Esophagocoloplasty in the management of postcorrosive strictures of the esophagus

BACKGROUND/AIMS

Esophageal replacement therapy has developed an increasing role in the management of severe esophageal strictures due to caustic ingestion. The aim of this study is to discuss methods of reconstruction and results of them in corrosive esophagitis at our Institute.

METHODOLOGY

Thirty-three patients underwent 34 esophagocoloplasties for benign strictures of the esophagus over a 17-year period. The left colon was used in 8 patients, the right colon in 3 patients, and the right colon with the terminal ileum in 23 patients.

RESULTS

Three patients died in the first postoperative month, and there was an overall mortality rate of 9%. The most severe complication was graft necrosis (2 patients). The remainder of the patients survived without any deleterious complications.

CONCLUSION

Esophageal replacement therapy using the right colon with the terminal ileum is superior to the modalities in terms of the continuity of peristalsis of the interposed bowel segment with an intact ileocecal valve, which decreases the hazard of regurgitation from the colon. It is also easier to perform an anastomosis between the ileum and the cervical esophagus from the point of view of surgical manipulation.

Neutrophil elastase promotes rapid exocytosis in human airway gland cells by producing cytosolic Ca2+ oscillations

The molecular and ionic mechanisms responsible for the regulation of mucus exocytosis in human airway gland cells remain poorly defined. To determine whether dynamic changes of intracellular free Ca2+ concentration [Ca2+]i can promote different exocytotic responses, we monitored dynamic changes in [Ca2+]i and secretory granule (SG) exocytosis in individual human tracheal submucosal serous gland (HTG) cells. These changes were in response to exposure of the cells to three different secretagogues associated with airway inflammation and disease: human neutrophil elastase (HNE), histamine, and ATP. Dynamic changes in [Ca2+]i from single cells were determined with Indo-1/AM using quantitative UV laser microspectrofluorometry. The rate of SG exocytosis was measured in single cells by fluorescence videomicroscopy of SG degranulation and by the ELISA method. Exposure of HTG cells to a low concentration of HNE (1.0 microM) caused a high rate of SG exocytosis (52% decrease in the initial quinacrine fluorescence) during the first 8-min stimulation period compared with that observed following exposure of the cells to 100 microM histamine (10% decrease) or 100 microM ATP (6% decrease). In contrast to a rapid and transient rise in [Ca2+]i induced by histamine (1.0-100 microM) and ATP (10-100 microM), HNE (0.01-1 microM) generated asynchronous oscillations in [Ca2+]i over the first 8-min period. Depletion of internal Ca2+ stores with thapsigargin (500 nM) induced a significant reduction (P < 0.01) in the observed increases in [Ca2+]i upon addition of each of the secretagogues, but did not greatly affect the SG exocytotic responses. Interestingly, the removal of extracellular Ca2+ (+5 mM EGTA) significantly reduced (P < 0.01) both the [Ca2+]i increases and the rate of SG exocytosis following exposure to the secretagogues. We also demonstrate that the influx of extracellular Ca2+ and [Ca2+]i oscillations rather than the absolute level of [Ca2+]i regulate the rapid onset and extent of exocytotic responses to HNE in airway gland cells. Taken together, these results provide strong evidence that [Ca2+]i is a critical intracellular messenger in the regulation of exocytosis process in human airway gland cells.

Imprinting of lyophilized alpha-chymotrypsin affects the reactivity of the active-site imidazole

Iodomethane reacted in vacuo with lyophilized alpha-chymotrypsin to give an inactive enzyme in which the active-site imidazole was dimethylated. However, alpha-chymotrypsin co-lyophilized with the competitive inhibitors, N-acetyl-L-tryptophan or N-acetyl-D-tryptophan, was fully protected from such inactivation. In contrast, indole by itself not only did not protect the lyophilized enzyme from inactivation by iodomethane but also increased the rate of inactivation. The lyoprotectants citrate or sorbitol also showed opposite effects when co-lyophilized with alpha-chymotrypsin. Citrate protected the lyophilized enzyme from inactivation, while bound sorbitol dramatically accelerated the inactivation. Imprinting of lyophilized alpha-chymotrypsin with indole or sorbitol increased the reactivity of the active-site histidine towards iodomethane. Co-lyophilization of alpha-chymotrypsin with appropriate ligands is known to increase significantly its enzymatic activity in hydrophobic organic solvents. It is proposed that this imprinting phenomenon arises because a greater proportion of the active-sites in the lyophilized enzyme are in a catalytically favorable conformation where the imidazole of His-57 is more strongly hydrogen bonded to the carboxylate of Asp-102.

