblastic leukemic cells from 228 children treated on protocols that included leukemogenic agents such as etoposide, 13 of whom developed t-ML. Expression of 68 probes, corresponding to 63 genes, was significantly related to risk of t-ML. Hierarchical clustering of these probe sets clustered patients into three groups with 94, 122 and 12 patients, respectively; 12 of the 13 patients who went on to develop t-ML were overrepresented in the latter group (P<0.0001). A permutation test indicated a low likelihood that these probe sets and clusters were obtained by chance (P<0.001). Distinguishing genes included transcription-related oncogenes (v-Myb, Pax-5), cyclins (CCNG1, CCNG2 and CCND1) and histone HIST1H4C. Common transcription factor recognition elements among similarly up- or downregulated genes included several involved in hematopoietic differentiation or leukemogenesis (Maz, PU.1, ARNT). This approach has identified several genes whose expression distinguishes patients at risk of t-ML, and suggests targets for assessing germline predisposition to leukemogenesis.

The effects of massage on intra muscular temperature in the vastus lateralis in humans

The aim of the current investigation was to evaluate the effect of different durations of massage, and ultrasound treatment, on the temperature of the vastus lateralis muscle in males. Deep effleurage massage of the vastus lateralis was performed on seven healthy males (mean +/- SD; age; 28 +/- 4 years, height 1.84 +/- 0.05 m, body mass 85.7 +/- 12 kg) for 5, 10 and 15 min periods. A 5-min period of ultrasound at 45 KHz was also completed by all subjects. Intra muscular temperature (at 1.5, 2.5 and 3.5 cm) and thigh skin temperature were assessed pre and post treatment. Heart rate was monitored continuously throughout all conditions. Pre treatment intra muscular temperature increased as depth of measurement increased (p = 0.00002). Changes in muscle temperature at 1.5 and 2.5 cm were significantly greater following massage than ultrasound (p < 0.002). No significant differences between massage treatments and ultrasound were noted when intra muscular temperature was measured at 3.5 cm (p > 0.05). Massage also significantly increased both heart rate and thigh skin temperature compared to ultrasound (p < 0.005). Increases in intra muscular temperature, heart rate and thigh skin temperature were the same irrespective of massage duration. These data suggest that massage and ultrasound have only limited effects on deep muscle temperature. As a result such approaches may not be suitable as a preparation strategy for exercise.

The effects of the absence of emergency medicine residents in an academic emergency department

OBJECTIVE

What are the quality effects of an emergency medicine (EM) residency, and the associated 24/7 supervision of residents by faculty, in an academic emergency department (ED)? The authors evaluated activity and quality indicators when there were no EM residents present. The hypothesis of the study was that there was no difference between the patient care provided by faculty supervising EM residents and that with an alternative model without EM residents (AbsenceEMResident).

METHODS

To support the weekly residency educational program (Thursday), EM residents are not scheduled clinically for a 24-hour period (ConfDay). Emergency medicine resident coverage (mean 62.7 hours) was replaced with incremental faculty and mid-level providers (mean 41.0 hours). This study was limited to adult patients (22,527 visits of 39,190 ED total) for six months (January-June 2001) and compared indicators for ConfDay (n = 23) with all other days (NotConfDay, n = 158).

RESULTS

Comparing ConfDay (2,842 visits) with NotConfDay (19,685 visits), there was no difference in mean daily visits, inpatient admissions, intensive care unit admissions, or emergency medical services arrivals. ConfDay decision-to-admit time (333 vs. 313 min, p = 0.03) and length of stay for admissions (490 vs. 445 min, p = 0.000) were longer, with no difference for treat/release patients. There was no difference in the numbers of laboratory or radiology tests, consultations, unscheduled return visits, or patient satisfaction.

CONCLUSION

During the study period, there was no measurable difference for most of the quality indicators studied. The AbsenceEMResident model is less efficient in admitting patients. Faculty supervision results in the same number of laboratory and radiology tests and consultations. Other specialties may consider this model if off-hours care becomes a concern.

