High-level expression of recombinant human fibrinogen in the milk of transgenic mice

Fibrinogen is a complex plasma protein composed of two each of three different polypeptide chains. We have targeted expression of r-human fibrinogen to the mammary gland of transgenic mice. Three expression cassettes, each containing the genomic sequence for one of the three human fibrinogen chains controlled by sheep whey protein beta-lactoglobulin promoter sequences, were coinjected into fertile mouse eggs. Southern blot analysis demonstrated that more than 80% of the transgenic founders contained all three fibrinogen genes. Reducing sodium dodecyl sulfate polyacrylamide gel electrophoresis of milk from the highest producing founder animal demonstrated the presence of human fibrinogen subunits at concentrations of 2000 micrograms/ml. In several animals with a balanced ratio of the individual fibrinogen subunits, up to 100% of the protein was incorporated into fully assembled fibrinogen hexamers. Incubation of the transgenic milk with thrombin and factor XIII resulted in a cross-linked fibrin clot, indicating that a major portion of the secreted fibrinogen was functional. These studies represent the first report of high-level biosynthesis and secretion of a functional, complex, hexameric protein in the milk of a transgenic animal.

Chronic cutaneous lupus erythematosus mimicking mycosis fungoides

Mycosis fungoides, which is characterized by a malignant infiltrate of T lymphocytes involving the epidermis, can be confused with other inflammatory skin diseases. We report the case of a patient with skin lesions containing an infiltrate of atypical lymphocytes with epidermotropism. This patient's condition was initially diagnosed as mycosis fungoides. Repeated biopsy samples had the histologic features of chronic cutaneous lupus erythematosus. The patient had a strongly positive antinuclear antibody response and the clinical lesions responded to hydroxychloroquine, however, and these findings led to an altered diagnosis. Other disorders that either clinically or histologically mimic mycosis fungoides are reviewed, and the diagnostic evaluation of patients in whom mycosis fungoides is suspected is summarized. Chronic cutaneous lupus erythematosus should be added to the list of diseases that can mimic mycosis fungoides.

Cetirizine and astemizole therapy for chronic idiopathic urticaria: a double-blind, placebo-controlled, comparative trial

BACKGROUND

Cetirizine and astemizole have been shown to be safe and effective in the treatment of patients with chronic idiopathic urticaria. Cetirizine brings about clinical benefit more rapidly.

OBJECTIVE

The purpose of this study was to compare the efficacy of single daily doses of cetirizine and astemizole in relieving the symptoms of chronic idiopathic urticaria, with particular emphasis on the commencement of action.

METHODS

Patients with chronic idiopathic urticaria were randomly assigned to relieve either 10 mg of cetirizine, 10 mg of astemizole, or placebo for 4 weeks in a multicenter double-blind trial. Patients rated symptom severity each night, and investigators rated symptoms weekly.

RESULTS

One hundred eighty-seven patients were enrolled in the trial; 180 were included in the safety analysis and 177 were included in at least one efficacy analysis. Both cetirizine and astemizole were significantly superior to placebo in relieving symptoms of chronic idiopathic urticaria. Both patients' and investigators' ratings indicated that cetirizine acted more rapidly. Both active treatments were well tolerated, and the incidence of somnolence did not differ statistically between cetirizine (14.5%) and astemizole (10.3%).

CONCLUSION

Both cetirizine and astemizole provide effective relief of the symptoms of chronic idiopathic urticaria with similar side-effect profiles. However, clinical benefit occurs significantly more rapidly with cetirizine.

