Effect of stent implantation on upstream coronary artery compliance--a cause of late plaque rupture?

Stent implantation in the rabbit aorta has been shown to increase vessel wall compliance at the inflow to the stent, but it is uncertain whether similar effects might be seen in the coronary arteries of humans and whether this would have any significant clinical consequences. First, we measured vessel compliance (systolic lumen area--diastolic lumen area/pulse pressure) before, immediately after, and at the 6-month follow-up visit at a site 5 mm upstream of the proximal edge of an implanted coronary stent in patients undergoing coronary intervention using motorized pull-back intravascular ultrasound recordings. Compliance in the upstream segment increased significantly immediately after stenting (before 7.13 +/- 1.49 vs after 10.73 +/- 1.36 mm2/mm Hg, p = 0.03), an effect that was unchanged at 6 months of follow-up (11.84 +/- 2.11 mm2/mm Hg, p = 0.08 vs before stenting). Second, we examined the site of plaque rupture in all patients presenting with an acute coronary syndrome in whom the culprit lesion was in a vessel that had had a stent implanted >12 months previously (n = 31). Plaque rupture was statistically more likely at the inflow to the stent (n = 22) than at other sites within the culprit vessel (n = 9, p <0.01). We conclude that stenting causes an increase in vessel compliance immediately proximal to the stent, and that when a vessel has been previously stented, plaque rupture is most likely to occur at the stent inflow site.

Nonmalignant superior vena cava syndrome: Pathophysiology and management

Superior vena cava (SVC) syndrome occurs following obstruction either from external compression or internal thrombosis or scarring. In the past, treatment was limited to medical therapy or surgical bypass but now percutaneous revascularization presents a viable therapeutic option. We present our experience in the percutaneous therapy of patients with nonmalignant SVC syndrome and review the condition with regard to its pathophysiology and management.

Recurrent varus angulation after high tibial osteotomy: an anatomic analysis

Recurrent varus deformity and an associated lateral instability are a common and perplexing concern after high tibial osteotomy. An anatomic study using fresh cadaver specimens was done to delineate the cause of this complication. A closing wedge osteotomy was done on four cadaveric knees, which then were subjected to a small varus load to simulate the adduction moment experienced by the knee during normal gait. The osteotomy was progressively closed in 5 degree increments and the angular alignment of the knee was measured with each incremental change. Experimental results identified postosteotomy angular corrections to be 50%, or less, of the predicted value. As the osteotomy was closed progressively the lateral joint space increased concomitantly, creating an effective lateral instability and negating much of the angular correction afforded by the osteotomy. At osteotomy angles greater than 10 degrees the lateral collateral ligament was rendered nonfunctional with the lateral capsule and the anterior cruciate ligament assuming the primary function of stabilizing the lateral side of the knee. As commonly done, a closing wedge valgus tibial osteotomy does not alter the lateral collateral tension, which allows the knee to swing back toward native alignment when subjected to a varus load.

Approaches to difficult filter retrieval in carotid stenting

The treatment of carotid disease continues to evolve with an increasing number of the lesions being successfully treated percutaneously. A large part of the success of percutaneous therapy has resulted from the use of distal protection devices and their ability to reduce embolization and subsequent strokes. However, device retrieval through implanted stents can be problematic. We describe situations in which difficulty was encountered advancing the distal protection filter retrieval device through the stent, as well as the different approaches to solve this potential problem.

Use of suture-mediated vascular closure devices for the management of femoral vein access after transcatheter procedures

Groin complications remain the most common complication of cardiac catheterization procedures. While the use of closure devices is increasing for arterial sheaths, venous sheaths tend to be removed and hemostasis achieved with manual compression. We report our experience using Perclose suture-mediated vascular closure device to achieve hemostasis and early mobility in patients who have had venous access as part of their procedure. There were a total of 42 patients (21 males; average age, 63.5 years) studied. The majority of the patients had 7 Fr sheaths (24), with access sites of sheaths up to 14 Fr being closed with this technique. Two patients developed complications at the access site: one patient requiring rehospitalization for intravenous antibiotics because of late access site infection, and one patient with deep venous thrombosis and pulmonary emboli. We conclude that the use of the Perclose suture-mediated closure device for closure of femoral venous access sites is feasible and should be considered especially in patients with larger venous sheaths and those at increased risk of groin complications.

Carotid stenting in the bovine arch

We report our experience in stent-supported angioplasty of the left internal carotid artery in patients with anomalous origin of the left common carotid, the so-called bovine arch, in which the right brachiocephalic and left carotid share a common trunk from the aortic arch. The occurrence of the anatomic variant is discussed, and techniques of femoral, brachial, and radial approaches are described.

An unusual cause of claudication

We describe a case of a patient who presented with claudication 3 months following a coronary angiogram in which the femoral arterial puncture site had been closed with an AngioSeal. The lesion was found to be due to the anchor of the AngioSeal, which embolized during attempted percutaneous revascularization and had to be snared and retrieved to the level of the sheath in the left femoral artery and was then surgically removed.

Patellar retinacular peel: an alternative to lateral retinacular release in total knee arthroplasty

The need to perform a lateral retinacular release (LRR) during total knee arthroplasty (TKA) may be lessened or eliminated by performing a patellar retinacular peel (PRP). PRP involves peeling the extensor retinaculum off the dorsolateral border of the patella to the extent necessary to facilitate patellar eversion. Generally, a portion of the lateral patellar facet is removed to allow conformity with a round patellar prosthesis. The combination of retinacular peel and partial facetectomy decreases lateral retinacular tension, which reduces the tendency toward lateral subluxation. In the study reported here, a series of 50 TKAs that included a PRP in all cases was compared with an earlier series of 50 TKAs that included LRR for control of patellar tracking, as needed. The incidence of anterior knee pain was lower in the PRP group than in the LRR group, though this difference was not significant from a statistical perspective. The 2 groups were virtually identical on other comparison criteria. PRP seems to be a viable alternative to LRR.

