The role of peroxisome proliferator-activated receptor γ in pancreatic β cell function and survival: therapeutic implications for the treatment of type 2 diabetes mellitus

The pathogenesis of type 2 diabetes mellitus involves both peripheral insulin resistance and dysfunctional insulin secretion from the pancreatic β cell. Currently, there is intense research focus on delineating the etiologies of pancreatic β cell dysfunction in type 2 diabetes. However, there remains an unmet clinical need to establish therapeutic guidelines and strategies that emphasize the preservation of pancreatic β cell function in at-risk and affected individuals. Thiazolidinediones are orally active agents approved for use in type 2 diabetes and act as agonists of the nuclear hormone receptor PPAR-γ. These drugs improve insulin sensitivity, but there is also a growing appreciation of PPAR-γ actions within the β cell. PPAR-γ has been shown to regulate directly key β cell genes involved in glucose sensing, insulin secretion and insulin gene transcription. Further, pharmacologic PPAR-γ activation has been shown to protect against glucose-, lipid-, cytokine- and islet amyloid polypeptide (IAPP)-induced activation of numerous stress pathways. This article will review the mechanisms by which PPAR-γ activation acts to maintain β cell function and survival in type 2 diabetes mellitus and highlight some of the current controversies in this field.

Anatomic basis of Arnold's ear-cough reflex

A clinical survey of 500 patients revealed 4.2% incidence of Arnold's ear-cough reflex. The reflex was bilateral in 2.8% of the patients. It was also elicitable from the anterior meatal wall in 2% of the patients, thus questioning the classically taught distribution of Arnold's nerve. Arnold's nerve also mediates the auriculo-palatal, auriculo-lacrimal, auriculo-cardiac and the ear-vomiting reflexes; but these are less apparent and not so commonly encountered.

Successful management of pulmonary tuberculosis in renal allograft recipients in a single center

BACKGROUND

Pulmonary infections, especially tuberculosis, are responsible for significant mortality and morbidity among renal transplant recipients in developing countries. Conventional diagnostic modalities are associated with a low yield, delaying specific therapy.

METHODS

All patients transplanted within a 1.5-year period were prospectively followed-up for one year. Patients were on a cyclosporine-based triple immunosuppressive regimen. None received isoniazid prophylaxis, and those transplanted in the last seven months of the study period received daily cotrimoxazole. Patients exhibiting unequivocal evidence of pulmonary infections underwent further evaluation. Search for offending organisms was made by sputum examination and bronchoalveolar lavage (BAL).

RESULTS

. Thirty-nine infection episodes were recorded in 34 patients. M. tuberculosis was isolated during 10 episodes, pyogenic bacteria and Pneumocystis carinii in 6 each, candida in 4, aspergillus in 3, cytomegalovirus (CMV) in 3, and nocardia and mucor in one episode each. More than one organism was isolated during five episodes. Bacterial pneumonia and tuberculosis were diagnosed in another seven and two patients, respectively, on the basis of a therapeutic response to specific chemotherapy. Over two thirds of the organisms were identified by examination of BAL fluid. BAL was useful in the diagnosis of tuberculosis and P. carinii pneumonia but was relatively insensitive for CMV and bacterial infections. An increased frequency of acute rejection and higher serum creatinine were factors that predisposed to infections. All patients with pulmonary tuberculosis made a full recovery.

CONCLUSIONS

Tuberculosis and P. carinii are the most common nonpyogenic infections in the first year after transplantation in developing countries. An aggressive search for tubercle bacilli should be made using bronchoscopy and examination of BAL fluid in patients not responding to a short trial of antibiotics. A four-drug regime without rifampicin given for 18 months is effective for pulmonary tuberculosis in patients on cyclosporine. We recommend routine prophylactic use of one single-strength tablet of cotrimoxazole daily for at least six months after transplantation.