Electron tomography of metaphase nucleolar organizer regions: evidence for a twisted-loop organization

Metaphase nucleolar organizer regions (NORs), one of four types of chromosome bands, are located on human acrocentric chromosomes. They contain r-chromatin, i.e., ribosomal genes complexed with proteins such as upstream binding factor and RNA polymerase I, which are argyrophilic NOR proteins. Immunocytochemical and cytochemical labelings of these proteins were used to reveal r-chromatin in situ and to investigate its spatial organization within NORs by confocal microscopy and by electron tomography. For each labeling, confocal microscopy revealed small and large double-spotted NORs and crescent-shaped NORs. Their internal three-dimensional (3D) organization was studied by using electron tomography on specifically silver-stained NORs. The 3D reconstructions allow us to conclude that the argyrophilic NOR proteins are grouped as a fiber of 60-80 nm in diameter that constitutes either one part of a turn or two or three turns of a helix within small and large double-spotted NORs, respectively. Within crescent-shaped NORs, virtual slices reveal that the fiber constitutes several longitudinally twisted loops, grouped as two helical 250- to 300-nm coils, each centered on a nonargyrophilic axis of condensed chromatin. We propose a model of the 3D organization of r-chromatin within elongated NORs, in which loops are twisted and bent to constitute one basic chromatid coil.

Taurocholate-induced dimerization of bovine cholesterol esterase in sodium dodecylsulfate

Purified bovine cholesterol esterase (CE) showed one major band with an apparent molecular mass of 58 kDa on sodium dodecylsulfate-polyacrylamide gel electrophoresis (SDS-PAGE). In the presence of taurocholate another major band with an apparent molecular mass of 116 kDa, corresponding to the dimer, appeared. Longer heating times and higher concentrations of CE in SDS-sample buffer increased the relative amount of the dimer. Higher SDS concentration in the sample buffer reduced the amount of dimer. Mercaptoethanol concentration had no effect. The dimer did not contain taurocholate and readily reverted to the monomer. It is concluded that taurocholate mediates the dimerization of CE in SDS by facilitating the formation of hydrophobic interactions between monomeric subunits.

Sensitivity and positive predictive value of Medicare Part B physician claims for rheumatologic diagnoses and procedures

OBJECTIVE

To examine the sensitivity and positive predictive value of Medicare physician claims for select rheumatic conditions managed in rheumatology specialty practices.

METHODS

Eight rheumatologists in 3 states abstracted 378 patient office records to obtain information on diagnosis and office procedures. The Medicare Part B physician claims for these patient visits were obtained from the Health Care Financing Administration. The sensitivity of the claims data for a specific diagnosis was calculated as the proportion of all patients whose office records for a particular visit documented that diagnosis and who also had physician claims for that visit which identified that diagnosis. The positive predictive value was evaluated in a separate sample of 331 patient visits identified in Medicare physician claims. The positive predictive value of the claims data for a specific diagnosis was calculated as the proportion of patients with that diagnosis coded in the claims for a particular visit who also had the diagnosis documented in the medical record for that visit.

RESULTS

Ninety percent of abstracted office medical records were matched successfully with Medicare physician claims. The sensitivity of the Medicare physician claims was 0.90 (95% confidence interval [CI] 0.85-0.95) for rheumatoid arthritis (RA), 0.85 (95% CI 0.73-0.97) for systemic lupus erythematosus (SLE), and 0.85 (95% CI 0.78-1.0) for aspiration or injection procedures. The sensitivity for osteoarthritis (OA) of the hip or knee was < or = 0.50 if 5-digit codes specifying anatomic site were required. The sensitivity for fibromyalgia (FM) was 0.48 (95% CI 0.28-0.68). The positive predictive values were at least 0.90 for RA, SLE, and aspiration or injection procedures. Positive predictive values for FM and the 5-digit site-specific codes for OA of the knee were 0.83 (95% CI 0.66-1.0) and 0.88 (95% CI 0.75-1.0), respectively, while the positive predictive value of the 5-digit site-specific codes for OA of the hip was zero (95% CI 0-0.26). The positive predictive value of OA at any site was 0.83 (95% CI 0.76-0.90).