Primary breast myoepithelial cells exert an invasion-suppressor effect on breast cancer cells via paracrine down-regulation of MMP expression in fibroblasts and tumour cells

In normal breast and ductal carcinoma in situ, myoepithelial cells form an incomplete layer separating the epithelial compartment from the stromal environment. Transition to invasive disease is marked by penetration of the myoepithelial-basement membrane (BM) interface. One mechanism involved in tumour invasion is breakdown of extracellular matrices by matrix metalloproteinases (MMPs). It was hypothesized that myoepithelial cells may modulate tumour invasion by controlling MMP gene expression, both in tumour cells and in peri-ductal fibroblasts. To investigate this, myoepithelial cells from normal breast were purified and characterized and their effect on tumour cell invasive potential was assessed. The effect on MMP gene expression of breast cancer cells cultured alone or in combination with primary normal breast fibroblasts was also analysed using RT-PCR with ELISA quantitation, with zymographic analysis to measure enzyme activity. Normal breast myoepithelial cells significantly reduced invasion by the breast cancer cell lines MCF-7, T47D, MDA-MB 231, and MDA-MB 468 when they were cultured alone or in the presence of a fibroblast population. Reduced invasion was associated with changes in MMP gene expression. In those tumour cells expressing MMP, there was a significant down-regulation of MMP-2 (MDA-MB 468, p<0.001), MMP-9 (MDA-MB 231, p=0.05; MDA-MB 468, p<0.001), and MT1-MMP (p<0.001 for both MDA-MB 231 and MDA-MB 468). Myoepithelial cells also caused a significant decrease in MMP gene expression in co-cultured fibroblasts. Furthermore, this was associated with reduced gelatinolytic activity as identified by zymography. This study demonstrates for the first time that primary myoepithelial cells from normal breast reduce breast cancer cell invasion and that this is mediated via modulation of both tumour cell and fibroblast function. This emphasizes the importance of the myoepithelial cell in controlling the breast microenvironment and focuses on the potential significance of the loss of this population with disease progression.

Evidence that superficial basal cell carcinoma is monoclonal from analysis of the Ptch1 gene locus

BACKGROUND

Superficial basal cell carcinoma (BCC) arises as an apparently multifocal proliferation of tumour nests attached to the epidermis, which is at odds with a monoclonal origin. Computer-assisted reconstruction shows that these nests join in three dimensions, but it remains unknown whether this tumour is monoclonal. An early event in BCC formation, loss of heterozygosity (LOH) at the Patched 1 (Ptch1) locus, can be used as a tool to address whether this tumour is monoclonal.

OBJECTIVES

To determine whether superficial BCC is monoclonal by analysing individually microdissected superficial BCC nests and looking for the same pattern of LOH in each.

METHODS

Six cases of superficial BCC were analysed for LOH at the Ptch1 gene locus using the D9S287 microsatellite marker. Identical allelic patterns were sought in each nest from a given tumour. These patterns were no allelic loss, loss of the shorter allele or loss of the longer allele, each with a respective probability of occurrence, as estimated from published findings.

RESULTS

All cases were informative. Four cases showed no LOH in each nest and two showed loss of the same allele. If these nests arose independently, then the probability of this result was between 4 x 10-11 and 2 x 10-14. The lack of LOH, seen in four cases, could be due to monoclonal expansion of a cell retaining both D9S287 alleles, or due to a polyclonal proliferation. Therefore, a separate analysis excluding these cases was done, giving a probability of between 2.2 x 10-4 and 1.0 x 10-7.

CONCLUSIONS

These probabilities were so extreme that it was unlikely that the nests arose independently, thus providing the first molecular evidence that superficial BCC is monoclonal.

A study of quetiapine: efficacy and tolerability in psychotic adolescents

OBJECTIVE

To study the effectiveness, safety, and tolerability of quetiapine in adolescents with psychotic disorders.

METHODS

This study was an 8-week, open trial using quetiapine with 15 adolescents, ages 13-17 years, mean age 15.1 years, with a diagnosis of a psychotic disorder. Our primary instruments focused on psychotic symptomatology as measured by the Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression (CGI), Positive and Negative Syndrome Scale (PANSS), and the Young Mania Rating Scale (YMRS). Other measures included adverse events, clinical laboratory tests, vital signs, electrocardiogram (ECG), extrapyramidal (EPS) measures, and ophthalmologic examination.

RESULTS

Quetiapine significantly reduced psychotic symptoms as measured by the BPRS, PANSS, YMRS, CGI, and CGI Severity of Illness scale. The average weight gain was 4.1 kg. After correction for expected weight gain, the mean weight gain over the 8-week period was 3.4 kg. Prolactin and cholesterol remained unchanged. Trends were found for a decrease in T4 and an increase in thyroid-stimulating hormone. Common adverse effects were somnolence, agitation, drowsiness, and headache. No significant findings were noted on repeat ECGs, EPS measures, or ophthalmic examination. The final average treatment dose was 467 mg/day (range 300-800 mg/day).

CONCLUSIONS

Quetiapine is suggested to be effective treatment of youths with psychotic disorders and to have a favorable side-effect profile.

Determinants of coronary artery compliance in subjects with and without angiographic coronary artery disease

OBJECTIVES

The goal of this study was to determine factors contributing to the biomechanical properties of coronary arteries in people with and without angiographic coronary artery disease (CAD).

BACKGROUND

The stiffness of the aorta is known to increase with increasing age and in the presence of CAD. However, little is known about the mechanics of coronary arteries, which may have important clinical consequences.

METHODS

Intravascular ultrasound was used to determine the mechanical properties of coronary arteries and plaque behavior in subjects with CAD (n = 38), those with chest pain but angiographically normal coronary arteries (N) (n = 9) and those early (<2 weeks) after cardiac transplant (T) (n = 14).