A comparison of the fine saccharide-binding specificity of Dioclea grandiflora lectin and concanavalin A

The lectin from the seeds of Dioclea grandiflora (DGL) is a Man/Glc-specific tetrameric protein with physical and saccharide-binding properties reported to be similar to that of the jack bean lectin concanavalin A (ConA). Unlike other plant lectins, both DGL and ConA bind with high affinity to the core trimannoside moiety, 3,6-di-O-(alpha-D-mannopyranosyl)-alpha-D-mannopyranoside, which is present in all asparagine-linked carbohydrates. In the present study, hemagglutination inhibition techniques have been used to investigate binding of DGL and ConA to a series of mono- and dideoxy analogs of methyl 3,6-di-O-(alpha-D-mannopyranosyl)-alpha-D-mannopyranoside and to a series of asparagine-linked oligomannose and complex oligosaccharides and glycopeptides. The results indicate that both DGL and ConA recognize epitopes on all three residues of the trimannoside: the 3-, 4-, and 6-hydroxyl groups of the alpha(1-6)Man residue, the 3-hydroxyl group of the alpha(1-3)Man residue, and the 2- and 4-hydroxyl groups of the central Man residue of the core trimannoside. However, unlike ConA, DGL does not bind to biantennary complex carbohydrates. This was confirmed by showing that biantennary complex glycopeptides do not bind to a DGL-Sepharose affinity column. Unlike ConA, DGL does not show enhanced affinity for a large N-linked oligomannose carbohydrate (Man9 glycopeptide) relative to the trimannoside. Thus, DGL and ConA share similar epitope recognition of the core trimannoside moiety. However, they exhibit differences in their fine specificities for larger N-linked oligomannose and complex carbohydrates.

Plasma testosterone and dihydrotestosterone in male rats during sexual maturation and following orchidectomy and experimental bilateral cryptorchidism

Plasma concentration of testosterone and dihydrotestosterone (17beta-hydroxy-5alpha-androstan-3-one) were measured at frequent intervals (daily between day 20 and 40) in intact male rats from early pre-pubertal stage to full maturity. Effect of orchidectomy and experimental bilateral cryptorchidism on these two blood-born compounds at different stages of sexual maturation was also studied. A distinct spurt in testosterone level was noted on day 26, and in 3 days a leval of 2600pg/ml was reached, which was about 90% of the highest peak value (2940 pg/ml) seen at day 70. In the same animals dihydrotestosterone spurt was noted at the same time, but the peak value (163 pg/ml) was reached later (day 33). Within 4 days after orchidectomy plasma testosterone level showed no significant change in 20-day old animals, but dropped to 15% of the intact value in 40-day old ones, while remaining at a steady level of about 23% in older animals. Plasma dihydrotestosterone was undetectable after orchidectomy at each stage of sexual maturation. With bilateral cryptorchid animals plasma testosterone was higher than seen in the intact 20-day old control, but remained similar at other stages of sexual maturation. Plasma dihydrotesterone in the same animals was significantly less (p less 0.01) than those seen in the intact controls at all stages of sexual development except in 20-day old ones, where it was essentially similar.

Non-invasive ventilation in acute cardiogenic pulmonary oedema

Non-invasive ventilation (NIV) is the delivery of assisted mechanical ventilation to the lungs, without the use of an invasive endotracheal airway. NIV has revolutionised the management of patients with various forms of respiratory failure. It has decreased the need for invasive mechanical ventilation and its attendant complications. Cardiogenic pulmonary oedema (CPO) is a common medical emergency, and NIV has been shown to improve both physiological and clinical outcomes. From the data presented herein, it is clear that there is sufficiently high level evidence to favour the use of continuous positive airway pressure (CPAP), and that the use of CPAP in patients with CPO decreases intubation rate and improves survival (number needed to treat seven and eight respectively). However, there is insufficient evidence to recommend the use of bilevel positive airway pressure (BiPAP), probably the exception being patients with hypercapnic CPO. More trials are required to conclusively define the role of BiPAP in CPO.