Evidence that a low-fat diet reduces the occurrence of non-melanoma skin cancer

The effect of a low-fat diet on occurrence of non-melanoma skin cancer was examined in a 2-year dietary intervention trial. A total of 101 skin-cancer patients were randomized either to a control group that consumed, on average, 38% of caloric intake as fat, and in which no changes in dietary habits were introduced, or to a low-fat dietary-intervention group, in which patients were instructed to limit their calories from fat to 20% of total caloric intake. Patients were examined at 4-month intervals by dermatologists blinded to their dietary assignments. Nutrient analyses, conducted at each of the 4-month follow-up visits, indicated that the % calories of fat consumed in the intervention group had been reduced to 21% at 4 months and remained below this level throughout the 2-year period. There were no significant differences in total calories consumed, or in mean body weights, between the control and the intervention groups. Nor were there significant group differences in P/S ratios until month 24. Numbers of new skin cancers treated at each examination were analyzed in 8-month periods of the 2-year study. Comparisons of skin-cancer occurrences revealed no significant changes in the control group from baseline values. However, cancer occurrence in the low-fat intervention group declined after the first 8-month period and reached statistical significance by the last 8-month period. Patients in this group had significantly fewer cancers in the last 8-month period than did patients in the control group. In addition, there was a significant reduction in the number of patients developing skin cancer in the last 8-month period, as compared with the first 8-month period, within the low-fat intervention group. There were no significant changes in the control group. These data indicate that a low-fat diet can significantly reduce occurrence of a highly prevalent form of cancer.

Herpesvirus-like DNA sequences in non-Kaposi's sarcoma skin lesions of transplant patients

Herpesvirus-like DNA sequences (KSHV) have been reported to be associated with various forms of Kaposi's sarcoma (KS). To determine if KSHV was associated with other proliferative skin lesions from non-AIDS immunocompromised patients, 33 skin lesions (basal cell carcinomas, squamous cell carcinomas, actinic keratoses, verruca vulgaris, atypical squamous proliferations, and seborrhoeic keratosis) from 4 organ-transplant patients receiving immunosuppressive therapy were tested for KSHV by PCR. KSHV sequences were detected in 82% of these skin lesions. Our results suggest that KSHV is associated with lesions other than KS in non-AIDS immunocompromised patients, and may also be involved in the pathogenesis of the various forms of proliferative skin lesions from organ-transplant patients.

Noninvasive investigation of infantile hepatic hemangioma: a case study

A preterm infant presented with high-output cardiac failure. Color Doppler imaging of the liver revealed a large hepatic hemangioma. Pulsed-wave Doppler of the proximal aorta was used to monitor noninvasively the reduction in flow through the arteriovenous malformation in response to steroid therapy. The hemangioma resolved completely by 7 weeks of age.

Basal cell carcinoma on the scalp of an Indian patient

BACKGROUND

Basal cell carcinoma (BCC) is the most common malignancy in whites, but it rarely occurs in dark persons.

OBJECTIVE

To report a BCC on the hairy scalp of an Asian Indian female with no obvious risk factors except previous scalp trauma.

METHODS

We review the English literature concerning BCC in Indians, and compare this with data for North American blacks and whites; and reports of BCC arising in areas of prior trauma.

RESULTS/CONCLUSION

Skin cancer accounts for 1-2% of malignancies in blacks and Indians, compared with one-third of neoplasms in whites. BCC comprises 75% of skin cancers in whites, but squamous cell carcinoma represents 60-65% of skin cancers in blacks and Indians. Although most BCCs occur in sun-exposed areas in whites, blacks, and Indians, a significant percentage also develop in photoprotected areas. Trauma may be a significant risk factor for BCC, either with actinic damage or alone, as in our case.

Skin cancer prevention and early detection intentions and behavior

This longitudinal study examined predictors of (1) skin cancer prevention and early detection intentions and (2) compliance with recommendation for medical follow-up for suspicious skin lesions. Subjects were 324 hospital employees who were at increased risk for skin cancer and who participated in a worksite skin cancer screening program. Based on behavioral self-regulation theory and the Health Belief Model, multivariate analyses showed that optimism, perceived risk, reasons for doing skin self-examination (SSE), and SSE frequency prior to screening were the best predictors of intentions to engage in future health promotion behaviors (i.e., monthly SSE, regular sunscreen use, and participation in a skin cancer screening program the following year). Although our results also showed that optimism, reasons for doing SSE, and SSE frequency were the best predictors of compliance with medical follow-up, these three variables accounted for only a small amount of the variance in compliance with recommended follow-up care.