RESULTS

Coronary arteries dilated during systole in all groups, but cross-sectional compliance and distensibility were lowest in the proximal left anterior descending artery (LAD) in the subjects with CAD compared with the N and T groups (compliance: 1.2 +/- 0.2 vs. 1.7 +/- 0.5 and 2.7 +/- 0.6 x 10(-2) mm(2) mm Hg(-1) [mean +/- SEM] respectively, p < 0.02 CAD vs. T; distensibility: 0.8 +/- 0.2 vs. 1.7 +/- 0.5 and 1.7 +/- 0.3 x 10(-3) mm Hg(-1), p < 0.05 CAD vs. T). There was extensive plaque in the CAD group, and plaque was also present in the N group, but minimal atheroma was present in the T group. Plaque cross-sectional area diminished significantly during systole in both the LAD and circumflex arteries. Absolute changes were: 0.50 +/- 0.30, 0.33 +/- 0.11 and 0.68 +/- 0.13 mm(2) in the proximal LAD, distal LAD and proximal circumflex arteries, respectively. In subjects with atheroma, there was a significant correlation between cross-sectional compliance and plaque compression at all sites, and plaque compression was a significant determinant of cross-sectional compliance at both proximal sites in multiple regression analyses with age, mean arterial pressure and extent of plaque as the other independent variables.

CONCLUSIONS

A major determinant of the systolic increase in coronary luminal area in patients with atheroma is a reduction in plaque cross-sectional area during systole.

Polarimetric measurements of long-wave infrared spectral radiance from water

Polarimetric measurements of the thermal infrared spectral radiance from water are reported and are compared with calculations from a recently published model over the spectral range of 600-1600 cm(-1) (6.25-16.67-mum wavelength). In this spectral range, warm water viewed under a dry, clear atmosphere appears vertically polarized by 6-12%. The measured spectral degree of polarization agrees with calculations within the measurement uncertainty (~0.5% polarization in spectral regions with high atmospheric transmittance and 1.5% polarization in spectral regions with low atmospheric transmittance). Uncertainty also arises from temporal changes in water and air temperatures between measurements at orthogonal polarization states, indicating the desirability of simultaneous measurements for both polarization states.

Summary of the practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults

This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed salts of amphetamine, and pemoline. They carry U.S. Food and Drug Administration indications for the treatment of attention-deficit hyperactivity disorder.

Summary of the practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions with special reference to seclusion and restraint

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients with regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint, and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

Chromosome 3p allele loss in early invasive breast cancer: detailed mapping and association with clinicopathological features

AIMS

Chromosome 3p allele loss is a frequent event in many common sporadic cancers including lung, breast, kidney, ovarian, and head and neck cancer. To analyse the extent and frequency of 3p allelic losses in T1N0 and T1N1 invasive sporadic breast cancer, 19 microsatellite markers spread along 3p were analysed in 40 such breast carcinomas with known clinicopathological parameters.

METHODS

Loss of heterozygosity analysis was carried out using 3p microsatellite markers that were non-randomly distributed and chosen to represent regions that show hemizygous and/or homozygous losses in lung cancer (lung cancer tumour suppressor gene region 1 ( LCTSGR1) at 3p21.3 and LCTSGR2 at 3p12), and regions demonstrating suppression of tumorigenicity in breast, kidney, lung, and ovarian cancer.

RESULTS

Allelic loss was seen at one or more loci in 22 of these clinically early stage sporadic breast tumours, but none had complete 3p allele loss. Several regions with non-overlapping deletions were defined, namely: (1) 18 tumours showed loss at 3p21-22, a physical distance of 12 Mb; (2) 11 tumours showed loss at 3p12 within a physical distance of 1 Mb, this region is contained within LCTSGR2; (3) six tumours showed loss at 3p25-24, including the von Hippel-Lindau (VHL) locus; (4) five tumours showed loss at 3p14.2, including the fragile histidine triad (FHIT) locus.

CONCLUSIONS

This is the largest study to date defining the extent and range of 3p allelic losses in early stage invasive breast cancer and the results indicate that region 3p21-22 containing LCTSGR1 and a region at 3p12 within LCTSGR2 are the most frequent sites of 3p allelic loss in these breast carcinomas. This suggests that tumour suppressor genes located in these regions may play important roles in the development of breast cancer. There was an association between increasing 3p allelic loss and increasing tumour grade and loss of progesterone (p = 0.0098) and oestrogen (p = 0.0472) receptor expression, indicating a link between 3p allelic loss and the regulation of differentiation.

A comparison of Hispanic and African-American sexually abused girls and their families

OBJECTIVE

To study the differential effects of sexual abuse on Hispanic (HN) and African-American (AA) girls.

METHOD

Sexually abused girls and their caretakers (N = 159), of which 52% (n = 82) were AA (mean age 9.8 years, SD = 3.4, R = 6-17) and 48% (n = 77) were HN (mean age 10.1 years, SD = 3.8, R = 6-18), were included in the study. The mother/caretaker was administered a demographic form, the Achenbach's Child Behavior Checklist (CBCL), and the Family Assessment Measure (FAM-P). The child completed the FAM-C and the Trauma Symptom Checklist for Children (TSCC). The clinician completed the Parental Reaction to Incest Disclosure Scale (PRIDS).

RESULTS

HN girls were found to have a greater number of sexually abusive episodes and waited longer to disclose their abuse while AA girls were more likely to have experienced vaginal penetration. The perpetrators of HN girls were older and more likely to be fathers or stepfathers. The mothers/ caretakers of HN girls perceived their children as having significantly more aggressive behavior, anxiety/depression, somatic complaints, internalizing and externalizing behaviors, and had a higher total score on the CBCL than did AA girls. The HN girls were more likely to see their family as dysfunctional with confusion regarding family values and rules. HN mothers/caretakers perceived their families as more conflicted regarding adaptability and family controls.