Effect of the pineal gland on circadian rhythmicity of colony forming units for granulocytes and macrophages (CFU-GM) from rat bone marrow cell cultures

The present study provides evidence that the pineal gland has a physiological role in the proliferation of colony forming units for granulocytes and macrophages (CFU-GM). A biphasic circadian rhythm of CFU-GM proliferation in rat bone marrow cell cultures (BMC) from intact animals peaking at 0600 and 1800 was observed. Pinealectomy (Px) at 1600 obliterated the circadian rhythm patterns of CFU-GM. Afternoon injections of melatonin (1630, 20 micrograms/per day for 10 days) to Px animals restored the rhythmicity. When pinealectomy was done at 0800, the morning peak remained unaltered and the colony number at 1800 was higher than that found in the afternoon Px animals. In conclusion, the pineal gland or its main hormone melatonin seems to have a regulatory role in the proliferation of CFU-GM in rat BMC. Further, the expression of the activity of CFU-GM in rat BMC depends on the time when pinealectomy is done or melatonin is substituted.

E2F4 regulates a stable G2 arrest response to genotoxic stress in prostate carcinoma

The retinoblastoma (pRB) family proteins regulate the E2F transcription factors; their complexes regulate critical transitions through the cell cycle. The function of these pRB family/E2F complexes, which includes p130/E2F4, in response to genotoxic agents, is not well understood. We investigated the role of E2F4 in the genotoxic stress response. Following radiation treatment, E2F4 colocalized with p130 in the nucleus during a radiation-induced stable G(2)-phase arrest. Arrested cells had significantly decreased expression of Cyclins A2 and B1 and decreased phosphorylation of mitotic protein monoclonal-2 (MPM-2) mitotic proteins. Small interference RNA (siRNA)-mediated knockdown of E2F4 sensitized cells to subsequent irradiation, resulting in enhanced cellular DNA damage and cell death, as determined by caspase activation and decreased clonogenic cell survival. Downstream E2F4 targets potentially involved in the progression from G(2) into M phase were identified by oligonucleotide microarray expression profiling. Chromatin immunoprecipitation localized E2F4 at promoter regions of the Bub3 and Pttg1 mitotic genes following irradiation, which were among the downregulated genes identified by the microarray. These data suggest that in response to radiation, E2F4 becomes active in the nucleus, enforces a stable G(2) arrest by target gene repression, and thus provides increased cell survival ability by minimizing propagation of cells that have irreparable DNA damage.

Extrauterine malignancies. Role of Pap smears in diagnosis and management

OBJECTIVE

To further elucidate the cytologic manifestations of extrauterine malignancies, to evaluate their possible distinction from primary cervical malignancies and to analyze their clinical significance and role in staging.

STUDY DESIGN

Papanicolaou (Pap) smears in 33 cases with abnormal cells originating in histologically proven extrauterine carcinomas were evaluated. These cases came from the files of the Medical College of Pennsylvania and Lankenau Hospitals.

RESULTS

Ovary, gastrointestinal tract and breast were the three most frequent primary sites, accounting for 28 of the 33 cases (85%). The histologic types encountered were adenocarcinoma, 29 cases (88%); mucoepidermoid carcinoma, 1 (3%); small cell carcinoma, 1 (3%); cloacogenic carcinoma and large cell lymphoma, 1 (3%). The following diagnoses were rendered at the time of initial evaluation: adenocarcinoma consistent with metastasis, 21 cases; carcinoma, primary versus metastatic, 2; adenocarcinoma, suspicious for endometrial primary, 2; suspicious for carcinoma, 1; and atypical glandular cells, 7.

CONCLUSION

The yield for positive Pap smear diagnoses in extrauterine malignancies is best in patients with an established diagnosis of a primary neoplasm. The degree of tumor differentiation and extent of tumor involvement did not appear to correlate with diagnostic yield. There appeared to be no statistically significant association of tumor diathesis with primary versus metastatic carcinoma and presence or absence of documented local involvement of the endometrium, cervix or vagina. Therefore, while Pap smears can serve as a diagnostic tool in the evaluation of extrauterine malignancies, they are best utilized as an adjunct to tumor staging and patient management.

Islet beta cell failure in the 60% pancreatectomised obese hyperlipidaemic Zucker fatty rat: severe dysfunction with altered glycerolipid metabolism without steatosis or a falling beta cell mass

AIMS/HYPOTHESIS

The Zucker fatty (ZF) rat subjected to 60% pancreatectomy (Px) develops moderate diabetes by 3 weeks. We determined whether a progressive fall in beta cell mass and/or beta cell dysfunction contribute to beta cell failure in this type 2 diabetes model.