Development and administration of a measure to assess adolescents' participation in leisure activities

This paper describes the development and administration of a measure (a self-report questionnaire) to assess the participation of adolescents in leisure activities. Questionnaire items were generated through a content analysis of focus group interviews with 130 young people aged 12 to 18 years. Specifically, the activities of approximately a thousand adolescents were investigated through a three-factor leisure typology--achievement, social, and time-out leisure--together with the leisure parameters of enjoyment, freedom of choice, and frequency of participation. Further, leisure engagement was examined based on gender and age (i.e., changes in activity participation across the adolescent years). The results are discussed in terms of the practical and theoretical implications of the relationship between gender and age in leisure activity participation.

Forced expression of murine IL-17E induces growth retardation, jaundice, a Th2-biased response, and multiorgan inflammation in mice

IL-17 is a proinflammatory cytokine, and its in vivo expression induces neutrophilia in mice. IL-17E is a recently described member of an emerging family of IL-17-related cytokines. IL-17E has been shown to bind IL-17Rh1, a protein distantly related to the IL-17R, suggesting that IL-17E probably possesses unique biological functions. In this study, we have identified the murine ortholog of IL-17E and developed transgenic mice to characterize its actions in vivo. Biological consequences of overexpression of murine (m)IL-17E, both unique to IL-17E and similar to IL-17, were revealed. Exposure to mIL-17E resulted in a Th2-biased response, characterized by eosinophilia, increased serum IgE and IgG1, and a Th2 cytokine profile including elevated serum levels of IL-13 and IL-5 and elevated gene expression of IL-4, IL-5, IL-10, and IL-13 was observed in many tissues. Increased gene expression of IFN-gamma in several tissues and elevated serum TNF-alpha were also noted. In addition, IL-17E induces G-CSF production in vitro and mIL-17E-transgenic mice had increased serum G-CSF and exhibit neutrophilia, a property shared by IL-17. Moreover, exposure to mIL-17E elicited pathological changes in multiple tissues, particularly liver, heart, and lungs, characterized by mixed inflammatory cell infiltration, epithelial hyperplasia, and hypertrophy. Taken together, these findings suggest that IL-17E is a unique pleiotropic cytokine and may be an important mediator of inflammatory and immune responses.

Evidence for opioid variability, Part 2: Psychosocial influences

There is substantial evidence to show that certain biological and psychosocial factors affect opioid requirements after surgery. In fact, evidence suggests that individuals are much more likely to be different rather than similar in how they sense pain, react to it and respond to therapy. In an earlier report (Seminars in Perioperative Nursing 10:3-16, 2001), we examined research related to the biological differences that explain variability in postoperative opioid use and defined relevant terminology. Here, we discuss the evidence that links psychosocial experiences to postoperative analgesic outcomes and pain, which include psychological states of patients, cultural influences and attitudes, and beliefs and biases held by both patients and health professionals. Content will assist perioperative nurses to understand the characteristics of their patients and circumstances that place patients at risk for needing increased analgesia or experiencing poor pain control. As perioperative nurses strive to integrate research into practice, it will be important to examine the results of research studies and to determine the usefulness of this information in developing individualized plans for postoperative pain management.

Cervical dysplasia, ploidy, and human papillomavirus status correlate with loss of Fhit expression

PURPOSE

The tumor suppressor gene, FHIT, has been cloned and mapped at chromosome region 3p14.2, one of the regions most frequently deleted in cervical carcinoma. In this report, we show that the expression of the Fhit protein in relation to human papillomavirus (HPV) subtype, the type of the intraepithelial lesion, HIV-induced immunodeficiency, and the DNA content (ploidy) correlates with the biological behavior of the lesions.

EXPERIMENTAL DESIGN

To investigate involvement of the FHIT gene in squamous intraepithelial lesions of low and high grade (LGSILs and HGSILs, respectively) of the uterine cervix, we examined the Fhit protein expression by immunocytochemistry in 131 cervical smears of 96 HIV-seropositive patients (42 with LGSILs and 10 with HGSILs) and 35 HIV-seronegative (5 with LGSILs) persons.