CONCLUSIONS

HN girls experienced more emotional and behavioral problems, and both HN girls and their mothers/caretakers perceived their families as more disturbed and dysfunctional.

Scanning infrared radiometer for measuring the air-sea temperature difference

We describe a vertically scanning infrared radiometer for measuring the air-sea temperature difference without disturbing the water skin layer. The radiometer operates with a single wavelength channel that is 1.1 mum wide, centered on 14.2 mum, on the short-wavelength edge of a CO(2) atmospheric absorption band. The resulting high atmospheric absorption enables calibration of the horizontal-viewing signal with an in situ air-temperature sensor. The signal at all other scan angles is measured relative to that at the horizontal, providing a differential air-sea temperature measurement that is nearly independent of calibration offsets that can be a problem with independent air- and water-temperature sensors. We show data measured on a ship in the Tropical Western Pacific Ocean during July 1999, which exhibit important discrepancies from in situ data using bulk air-and water-temperature sensors. These discrepancies illustrate important differences between bulk versus skin water temperature.

MR imaging and histologic features of capillary telangiectasia of the basal ganglia

Capillary telangiectasias are being recognized with increasing frequency on MR imaging studies. Most are located in the brain stem and show slightly increased signal intensity on T2-weighted images, low signal intensity on T2*-weighted images (reflecting the presence of deoxyhemoglobin), and contrast enhancement. These findings are considered fairly typical for capillary telangiectasia, and pathologic correlation is not generally pursued. We present a case of a proven capillary telangiectasia in the basal ganglia. The imaging features of the lesion were identical to those described for capillary telangiectasias in the brain stem.

Methylation associated inactivation of RASSF1A from region 3p21.3 in lung, breast and ovarian tumours

Previously we analysed overlapping homozygous deletions in lung and breast tumours/tumour lines and defined a small region of 120 kb (part of LCTSGR1) at 3p21.3 that contained putative lung and breast cancer tumour suppressor gene(s) (TSG). Eight genes including RASSF1 were isolated from the minimal region. However, extensive mutation analysis in lung tumours and tumour lines revealed only rare inactivating mutations. Recently, de novo methylation at a CpG island associated with isoform A of RASSF1 (RASSF1A) was reported in lung tumours and tumour lines. To investigate RASSF1A as a candidate TSG for various cancers, we investigated: (a) RASSF1A methylation status in a large series of primary tumour and tumour lines; (b) chromosome 3p allele loss in lung tumours and (c) RASSF1 mutation analysis in breast tumours. RASSF1A promoter region CpG island methylation was detected in 72% of SCLC, 34% of NSCLC, 9% of breast, 10% of ovarian and 0% of primary cervical tumours and in 72% SCLC, 36% NSCLC, 80% of breast and 40% of ovarian tumour lines. In view of the lower frequency of RASSF1 methylation in primary breast cancers we proceeded to RASSF1 mutation analysis in 40 breast cancers. No mutations were detected, but six single nucleotide polymorphisms were identified. Twenty of 26 SCLC tumours with 3p21.3 allelic loss had RASSF1A methylation, while only six out of 22 NSCLC with 3p21.3 allele loss had RASSF1A methylation (P=0.0012), one out of five ovarian and none out of six cervical tumours with 3p21.3 loss had RASSF1A methylation. These results suggest that (a) RASSF1A inactivation by two hits (methylation and loss) is a critical step in SCLC tumourigenesis and (b) RASSF1A inactivation is of lesser importance in NSCLC, breast, ovarian and cervical cancers in which other genes within LCTSGR1 are likely to be implicated.

Lipids and atherosclerosis: clinical management of hypercholesterolaemia

Hypercholesterolaemia is a major risk factor for the development of atherosclerosis which, in turn, underlies most ischaemic heart disease (IHD). This review deals briefly with the pathophysiology of lipids in humans and follows with a discussion of current lipid-lowering therapies. In those patients with a history of myocardial infarction (MI) or unstable angina, appropriate lipid-lowering therapy has been convincingly shown to reduce not only cardiac events but also overall mortality. The advent of the HMG CoA reductase inhibitors in the late 1980s has had a revolutionary impact in the clinical management of hypercholesterolaemia, not only because of their efficacy but especially because they are well-tolerated. The use of other treatments such as the fibrates and bile acid resins are also discussed. Given the successful use of the statins, it is felt that an emergence of a different class of LDL-cholesterol lowering compound is unlikely in the near future and rather that compounds which can increase HDL-cholesterol while lowering LDL will be of greater impact. There may also be a shifting trend towards such naturally occurring compounds as plant stanols and phytoestrogens.

Diurnal variation in endothelium-dependent vasodilatation is not apparent in coronary artery disease

BACKGROUND

Acute coronary syndromes present with an increased incidence from 6:00 AM to 12:00 noon. Whether endothelial function follows a diurnal rhythm and whether this rhythm is impaired in coronary artery disease (CAD) has not previously been studied.

METHODS AND RESULTS

Diurnal variation in endothelium-dependent vasodilatation was examined in 10 CAD patients and 10 control subjects. Forearm blood flow responses to acetylcholine, sodium nitroprusside, and N(G)-monomethyl-L-arginine were determined by plethysmography at 8:00 AM, 2:00 PM, and 8:00 PM. Heart rate, blood pressure, plasma cortisol, and inflammatory markers were also determined. Heart rate and the low-frequency component of heart rate variability were greatest in the morning in control subjects, suggesting a diurnal variation in sympathetic activity. Basal forearm blood flows were significantly reduced in control subjects at 8:00 PM compared with 8:00 AM and 2:00 PM (1.2+/-0.2 versus 2.1+/-0.2 [8:00 AM] and 2.1+/-0.3 [2:00 PM] mL. 100 mL(-1). min(-1); P<0.05) but unchanged in the CAD group. Acetylcholine (37 microgram/min) responses were greater at 8:00 AM than at 8:00 PM in control subjects (12.5+/-3.7 versus 19.6+/-2.9 mL. 100 mL(-1). min(-1), respectively; P<0.05), but these responses were not time dependent in the CAD group. Responses to sodium nitroprusside were similar at all time points and between those with and without CAD.