METHODS

Partial (60%) or sham Px was performed in ZF and Zucker lean (ZL) rats. At 3 weeks post-surgery, beta cell mass and proliferation, proinsulin biosynthesis, pancreatic insulin content, insulin secretion, and islet glucose and lipid metabolism were measured.

RESULTS

ZL-Px rats maintained normal glycaemia and glucose-stimulated insulin secretion (GSIS) despite incomplete recovery of beta cell mass possibly due to compensatory enhanced islet glucose metabolism and lipolysis. ZF-Px rats developed moderate hyperglycaemia (14 mmol/l), hypertriacylglycerolaemia and relative hypoinsulinaemia. Despite beta cell mass recovery and normal arginine-induced insulin secretion, GSIS and pancreatic insulin content were profoundly lowered in ZF-Px rats. Proinsulin biosynthesis was not reduced. Compensatory increases in islet glucose metabolism above those observed in ZF-Sham rats were not seen in ZF-Px rats. Triacylglycerol content was not increased in ZF-Px islets, possibly due to lipodetoxification by enhanced lipolysis and fatty acid oxidation. Fatty acid accumulation into monoacylglycerol and diacylglycerol was increased in ZF-Px islets together with a 4.5-fold elevation in stearoyl-CoA desaturase mRNA expression.

CONCLUSIONS/INTERPRETATION

Falling beta cell mass, reduced proinsulin biosynthesis and islet steatosis are not implicated in early beta cell failure and glucolipotoxicity in ZF-Px rats. Rather, severe beta cell dysfunction with a specific reduction in GSIS and marked depletion of beta cell insulin stores with altered lipid partitioning underlie beta cell failure in this animal model of type 2 diabetes.

Molecular characterization of the Rep protein of the blackgram isolate of Indian mungbean yellow mosaic virus

The complete nucleotide sequence of the blackgram isolate of mungbean yellow mosaic virus, IMYMV-Bg, which infects legumes in India, was determined and compared at the amino acid level with those of other whitefly-transmitted geminiviruses. The genome organization of IMYMV-Bg was similar to that of the begomoviruses. A unique feature of the genome organization was the sequence divergence of the common region (CR) between DNA-A and DNA-B. In order to understand the mechanism of viral DNA replication, the replication initiator protein, Rep, of IMYMV-Bg was overexpressed in E. coli. The recombinant and refolded Rep bound to CR-sequences of IMYMV-Bg in a specific manner. In this study, evidence is presented for ATP-upregulated cleavage function and ATP-mediated conformational change of Rep. It is hypothesized that, although ATP is not required for cleavage, ATP-mediated conformational changes may result in better access of Rep to the DNA-cleavage site. Evidence is also presented for a site-specific topoisomerase function of Rep, which has not been demonstrated before. The Rep protein can be classified as a type-I topoisomerase because of its nicking activity and sensitivity towards camptothecin, a topoisomerase type-I inhibitor.

A study of chorda tympani nerve injury and related symptoms following middle-ear surgery

This is a prospective study that looks into the prevalence of chorda tympani nerve (CTN) injury and related symptoms following varying degrees of trauma to the nerve during three common types of middle-ear operation: myringoplasty, tympanotomy and mastoidectomy. The number of patients with CTN-related symptoms varied widely between the three groups. Increased occurrence of the nerve related symptoms and a prolonged recovery time were observed in the tympanotomy group. Stretching of the nerve produced more symptomatic cases than cutting it in the myringoplasty and mastoidectomy groups. Recovery was complete in 92 percent of the symptomatic patients by 12 months. It is important to inform patients about the possibility of CTN injury during middle-ear operations, and it should also be emphasized that symptoms related to CTN injury can occur irrespective of the type of damage to the nerve.

Vitamin D and prostate cancer risk: a review of the epidemiological literature

Prostate cancer is the most commonly diagnosed cancer in the United States. Prostate cells contain vitamin D receptors as well as enzymes necessary for vitamin D metabolism. Vitamin D metabolites have an antiproliferative and a pro-differentiating effect on prostate cancer cell lines in vitro and in vivo. As a result, there has been an emerging interest in the potential role of vitamin D in the etiology of prostate cancer. This review summarizes all available epidemiological literature on the association between dietary vitamin D, circulating levels of vitamin D and sunlight exposure in relation to prostate cancer risk. To place these studies in context, we also provide some background information on vitamin D, such as its dietary sources, metabolism, optimal levels, hypovitaminosis and relationship with the prostate.