CONCLUSION

In specialty practice, Medicare physician claims had high sensitivity and positive predictive value for RA, SLE, OA without specification of anatomic site, and injection or aspiration procedures. The claims had lower sensitivity and predictive value for FM and for OA of the hip. The accuracy of Medicare physician claims for other conditions and in the primary care setting requires further investigation.

Induction of a cAMP-stimulated chloride secretion in regenerating poorly differentiated airway epithelial cells by adenovirus-mediated CFTR gene transfer

In cystic fibrosis (CF), the airway epithelium is in the process of injury and regeneration. In the context of the CF gene therapy, we previously reported that regenerating poorly differentiated (PD) cells of human airway epithelium represent preferential cell targets for recombinant adenoviral gene vectors. To define whether PD non-CF and CF epithelial cells possess a functional cystic fibrosis transmembrane conductance regulator protein (CFTR) chloride channel, we analyzed the CFTR expression and the regulation of chloride secretion under cyclic (c)AMP stimulation in these regenerating PD epithelial cells of non-CF and CF airway tissue. Moreover, we studied the effects of CFTR gene transfer mediated by a replication-defective adenovirus containing the wild-type CFTR gene (AdCFTR) on CFTR expression and on cAMP-stimulated chloride secretion. Distribution of the CFTR protein was evaluated in regenerating PD airway cells by light fluorescence microscopy and scanning laser confocal microscopy. The cAMP-mediated regulation of cell membrane chloride secretion was investigated using the whole-cell patch clamp and SPQ (6-methoxy-N-[3-sulfopropyl]quinolinium) techniques. Compared with the absence of CFTR expression and cAMP-regulated chloride secretion in nontransduced regenerating PD cells of either non-CF or CF origin, transduction with AdCFTR induces a CFTR expression and a cAMP-regulated stimulation of the cell membrane chloride secretion in the regenerating PD cells. These results suggest that, out of the context of CF, remodeled and poorly differentiated airway epithelium may present abnormalities in ion transport. Moreover, our data suggest that, in the context of CF gene therapy, adenoviral vectors can be efficient in correcting, at least partially, the chloride secretion defect in the remodeled CF airway epithelium.

Evidence for reduced drug influx in multidrug resistant CEM cells by a fluorescent dye

Multidrug resistance (MDR) in cancer cells is commonly ascribed to a reduced drug accumulation mediated by an ATP dependent efflux pump. We have developed a new, rapid and quantitative method for measuring influx of BCECF-AM in sensitive (CEM) and MDR cells (CEM/VLB100). The fluorescence of intracellular accumulated BCECF after hydrolysis of BCECF-AM is rapidly visualized by spectrofluorometry. The rate of BCECF-AM entry into CEM/VLB100 cells is considerably lower than that found in CEM cells, similar to 10-fold after 10 min of incubation. This phenomenon is not in relation with a difference of esterase activities, it is not energy or intracellular pH-dependent, and BCECF efflux is negligible. CEM cells exhibited diffuse fluorescence within cytoplasm in contrast with numerous spots of intense labelling, related to the presence of the cytoplasmic vesicles in CEM/VLB100 cells demonstrated by Nomarski's microscopy. MDR modulators such as verapamil, sodium orthovanadate, chlorpromazine or trifluoperazine induce an enhanced influx in CEM/VLB100 cells (150+/-4%; 204+/-17%; 410+/-17% and 229+/-7% respectively) whereas no major differences were noted with the parental sensitive cells. Vinblastine (under conditions close to IC50) increases the influx only in MDR cells (481+/-6%) by a process that is not linked to competitive inhibition of the P170 efflux pump. These results suggest that reduced influx of drugs could be a major defect in MDR cells, a possible role for P170-membrane lipids interactions is discussed.

Communication Scale for Older Adults (CSOA)

The communication Self-Assessment Scales for Older Adults (CSOA) are comprised of a 41-item Communication Strategies scale and a 31-item Communication Attitudes scale. Three-point and 5-point response formats are available. The scales were standardized on a population of 135 independent-living adults with hearing loss, ranging in age from 60 to 88 years. Item analysis, internal consistency reliability, test-retest reliability, normative data, and 95 percent confidence intervals are presented. A sample case illustrates how the scales can be used to evaluate the communication strategies and attitudes of an individual client. In addition, data are presented to show changes in the use of communication strategies and attitudes of a group of clients 3 months and 9 months after completion of aural rehabilitation programs.