CONCLUSIONS

Thus, normal volunteers have a diurnal variation in their endothelium-dependent vasodilatation that may counteract other, potentially adverse, diurnal variations in hemodynamic and other parameters. In contrast, CAD patients who had presented with acute coronary syndromes showed a loss of this protective mechanism.

Child on child sexual abuse: psychological perspectives

OBJECTIVE

This study describes the emotional and behavioral responses of children who have been sexually victimized by juveniles (CC) 17 years of age and younger compared to child victims of adults (CA) 18 years of age and older.

METHOD

A total sample of N = 194 children and adolescents participated in the study, with 26% (n = 51) comprising CC and 74% (n = 143) encompassing CA. The mother/caretaker was administered a demographic form, Achenbach's Child Behavior Checklist (CBCL), and the Family Assessment Measure (FAM-P). The child was given the Family Assessment Measure (FAM-C) and the Trauma Symptom Checklist for Children (TSCC). The clinician completed the Parental Reaction to Incest Disclosure Scale (PRIDS).

RESULTS

No differences were found between the two groups for the type of sexual abuse, penetration, or the use of force. CC were younger and more likely to be males who were abused in a school setting, home, or a relative's home by a sibling or a non-related male. CC endorsed clinically significant sexual preoccupations and manifested borderline clinically significant symptomatology.

CONCLUSIONS

Children victimized by other children manifested elevated levels of emotional and behavioral problems and were not significantly different from those who had been sexually abused by adults.

Differential effects of cyclosporin and tacrolimus on the expression of fibrosis-associated genes in isolated glomeruli from renal transplants

BACKGROUND

Chronic allograft nephropathy is characterized by an excessive accumulation of extracellular matrix proteins leading to glomerular and interstitial fibrosis. The aim of this study was to determine the effects of two different immunosuppressive agents (cyclosporin and tacrolimus) on the expression of the genes controlling extracellular matrix deposition in renal transplant glomeruli.

METHODS

Fifty-one renal transplant recipients were randomized to receive immunosuppression with either microemulsion cyclosporin or tacrolimus. Isolated glomeruli were plucked from protocol transplant biopsies performed 1 week, 3 months and 6 months after transplantation. Expression of the genes for collagen IValpha2, collagen III, matrix metalloproteinase 2, tissue inhibitor of metalloproteinases (TIMP) 1 and TIMP-2, tenascin and transforming growth factor (TGF) beta1 was studied by quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

The expression of messenger RNA (mRNA) for collagen III and TIMP-1 was significantly higher in patients receiving cyclosporin therapy than in those having tacrolimus (P < 0.01); this finding was accounted for by differences in the biopsy material at 1 week. A significant difference in collagen III, TIMP-1 and TIMP-2 mRNA expression was also detected between patients depending on the source of renal donor (cadaveric or living). There were no significant differences in the level of glomerular TGF-beta1.

CONCLUSION

The data provide new in vivo evidence that tacrolimus may exert a less fibrogenic influence on transplant glomeruli than cyclosporin.

Expression of oestrogen receptor alpha variants in non-malignant breast and early invasive breast carcinomas

Oestrogen receptor (ER) alpha variants have been described in normal breast and breast carcinomas, but their presence in a range of benign conditions and in small early invasive breast carcinomas has not been considered. Cryostat tissue sections from 19 normal and proliferative breast lesions and 44 carcinomas 15 mm and less in size detected by mammographic screening were screened for ERalpha splice variants using reverse transcriptase-nested PCR. The carcinomas were assessed for mutation by single-stranded conformational polymorphism analysis and variant forms/band shifts were sequenced. ERalpha was detected in all 19 non-malignant cases and exon 7-deleted variants were found in 16 of them. Three cases showed weak expression of exon 5, and two of exon 3 variants. There was no relationship between the presence of variants and the extent of proliferative change, ER status or age. ERalpha mRNA was not detected in two carcinomas; exon 3 deletions were found in four (9. 5%) of the other carcinomas, exon 5 in two (4.8%), and exon 7 in 11 (26.2%), with two variants in four carcinomas and a total of 29.5% of all cases having detectable variants. Two point mutations were found in one, which was a tubular carcinoma. Variant forms were identified in carcinomas of all sizes (bar<10 mm) but were more frequent in those of 15 mm. There was no relationship with type, grade or receptor status. The main difference between non-malignant breast and early invasive cancers related to exons 3 and 5. The findings suggest that ERalpha variants are not involved in breast cancer development but occur with tumour progression and may be a consequence rather than a cause.

Inactive matrix metalloproteinase 2 is a normal constituent of human glomerular basement membrane. An immuno-electron microscopic study

Remodelling of the extracellular matrix requires tight control not only of matrix synthesis, but also of matrix degradation. Control of matrix degradation is achieved mainly through the matrix metalloproteinase (MMP) enzymes. In the glomerulus, MMP-2 and MMP-9 are believed to be particularly important, as they have activity against type IV collagen. This study has demonstrated by immuno-electron microscopy that most of the immunoreactivity for MMP-2 in the normal glomerulus is located within the glomerular basement membranes and mesangial matrix. mRNA for MMP-2 is also detectable in normal glomeruli, but the other main gelatinase, MMP-9, could not be localized by immuno-electron microscopy. In the normal glomerulus, it seemed likely that MMP-2 is present in an inactive form. To confirm this, in situ zymography was carried out using frozen sections of normal kidney. Baseline activity of normal kidney was relatively weak, but this was dramatically increased by chemical activation of metalloproteinases. The results imply that MMP-2, in an inactive form, is a normal constituent of the extracellular matrix and glomerular basement membranes. Activation would presumably render the matrix 'self-degrading'; membrane-bound MMPs (MT-MMPs) seem particularly likely to be involved in leukocyte penetration of basement membranes in inflammation.