Pathogenesis of the prune belly syndrome

The triad of abnormalities of the prune belly syndrome may arise simply from the effects of early urethral obstruction or alternatively from a basic defect of the mesoderm from which the triad of abnormalities develops. The urethra and genital tract of 21 prune belly syndrome specimens and 23 specimens of Young's posterior urethral valves types 1 and 3 were compared in a study for differences in the pathological anatomy that may elucidate the controversy. The specimens were dissected and investigated radiographically and histologically. The seminal ducts and vesicles, and prostatic glands were abnormal in the prune belly syndrome specimens and normally developed in the posterior urethral valve specimens. We contest that this major difference stems from a primary defect of the intermediate and lateral plate mesoderm in the prune belly syndrome which would affect the embryogenesis not only of the mesonephric and paramesonephric ducts but also of the musculature of the abdominal wall and urinary organs, and that prune belly valves when present are intrinsic components of the mesodermal defect of the prune belly syndrome urethra.

A longitudinal study of the urinary excretion of individual steroids in children from 8 to 12 years old

A longitudinal study was made of the urinary excretion of a number of C19 and C21 steroids in 11 healthy boys and 9 healthy girls aged 8–12 yr. Urine collections were made every 6 months, over periods ranging from 1 to 2½ yr. in different children. The excretions of most substances showed surprisingly regular increments in individual children. Differences between individual children were marked and often consistent; some children excreted high amounts of one substance and low amounts of another, and other childen the reverse. The variation between individuals in the excretion of substances such as androsterone and aetiocholanolone was reduced when the results were plotted against skeletal rather than chronological age. DHA was excreted by all subjects, but at a very low level before the skeletal age of 10 yr. The glucuronide: sulphate ratio of the 11-deoxy-17-oxosteroids fell consistently from 8 to 12 yr. whereas the ratio of 5α-: 5β-11-deoxy-17-oxosteroids increased. Boys excreted more C19 steroids than girls with the same skeletal maturity score. This comparison is physiologically more meaningful than comparing boys and girls of the same chronological age.

Genetic polymorphisms in the P2X7 gene and its association with susceptibility to tuberculosis

BACKGROUND

Several studies have reported the influence of genetic variations on susceptibility to tuberculosis (TB). Polymorphism in P2X7 gene coding for P2X7 receptor present on macrophages has been linked to TB in different populations.

OBJECTIVE

To assess the role of P2X7 gene -762T/C and -1513A/C polymorphisms in TB susceptibility.

DESIGN

In a case-control study, polymerase chain reaction (PCR) amplification of genomic DNA extracted from peripheral blood samples of cases and controls was followed by restriction fragment length polymorphism or allele-specific PCR.

RESULTS

The 1513C allele was found to be associated with TB susceptibility (P = 0.02, OR for variant C allele 1.33, 95%CI 1.03-1.73). A significant protective association against TB was found for -762T/C polymorphism (P < 0.01, OR for variant C allele 0.72, 95%CI 0.57-0.91). On classifying samples on the basis of sex, only males showed a significant association between P2X7 -1513A/C and P2X7 -762T/C and TB in the present study.

CONCLUSION

A significant association of 762T/C and 1513A/C polymorphisms with TB in the P2X7 gene was found in our study population. A sex bias, with only males showing a significant association with the disease, is the first report of this kind. Genetic studies for the characterisation of the susceptibility genes can help to gain a better understanding of TB pathogenesis.