The presence of complete but masked freezing nuclei in various artificially constructed ice nucleation-active proteobacteria

Disparate gamma-subdivision proteobacteria artificially endowed with the same ice gene of enteric origin acquired water-freezing potential at -12 degrees C, but expressed it to varying extents under identical conditions of culture as well as after being subjected to certain post-culture treatments. Varying rates of cell-bound ice nucleus synthesis were probably not the root cause of these observed interspecies differences in nucleation-active cell frequency because potentially functional but masked ice-forming templates were found in the outer cell envelope of even initially inactive individuals taken from physiologically uniform populations of virtually all tested species. We therefore propose that the extent of bacterial ice nucleation generally reflects species-specified extent of ice nucleus sequestration.

Chemical modification of lyophilized proteins in nonaqueous environments

Lyophilized proteins were reacted in vacuo with a volatile reagent or dispersed in octane and reacted with dissolved reagent. Three novel derivatives were formed with iodomethane: (a) quaternized trimethyl amino groups, (b) N1,N3-dimethylimidazolium cation, and (c) phenolic O-methyl ether. Acid anhydrides acylated amino groups and formed mixed anhydrides with side-chain carboxyl groups. Under nonaqueous conditions it was observed that: (i) The same derivatives are formed as under aqueous conditions. (ii) Hydrolytic breakdown of protein is prevented. (iii) Less reagent is required. (iv) Unreacted reagent can be recovered. (v) Water-labile derivatives can be isolated as stable intermediates. (vi) The yield of a derivatized functional group was directly related to its pK(a), its surface exposure, and the pH of the solution from which the protein was lyophilized. (vii) The physicochemical factors governing the reactivity of protein functional groups in nonaqueous environments appear to reflect the protein solution structure prior to lyophilization.

Fibronectin and its alpha 5 beta 1-integrin receptor are involved in the wound-repair process of airway epithelium

The cell migration that occurs during wound repair is dependent on modifications of the cell-matrix interaction in which extracellular matrix proteins and their receptors, the integrins, are involved. To study the interactions between airway epithelial cells and the extracellular matrix during the process of wound repair, we developed an in vitro wound model of human epithelial cells. Surface epithelial cells were dissociated from human nasal polyps and cultured on a type I collagen matrix. At confluency, a wound was made by the addition of 2 microliters of NaOH (1 N) to the cell culture. After the cell culture was washed, the wound area was recorded every 12 h for 96 h by a videomicroscopic technique. We calculated the wound-repair index that represents the decrease in the wound area per hour. Using immunofluorescence techniques, we first examined the localization, during wound repair, of fibronectin and of the beta 1-, alpha v-, alpha 2-, alpha 3-, and alpha 5-integrin subunits. Secondly, we carried out a series of wound-repair blocking experiments with the use of anti-integrin or anti-fibronectin antibodies diluted in the culture medium. We observed that fibronectin and the alpha 5- integrin subunit were exclusively expressed by the migratory cells in the wounded area. No difference in the localization of the alpha v-, alpha 2-, and alpha 3-integrin subunits was observed between the nonrepairing and repairing cells. The blocking experiments showed a significant decrease in the wound-repair index in the presence of either the anti-beta 1, -alpha 3, alpha 5, or the anti-fibronectin antibodies. Furthermore, the addition of fibronectin to the culture medium induced a significant increase in the wound repair index. These results suggest that fibronectin and the corresponding alpha 5 beta 1-integrin play an important role in the process of airway epithelium wound repair.

Assistive devices for the elderly

This article presents a review of assistive technology as it applies to elderly hearing-impaired people living independently and in group environments. Listening systems for personal communication and large area amplification, telephone, and television use are described. Visual systems that can be used to meet the communication needs of elderly persons and alerting systems are included. Issues that must be considered in the selection of personal and large area listening systems are discussed.