Cytomorphologic features of Merkel cell carcinoma in fine needle aspiration biopsies. A study of two atypical cases

OBJECTIVE

To report atypical cytomorphologic features in fine needle aspiration biopsies (FNABs) from two cases of Merkel cell carcinoma (MCC), a primary neuroendocrine neoplasm of skin.

STUDY DESIGN

Retrospective review of FNABs with histologic correlation from six patients with MCC and a report of findings from two whose smears showed atypical features.

RESULTS

Typically the aspirates produce highly cellular smears of loosely clustered and individual, relatively monomorphic, small tumor cells with round to oval, regularly contoured nuclei. In two of our cases, the tumor cell nuclei exhibited a spectrum of pleomorphism ranging from moderately complex nuclear membranes with cleaves, indentations and protrusions in one case to large, markedly bizarre, convoluted nuclei and multinucleate tumor cells in the extreme case. Both cases were primary neoplasms, and the diagnosis was based on clinical, histologic and immunohistochemical data. Additionally, electron microscopy was performed on the tumor with bizarre nuclei and demonstrated rare, dense core neurosecretory granules and paranuclear bundles of intermediate filaments.

Microsatellite alterations plasma DNA of primary breast cancer patients

The aim of this study was to analyze plasma DNA from primary and metastatic breast cancer cases for tumor-specific alterations and to compare these findings with immunocytochemistry and estimation of cytokeratin 19 (CK19) mRNA for detection of micrometastases. DNA was extracted from plasma, lymphocytes, and microdissected tumor tissue sections obtained from 71 patients with breast cancer and 9 controls. DNA samples were analyzed for loss of heterozygosity (LOH) and/or microsatellite instability (MI) by PCR with two polymorphic markers (DM-1 and D16S400). Reverse transcription-quantitative PCR (QPCR) and immunocytochemistry were used for detection of CK19 mRNA and protein. Breast cancer plasma DNA displayed frequent LOH (31.3%) and MI (11.6%) supported by the same alteration in microdissected tumor DNA. Most notably, 10 of the 39 patients with primary breast cancer showed LOH (n = 6) or MI (n = 4). We compared plasma tumor DNA, plasma and bone marrow QPCR, and blood and bone marrow immunocytochemistry in 32 of the patients with primary cancer. Of these, only one patient had immunocytochemically detectable carcinoma cells in the blood, and three showed abnormally high levels of plasma CK19 mRNA. All four of these patients had plasma DNA alterations. We then compared bone marrow findings: of the 10 primary breast cancers that showed LOH or MI, 6 had elevated CK19 mRNA and 5 had immunocytochemically positive cells. Tumor DNA is readily detectable in plasma of primary and metastatic breast cancer patients, and plasma DNA alterations (LOH and MI) reflect those seen in the tumor. The application of microsatellite analyses to plasma DNA may be useful in assessing tumor burden in breast cancer patients, particularly when combined with QPCR, and is preferable for patients with breast cancer, for whom sequential bone marrow aspiration is undesirable.

Children, adolescents and trauma

This paper presents an overview of the psychological effects of trauma on children and adolescents with specific attention to the epidemiology of traumatic experiences, risk factors, developmental effects, the types of traumatic experiences albeit a single event trauma or a chronic process trauma, the spectrum of clinical presentations, psychiatric and psychological comorbidities as well as assessment and therapeutic principles. In addition to the child's psychological response to the traumatic stressor communities are often devastated by natural or man made disasters. The interactions between the child's response with the family and community response as well as community interventions are discussed.

Narcissism as a motivational structure: the problem of personal significance

An understanding of individual life is contingent on understanding not only man's traditional motivations but also the individual strategy for resolving the problem of personal insignificance. Man's sense of personal insignificance comes from two primary experiences: (a) the developmental experience with its increasing awareness of separation and loss, transience, and the sense of lost felt perfectibility; and (b) the increasing cognitive awareness of the immutable laws of biology and the limitations of the self and others in which idealization gives way to painful reality. Each individual seeks narcissistic reparation through the elaboration of a personal narrative or myth, a story, which gives one's life a feeling of personal significance, meaning, and purpose. What is relevant is not the presence or absence of a myth or personal narrative but within which myth one chooses to live one's life. Myths are not explanations rooted in scientific evidence but rather are belief systems lived as if they were truths. Myths provide the individual with a personal sense of identity, and they confirm and affirm memberships in a group or community, and provide guidelines and an idealized set of behaviors within which to operate. Lastly, they may endorse an explanation for the mysterious universe. Three motivational strategies in which the aim is to create a personal myth or personal narrative that ensures a sense of personal significance are described in this article: (a) transcendental or spiritual myths, (b) group or interpersonal myths, and (c) humanistic or personal myths.

Practice parameters for the assessment and treatment of children and adolescents who are sexually abusive of others. American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues

The assessment and treatment of children and adolescents with sexually abusive behavior requires an understanding of normal sexual development. A multiplicity of biological and psychosocial factors determines the child's sexual development, gender role, sexual orientation, patterns of sexual arousal, sexual cognitions, sexual socialization, and the integration of sexual and aggressive patterns of behavior. The individual's sexuality evolves in concert and as a result of interaction with family, ethnic, social, and cultural influences. These parameters summarize what we know about the epidemiology and phenomenology of sexually abusive youths and provide guidelines for the assessment and the selection of treatment interventions for these youths. Essential considerations in the assessment and treatment of sexually abusive youths, as well as the different categories of sexually abusive youths which should be recognized and which influence treatment decisions, are presented. The spectrum of currently available psychosocial and biological treatments will be summarized.