Metastases to breast simulating ductal carcinoma in situ: report of two cases and review of the literature

The breast is an uncommon site for metastases. Nevertheless, it is important to differentiate primary from secondary tumors of the breast, because clinical management and expected outcomes are vastly different. We report two examples of tumors with a papillary histologic pattern metastasizing to the breast. One of the cases occurred in a 31-year-old woman with a primary renal cell carcinoma, the other was in a 42-year-old woman with an ovarian papillary serous adenocarcinoma. In the first case, the patient's previous history of cancer was not known to the pathologist. The cases highlight the difficulty in distinguishing primary from metastatic tumors in the breast. In both cases the tumors infiltrated in a pattern that mimicked in situ ductal carcinoma changes. Additionally, in both cases, the metastasizing tumor was unusual with the tumor cells diffusely permeating the lymphatic spaces, not in a solid mass. These cases and a review of the literature indicated that breast metastases, although rare, must be recognized and differentiated from primary breast tumors to avoid unnecessary radical surgery to the breast. Moreover, the presence of changes similar to in situ carcinoma of the breast are not conclusive evidence that one is evaluating a primary breast carcinoma. When there is any unusual histomorphology, a good degree of suspicion is necessary. Ann Diagn Pathol 5:15-20, 2001.

Phenotypic and molecular analysis of six human cell lines derived from patients with plasma cell dyscrasia

Cell lines RPMI 8226, JJN3, U266 B1, NCI-H929 (all EBV-) and ARH77 and HS-Sultan (both EBV+) have been extensively characterized in this study. EBV- lines expressed the phenotype (CD138-, CD19+, CD20+) whereas EBV+ were (CD138+, CD19-, CD20-). CD56 expression was restricted to EBV- cell lines, with the exception of U266 B1, whereas PCA-1 was strongly expressed on five of the six cell lines. Only EBV+ cell lines bound peanut-agglutinin (PNA). However, all cell lines bound the lectin Jacalin that binds the same receptor as PNA, irrespective of the receptors sialylation status. By RT-PCR and direct sequencing of their IgH V/D/J domains, ARH77 was demonstrated to use the germline sequence VH4-34/dm1/JH6b, whereas no arrangement was demonstrated for RPMI 8226, suggesting IgH gene deletion or mutation. HLA class I and II antigens were detected using HLA typing on all cell lines warranting their use as suitable targets for HLA-restricted cytotoxic T cells. By sensitive RT-PCR, mRNA for IL-6, IL-6R and TNFbeta was found expressed in all cell lines. IL-1 mRNA expression was predominantly associated with the EBV+ phenotype. Although mRNA for IL-3 and GM-CSF was never detected, transcripts for c-kit ligand and, more commonly, its receptor were. Likewise GM-CSF, M-CSF and erythropoietin mRNA transcripts were detected in the majority of cell lines.

Heterogeneity of rat FSH by chromatofocusing: studies on serum FSH, hormone released in vitro and metabolic clearance rates of its various forms

Rat pituitary FSH was fractionated by chromatofocusing between pH 6 and 3. Ten components were resolved having apparent isoelectric points between 3.1 and 5.1. A comparative study of pituitary FSH and FSH secreted in vitro by quartered pituitary glands in the presence and in the absence of gonadotrophin-releasing hormone (GnRH) revealed similar patterns of charged species of intracellular and released FSH. Although GnRH increased FSH secretion about fourfold, no influence on the pattern of charged species was observed. Utilizing exclusion chromatography and chromatofocusing, pituitary FSH was compared to serum FSH which had been extracted by immuno-affinity chromatography. The results demonstrate for serum FSH a larger molecular size and a relative shift to more acidic components. Metabolic clearance rates of eight FSH components separated by chromatofocusing were measured in adult male rats. Half-lives varied between 13 min and several hours. A correlation existed between decrease of isoelectric points and decrease of metabolic clearance rates. These findings suggest that all hypophysial FSH components are secreted into the circulation at similar rates and the more acidic FSH components which appear to contain increased sialic acid, have a longer circulatory half-life and are more abundant in serum. It is concluded that sialylation may be involved in modulating serum FSH levels.

Clinical characteristics and outcomes of empyema thoracis in 117 patients: a comparative analysis of tuberculous vs. non-tuberculous aetiologies

BACKGROUND

Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema.

METHODS

Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression.

RESULTS

One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis.

CONCLUSIONS

Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.