RESULTS

Fhit protein was detected in normal cells, whereas dysplastic cells (independently of HPV infection and HPV subtypes) showed reduced expression of Fhit (P = 0.00001). Lesions from 52 HIV-seropositive patients, 42 LGSILs and 10 HGSILs, showed diploid DNA content in 63.5%, aneuploid in 32.7%, and polyploid in 3.8%, but 90% of the HGSILs showed an aneuploid DNA content, and all were infected by HPV 16/18 subtypes. 23.8% of LGSIL cases were associated with HPV 16.

CONCLUSIONS

These data clearly suggest that loss of Fhit expression occurs in the early stages of cervical carcinogenesis. Pap test represents one of the most convenient and rapid procedures available in identification of cellular changes; hence, Fhit staining might be used as an useful tool in larger population screening to detect early alteration in cellular behaviors.

Evidence for opioid variability, Part 1: A biological perspective

The interplay of biological and pyschosocial factors explain the unique individual differences in opioid requirements that occur among postoperative patients. Nurses must be familiar with the physiologic mechanisms that influence opioid analgesia. Despite growing evidence that doses of opioid analgesics needed to achieve pain relief vary significantly from patient to patient, standardized dosing regimens continue to drive administration of medications for postoperative pain. In this article, evidence-based literature related to the biologic factors that contribute to differences in responses to opioid medication will be examined. Content will assist the Perioperative Nurse to recognize the pharmacology of opioid analgesics and the scientific basis for differences in the body's ability to metabolize and excrete opioids. These differences include age, gender, genetic predisposition, type of surgical procedure, preexisting pain, and prior or concurrent opioid use. Specific terms are introduced and defined to increase understanding of opioid variability.

Interferon-mediated block in cell cycle and altered integrin expression in a differentiated salivary gland cell line (HSG) cultured on Matrigel

Sjögren's syndrome (SS), an idiopathic, autoimmune exocrinopathy, is partly characterized by diminished salivary flow, acinar cell atrophy, and increased expression of several cytokines. Several in vivo characteristics of the sialoadenitis are also evident in a human salivary gland ductal epithelial cell line (HSG) treated with cytokines. HSG cells differentiate to the acinar phenotype when cultured on Matrigel (Becton Dickinson, Bedford, MA), a basement membrane extract. To elucidate mechanisms of salivary gland pathology, the effects of interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha) on cell cycle progression and integrin expression were evaluated in HSG acinarlike cells. Flow cytometry experiments showed that cytokine treatment for 2 days arrested cells in G(1) phase of the cell cycle, and this preceded significant morphologic changes and decreased viability. Whereas only modest cytokine-mediated increases in protein expression for the alpha 3 and beta 1 integrin subunits were seen by immunoprecipitation, a form of alpha 3 integrin displaying enhanced electrophoretic mobility was evident after 6 days of cytokine treatment. To our knowledge, this is the first report demonstrating an IFN-mediated alteration in the electrophoretic mobility of integrin subunits. From this study, it was evident that the combination of IFN-gamma and TNF-alpha resulted in a block in G(1) phase for acinar cells before accumulation of the alpha 3 integrin variant or significant degenerative cellular changes. Information from the present and previous studies suggests that cytokines may alter the pattern of integrin expression and block cell cycle progression in salivary gland cells grown in three-dimensional acinarlike clusters. These experiments may provide a new cell culture model to study the effects of cytokines in normal and diseased salivary glands, including SS.

A regulator of transcriptional elongation controls vertebrate neuronal development

The development of distinct vertebrate neurons is defined by the unique profiles of genes that neurons express. It is accepted that neural genes are regulated at the point of transcription initiation, but the role of messenger RNA elongation in neural gene regulation has not been examined. Here we describe the mutant foggy, identified in a genetic screen for mutations that affect neuronal development in zebrafish, that displayed a reduction of dopamine-containing neurons and a corresponding surplus of serotonin-containing neurons in the hypothalamus. Positional cloning disclosed that Foggy is a brain-enriched nuclear protein that is structurally related to the transcription elongation factor Spt5 (refs 5-12). Foggy is not part of the basic transcription apparatus but a phosphorylation-dependent, dual regulator of transcription elongation. The mutation disrupts its repressive but not its stimulatory activity. Our results provide molecular, genetic and biochemical evidence that negative regulators of transcription elongation control key aspects of neuronal development.