Febrile response after knee and hip arthroplasty

Documentation of the normal fever response after total knee and hip replacement is important to avoid an unnecessary workup for sepsis, and to provide justification for early discharge (dictated by the current medical reimbursement climate) despite persistent postoperative fever. One hundred patients who underwent total knee arthroplasty and 100 patients who underwent total hip arthroplasty were reviewed, several of whom had extensive sepsis workups for evaluation of postoperative fever. No patient in this series had a documented joint infection. All patients were treated with warfarin for deep vein thombrosis prophylaxis. All patients used incentive spirometry and were started on ambulation training on postoperative Day 1. All were given antibiotic prophylaxis for 48 hours. The maximum daily postoperative temperature occurred in most patients on postoperative Day 1 and gradually leveled off toward normal by postoperative Day 5. Only one patient had a maximum temperature on postoperative Day 4 that was greater than that on postoperative Day 3. Patients undergoing revision procedures tended to have a more pronounced febrile response, but the differences were not statistically significant. No significant differences were seen between patients who had epidural anesthesia and patients who had general anesthesia. Seventeen patients had postoperative chest radiographs for evaluation of fever. None had significant atelectasis. The presence of a positive urine culture had no effect on the fever response, with most positive results being identified after the fever had returned toward normal. Postoperative fever after total joint arthroplasty is a normal inflammatory response. A workup for sepsis is not indicated in the perioperative period unless corroborating signs or symptoms are present. Early discharge is appropriate if the febrile response is decreasing progressively.

Degree of linear polarization in spectral radiances from water-viewing infrared radiometers

Infrared radiances from water become partially polarized at oblique viewing angles through both emission and reflection. I describe computer simulations that show how the state of polarization for water varies with environmental conditions over a wavelength range of 3-15 microm with 0.05-microm resolution. Polarization at wavelengths longer than approximately 4 microm generally is negative (p, or vertical) and increases with incidence angle up to approximately 75 degrees, beyond which the horizontally polarized reflected atmospheric radiance begins to dominate the surface emission. The highest p polarization (approximately 4-10%) is found in the atmospheric window regions of approximately 4-5 and 8-14 microm. In the 3-5-microm spectral band, especially between 3 and 4 microm, reflected atmospheric radiance usually is greater than surface emission, resulting in a net s polarization (horizontal). The results of these simulations agree well with broadband measurements of the degree of polarization for a water surface viewed at nadir angles of 0-75 degrees.

Glomerular expression of nephrin is decreased in acquired human nephrotic syndrome

BACKGROUND

Nephrin recently has been identified as a putative adhesion molecule, expressed in the glomerulus, in which mutations cause congenital nephrotic syndrome of Finnish type. We sought to determine whether expression of nephrin is altered in human glomeruli in patients with acquired nephrotic syndrome.

METHODS

We performed PCR amplification of nephrin cDNA, using cDNA previously prepared from single human glomeruli plucked fresh from the surface of human renal biopsies. We had available four cases of nephrotic syndrome (one membranous, three minimal change) and six normal controls. PCR product quantitation was by gel densitometry, confirmed by enzyme-linked immunosorbent assay using a specific oligonucleotide probe. Results were corrected for reaction efficiency and glomerular cellularity by expression as a ratio to levels of the 'housekeeping gene' glyceraldehyde phosphate dehydrogenase.

RESULTS

Glomerular levels ofnephrin mRNA are significantly decreased in cases of minimal change nephrotic syndrome. An apparent reduction was also seen in the single case of membranous nephropathy which was available for study.

CONCLUSIONS

Abnormalities of nephrin expression appear to be associated with acquired as well as congenital causes of human nephrotic syndrome.

Comparison of monthly intramuscular injections of Sandostatin LAR with multiple subcutaneous injections of octreotide in the treatment of acromegaly; effects on growth hormone and other markers of growth hormone secretion

OBJECTIVE

To compare the effects of monthly intra-muscular injections of a long acting preparation of octreotide, Sandostatin LAR, with multiple daily subcutaneous injections of octreotide and to study the interrelationships between mean 24 h growth hormone profile, serum total and free IGF-1 levels, 24 h urinary growth hormone levels and serum IGFBP-3.

DESIGN

Patients were assessed by 24 h GH profile off octreotide or any other GH modifying drug therapy; on subcutaneous octreotide (200-600 micrograms daily in divided doses for six weeks); and 28 days after the second of two injections of Sandostatin LAR (20 mg by intra-muscular injection) administered 28 days apart. Serum total and free IGF-1, serum IGFBP-3 and 24 h urinary GH were also measured on each occasion.

RESULTS

Sandostatin LAR was well tolerated. None of the patients reported any adverse effect and all completed the study uneventfully. Mean GH off treatment was 10.1 +/- 3.0 micrograms/l falling equally significantly (P < 0.05) during therapy with subcutaneous octreotide to 3.0 +/- 0.7 micrograms/l and Sandostatin LAR to 2.8 +/- 0.7 micrograms/l. Fasting 0900 h GH was significantly reduced (P < 0.05) on Sandostatin LAR (3.0 +/- 0.7 micrograms/l) compared with subcutaneous octreotide (5.1 +/- 1.2 micrograms/l). Mean total IGF-1 off treatment was 658.6 +/- 56.1 micrograms/l and was reduced to a comparable extent with subcutaneous octreotide and Sandostatin LAR (466.0 +/- 59.7 and 448.6 +/- 59.5 micrograms/l respectively; both P < 0.05). Free IGF-1 off treatment was 3.1 +/- 0.6 micrograms/l and was reduced equally by subcutaneous octreotide and Sandostatin LAR (1.2 +/- 0.2 and 1.2 +/- 0.2 micrograms/l; both P < 0.05). IGFBP-3 was reduced to a greater extent during Sandostatin LAR than during subcutaneous octreotide (4518.2 +/- 247.3 vs 5132.8 +/- 280.7 micrograms/l; P < 0.05). Twenty-four hour urinary GH excretion was reduced to a comparable extent with both therapies. Highly significant positive correlations were found between mean 24 h GH levels and free IGF-1 (r = 0.66, P < 0.0001) and 24 h urinary GH excretion (r = 0.94, P < 0.0001). The relationships between mean 24 h GH levels and total IGF-1 and IGFBP-3 although significant showed less powerful correlations.