Computer analysis of the early diastolic notch in Doppler sonograms of the uterine arteries

This article describes a set of processing and analysis techniques for automated identification and quantification of the early diastolic notch (EDN), a feature of Doppler sonograms from the uterine arteries which has been associated with adverse pregnancy outcomes such as preeclampsia and intrauterine growth retardation. Examples covering different sonogram types are provided to illustrate the effectiveness and reproducibility of the processing/analysis tools. Also, a receiver-operating characteristic-based evaluation of the EDN quantification and pulsatility indexes is presented, which examines the ability to predict hypertension and/or intrauterine growth retardation, using a set of uterine Doppler sonograms from 92 patients acquired at 18 weeks of gestation. In summary, the ROC results confirm the link between the EDN and abnormal pregnancy outcomes, and suggest that EDN quantification has a higher diagnostic accuracy than the pulsatility index, which characterises the flow waveform in a global manner and therefore does not take explicitly into account the localised nature of the EDN. Quantification of the EDN at 18 weeks of gestation appears to best predict the most severely abnormal pregnancy outcomes.

Comparative study of calcipotriene (MC 903) ointment and fluocinonide ointment in the treatment of psoriasis

BACKGROUND

The topical vitamin D analogue calcipotriene has been reported to be an effective treatment for patients with psoriasis. Comparative studies with topical steroids are informative in judging this new therapy.

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of calcipotriene ointment 0.005% versus fluocinonide ointment 0.05% in the treatment of plaque psoriasis.

METHODS

This study was a randomized, double-blind, parallel-group, active-controlled trial in adults who had at least mild overall disease severity and plaque elevation of at least moderate severity. Treatments were applied twice daily for 6 weeks, and subjects were evaluated at weeks 0, 2, 4, and 6. Subjects were graded on a 9-point scale (0 to 8) for scaling, erythema, plaque elevation, and for overall disease severity. A physician's global assessment of improvement/worsening was performed at every visit.

RESULTS

A total of 114 subjects were enrolled at six study sites. Ninety-nine subjects completed the trial. Mean scores for signs of scaling and plaque elevation in calcipotriene-treated subjects were significantly lower by week 2 than in the fluocinonide-treated subjects. These scores continued to be significantly lower than fluocinonide through week 6 (p < 0.05). Mean scores for erythema in calcipotriene-treated subjects were significantly lower than those in fluocinonide-treated subjects at weeks 4 and 6 (p < 0.05). Both the physician's global assessment and overall disease severity showed statistically significant treatment differences in favor of calcipotriene at week 4 (p < 0.05). This superior efficacy continued through week 6. Treatment-related adverse events were observed in 12 calcipotriene-treated subjects and 5 fluocinonide-treated subjects; all were considered minor.

CONCLUSION

Calcipotriene was superior to fluocinonide in the treatment of plaque psoriasis.

Beau's lines and pyogenic granulomas following hand trauma

We report two cases of trauma-induced Beau's lines accompanied by pyogenic granulomas of the proximal nail folds of the affected fingers. The preceding trauma was not directly to the nail matrix but was more proximal, on the palm in one case and the arm in the other. The simultaneous occurrence of Beau's lines and pyogenic granulomas following trauma has not been reported previously in the literature.

Color Doppler imaging of the uteroplacental circulation in the middle trimester: observations on the development of a low-resistance circulation

We aimed to study the changes in the flow dynamics of the uteroplacental and umbilical circulations in the middle trimester of normal pregnancy, and establish normal ranges for indices of the Doppler flow velocity waveforms (FVWs) from both circulations at 14, 18 and 24 weeks. A longitudinal study was conducted with the use of color Doppler imaging to localize both uterine arteries and umbilical arteries and obtain FVWs from 106 healthy nulliparous women with a singleton pregnancy. Of these, 70 did not have a complicated pregnancy outcome, defined as hypertension, growth retardation, preterm delivery or perinatal death. We measured the resistance index (RI), pulsatility index (PI), systolic/diastolic (S/D) ratio and presence of early diastolic notching in both uterine arteries, and RI, PI and S/D in one umbilical artery. The results showed a fall in all measured indices of blood flow impedance in the uteroplacental and umbilical circulations and a marked reduction in the incidence of the early diastolic notch in the uterine artery FVWs during the mid-trimester. Our conclusion was that color Doppler imaging allows for the accurate localization of both uterine and umbilical arteries. Doppler FVWs then obtained confirm the development of the low-resistance uteroplacental and umbilical circulations in the mid-trimester. Diastolic notching is common at 14 weeks in normal pregnancy but uncommon at 24 weeks.