HPV infection and microsatellite instability in squamous lesions of the uterine cervix

The role of human papillomavirus (HPV) in the development of squamous lesions of the uterine cervix has been clearly established but other factors could be involved in cervical tumorigenesis, such as microsatellite instability (MI). The aim of the present study was to analyze the relationship between HPV infection and MI. Thirty-two cervical samples were analyzed: 11 low-grade CIN (LCIN), 18 high-grade CIN (HCIN) and 3 carcinomas. DNA was extracted from formalin-fixed, paraffin embedded tissue for PCR study with HPV 6/11, 16, 18 and 7 microsatellite primers: D2S123 (cr2), MFD39 (cr8), 635-636 (cr15q), MFD67 (cr1), D11S905 (cr11), SCZD1 (cr5q) and DM (cr19). HPV was detected in 82% of LCIN (16 and 18 types in 64% of cases) and in 33% of HCIN (16 type in 22% of cases). The difference between LCIN and HCIN was statistically significant (p = 0.014), in particular for 16 and 18 HPV types (p = 0.033). Forty-seven per cent of total cases showed MI with no more than 3 different loci per case: 27% of LSIL, 61% of HCIN and 33% of carcinomas (not statistically significant). In 45% of HCIN cases there were both MI and HPV. In conclusion, cervical carcinoma is linked to HPV infection but MI could also be involved in cervical tumorigenesis.

Differential recognition of snake venom proteins expressing specific Arg-Gly-Asp (RGD) sequence motifs by wild-type and variant integrin alphaIIbbeta3: further evidence for distinct sites of RGD ligand recognition exhibiting negative allostery

Several studies have demonstrated that the amino acid residues flanking the Arg-Gly-Asp (RGD) sequence of high-affinity ligands modulate their specificity of interaction with integrin complexes. Because of the absence of structural data for integrin complexes with bound ligand, the molecular basis for this specificity modulation remains obscure. In a previous paper [Rahman, Lu, Kakkar and Authi (1995) Biochem. J. 312, 223-232] we demonstrated that two genetically distinct venom-derived RGD proteins, kistrin and dendroaspin (both containing the sequence PRGDMP), were simple competitors, indicating the recognition of an identical binding site on the alpha(IIb)beta(3) complex. Furthermore, both kistrin and dendroaspin inhibited the binding of the disintegrin elegantin (containing the sequence ARGDNP) via a non-competitive mechanism, suggesting that the binding of elegantin to the alpha(IIb)beta(3) complex was at a remote site and down-regulated via an allosteric mechanism. Here we present further evidence for distinct RGD ligand recognition sites on the alpha(IIb)beta(3) complex that exhibit a negative allosteric relationship. A panel of well-characterized recombinant dendroaspin and elegantin derivatives were employed for this study. These recombinant molecules were constructed as glutathione S-transferase fusion proteins with either an Ala or Pro residue N-terminal to the RGD sequence in combination with either a Met or an Asn residue immediately C-terminal. Equilibrium competition experiments showed that elegantin binding to ADP-treated platelets was inhibited by derivatives Eleg. AM (ARGDMP) and Eleg. PM (PRGDMP) via an allosteric competitive mechanism, providing direct evidence that modulation of the RGD motif can alter competitive behaviour. In addition, recombinant kistrin and dendroaspin both inhibited elegantin binding via a non-competitive mechanism, confirming our previous observations. Further evidence for distinct binding sites employing an independent approach was obtained by analysing the binding of the panel of venom proteins to the functionally defective heterodimer alpha(IIb)beta(3) Ser(123)-->Ala expressed on Chinese hamster ovary cells. These studies demonstrated that simple competitors kistrin and dendroaspin bound with high affinity to the variant integrin complex. In contrast, the binding of elegantin and most significantly, recombinant Dendro. PN (PRGDNP) and Dendro. AN (ARGDNP) were abolished. These observations, taken together, are consistent with a model depicting the presence of distinct sites of RGD ligand recognition on the alpha(IIb)beta(3) complex that show the preferential recognition of specific RGD motifs. Competition experiments demonstrate a negative allosteric relationship between these RGD recognition sites.