CONCLUSIONS

These results suggest that Sandostatin LAR is well tolerated and as effective as subcutaneous octreotide. In addition, urinary growth hormone and serum free IGF-1 may prove valuable for outpatient follow-up of acromegalic patients, as both correlate well with mean 24 h serum growth hormone levels.

Microsatellite instability in ductal carcinoma in situ of the breast

Microsatellite instability (MI+) is associated with defects in mismatch repair, resulting in a 'mutator' phenotype and the development and progression of cancer. MI+ has been documented in invasive breast carcinomas. This study was undertaken to determine whether MI+ is found in the early non-invasive form of breast cancer, ductal carcinoma in situ (DCIS). We examined microdissected ducts from 23 cases of DCIS with 11 markers comprising mono-, di-, and trinucleotide repeats from six chromosomal regions. Five tumours (22 per cent) displayed MI+ at two or more loci, in all ducts examined. A further seven (30 per cent) tumours showed alterations at a single locus (the DM-1 trinucleotide), and for two of these, heterogeneity between ducts was observed. Alterations at microsatellite repeat motifs in the coding regions of four cancer-associated genes (TGF beta RII, IGFIIR, BAX, and E2F-4) were not observed. Immunohistochemistry revealed that there was no loss of reactivity for the mismatch repair proteins, MLH1, MSH2, and PMS2, in the DCIS cases. In general, MI+ tumours and those with alterations at the DM-1 microsatellite were predominantly of higher nuclear grade and expressing c-erbB-2, suggesting that aberrations in DNA repair functions may lead to the acquisition of a more aggressive phenotype in breast cancer.

Reproducibility in the quantification of mRNA levels by RT-PCR-ELISA and RT competitive-PCR-ELISA

The use of reverse transcription (RT) PCR for relative quantitation of gene transcripts relies on the reproducibility of the individual RT, PCR and product measurement steps. Semi-competitive RT-PCR (RT-cPCR) uses an internal competitor template in the PCR step to improve quantitation. We have surveyed the reproducibility of RT, PCR, RT-cPCR and measurement, amplifying the glyceraldehyde-3-phosphate dehydrogenase "housekeeping" gene from isolated renal glomeruli. We used an enzyme-linked immunosorbent assay (ELISA) to quantify PCR products. We also report our PCR-based method for constructing a competitor DNA identifiable independently of the native product. Our results show that the entire RT-PCR and ELISA process had a standard deviation (SD) of less than 10% (n = 10). This compared to an SD of less than 13% (n = 10) in PCR and ELISA. The SD for ELISA alone was less than 11% (n = 10). RT-cPCR quantitation gave an SD of approximately 15% (n = 10). These results support the use of standard RT-PCR for the relative quantitation of mRNA. RT-cPCR is also suited to relative quantitation, but it is also independent of the amplification saturation curve and permits the identification of differences in cellularity between samples.

Numerical chromosomal aberrations in Hodgkin's disease detected by in situ hybridisation on routine paraffin sections

AIMS

To visualise directly numerical chromosomal aberrations and polyploidy in both Hodgkin and Reed Sternberg (HRS) cells and background cells from cases of Hodgkin's disease using in situ hybridisation.

METHODS

Non-isotopic DNA in situ hybridisation was applied to interphase cell nuclei of Hodgkin's disease within routine paraffin embedded tissue sections. Two a satellite DNA probes, specific for chromosomes 3 and 12, were used to evaluate the feasibility of this approach. Double labelling with immunocytochemical detection of the CD30 antigen was used to identify HRS cells. Cytogenetic normal diploid and triploid placental tissue served as controls.

RESULTS

The eight cases of Hodgkin's disease investigated displayed frequent polysomy, while the majority of background cells showed disomy signals.

CONCLUSIONS

Numerical chromosomal aberrations were detected in HRS cells from eight cases of Hodgkin's disease by in situ hybridisation. These data show that in Hodgkin's disease HRS cells frequently display polyploidy compared with background cells and are, therefore, probably the only neoplastic component in this disease. Correlations between polysomy and tumour type or grade could not be made from these data owing to the limited number of cases examined and to problems with interpreting data from truncated nuclei.

Scanning-laser glint measurements of sea-surface slope statistics

A scanning-laser glint meter designed for field measurements of sea-surface slope statistics is described. A narrow laser beam is scanned in a line, and specular reflections (glints) are counted in bins according to their slope angle. From normalized glint histograms, moments to the fourth order are calculated, and slope probability density functions are approximated with a Gram-Charlier expansion. Field measurements with this instrument show good agreement with previous results when the stability (essentially air-sea temperature difference) is near neutral (zero). Under conditions of negative stability (warm ocean), both the mean-square slope and the probability density function kurtosis increase.

Molecular pathology of breast cancer and its application to clinical management

Breast cancer is a major cause of morbidity and mortality in women in many parts of the world. Breast carcinomas are heterogenous in their biological and clinical behaviour and a greater understanding of how they develop and progress could lead to more directed forms of screening and therapy. It is important to determine the molecular mechanisms underlying the natural history of breast cancer. Developments in the techniques for molecular analysis have meant that they can now be applied to a large range of clinical material such as cytological preparations and fixed, embedded material, so increasing the potential for relating any molecular alterations to clinical behaviour and response to therapy. In this review we consider recent developments in three areas of importance to breast cancer; genetic analysis-oncogenes, tumour suppressor genes, loss of heterozygosity, microsatellite instability, familial breast cancer; steroid receptors, oestrogen regulated proteins, epidermal growth factor receptor, growth factors particularly transforming growth factor beta; and cell adhesion, invasion and metastasis-E-cadherin, integrins, proteases. These are discussed in relation to potential for screening, prognosis and treatment.