CD34+-selected peripheral blood progenitor cell transplantation in patients with multiple myeloma: tumour cell contamination and outcome

Thirty-six patients with multiple myeloma (23 PR1, nine PR2, four stable disease) were entered into a pilot study evaluating the use of CD34+-selected peripheral blood progenitor cell transplantation (PBPCT) following high-dose melphalan alone or high-dose melphalan and total body irradiation. Peripheral blood progenitor cells (PBPCs) were mobilized with cyclophosphamide and granulocyte colony stimulating factor (G-CSF). CD34+ selection using the Cellpro Ceprate-SC system was performed in 22 cases with an adequate yield in 20. 10 patients failed to mobilize sufficient cells to permit selection and in four cases selection was not performed for other reasons. 16 patients therefore received unselected PBPC. Tumour cell contamination was evaluated by IgH gene fingerprinting (fpPCR). Harvested PBPC were fpPCR positive in 13/20 CD34+-selected cases and remained positive after selection in seven. Harvested PBPC were studied in 9/16 patients receiving unselected cells; fpPCR was positive in five and negative in four. There was no difference in event-free survival (EFS) between the CD34+-selected group and the unselected group (median 21 and 26 months, respectively, P=ns). The CD34+-selection process therefore reduced contamination but did not eliminate it completely, and in this small non-randomized study there was no apparent clinical benefit of CD34+ selection.

Comparison of the incidence and severity of cough induced by sufentanil and fentanyl: a prospective, randomised, double-blind study

We compared the incidence and severity of cough following a bolus of sufentanil with that following fentanyl in 510 patients, randomly allocated to receive sufentanil 0.3 microg.kg(-1), fentanyl 3 microg.kg(-1) or 5 ml sterile water intravenously over 5 s. Coughing was graded depending on the number of coughs as mild (1-2), moderate (3-5) and severe (> 5). The incidence of coughing was higher after sufentanil (26/165; 15%) and fentanyl (54/169; 32%) than in the control group (0/168; p < 0.001). Sufentanil was also associated with a lesser severity (p = 0.039) of coughing compared with fentanyl. We conclude that equipotent boluses of sufentanil and fentanyl increase the incidence of cough, although the incidence and severity of coughing with sufentanil are less than those with fentanyl.

Role of MD-2 in TLR2- and TLR4-mediated recognition of Gram-negative and Gram-positive bacteria and activation of chemokine genes

MD-2 is associated with TLR4 on the cell surface and enables TLR4 to respond to LPS. TLR2 without MD-2 does not respond to pure protein-free endotoxic LPS, ReLPS, and lipid A. MD-2 enables TLR2 to respond to non-activating LPS, ReLPS, and lipid A, and enhances TLR2-mediated responses to Gram-negative and Gram-positive bacteria, protein-containing LPS, peptidoglycan, and lipoteichoic acid. MD-2 enables TLR4 to respond to a wide variety of endotoxic LPS partial structures, Gram-negative bacteria, and Gram-positive lipoteichoic acid, but not to Gram-positive bacteria, peptidoglycan, and lipopeptide. MD-2 physically associates with both TLR4 and TLR2, but the association with TLR2 is weaker than with TLR4. Also, MD-2 and TLR2 and TLR4 enhance each other's expression. The highest induced genes in human monocytes stimulated with Gram-positive and Gram-negative bacterial cell wall components are chemokine genes, and IL-8 is the highest induced chemokine. Both Gram-positive and Gram-negative bacteria activate TLR2-->MyD88-->IRAK-->TRAF-->NIK-->IKK-->NF-->kappaB signal transduction pathway that induces transcription of the IL-8 gene. Therefore, TLR2 is a functional receptor for both Gram-positive and Gram-negative bacteria and it induces activation of IL-8.

Sonographically guided fine-needle aspiration biopsy of superior mediastinal lesions by the suprasternal route

OBJECTIVE

Our objective was to assess the technical feasibility, safety, and accuracy of sonographically guided fine-needle aspiration biopsy of superior mediastinal masses by the suprasternal route.

CONCLUSION

Sonographically guided biopsy through the suprasternal route is safe and effective for lesions in the pretracheal, right paratracheal, and prevascular compartments of the superior mediastinum. This procedure is especially useful for lesions with an acoustic window too small for parasternal biopsy under sonographic guidance.