Effect of a low-fat diet on the incidence of actinic keratosis

BACKGROUND

Actinic keratoses are premalignant lesions and are a sensitive and important manifestation of sun-induced skin damage. Studies in animals have shown that dietary fat influences the incidence of sun-induced skin cancer, but the effect of diet on the incidence of actinic keratosis in humans is not known.

METHODS

We randomly assigned 76 patients with nonmelanoma skin cancer either to continue their usual diet (control group) or to eat a diet with 20 percent of total caloric intake as fat (dietary-intervention group). For 24 months, the patients were examined for the presence of new actinic keratoses by physicians unaware of their assigned diets.

RESULTS

At base line, the mean (+/- SD) percentage of caloric intake as fat was 40 +/- 4 percent in the control group and 39 +/- 3 percent in the dietary-intervention group. After 4 months of dietary therapy the percentage of calories as fat had decreased to 21 percent in the dietary-intervention group, and it remained below this level throughout the 24-month study period. The percentage of calories as fat in the control group did not fall below 36 percent at any time. The cumulative number of new actinic keratoses per patient from months 4 through 24 was 10 +/- 13 in the control group and 3 +/- 7 in the dietary-intervention group (P = 0.001).

CONCLUSIONS

In patients with a history of nonmelanoma skin cancer, a low-fat diet reduces the incidence of actinic keratosis.

Early detection of skin cancer: racial/ethnic differences in behaviors and attitudes

Data from 384 individuals participating in a worksite skin cancer screening program were used to assess racial/ethnic differences in attitudes toward and practice of prevention and early detection of skin cancer. Caucasians and Hispanics were more likely than African Americans to report having used a sunscreen during the past year. Caucasians performed skin self-examination more frequently than Hispanics, but African Americans did not differ in their frequency of skin self-examination from the other two groups. African Americans and Hispanics reported that they would be less likely than Caucasians to seek immediate follow-up care for suspicious skin lesions. Both similarities and differences were found in a variety of health belief variables across the three groups. These findings suggest a need for intensified efforts at primary and secondary prevention of skin cancer among African Americans.

Skin self-examination in a population at increased risk for skin cancer

This cross-sectional study examined predictors of skin self-examination (SSE) in a population at increased risk for skin cancer. Subjects were 384 hospital employees participating in a worksite skin cancer screening. Although 61% reported that they performed SSE at least once during the past year, only 20% reported monthly SSE. Only a minority of the subjects were knowledgeable about most of the recommended SSE steps. Based on behavioral self-regulation theory, multivariate analysis showed that a variety of psychological factors (including optimism, knowledge about SSE, perceived self-efficacy, and number of reasons for doing SSE) correlated positively with frequency of SSE. Demographic variables accounted for about 6% of the variance in frequency of SSE. Overall, the variables in this model accounted for about 25% of the variance.

Intralesional interferon-alpha and zidovudine in epidemic Kaposi's sarcoma

BACKGROUND

Kaposi's sarcoma (KS) is the most common neoplasm in patients with acquired immunodeficiency syndrome (AIDS). To date, no therapy has proved to be consistently effective.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of intralesional interferon-alpha in patients with epidemic KS who were taking zidovudine.

METHODS

Up to five lesions in each of 14 patients entered into the study were injected with 1 million U of interferon-alpha three times weekly for 6 weeks. Sterile water was used as a placebo control. The median zidovudine dose was 500 mg/day. The median CD4 count was 23/microliters.

RESULTS

Of 14 patients evaluated, 13 of 14 (93%) showed a clinical complete response (CR) or partial response (PR) to therapy. Of 54 lesions injected, 41 (76%) showed a CR and 5 (9%) showed a PR, which resulted in an overall response rate of 85%.

CONCLUSION

Intralesional interferon-alpha produced a high response rate in injected lesions of KS, but it failed to demonstrate superior efficacy over the placebo.

Pyoderma gangrenosum treated with hyperbaric oxygen therapy

The management of pyoderma gangrenosum often requires systemic drug therapy, such as corticosteroids, sulfones, or immunosuppressants, either alone or in combination. Inconsistent response to therapy is a source of frustration to both patient and physician. Several reports in the literature document the successful treatment of pyoderma gangrenosum with hyperbaric oxygen therapy. In our patient, a woman with severe rheumatoid arthritis and diabetes mellitus, hyperbaric oxygen therapy not only promoted healing of pyoderma gangrenosum but permitted reduction of systemic corticosteroids.