A protein complex from Choristoneura fumiferana gut-juice involved in the precipitation of delta-endotoxin from Bacillus thuringiensis subsp. sotto

A 75 kDa protein from spruce budworm (Choristoneura fumiferana) gut-juice has been isolated and shown to cause a specific precipitation of the delta-endotoxin from Bacillus thuringiensis subsp. sotto. This 75 kDa protein, separated by either column chromatography or SDS-PAGE, caused precipitation of the sotto toxin in both agarose diffusion gels and the PAGE gels. The precipitation event leads to limited proteolysis of the toxin and loss of larval toxicity. SDS-PAGE analysis of the precipitated toxin indicates that proteolysis of the toxin is not a prerequisite for precipitation. The protein responsible for precipitation, exhibits elastase-like activity and appears to be a complex which partially dissociates during boiling in SDS-PAGE sample buffer. Gut-juice from gypsy moth, forest tent caterpillar and white mark tussock moth also precipitated delta-endotoxin, but silkworm gut-juice gave a much weaker response. These results provide further evidence that, in the larval gut, differential processing of delta-endotoxin may play a role in the expression of activity towards various insect larvae.

Tenidap in rheumatoid arthritis. A 24-week double-blind comparison with hydroxychloroquine-plus-piroxicam, and piroxicam alone

OBJECTIVE

To compare the clinical efficacy, effect on serum C-reactive protein (CRP), serum amyloid A (SAA), and plasma interleukin-6 (IL-6) levels, and safety of tenidap with a combination of hydroxychloroquine-plus-piroxicam, and piroxicam alone, in the treatment of rheumatoid arthritis (RA) patients.

METHODS

A double-blind, randomized, multicenter study in which patients with active RA were treated with tenidap 120 mg/day, hydroxychloroquine 400 mg/day and piroxicam 20 mg/day, or piroxicam alone 20 mg/day, for 24 weeks.

RESULTS

At weeks 12 and 24, tenidap produced greater improvements than piroxicam based on 5 primary efficacy parameters; this improvement showed statistical significance in 4 of the 5 measures at week 12, and in 3 of the 5 measures at week 24. Clinical improvements in the hydroxychloroquine-plus-piroxicam-treated with tenidap. Compared with piroxicam, tenidap was associated with significantly greater reductions in serum CRP concentrations at 4, 12, and 24 weeks, and significantly greater reductions in SAA concentrations at weeks 12 and 24. The decrease in SAA concentrations was also significantly greater at weeks 4 and 24 in the tenidap-treated group than in the hydroxychloroquine-plus-piroxicam-treated group. Significant reductions in plasma IL-6 levels were observed at weeks 4, 12, and 24 within the tenidap group, and at week 24 within the hydroxychloroquine-plus-piroxicam-treated group. The overall occurrence of side effects, including gastrointestinal side effects, was similar in all 3 treatment groups. A small proportion of tenidap-treated patients (6.4%) manifested mild, nonprogressive, reversible proteinuria of presumed renal proximal tubular origin, and 3-4% of patients had elevated transaminase levels.

CONCLUSION

In the treatment of patients with RA, tenidap is as effective as the combination of hydroxychloroquine-plus-piroxicam, and is more effective than piroxicam alone; moreover, tenidap's safety profile is comparable to that observed with piroxicam alone, and with hydroxychloroquine-plus-piroxicam. The clinical response observed in this study, as well as the prompt decreases in acute-phase protein levels of CRP and SAA, and in plasma IL-6 levels, suggest that tenidap represents a new type of antiarthritic medication, with properties similar to, but not identical to, a therapeutic combination of a nonsteroidal antiinflammatory drug with disease-modifying antirheumatic drugs.

Characterization of the S3 subsite specificity of cathepsin B

Five synthetic substrates containing different amino acid residues at the P3 position (acetyl-X-Arg-Arg-AMC, where X is Gly, Glu, Arg, Val, and Tyr and where AMC represents 7-amindo-4-methylcoumarin) were used to investigate the S3 subsite specificity of cathepsin B. At pH 6.0, the specificity constant, kcat/Km, for tripeptide substrate hydrolysis was observed to increase in the order Glu < Gly < Arg < Val < Tyr. Molecular modeling studies of substrates containing a P3 Glu, Arg, or Tyr covalently bound as the tetrahedral intermediate to the enzyme suggest that the specificity for a P3 Tyr is because of a favorable aromatic-aromatic interaction with Tyr75 on the enzyme as well as a possible H bond between the P3 Tyr hydroxyl and the side chain carboxyl of Asp69.