Evidence for percutaneous inoculation as the mode of transmission for chromoblastomycosis

The exact pathogenesis of chromoblastomycosis is unknown. Direct percutaneous inoculation, inhalation, and hematogenous dissemination have been implicated. We report a case of chromoblastomycosis that followed a well-defined episode of penetrating trauma. The causative organism, Fonsecaea pedrosi, was cultured from the patient's lesion and from the tree branch responsible for the trauma. This "natural" experiment supports the contention that one cause of chromoblastomycosis is traumatic cutaneous implantation of the fungus.

Suppressed natural killer cell activity in patients with chronic autoimmune thrombocytopenic purpura

Natural killer (NK) cell activity was studied in 17 patients with primary chronic idiopathic autoimmune thrombocytopenic purpura (ATP). Fifteen of 17 patients had a significantly reduced NK cytotoxicity against 51chromium labeled K562 target cells (mean LU20% = 18 +/- 20 in patients versus 65 +/- 25 in controls, P less than 0.001). NK activity was also significantly reduced in all of six patients with secondary ATP as compared with normal controls (LU20% 28 +/- 15, respectively, P less than 0.005). The NK activity in both patient groups correlated with the duration of therapy being received (r = 0.60, P less than 0.001). Immunophenotypic analysis of peripheral blood mononuclear cells from patients with ATP revealed that CD8- cells bearing CD57 (HNK-1, Leu 7) and CD3- cells bearing CD56 (Leu 19) were quantitatively within the normal range. These findings indicate that patients with ATP have a functional defect in NK cytolytic activity.

Ichthyosiform sarcoidosis: report of a case

Sarcoidosis is a systemic granulomatous disease of undetermined cause, with cutaneous manifestations occurring in up to 35 percent of patients. We report a case of the rare form of ichthyosiform sarcoidosis occurring in a young black woman.

Estimating left ventricular ejection fraction from two-dimensional echocardiograms: visual and computer-processed interpretations

Digital echocardiography makes computer-processed estimates of ejection fraction feasible for clinical use but increases physician reading time. The practicabilities were examined by three novice fellows and four experienced attendings. Ejection fraction was visually estimated from playback of videotape or cine-loop displays. Ejection fraction was also estimated from single tracings of endocardium, digitized and applied to biplane Simpson's rule, and expressed in whole units. Differences between fellows' and attendings' visual estimates were close to 0 +/- 6.4 median standard deviation. The 95% confidence intervals for reproducing visual and computer-processed ejection fractions ranged from 15% to 46% of mean ejection fraction; for comparing the two methods, from 7% to 36%. Intraobserver reading errors varied widely and with one observer, systematically, and were independent of experience, but dependent on the quality of signals. Computer-processed readings of ejection fraction should be reserved for images of reasonable quality and for confirming visually estimated ejection fractions between the lower limits of normal (45%-50%) to moderately severely depressed (25%-30%), when accuracy is clinically relevant or when a serial change is at the confidence limits of the reader and needs verification.

Urticaria: clinical efficacy of cetirizine in comparison with hydroxyzine and placebo

Chronic urticaria is a problem for both physician and patient. In an effort to avoid the risks associated with corticosteroid treatment, many first-generation H1-receptor antagonists have been tried and found to induce undesirable levels of sedation when given in amounts sufficient to control urticaria. Cetirizine, a pharmacologically active oxidized metabolite of hydroxyzine, was developed to provide selective H1-receptor inhibition without depression of the central nervous system. In a 4-week, multicenter, double-blind, placebo-controlled safety and efficacy study, cetirizine, in a once-a-day dose (5 to 20 mg), was equivalent in efficacy to hydroxyzine in divided doses (25 to 75 mg/day). The incidence of somnolence in the cetirizine group was not significantly different from that of the placebo group. However, in the hydroxyzine group, the incidence of somnolence was significantly higher than that in the placebo group (p = 0.001). The results of this study demonstrate that cetirizine has a greater safety margin over the older parent drug hydroxyzine.