Revised Communication Self-assessment Scale Inventory for Deaf Adults (CSDA)

The 125-item Communication Self-assessment Scale Inventory for Deaf Adults evaluates difficult communication situations, their importance to the client, communication strategies, and attitudes toward hearing loss. Each scale contains subscales, and the scales may be used independently of each other. The original 115-item scale was revised to improve internal consistency of some of the subscales and modify language in some items. Internal consistency reliability, test-retest reliability, and normative data are presented. The scales were presented to a group of prelingually deaf adults and adolescents who differed in the frequency of hearing aid use, primary mode of communication home, school, and work, and educational background. Subjects responded to some of the scales and subscales in a significantly different manner based on these parameters.

Analysis of clonal CD8+ T cell expansions in normal individuals and patients with rheumatoid arthritis

In the course of studying the circulating TCR repertoire in humans, we noted several individuals with an increase in the percentage of CD8+ T cells expressing a particular V region. In some cases, these CD8 expansions were dramatic, occupying over 40% of the total CD8 repertoire. Using a panel of mAbs to different TCR V regions, we found that over 30% of healthy adults (&gt; 35 years of age) harbor an expansion that alters the peripheral blood CD8 TCR repertoire. A wide range of V regions were expressed by these expansions. Considering that the mAbs used cover only a portion of the V beta repertoire, the data suggest that over 70% of adults are likely to harbor such expansions. Junctional region sequencing showed that the CD8 subset expansions were clonal, and serial studies as long as 4 years showed that they persisted indefinitely. Expansions were not identified in the CD4 population. Discordant expression of one large V beta 6.7+ clone was found in one identical twin set, suggesting the possibility that an environmental exposure is involved in their generation and/or expansion. In one large family, we found five family members with a large CD8 subset expansion. Remarkably similar usage of J beta regions was noted, and two individuals demonstrated V beta 3-expressing clones with homologous CDR3 regions, differing by only one major substitution. The repertoire data from this family suggest that the T cell clones have arisen in response to a common Ag. Studies of patients with rheumatoid arthritis found a significantly increased frequency of circulating CD8 subset expansions that expressed a different V region repertoire compared with the healthy individuals studied. Overall, our results emphasize a frequent alteration in the human CD8 TCR repertoire, most likely related to an environmental exposure, in both healthy individuals and patients with rheumatoid arthritis. The presence of these expansions will be important to consider in any study of human TCR repertoire, and their implication for health and disease will be important to understand.

Analysis of clonal CD8+ T cell expansions in normal individuals and patients with rheumatoid arthritis

In the course of studying the circulating TCR repertoire in humans, we noted several individuals with an increase in the percentage of CD8+ T cells expressing a particular V region. In some cases, these CD8 expansions were dramatic, occupying over 40% of the total CD8 repertoire. Using a panel of mAbs to different TCR V regions, we found that over 30% of healthy adults (> 35 years of age) harbor an expansion that alters the peripheral blood CD8 TCR repertoire. A wide range of V regions were expressed by these expansions. Considering that the mAbs used cover only a portion of the V beta repertoire, the data suggest that over 70% of adults are likely to harbor such expansions. Junctional region sequencing showed that the CD8 subset expansions were clonal, and serial studies as long as 4 years showed that they persisted indefinitely. Expansions were not identified in the CD4 population. Discordant expression of one large V beta 6.7+ clone was found in one identical twin set, suggesting the possibility that an environmental exposure is involved in their generation and/or expansion. In one large family, we found five family members with a large CD8 subset expansion. Remarkably similar usage of J beta regions was noted, and two individuals demonstrated V beta 3-expressing clones with homologous CDR3 regions, differing by only one major substitution. The repertoire data from this family suggest that the T cell clones have arisen in response to a common Ag. Studies of patients with rheumatoid arthritis found a significantly increased frequency of circulating CD8 subset expansions that expressed a different V region repertoire compared with the healthy individuals studied. Overall, our results emphasize a frequent alteration in the human CD8 TCR repertoire, most likely related to an environmental exposure, in both healthy individuals and patients with rheumatoid arthritis. The presence of these expansions will be important to consider in any study of human TCR repertoire, and their implication for health and disease will be important to understand.